summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Center for Success and Independence
Youth Opportunity Investments, LLC
(Contract Provider)
4055 NW 105th Street
Ocala, Florida 34482
Review Date(s): April 22-25, 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:
Lori Bright, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 6)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Forrest Hallam, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Jillian Lewandowski, Circuit 7 Probation, Assistant Chief Probation Officer (Standard 2)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 1)
and Standard 6)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Center for Success and Independence MQI Program Code: 1449
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10790
Location: Marion County / Circuit 5 Number of Beds: 72
Review Date(s): April 22-25, 2025 Lead Reviewer Code: 230
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 72 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
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 72 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
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 72 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * 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 72 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 72 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
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 * Satisfactory
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 72 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 72 (Revised September 2022)
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Program Overview
The Center for Success and Independence (CSI) is a seventy-two bed program, for fifteen to
eighteen-year old males, located in Ocala, Florida. The program is operated by Youth
Opportunity Investments, LLC through a contract with the Department. The program provides
Substance Abuse Treatment Overlay Services (SAOS) and Mental Health Overlay Services
(MHOS). In addition, the program fosters each youth by providing Moral Reconation Therapy,
the Seven Challenges, Trauma-Focused Cognitive Behavioral Therapy, Skillstreaming the
Adolescent, and Impact of Crime. Additional treatment services provided include family,
individual, and animal therapy. Program administration is comprised of a facility administrator,
assistant facility administrator, human resources business manager, and physical plant
manager. Case management services are provided by one case manager supervisor, two
transition services managers, and four case managers. Mental health staff at the program
include a clinical director, clinical coordinator, contracted psychiatrist, five master’s-level
therapists, a recreation therapist, and a contracted behavioral analyst. Medical services are
offered seven days a week for 120 hours by three registered nurses (RNs), one of whom serves
as the health services administrator (HSA), and two licensed practical nurses (LPNs). The
program also has a contract with a physician who serves as the designated mental health
clinician authority (DMHCA). Educational services are provided by the Florida Scholars
Academy operated by Florida Virtual School (FLVS). The layout of the program includes two
dormitories, an administration building, a dining hall and kitchen, four portables which serve as
classrooms, and a building which houses medical as well as two conference rooms. The
program has 125 cameras, located in master control, all of which were operational during the
annual compliance review week. At the time of the annual compliance review week, all
vacancies were filled; however, two positions were in the background screening process.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 72 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures which indicate background screenings shall be
conducted on all employees and contracted providers. During the annual compliance review
period, the program had thirty-five newly hired staff. Thirty-four staff had a clear background
screening completed in the Agency for Healthcare Administration’s Clearinghouse prior to
working with youth and youth records. One staff needed an exemption, and they received a
clear background screening during the review. They had not worked with the youth as verified
with the personnel manager. All thirty-five staff completed and passed a pre-employment
assessment tool, and the passing score was maintained in each staff’s record. Each staff’s
criminal history and the Department’s Staff Verification System (SVS) was reviewed, and all
were placed on the program’s Clearinghouse roster. Four staff were applicable for a break in
service as indicated in the SVS and a new background screening was completed. The program
did not have contracted/provider and grant recipient volunteers, mentors, and interns who
required a background screening during the annual compliance review period.The Annual
Affidavit of Compliance with Level 2 Screening Standards was completed and sent to the
Department’s Background Screening Unit (BSU) on January 1, 2025. The teachers with Florida
Virtual School (FLVS) received an annual screening on January 28, 2025. Both were sent to the
BSU by January 31,2025. The program has a policy and procedures for volunteers, mentors,
and interns who work with youth less than 10 hours a month requiring sight and sound
supervision. All thirty-five staff signed a contraband attestation form.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 72 (Revised September 2022)
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures which indicate all staff receive a background
rescreening every five years from initial date of employment. The five-year resubmission will be
completed on or before the five-year anniversary date. A review of the program’s staff found six
staff to be applicable for a five-year background screening during the annual compliance review
period. There were only six staff who needed a five-year background check at the program for
the annual compliance review. One other staff was reviewed and was not due until December
of 2025.The re-screenings were esubmitted to the Department’s Background Screening Unit
(BSU) as required, within the applicable timeframe.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a policy and procedures to ensure they provide an environment in which
youth, staff, and others feel safe, secure, and not threatened by any form of abuse or
harassment. Nine staff records were reviewed, and all nine staff signed a code of conduct
contained in the employee handbook which communicates expectations for ethical and
professional behavior. During the tour, the Florida Abuse Hotline telephone number and the
Department’s Central Communications Center (CCC) telephone number for youth eighteen
years of age and older, were observed to be posted throughout the program. The program’s
policy requires staff to provide unhindered access to report alleged abuse. At no time should
youth be prevented from self-reporting or making a call to the Florida Abuse Hotline or the CCC.
The shift supervisor must be notified immediately of a youth's request to contact the Florida
Abuse Hotline or CCC. The shift supervisor shall immediately attempt to notify the facility
administrator (FA) or an assistant facility administrator (AFA) regarding placement of an abuse
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 72 (Revised September 2022)
call. Staff will assist youth in placing the abuse call, dialing the phone number, recording the
date and time of the call, obtaining the operator’s name and number, and documenting
everything on the internal incident report. Staff will remain in the area; however, allowing for
youth to freely and confidentially make a report. The shift supervisor shall complete an internal
incident report documenting the youth's statement and statements from other observers in the
event an incident of abuse or neglect by a staff member is witnessed, suspected, or reported by
youth. The program had one instance of allegations of abuse against staff during the annual
compliance review period and the program provided the incident report, supplemental
statements, and date and time of contact with the Florida Abuse Hotline and law enforcement.
The incident was reviewed and was unsubstantiated. An interview with the FA confirmed the
program’s abuse policy,, as well as the incorporation of trauma responsive practices in the
policy. The program provides new hire and annual training regarding incident reporting,
including CCC incident reporting. Additionally, staff review incident reporting during monthly all
staff meetings as needed. The program’s Trauma Responsive and Caring Environment
(TRACE) self-assessment is scheduled for May 9, 2025. Nine youth interviews indicated all nine
youth feel safe in the program and they stated they have never been stopped from making a call
regarding abuse. All nine interviewed youth indicated staff are respectful. Two of the nine youth
stated they overheard staff use profanity. Each of the nine-youth stated they never exchanged
social media information with staff. Nine interviewed staff were able to articulate the process for
calling in suspected abuse and none of the nine staff ever observed another staff telling youths
they could not make a call. Two out of the nine staff interviewed have heard staff use profanity,
once and occasionally, in relation to frustration but not directed at youth, the remaining staff
reported never hearing staff use profanity.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures in place to address incidents of physical,
psychological, and emotional abuse. There has been one allegation of abuse involving three
staff since the last annual compliance review. All three staff were placed on administrative leave
pending results of the Inspector General (IG) investigation. Allegations of abuse were not
substantiated. The interviewed facility administrator (FA) stated youth and staff have unhindered
access to report alleged abuse to the Florida Abuse Hotline, staff shall provide the youth with
timely telephone access to report allegations of abuse, the shift supervisor must be notified
immediately of the youth’s request, the shift supervisor must immediately notify administration of
the youth’s request, staff shall assist youth with placing the abuse call, and record the date,
time, and the operator’s name/badge. The FA also stated the staff give youth the opportunity to
speak freely while maintaining sight of the youth, in the event the youth change their mind, a
refused call is documented on an internal incident report, and the FA completes appropriate
notifications to the Department’s Central Communications Center (CCC), and provides
leadership all documentation and notifications included on the internal incident form.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 72 (Revised September 2022)
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures for reporting incidents to the Department’s Central
Communications Center (CCC). During the annual compliance review period, the program had
thirteen incidents reported to the CCC, of which, five were reviewed. All five of the reviewed
incidents were reported to the CCC within two hours of the incident or within two hours of the
individual becoming aware of the incident, thirteen of the CCC reports were documented in the
logbook. During the annual compliance review week, there were no additional internal
incidents/grievances found, which should have been reported to the CCC. The program did not
experience an increase in the number of reportable incidents since the last 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 has a policy and procedures for using Right Interactions (RI) when working with
the youth. The program had thirteen RI incidents during the annual compliance review period.
All of the thirteen incidents were documented on monthly summaries and submitted to the
Department’s regional office. The RI plan was updated and approved by the Department on
December 13, 2024. During the previous annual compliance review period, the program had
twenty-eight RI incidents. The program’s RI rate during the previous quarter was 0.18, which is
below the statewide Residential RI rate of 1.71. The facility administrator’s (FA) interview
indicated incidents are tracked using incident report trackers and monthly Protective Action
Response (PAR)/RI reports. Video is reviewed to ensure the use of force is according to the
PAR/RI matrix. Retraining or a staff coaching occurs if there are deviations. Once a month, the
PAR/RI incident tracker is reviewed with the program and corporate to determine if there is a
rise of incidents. If so, corrective action plans are developed to prevent further incidents. All nine
interviewed staff have used RI and were able to articulate the process. Five of the thirteen RI
incidents were reviewed. Each report was completed by the end of the staff’s workday and
included statements from all staff involved. None of the incidents required mechanical restraints.
In two of the five incidents either a staff or youth was injurrd and the Department’s Central
Communication Center (CCC) was called within two hours of the incident. Three of the incidents
were not applicable. In one of the five incidents, the youth alleged abuse and the Florida Abuse
Hotline was called immediately. Four of the incidents were not applicable. In all five incidents, a
supervisor and a RI instructor reviewed the incident. In two records the youth were applicable
for and had a RI medical review conducted and three incidents were not applicable. One of the
records indicated youth was taken off-site for evaluation and four records were not applicable.
All five incidents were reviewed by an administrator within seventy-two hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 72 (Revised September 2022)
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures addressing pre-service training requirements for new
staff during the initial 180 days of employment. Staff who are direct care staff and are counted in
the staff-to-youth ratio are safety and security specialists (levels one through three), and
supervisors/administrators may be included in ratio, providing they are not conducting their
regular duties. All staff are trained in Right Interactions (RI). Nine staff records were reviewed.
All nine staff completed a minimum of 120 hours of pre-service training within 180 days of hire.
All reviewed staff records documented completion of the essential skills trainings including
cardiopulmonary resuscitation (CPR), first-aid, automated external defibrillator (AED), forty
hours of Protective Action Response (PAR)/RI, professionalism and ethics including standards
of conduct, suicide awareness and prevention, emergency procedures, child abuse recognition,
reporting, and prevention, Prison Rape Elimination Act (PREA) and Facility Operating
Procedures (FOPs) within ninety days of hire and prior to contact with youths. All nine staff
completed the remaining required courses. Two staff had physical copies of training due to
ongoing Department’s Learning Management System (SkillPro) systems issues. All remaining
training was found in SkillPro.
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 has a policy and procedures addressing annual in-service training. Nine staff
training records were reviewed for in-service training. Each of the staff completed the essential
in-service training including cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking, active shooter, stress management, Information Security
Awareness, Mental Health and Substance Abuse, Protective Action Response/Right
Interactions model (PAR/RI) update, professionalism, interpersonal communication, and ethics,
sexual harassment, Prison Rape Elimination Act (PREA), trauma responsive practices, and
suicide awareness and prevention which included two hours of web-based training in the
Department’s Learning Management System (SkillPro) and four hours of instructor-led training.
All nine staff also completed other required trainings specific to their positions. Seven staff’s
trainings were documented in SkillPro, the remaining two staff did not have all training
documented in SkillPro due to ongoing systems issues at the time they were in training. Each of
the nine staff had more than the required twenty-four hours of training. Three supervisor records
were reviewed. All three supervisors received the required eight hours of training, which
included training on coaching, leadership, and personal accountability. All instructors were
qualified to deliver the trainings provided. The list of in-service trainings, including course
names, descriptions, objectives, and training hours for any instructor-led training based on the
above topics was approved by the Department’s regional director on December 14, 2024, and
signed by all required parties. The program has an annual in-service training calendar, which is
updated as changes occur.
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1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures regarding the grievance process. The process
includes three phases; informal, formal, and appeal. The informal phase includes the use of
communication request forms which encourage the youth to make all efforts to reach resolution
of issues and complaints immediately and directly with the program staff involved. All staff shall
make a reasonable effort to discuss the youth’s concern and assist the youth to resolve the
issue. The formal phase includes grievance forms available on each module. Youth fill out the
form and place it in a secure grievance form box. All grievances received are reviewed in daily
management meetings and are assigned to an appropriate staff for investigation. During the
annual compliance review week, nine youth were interviewed. All nine youth were aware of how
to submit a grievance and knew they could ask for assistance filling out the form if needed. All
nine staff interviewed were aware of how a grievance is submitted and they can assist youth
who need help completing the form. The facility administrator (FA) was interviewed and
indicated all three phases of the grievance procedure. The phases include an informal phase,
formal phase, and the appeal phase. All grievances are logged and maintained in a binder for a
period of twelve months. The program had no 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.
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 has a policy and procedures addressing the provisions of a delinquency
intervention model or strategy which is an evidence-based practice, promising practice, or a
practice with demonstrated effectiveness, as well as life and social skills training for each youth.
The program’s life and social skills groups are primary or clinical groups; therefore, not
applicable for review. No other activities were provided by the program. Nine youth were
interviewed and reported they participated in Impact of Crime (IOC) and learned from the group
consequences of actions, restorative justice, staying away from negative peers, different
aspects of crime, completing packets, and having group discussions on a regular basis. The
designated mental health clinician authority (DMHCA) was interviewed and listed all of the staff
who provide the different groups and the length of each curriculum. The DMHCA indicated
youth are provided an opportunity to practice learned skills daily, in group, on the dorm, in
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school, and through all other activities at the program. The facility administrator was interviewed
and verified youth learn life skills through structured instruction with the education department
plus one on one training on resumes, communication skills and mock job interviews. Physical
plant staff train youth on essential safety skills such as fire extinguisher use and how to change
smoke detector batteries. The program partners with community stakeholders, such as a local
bank for youth to attend a class related to having better money habitswhich provides youth with
financial responsibility and budgeting. The program hosted a four-week parenting class which
provided information and insight into being a parent.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures addressing the provision of activities and instructions
intended to increase youth awareness of, and empathy for crime victims and survivors, and
increase personal accountability for criminal actions and harm to others through the
implementation of Impact of Crime (IOC) and community service projects. Each case manager
at the program completes one restorative justice project every sixteen weeks. Newsletter entries
coupled with photographs were reviewed for the annual compliance review period regarding
restorative justice projects to include a fundraiser for a local Pediatric cancer center, assisting
maintenance staff at the program to clean up the program campus, participating in a walk-a-
thon to raise money for hurricane relief, and giving back to staff at the program by serving hot
cocoa or coffee during a cold front. A restorative justice project did not occur during the annual
compliance review week while the team was on site. The facility administrator (FA) was
interviewed and confirmed youth who have been identified with high-risk criminogenic factors on
the Community Assessment Tool (CAT)/Residential Assessment for Youth (RAY) participate in
the IOC group. Through this group they engage in restorative justice projects aimed at giving
back to the program and community. The IOC group helps youth understand the effects of their
crimes on victims and the community. If the youth have already received the IOC group, they do
not participate in any other group related to restorative justice programming; however, the
program provides ongoing opportunities for youth to complete restorative justice projects and
actively apply the skills they learned during the group. Youth are permitted to participate in
activities aimed at restoring victims and communities through Impact of Crime restorative justice
projects, as well as community service projects both within the program and in the local
community. Nine youth were interviewed and able to express ways they have put what they
have learned into practice.
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1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to determine how alerts are identified, documented,
updated, and communicated to staff. Program alerts were consistent with the alerts in the
Department’s Juvenile Justice Information System (JJIS). Any staff member, direct care staff,
case manager, clinicians, facility nurse may place a youth on alert status if they meet criteria for
an alert. Notification of alerts is through the JJIS Critical Alert List, alert communication board,
shift briefings and logbook communications. Only the following staff are permitted to downgrade
or discontinue a youth’s medical, mental health or security alert status: a medical staff person
for medical alerts upon verification the health condition or situation no longer exists or changed,
the facility administrator or on-site supervisor for security alerts, and the designated mental
health clinician authority (DMHCA) for mental health alerts. All alerts are documented internally
through the communication board and logbook to include instructions for the staff regarding the
alert. In nine reviewed youth records a total of twenty-five alerts were applicable and each of the
applicable youth’s alerts were verified, entered, removed, or downgraded by the appropriate
staff as needed. All nine youth were placed on the program’s internal alert system as required
by the program’s written procedures. An interview with the facility administrator (FA) confirmed
healthcare staff participate in daily management meetings to address any important medical or
mental health issues concerning the youth in the program. Additionally, medical concerns are
reviewed weekly during the designated health authority’s (DHA) visit with the health services
administrator (HSA) and FA. Internal alerts are updated daily, as applicable, and are reviewed
during the daily management meeting. These alerts are then communicated to staff through the
daily shift briefing and recorded in the logbook. Depending on the nature of the alert, updates
are also entered into JJIS by the appropriate department heads. Medical staff are responsible
for updating the medical alert system as confirmed by the nursing staff interview. Nine
interviewed staffconfirmed they have access to JJIS, alert board, shift briefings, text messages
and youth records regarding youth alerts.
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 separates the youth record into an Individual Healthcare Record and individual
management record. All records reviewed documented the youth’s name, Department
identification number, date of birth, county of residence, and committing offense. The individual
management records contained sections including legal information, demographic and
chronological information, correspondence, case management and treatment team activities,
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and miscellaneous. Youth records were labeled “Confidential.” All official youth records are
secured in a locked file cabinet in a locked room. The program clearly identifies any file cabinet
used to store official youth case records as “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 has a community advisory board which meets at least every ninety to 120 days. A
review of sign-in sheets for the annual compliance review period confirmed the community
advisory board met as required. Documentation confirmed the facility administrator (FA)
solicited active involvement from law enforcement, the judiciary community, community
partners, business community, school district, faith community, LGBTQIA+ community, victims,
victim advocates, or other victim services community representatives, and a parent/guardian
whose child was previously in the juvenile justice system. The facility has held virtual meetings
in the past when it is not possible for everyone to make it to an in-person meeting. A review of
sign-in sheets confirmed participation from all members. During the annual compliance review
week, the law enforcement community liaison was interviewed by telephone. They stated
everyone participates in the quarterly meetings and some of the youths have made positive
relationships with members of the local police department. The advisory board serves as a
support to the program and a link to community resources.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which address the program’s system for evaluating
staff, performance standards, and frequency of evaluations. The program conducts an initial
ninety-day review and annual reviews thereafter for all staff. A review of five position
descriptions reflected each staff’s performance standards were clearly identified and matched
the job descriptions for each staff including implementation of the program’s Behavior
Managment SystemNine staff’s records were reviewed, and the evaluations were completed as
outlined in policy. The performance standards match the job descriptions for staff. The
program’s contract was reviewed, and the specific job functions were maintained and performed
as outlined in the contract. During the annual compliance review week, there were no open
vacancies; however, two staff had not officially started working with the youth as they were still
in the background screening process. The facility administrator (FA) was interviewed and stated
the program implements a staff morale committee which supports employee recognition efforts
and organizes morale-boosting events. Additional strategies used to enhance staff morale and
retention include coaching notes for performance feedback, recognition, employee of the month
awards, a staff shoutout board, and birthday celebrations. To address staffing needs, the
program also follows a structured monthly orientation plan for new hires. As a result of these
efforts, the program has maintained a consistently low vacancy rate. Nine staff were
interviewed, and seven reported evaluations are conducted monthly, one reported they are
done annually, and one replied bi-annually.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
In the program’s contract with the Department has program-specific requirements. The program
provided documentation of all contract-specific requirements. These requirements include
providing each youth specific type clothing upon release, as well as all clothing acquired during
their stay. While staying at the facility, youth are able to get new clothing if it becomes ripped or
stained. The program has several incentives the youth can choose to partake in. A barbershop
which twenty-three to thirty-three youth can utilize each month. A music studio eight youth
participated in during the annual compliance review period. Youth in high enough levels of the
behavior management system can use a game room to include big screen televisions, game
consoles, games, and books, as well as an incentive point store to get snacks. . In addition, the
facility administrator (FA) confirmed in an interview, the program offers vocational opportunities
in cardiopulmonary resuscitation (CPR)/first-aid, food handling, Occupational Safety and Health
Administration (OSHA), Florida Ready to Work, and EmployU.
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’s practice regarding data trend analysis states the program shall maintain a quality
assurance program designed to monitor and evaluate program outcomes, system fidelity,
compliance, the appropriate and quality of care ensuring program services are consistent with
prevailing professional standards, and to identify and resolve problems objectively and
systematically. Satisfaction surveys are incorporated into the monitoring and verification
activities as a part of the program's quality assurance program. Satisfaction surveys are
provided routinely and are completed on at least a quarterly basis. Surveys include youth
surveys, family surveys, and staff surveys at a minimum. Surveys target admission activities,
topic-specific assessments, and discharge satisfaction. Survey data is reviewed and evaluated
monthly in program-level and corporate leadership meetings. Survey outcomes are collected
and communicated as part of ongoing program communication and quality improvement
activities. Monthly incident trackers are distributed to the programs. Department reports are
incorporated in monthlymonitoring and verification reporting. Quarterly monitoring and
verifications are conducted by the provider compliance team who formulate a report, and
provide support, technical assistance, and coaching to promote improvement, professional
development, and ensure implementation of corrective strategies as appropriate. Program and
corporate leadership meetings include monthly quality assurance review processes which
incorporate review of facility data, surveys, and findings of formal monitoring and verification
activities. Progress to date, program strengths, improvement needs, and corrective action are
discussed, within each meeting. Recommendations are made by the team with ongoing review
and follow up, and technical assistance will be provided as applicable. Stakeholders are
informed and are provided opportunities for feedback, performance improvement, and
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budgeting. Data gathered by the program and Department are used for long-term planning,
provisions for staffing, and a system of communication to retain staff.
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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 addressing youth admissions, which indicates all
youth admissions shall be accepted Monday through Friday between the hours of 8:00 a.m. and
5:00 p.m. According to the program’s policy, the admission process includes a notification to the
parent/guardian by telephone during the intake process or no later than twenty-four hours
following the youth’s arrival and this notification is to be documented on a chronological note.
The policy states the case manager is to send an original admission notification letter to the
committing judge within five working days and a copy to the juvenile probation officer. The
program’s policy requires a copy of the notification letter to be filed in the youth’s individual
management record. Nine youth records were reviewed for the initial contacts to the
parent/guardian and the court. Each record documented the parent/guardian was notified by
telephone within twenty-four hours, and in writing within forty-eight hours of youth’s admission.
Each record documented the court and juvenile probation officer was notified of the youth’s
admission within five working days.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures addressing youth orientation. According to the
program’s policy, the facility administrator has designated the case management staff to ensure
a comprehensive youth orientation to program rules, expectations, goals of the program, and
services applicable to the youth. According to the program’s policy, youth orientation begins on
the day of the youth’s admission and is to be documented on the orientation checklist. The
program’s policy also indicates the youth handbook is reviewed within the orientation process
and a copy of the handbook is to be provided to the youth with receipt of the handbook verified
through a youth signature and date on the statement of understanding. Nine youth case
management records documented the program provided youth an orientation on the date of
each youth’s admission. The reviewer was unable to observe an orientation during the annual
compliance review week due to program operations not notifying the review team of the
orientation as requested. Documentation in each youth record confirmed the program’s
orientation process included a review of the services available, the daily schedule, the
expectations and responsibilities of the youth, the written behavioral management system, and
access to medical and mental health services. Each orientation included information regarding
access to the Florida Abuse Hotline or the Department’s Central Communications Center (CCC)
if the youth was 18 years of age or older, the program’s zero tolerance policy, available special
accommodations, and the right to be free from sexual misconduct, from retaliation for reporting
such misconduct, and the agency’s sexual misconduct response policy and procedures.
Documentation confirmed the youth’s orientation process included a review of the items
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considered contraband, the performance planning process, dress code and hygiene practices,
procedures on visitation, mail and use of the telephone, expectations for release from the
program, community access, grievance procures, client rights, emergency procedures, a facility
tour, and an assignment to a living unit and room, treatment team and youth group. Nine
interviewed youth confirmed they received an orientation within twenty-four hours of admission.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures addressing written consent for youth eighteen years
of age or older, which states the case manager is to obtain written consent for youth eighteen
years 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 screening, assessment, or treatment. According to the program’s policy, the
consent form shall include information required by federal regulations and is to be completed in
its entirety prior to signing. Two youth were applicable for being eighteen years of age or older;
therefore, one additional record was reviewed. All three applicable case management records
documented a written consent was obtained and signed by each youth eighteen years of age or
older before providing or discussing information related to the youth’s physical or mental health
screenings, assessments, or treatments with each parent/guardian.
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 addressing classification which outlines following the
completion of the initial intake screening process, an admission classification meeting is to be
conducted to formally review the youth’s history, special needs and risk factors in order to
determine appropriate levels of supervision, alert status needs and to identify potential safety
and security risks which may impact living unit and room assignments, assignment to group or
therapist, or any other placement needs. According to the program’s policy, the classification
factors shall contain at a minimum, a review of the youth’s physical characteristics, including
sex, height, weight, and general physical stature, age and maturity level, any identified special
needs, like mental, developmental, intellectual, or physical disabilities, history of violence, gang
affiliations, criminal behavior, sexual aggression or vulnerability to victimization, any identified or
suspected risk factors such as medical, suicide, escape, or security risks, history of potential or
verified human trafficking, and a review of the Department’s Juvenile Justice Information
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System (JJIS) Alert List for any issues affecting classification. The program’s policy states the
admission classification meeting outcome is to be documented and a justification for room
placement is to be identified on the Admission Classification form. In addition, the program
policy addresses the re-classification process in which each youth is to be re-classified at
intervals throughout their length of stay to include changes in the student’s supervision status,
new/updated alerts, behavioral concerns and relevant information from the treatment team to
ensure safety and security of the student and program. The program policy indicated several
examples requiring re-classification including living unit or room assignment change,
assignment to work projects or activities involving tools or instruments which may be used as
potential weapons or means of escape, prior to level change, increase in youth privileges and
advancement or freedom of movement, prior to anticipated off campus activity, or at the request
of facility administrator or designee. The program’s policy indicates youth who have transitioned
to phase two of the “All-Star” level will be assessed for off campus eligibility. Nine reviewed case
management records confirmed an admission classification meeting occurred and the program
utilized the classification forms which addressed each youth’s physical characteristics, age and
maturity level, any identified special needs, their history of violence, any gang affiliation, criminal
behavior, sexual aggression or their vulnerability to victimization, each youth’s history of
potential or verified human trafficking, and any suicide risk, medical risk, escape risk or security
risk. The admission classification form did not include the youth’s perception of vulnerability,
which the program indicated the Screening for Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) addresses the perception of vulnerability. Each of the nine
reviewed youth case management records documented the initial classification occurred on the
date of youth admission. Each of the nine youth were identified as having a medical alert for a
sports restriction; however, only three youth had an applicable alert entered into the JJIS. One
youth was identified as being an escape risk, and the youth had an applicable alert in JJIS.
Each youth record documented a review of the JJIS alert list for any issues affecting
classification. Each youth was classified for purposes of assigning to a living area, sleeping
room, and the youth group. Each record contained a classification re-assessment for any
increase in the youth’s privileges or freedom of movement, participation in work projects or
participation in off-campus activities. An interview with the facility administrator (FA) indicated
youth are evaluated immediately upon admission through intake screening, evaluation, and
admission classification processes. According to the FA, the admission classification process is
used to assist in determining special needs of the youth and to assist with room placement
which provides for the youth’s safety and security. The FA also stated the program will provide
appropriate and reasonable accommodations for youth needs and will assist the youth on an
individual basis as needed ensuring the protection of their rights and dignity.
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 addressing gang identification. The program’s policy
states all newly admitted youth will be screened to determine if the youth is a criminal street
gang member or is affiliated with any criminal street gangs, which is part of the admission and
classification process conducted on-site by the intake staff. According to the program’s policy, a
youth’s gang involvement is documented in the master control logbook, on the alert board, and
all staff who work with the youth will be notified verbally. In addition, the program gang specialist
notifies local and the youth’s home county law enforcement, and the juvenile probation officer.
The program’s policy also indicates any gang activity is reported to the local law enforcement
gang unit and documented in the youth’s record. Two of the nine case management records
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were applicable for youth who were identified as having gang involvement prior to their
admission into the program. A third youth was identified as having gang involvement upon
admission into the program. All three applicable youth records documented local law
enforcement and in the youth’s home county were notified of the suspected gang
activity/involvement. All three youth’s gang alerts were entered into the internal alert system and
the Juvenile Justice Information System upon identification. In accordance with the program’s
policy, the facility logbook documented the three youth were identified as having gang
involvement upon admission. Each of the three applicable case management records
documented the education provider at the program, the juvenile probation officer and the post-
residential counselor were provided information on the youth’s gang status.
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 which addresses gang prevention and intervention
activities to be implementedthrough Impact of Crime when youth are identified as being a
criminal street gang member, affiliated with a criminal street gang, or are at high risk of
involvement with a criminal street gang. The program policy indicates the youth’s performance
plan is to include goals and objectives related to gang activities and if the youth desires, a plan
to disaffiliate prior to their release from the program. Three case management records were
applicable for youth identified as a gang member, affiliated gang member, or having suspected
gang involvement. Program documentation confirmed all three applicable youth participated in
monthly gang prevention and intervention strategies, and each performance plan included
relevant goals and objectives related to gang intervention strategies for each youth to complete
prior to release from the program. The program utilizes the Gang Resistance and Drug
Education (GRADE) material sponsored by the local police department youth liaison unit for
gang prevention and intervention strategies. GRADE is a seven-lesson program designed to
educate youth on setting goals, respect, making good choices, conflict resolution, internet
safety, gang intervention and drug awareness. The program maintained monthly sign in sheets
to verify the interventions activities were conducted and also listed which intervention lesson the
youth was working on. An interview with the facility administrator confirmed the program utilizes
curriculum for monthly gang intervention services. According to the facility administrator, the
gang intervention services are facilitated by a program therapist.
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 addressing the timeframe for the Residential
Assessment for Youth (RAY) and reassessments. According to the program’s policy, the RAY is
to be completed within thirty days of the youth’s admission to the program and ongoing with
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reassessments of each youth conducted within ninety days and to continue through the youth’s
length of stay. Nine reviewed case management records contained a completed RAY within
thirty days of each youth admission date into the program, maintained in the Department’s
Juvenile Justice Information System (JJIS) and each youth’s official case record. Four youth
records were applicable for a RAY re-assessment and each record contained a RAY
reassessment completed at least every ninety-days after completion of the initial RAY. Two
youth records documented a RAY reassessment was completed when deemed necessary by
the intervention and treatment team to effectively manage both youth’s case. Each applicable
record maintained the reassessment documentation in each youth’s official case record
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures addressing the timeframe for the Youth Needs
Assessment Summary (YNAS), which states it is completed within thirty days of the youth’s
admission to the program. Nine reviewed case management records documented the YNAS
was completed within thirty days of each youth’s admission and each YNAS was documented in
the Department’s Juvenile Justice Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
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 addressing the development of the youth’s
performance plan. According to the program’s policy, the youth is to participate in a formal
treatment team meeting within thirty days of admission to the program for the development of
the youth’s performance plan, which is to include prioritized goals and objectives as indicated in
the Youth Needs Assessment Summary (YNAS). According to policy, the treatment team
evaluates data on the youth and assists with the development of performance plan goals and
objectives designed to decrease the youth’s overall potential recidivism. Upon completion of the
performance plan, the case manager is to copy and distribute the plan to the committing court,
juvenile probation officer, the Department of Children and Families (DCF) for jointly served
youth, parent/guardian, and other pertinent parties within ten working days. Nine reviewed case
management records contained a completed Individualized Performance Plan developed within
thirty days of each youth’s admission and after completion of the initial Residential Assessment
for Youth (RAY) and YNAS. Each case management record documented the Initial Performance
Plan was developed with the intervention and treatment team members present to include the
treatment team leader, the youth, a representative from administration, a living unit
representative, treatment staff, and educational staff, and all other parties who have significant
responsibility in goal completion. One youth was applicable for involvement with DCF and the
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DCF caseworker was involved in the development of the initial performance plan.
Documentation confirmed a copy of the performance plan with the signature sheet was mailed
to each youth’s parent/guardian for signature; however, none of the signature sheets were
returned to the program. All nine records contained the signature sheet attached to the original
performance plan, which was filed in each youth’s official case record. Each performance plan
had individualized goals based on the prioritized needs reflecting the risk and protective factors
during the initial assessment process. Eight of the nine records documented the performance
plan had individualized goals addressing the youth’s top three criminogenic needs based on the
RAY and targeted court order sanctions which could be reasonably initiated/completed while in
the program. The remaining record addressed two of the youth’s top three criminogenic needs
and did not contain the court ordered sanctions. The performance plan was revised twenty days
later after the program identified the youth’s Initial Performance Plan did not include the required
criminogenic need domain and court ordered sanctions. Each of the nine case management
records included delinquency interventions, transition activities targeted for the last sixty days of
each youth’s anticipated stay, youth responsibility to accomplish goals, program staff
requirements to enable youth to complete goals, and target dates for goal completion. Each
initial performance plan was mailed to the committing court/judge, the juvenile probation officer,
the parent/guardian, and the DCF caseworker where applicable, within ten days of the
performance plan completion. Nine interviewed youth confirmed they participate in the
development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
Nine case management records were reviewed for performance plan revisions and
incorporation of other plans into the performance plan. One youth record documented the
performance plan was revised when Residential Assessment for Youth (RAY) reassessment
results warranted the revision, and in two records the plans were revised when there was newly
acquired information which warranted the revision. Three performance plans were revised when
each youth demonstrated progress or lack of progress toward completing a goal. One youth
record documented an addendum to the performance plan due to negative behaviors displayed
in the program. Two of the nine records documented a revision was made to the Individualized
Performance Plan to facilitate transition activities during the last sixty days of the youth’s stay.
Each youth’s performance plan incorporated academic and treatment plans. None of the youth
were applicable for incorporation of a Department of Children and Families (DCF) or Agency for
Persons with Disabilities (APD) plan.
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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 addressing performance summaries, which states the
assigned intervention and treatment team is to prepare a Performance Summary for each youth
every ninety calendar days following the development and signing of the Performance Plan,
unless requested at shorter intervals by the committing court. Additionally, the program’s policy
states the performance summaries shall be prepared prior to youth release, discharge, or
transfer from the program. The program policy also dictates the case manager is to distribute
the Performance Summary to the committing court every ninety days, unless the committing
court has requested for completion and submittal every thirty days. The program is to provide a
copy of the Performance Summary to the youth’s parent/guardian, juvenile probation officer, the
post residential services counselor, if applicable, and a copy to the Department of Children and
Families (DCF) family services worker for youth jointly served by the Department and DCF
within ten working days of signing the summary. A review of nine case management records
revealed four youth had been in the program more than ninety days; therefore, were applicable
for requiring a performance summary. Each of the applicable youth records confirmed
performance summaries were completed every ninety calendar days following the signing of the
initial performance plan. Two of the nine youth were applicable for requiring a performance
summary in preparation for each youth’s release from the program, which were completed. All
four applicable performance summaries included youth’s status on each performance plan goal,
youth’s overall treatment progress, and academic status. Three of the four applicable case
management records documented the youth’s grades in progress, and credits earned in the
program. One youth case management record documented the youth’s academic status and
progress in the program but did not specifically address the youth’s grades and credits earned
in the program. Each applicable performance summary documented the youth’s behavior, level
of motivation/readiness to change, interaction with peers, interaction with staff, overall behavior
adjustment to the program, and significant positive and negative events. Each applicable
performance summary confirmed each youth was allowed to read and add comments prior to
signing, and was provided a copy of the summary, and the original summary was filed in each
youth’s case management record. Each performance summary was signed and dated by the
treatment team leader, the staff preparing the summary, the program director or designee, and
youth. Each record contained documentation a copy of the summary was sent to the committing
court, youth’s juvenile probation officer, and parent/guardian. Three closed case management
records were reviewed for a release summary. All three case management records contained
the original summary, along with the justification for release and Pre-Release Notification (PRN)
sent to the juvenile probation officer. One of the three youth was a direct discharge. Each youth
was in the program longer than forty-five days, and each record documented the release
summary, and the PRN were sent to the juvenile probation officer at least forty-five days prior to
each youth’s release date. Each record maintained signed copies of the required documents. All
three PRNs were approved by the court, and once the PRN was approved, the program
provided written notification to each youth’s parent/guardian regarding the planned release.
Each record contained a completed exit Residential Assessment for Youth (RAY). None of the
youth were applicable for sex offender or victim notification requirements.
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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 encouraging family involvement beginning at the time
of the youth’s admission to the program. The program policy indicates the family is encouraged
to provide input into performance, treatment, and transition planning, participation in treatment
team meetings, family therapy sessions as needed and specified within the individualized
treatment plan, as well as participate in conferences for family outreach to address family
reunification issues. Nine case management records contained documentation the program
encouraged and facilitated involvement of each youth’s parent/guardian in the case
management process to include the assessment process, participation in the development of
the performance plan, progress reviews, transition planning, and they provided advance notice
of formal treatment team meeting dates and times. If the parent/guardian was unable to
physically attend treatment team, the parent/guardian was given the opportunity to participate
by telephone/video conferencing or provide verbal/written input prior to the meeting. The
program contacts the parent/guardian by telephone, mailing letters, and/or sending email
notifications for treatment team meetings, and family day events. A treatment team meeting was
unable to be observed due to no treatment team meeting being scheduled during the annual
compliance review week. Nine interviewed youth confirmed the parent/guardian is contacted for
treatment team meetings. Five youth reported their parent/guardian is also contacted for family
therapy, and three youth indicated they have weekly telephone calls. One youth reported the
parent/guardian is also contacted for family day. An interview with the facility administrator
indicated the program encourages parent involvement through a variety of opportunities,
including quarterly family days and family forums, monthly treatment team meetings and family
sessions, as well as weekly visitation and regular telephone call opportunities.
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.
Nine reviewed case management records contained documentation a formal treatment team
meeting was conducted at least once every thirty days. All formal treatment team meetings
documented each youth’s name, the date of the review, and required attendees to include each
youth, the juvenile probation officer, the treatment leader, program management, living unit
representative, education, mental health, medical, and transition staff. Each formal treatment
team documentation confirmed treatment team members and others were able to provide
comments, as well as a brief synopsis of each youth’s progress in the program, progress on
performance plan goals, positive and negative behaviors, and performance plan revisions when
applicable. None of the records reviewed were applicable for youth’s behavior resulting in
physical interventions. Each youth was provided an opportunity to demonstrate skills acquired in
the program and each treatment team documentation included treatment progress, and
Residential Assessment for Youth (RAY) reassessment results. All formal treatment team
documentation was maintained in each youth’s record. Nine case management records
reviewed documented an informal treatment team meeting was held on a bi-weekly basis each
month alternating with formal treatment team meetings. The informal treatment team meeting
forms documented each youth’s name, date of the review, meeting attendees, any comments
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from treatment team members, a brief synopsis of each youth’s progress in the program, and
performance plans revisions when applicable. Each informal treatment team meeting forms
documented each youth’s progress on the performance plan goals, positive and negative
behaviors, treatment progress, and RAY reassessment results. Each youth was provided an
opportunity to demonstrate skills acquired in the program and all informal treatment team
meetings were documented in each youth’s record. None of the case management records
documented the youth had any behaviors resulting in physical interventions during formal or
informal treatment team meetings. The juvenile probation officer, parent/guardian, and pertinent
parties were invited and encouraged through advance notification to participate and if
participation could not be arranged, they were provided the opportunity to provide input, either
verbal or written. A treatment team meeting was unable to be observed due to no treatment
team meeting being scheduled during the annual compliance review week. Nine interviewed
youth indicated staff talk about their performance to include progress on performance plan
goals, positive and negative behavior, and treatment progress. Each interviewed youth was able
to indicate how they show the skills they have learned in the program during treatment team. Six
youth reported they discuss the level the youth are currently on in the program and review their
goals. Two youth stated they discuss the groups they participate in, review their
school/education, and their progress within the program.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Three closed case management records were reviewed for transition planning, a transition
conference, and a Community Reentry Team (CRT) meeting. The three records documented a
transition conference was held at least sixty days prior to each youth’s targeted release. The
transition conference documentation confirmed each youth, treatment team leader, program
director or designee and other team members were present for the transition conference. Those
treatment team members who were unable to participate in the transition conference were able
to provide written input to the team leader prior to the conference. Program documentation
confirmed the intervention and treatment team invited and encouraged participation of each
youth’s juvenile probation officer, parent/guardian, education staff, and any other pertinent
parties. Documentation reflected during the transition conference, the participants reviewed
transition activities on each youth’s performance plan, identified additional transition activities as
needed, identified target completion dates, and identified persons responsible for completion.
Documentation confirmed the treatment team leader obtained attendees dated signatures,
representing their acknowledgement of the transition goals and accountability for completion.
Each youth case management record contained documentation a copy of the plan was sent with
a request for signatures to anyone not in attendance who had a responsibility for completion of
transition goals. Each plan was transmitted electronically to the juvenile probation officer with
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the return email acknowledgement receipt being printed and placed in the closed case
management record. Each closed case management record contained documentation the CRT
was conducted prior to each youth’s release and the youth and case manager participated in
the CRT. The closed case management records contained a printed copy of the CRT invitation.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
A review of three closed case management records confirmed an exit portfolio was discussed
and initiated for each youth during the transition conference. Each exit portfolio contained a
state-issued identification card, a copy of youth’s transition plan, and a calendar with all dates,
times, and locations for upcoming community appointments. One of the three case
management records contained a social security card and birth certificate for the youth;
however, the two remaining records did not contain this documentation. Each reviewed closed
case management record contained education and/or vocational certificates earned in the
program, to include a copy of two of the three youth’s high school diplomas. Each youth record
contained a servsafe certification, a cardiopulmonary resuscitation (CPR), automated external
defibrillation (AED), and first-Aad certification card, and a ten-hour construction safety and
health card. Each closed case management record contained educational records/documents,
school transcripts, a resume, and a completed sample employment application. Documentation
reflected each youth’s exit portfolio was verified during the exit conference and a signed
document verified each youth was given a copy of the exit portfolio upon release. Each closed
case management record contained documentation the exit portfolio was sent electronically to
each youth’s juvenile probation officers. The program does not have any secure maximum risk
youth and the program’s contract does not contain additional requirements for the Exit Portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed case management records were reviewed and all documented an exit conference
was conducted after the program notified the juvenile probation officer (JPO) of the release.
Each exit conference was held at least fourteen days prior to youth’s release date from the
program. Each exit conference form documented the date of the exit conference, signatures of
those who participated in-person, names of individuals who participated by telephone, and a
summary of pending transition goals. A review of the case management records, and the
Department’s Juvenile Justice Information System (JJIS) confirmed each youth’s date of
admission and date of termination/release matched. Documentation indicated the status of
transition activities established at the transition conference, and plans for the youth’s release
were finalized, provision for continuation of education and/or employment were reviewed,
documentation each youth’s parent/guardian and JPO were aware of the vocational plan for
each youth, and youth’s case manger and parent/guardian were aware of the plan, documents,
and post-release discharge plans. Each closed case management record documented the exit
conference participants included intervention and treatment team leader, parent/guardian,
education representative, JPO, youth, and any other pertinent parties. Documentation confirmed
the exit conference was held separately from the transition conference and the Community
Reentry Team meeting.
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2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures addressing channels of communication to include a
youth student council. According to the program policy, the facility administrator (FA) is to
ensure the youth have a voice within the program, an opportunity to be part of program decision
making, be part of planning and preparation for reparation activities, recreational activities,
incentives, and have an established forum to communicate directly with representatives of the
program management team. According to the program policy, student council is to be facilitated
bi-weekly by the assistant FA, appointed youth, and designated management staff, and advisory
council members are to keep meeting minutes and signatures of participants. A review of the
youth advisory board sign in sheets, minutes, and agendas from October 2024 to April 2025
confirmed the program conducts a youth advisory board meeting on a bi-weekly basis. The
program documentation included a review of any program concerns, youth concerns, youth
leadership and mentoring, new ideas and activities, youth outings, menu planning, and an open
floor forum. Nine interviewed youth reported they can provide input about what happens at the
program during town hall meetings, two youth reported they participate in student council and
four youth indicated they are able to utilize speak out forms. An interview with the facility
administrator confirmed the program solicits input from youth on systemic issues impacting the
residential environment through twice a month student advisory council meetings, monthly
surveys, and weekly town hall meetings. A review of the town hall meeting documentation
provided by the program from October 2024 to April 2025 revealed the program is conducting a
town hall meeting at least once a week with the month of January to April 2025 having two town
hall meetings a week. The meeting notes included a review of weekly progress and
improvements, old business, new business, program concerns, youth input on concerns, and
open floor. The program maintains sign-in sheets, agenda, and meeting notes.
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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 employs a designated mental health clinician authority (DMHCA) who is on-site
forty hours a week. The DMHCA is a mental health counselor in the State of Florida with a clear
and active license which expires March 31, 2027. The DMHCA is also available twenty-four
hours a day, seven days a week for emergencies. Services are provided seven days a week.
The program has a back-up DMHCA who is a licensed marriage and family therapist in the
State of Florida. The back-up DMHCA has a clear and active license which expires on March
31, 2027. The DMHCA was interviewed and summarized the responsibilities for the DMHCA
which included coordination and implementation of mental health and substance abuse
services. Specialized treatment services are coordinated as required by the DMHCA.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) is the clinical director at the program.
The back-up DMHCA is the assistant clinical director. The program employs a psychologist who
is available as needed. The psychologist has an active and valid license with an expiration of
May 31, 2026. Copies of licenses are maintained in a binder, which was provided for review.
The program has an active Chapter 397 license to provide substance abuse services with an
expiration date of October 15, 2025. The licensed clinical staff positions are fully met and are in
accordance with the program’s contract.
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.
All non-licensed staff at the program had appropriate levels of education, training, and
experience. Direct supervision is provided by the designated mental health clinician authority
(DMHCA) and the department supervision logs were reviewed for the annual compliance review
period to confirm the DMHCA is meeting with staff weekly, reviewing cases, and providing
oversight. The DMHCA also maintains a binder with credentials to ensure the licensed clinical
staff working under her supervision are performing services that are qualified to provide based
on education, training, and experience. During the annual compliance review week, the program
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had no vacancies in non-licensed mental health and substance abuse clinical staff positions.
The program is meeting the contract requirements for staffing and service hours. The program
only has five non-licensed clinical staff at the master’s level in an approved human services field
and they all practice under a Chapter 397 license for the program. All five staff had the
appropriate hours of training in Assessment of Suicide Risk (ASR) as well as supervised
experience in assessing suicide risk, mental health crisis intervention, and emergency mental
health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
A review of nine youth mental health and substance abuse records indicated all youth received
a Massachusetts Youth Screening Instrument – Second Version (MAYSI-2) on their date of
admission. All nine youth records documented the clinical staff reviewed available information to
include the commitment packet, reports, mental health records, and any documentation of
human trafficking. The MAYSI-2 was completed in full and in the Department’s Juvenile Justice
Information System (JJIS) by a trained staff. All nine youth were referred for a comprehensive
evaluation and an Assessment of Suicide Risk (ASR) regardless of results on their MAYSI-2.
The ASR was conducted on the same date of admission. Two of the nine youth were applicable
for being placed on Precautionary Observation (PO) and were not stepped down to standard
supervision until recommended by completion of an ASR. The program has a policy and
procedures which address a standardized screening process with all required elements. The
facility administrator (FA) interview confirmed screening staff complete a MAYSI-2 and an ASR.
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.
Nine youth mental health and substance abuse records were reviewed; all nine youth had a new
mental health and substance abuse evaluation completed within thirty days of admission. All
nine youth had signed consents for substant abuse services. All evaluations were completed by
non-licensed staff and reviewed by a licensed clinical staff within ten calendar days. All nine
comprehensive evaluations contained all required elements including identifying information,
reason for the evaluation, relevant background information, behavioral observation, mental
status exam, documentation of an interview, discussion of findings, diagnostic impressions
which included the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-
V), patterns of alcohol and/or drug abuse, how alcohol and other drugs are affecting the major
life areas, risk factors for continued use of alcohol and/or drugs and recommendations.
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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.
Nine youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All nine records had initial treatment plans which were developed
on the day of admission. The reviewed Initial Mental Health/Substance Abuse Treatment Plans
contained all required elements and were all completed by a licensed mental health clinical
staff. The youth, treatment team leader, program management living unit representative,
education, and medical personnel signed off on all initial treatment plans. Parents/guardians
and juvenile probation officers (JPO) were contacted telephonically and noted on the initial
treatment plans. Individualized Treatment Plans were developed including all required elements
within thirty days of each youth’s admission. Each plan was individualized to the goals and
objectives of each youth, to include all treatment services. Two youth had individualized
treatment plans which included psychotropic medications. The plans included frequency of
monitoring and had a clinical psychotropic progress note (CPPN) attached. Individualized
treatment plans were maintained on a standardized form and contained all the elements of the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review.
Treatment plan reviews were conducted on eight of the nine youth every thirty days. One youth
was admitted within the last thirty days and was not due to have a review at the time of the
annual compliance review week. Video review of groups was not applicable as all program
groups are primary or clinical groups.
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.
Nine youth mental health and substance abuse records were reviewed for treatment and
discharge planning. All nine youth records indicated youth were assigned to a treatment team
upon arrival to the program. Documentation revealed the treatment team included youth,
program administration, a staff from the residential living unit, education, medical staff, mental
health/substance abuse staff, and the parent/guardian. Six of the nine reviewed youth records
indicated the youth required substance abuse treatment. All nine youth records had Authority for
Evaluation and Treatment (AET) forms which were appropriately completed. All six-youth
requiring substance abuse treatment had signed Youth Consent for Substance Abuse
Treatment forms. Three of the five youth reviewed were determined to be in need of substant
abuse treatment and received counseling provided by a licensed qualified profressional or a
non-licensed substant abuse clinical staff in accordance with the youth’s initial or individualized
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substance abuse treatment plan. Treatment notes for all youth were entered on a form which
contained the same information as the Department’s Counseling/Therapy Progress Notes form.
All nine-youth's mental health and substance abuse records reviewed had individual counseling.
The youth records indicated all the youth received psychosocial skills training and the program
notes indicated the youth received services as stated on their treatment plans. Three closed
youth records were reviewed and included the mental health discharge plans. The discharge
plans were documented on the Department’s Mental Health/Substance Abuse discharge
summary form. None of the reviewed closed records indicated any youth were on suicide alert
or precautions at the time of release. The discharge summaries for all three records indicated
what future services would be needed. Documentation reflected each parent/guardian and
juvenile probation officer (JPO) discussed the discharge plan at the exit conference and a copy
of the discharge summary was provided to each youth.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program provides specialized services for the youth at the program to include Mental
Health Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services (SAOS).
The program’s required clinical groups are Moral Reconation Therapy (MRT) for MHOS, and the
Seven Challenges for SAOS. These services are primary services and reviewed by the
Technical Assistance Team. In additional supplemental groups were Skillstreaming the
Adolescent for MHOS youth and Trauma-Focused Cognitive Behavioral Therapy (TFCBT) for
youth requiring SAOS. All nine records indicated the youth participate in groups. All nine
interviewed youth indicated family counseling is conducted once a month and individualized
counseling occurs every other week. Nine staff were interviewed regarding services provided at
the program. Four staff advised they do not conduct groups, four staff indicated they are present
but do not conduct groups, and one staff who was a non-licensed clinical staff indicated they do
conduct groups. The designated mental health clinician authority (DMHCA) was interviewed and
explained the program provides individual and family therapy, supportive counseling, and
groups consisting of MRT, Skillstreaming the Adolescent, Seven Challenges, and TFCBT. The
DMHCA is on-site forty hours each week and provides oversight of MHOS and SAOS services.
The DMHCA meets with clinical staff briefly each day and provides supervision for an extended
period at least once a week. A licensed psychologist or licensed mental health counselor
provides on site services as needed. The facility administrator was interviewed and reported the
program provides MHOS and SAOS services. The focus of treatment includes targeting and
reducing youth symptoms of mental health and substance related disorders to improve
functionality within the community. The facility administrator advised additional services can be
provided directly or through referral in instances where the provider cannot meet the youth’s
need. The counselor to youth to ratio is one to thirteen. All non-licensed clinical staff hold at
minimum a master’s level degree. Individual therapy for both MHOS and SAOS was conducted
at least every other week. Family therapy for SAOS and MHOS was completed once a month.
Psychiatry services were provided at least every two weeks. Four mental health and substance
abuse groups are scheduled weekly.
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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 who is board certified and has a clear and active license in
the State of Florida, which expires January 31, 2026. The psychiatrist advised in their interview
they are available twenty-four hours a day, seven days a week. The psychiatrist evaluation and
recommendations are utilized in developing the individualized mental health and substance
abuse treatment plan. The psychiatrist is on site bi-weekly to provide medication management,
psychiatric services, input for treatment team, and is on-call for any psychiatric needs of the
program. The program also utilizes a psychiatric advance practical registered nurse (APRN).
The APRN has an active and clear license in the State of Florida and licensure in psychiatry is
included in their licensing. The APRN’s license expires on July 31, 2026. A collaborative
practice protocol is in place and was verified on-site. The APRN is only utilized when the
psychiatrist is not available to come on-site. The psychiatrist was not on-site during the annual
compliance review. The psychiatrist was available to the APRN by telephone when they were
not on-site. The designated mental health clinician authority (DMHCA) advised in an interview
they meet with the psychiatrist every other week on Wednesdays. Nine youth mental health and
substance abuse records were reviewed for psychiatric services. Three youth records were
applicable. In two of the three records, the youth came into the program on psychotropic
medications, the third was placed on the medications on a later date. Both youth who arrived
with medication received a diagnostic interview within fourteen days of admission. The initial
diagnostic psychiatric interview included history, mental status examination, Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment
recommendations, and prescribed medications if applicable. Both youth records included
documentation the psychiatrist explained the need for the medication regarding the diagnosis,
treatment goals, potential side effects, risks and benefits of taking medication, as well at the
frequency of the medication monitoring. The initial diagnostic psychiatric interviews were
documented on the Department’s Clinical Psychotropic Progress Note (CPPN) Form and were
clearly labeled. For both youths admitted with psychotropic medications page three of the CPPN
was completed. For all three youth medication reviews were completed within thirty days of the
last review by the psychiatrist. Two of the three youth records had changes in medication or
added to medications and the page three of the CPPN was completed with all required
elements. The program does not utilize tele-psychiatry services.
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 policy and procedures for suicide prevention. The suicide prevention plan
includes identification and assessment of youth at risk of suicide, staff training, suicide
precautions, levels of supervision, referrals, communications, notifications, documentation,
immediate staff response, and a review process. The review process also contains all required
elements for reviewing suicide attempts and mortality review. The suicide prevention plan was
signed on November 22, 2024, by the facility administrator (FA), the designated mental health
clinician authority (DMHCA), and corporate staff.
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3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
A review of nine mental health and substance abuse records indiciated two were applicable for
suicide prevention services. There were no other applicable youth during the annual compliance
review period. Both were placed on precautionary observation (PO) during admission screening
based on a review of their history and had immediately an Assessment of Suicide Risk (ASR)
completed on the Department form by a licensed clinician. The program has a policy and
procedures prohibiting
secure observation. The level of supervision changed to standard supervision in both records
after the initial ASRs were completed. There was no documentation the parent/guardian and
juvenile probation officer were notified of each youth being placed on PO status. The mental
health staff provided supportive services to each youth. The assessments were completed by
non-licensed clinical staff under the supervision of a licensed mental health professional. The
results of both ASRs were for youth to be stepped down to standard supervision. The ASRs
were completed within twenty-four hours of each screening. The discontinuation was
documented by a non-licensed staff, and the decision was reviewed by the licensed staff. The
dates and times the clinician conferred with the program director or designee, and the
designated mental health clinician authority (DMCHA) was documented on the reviewed ASRs.
Neither youth required a follow-up ASR. All discontinuations were reviewed by the designated
mental health clinician authority (DMHCA) and each parent/guardian was notified of youth’s
status. Youth were not transitioned to standard supervision until the clinical staff conferred with
the licensed mental health professional and had documentation of conferring with the program
director or designee of the youth’s status. While reviewing Crisis Assessments, the review team
found one instance in which the program should have placed a youth on precautionary
observation and follow-up with an ASR; however, a Crisis Assessment was completed instead.
Documentation was provided this incident was discussed during weekly supervision and the
youth cleared through the Crisis Assessment process. A video review to verify PO could not be
conducted. The program administration reported there had not been any youth placed on PO
within the last thirty days of the annual compliance review week. There were two examples of
youth being placed on suicide risk screening. In both situations where a youth was placed on
suicide precautions, they were seen during the admission process and stepped down from
suicide risk supervision, so there were not additional instructions related to suicide risk
assessment findings. Youth are 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 does not utilize secure observation; therefore, this indicator is rated as non-
applicable.
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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.
Nine youth mental health and substance abuse records were reviewed for precautionary
observation log documentation. Two youth records were applicable for precautionary
observation. There were no additional youth applicable for precautionary observation during the
annual compliance review period. Both records included documentation each youth’s
supervision was noted on the Department’s Suicide Precaution Observation Log for the duration
of the precautionary supervision. Observations of the youth behavior were documented in real
time in increments of no less than thirty minutes. Both logs were signed by the shift supervisors
and mental health clinical staff. Both logs contained the safe housing requirements. No warning
signs were documented on the precautionary observation (PO) logs. .
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.
Nine pre-service and nine in-service staff training records were reviewed and had all required
suicide prevention training. Three suicide response kits were maintained in master control, sub-
control, and in the medical clinic and are co-located with first-aid kits. Drills were conducted at
least quarterly for each shift. Drill forms indicated the drills were simulated. Drills were all in
response to a simulated suicide attempt or serious self-injury. Life saving measures
implemented during drills included cardiopulmonary resuscitation (CPR), first-aid kits, suicide
kits, and automated external defibrillator (AED). The program completed training at least semi-
annually for a suicide attempt or serious injury with the utilization of CPR. Youth were not
utilized in any suicide prevention drills. Staff were provided an opportunity to review drills, if they
were absent during the simulated drill. A video review was conducted to observe a simulated
suicide prevention drill. Seven staff were observed utilizing the suicide response kit, checking
for vitals, calling for assistance, and utilizing the AED. Nine staff were interviewed about drills
and all nine advised they complete drills once a month. The facility administrator was
interviewed regarding suicide drills and indicated drills are conducted monthly and staff
participate in drills on each shift. The facility administrator reported drill types include continuity
of operations, escape, medical, and mental health scenarios.
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3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a mental health crisis intervention plan. The plan includes notification and alert
system, means of referral, communication, supervision, documentation, and review. The crisis
intervention plan was signed by the designated mental health clinician authority (DMHCA) and
facility administrator on November 22, 2024.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Nine youth mental health and substance abuse records were reviewed for Crisis Assessments.
One youth was applicable for review. There were no additional applicable youth during the
annual compliance review period. The Crisis Assessment contained the reason for assessment,
mental status examination and interview, determination of danger to self or others, initial clinical
impressions, supervision and treatment recommendations, and recommendations for follow-up.
The Crisis Assessment was completed by a non-licensed clinical staff and reviewed by the
designated mental health clinician authority (DMHCA). The Crisis Assessment did not determine
the youth posed a safety and security-risk so an alert and follow-up were not required. The
youth was not maintained on one-to-one supervision or constant supervision while on the
mental health alert. No observation logs were provided for review. The DMHCA and statewide
clinical director were informally interviewed regarding this youth. The statewide mental health
director reported on November 12, 2024, a therapist emailed the youth's therapist a case
manager reported to the therapist the youth made suicidal statements and had suicidal
thoughts. The therapist emailed back the following morning they would meet with the youth on
the same day. A progress note was completed documenting the therapist met with the youth on
November 13, 2024, at 12:30 p.m. to 12:45 p.m. for a supportive counseling session. The youth
reported to the therapist they were not suicidal and did not want to self-harm. A progress note
was also reviewed from November 14, 2024, from 10:00 a.m. to 10:15 a.m. This progress note
indicated the therapist met with the youth for "Crisis". The therapist documented they asked the
youth the same questions from the session the day before but also discussed communication
and how others can perceive what the youth had said. Another progress note was completed on
November 14, 2024, for an individual therapy session from 10:15 a.m. to 10:45 a.m. There was
no further discussion about suicidal statements. No Assessment for Suicide (ASR) was
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completed at any point in the process; however, a Crisis Assessment was completed on
November 14, 2024, at 2:00 p.m. The Crisis Assessment was completed in full. An informal
interview was conducted with the DMHCA and the statewide clinical director for the provider.
The DMHCA stated the youth should have been placed on precautionary observation (PO). The
statewide clinical director stated the therapists were talked to and a Crisis Assessment was
done. The DMHCA also stated the issue was discussed during weekly supervision the week of
the annual compliance review. The weekly supervision from the annual compliance review week
was provided for review and the issue was discussed with the clinical staff. The DMHCA also
reported an all-staff training would be taking place. The program had no other examples of a
Crisis Assessment to review. The Office of Health Services (OHS) was also contacted. It was
advised for the DMHCA to conduct training with all staff to review the process for a youth in
crisis. This was done with the clinical staff prior to the end of the annual compliance review
week. A training will take place at an all-staff meeting and the OHS will follow-up with the
program.
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 policy and procedures for emergency mental health and substance abuse
services. The plan includes immediate staff response, notifications, communications,
supervision, authorization to transport for emergency mental health or substance abuse
services, transport for emergency evaluation and treatment under Baker Act and Marchman Act,
documentation, training, and review. The emergency mental health and substance abuse
services plan was signed by the designated mental health clinician authority (DMHCA) and the
facility administrator (FA) on November 22, 2024.
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.
Nine youth mental health and substance abuse records were reviewed for safety planning
documentation. All nine youth had a safety plan completed within fourteen days of admission.
The plans were jointly prepared by each youth, parent/guardian, and clinical staff. Plans
incorporated all required elements, recommendations from clinical assessments, and
incorporated trauma responsive practices. All safety plans were updated at least every thirty
days. One youth had a Crisis Assessment and did not have an updated safety plan completed
following the Crisis Assessment. All safety plans included warning signs, baseline behaviors,
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coping strategies, crisis recognition, intervention strategies, and a debriefing process. Safety
plans were reviewed by unit staff and plans were maintained in youth records. All nine
interviewed youth indicated they provide input in their safety plans. The facility administrator
advised during interview,plans are reviewed and updated every thirty days as well as following
any significant changes or mental health events.
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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 center’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD) specializing in family medicine. The DHA license is unrestricted and meets
all requirements to practice in the state of Florida, which expires on March 31, 2026. The
program does not utilize an advanced practice registered nurse (APRN) or physician’s assistant
(PA); therefore, a collaborative practice protocol is not warranted. A review of the sign-in logs for
the annual compliance review period indicated the DHA was on-site once a week, as required. If
the DHA has scheduled absences, the program has a back-up DHA, but the back-up DHA had
not been utilized during the annual compliance review period. No tele-medicine was used during
the annual compliance review period. The DHA was interviewed and stated their role was
performing Comprehensive Physical Assessments, conducting periodic evaluations, sick call,
and policy and procedure development. The DHA stated they communicate with the program
staff regarding youth medical needs by telephone or when they are on-site. If off-site, they are
on call twenty-four hours a day, seven days a week and staff call them with any needs or
concerns. Any off-site care findings, instructions, or information is reviewed by the DHA on a
weekly basis.
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 one licensed practical nurse (LPN) and four registered nurses (RNs); one of
the RNs serves as the health services administrator (HSA). A review of the nurses license
reflected each of the nurses had a clear and active license, in the State of Florida,
according to the Florida Department of Health Medical Quality Assurance website, with
expiration dates of April 30, 2027, April 30, 2026, and July 31, 2025. In addition, each of the
LPN and RNs had current cardiopulmonary resuscitation (CPR) certifications with expiration
dates of March 26, 2027, November 1, 2026, September 23, 2026, and March 27, 2026. The
contractually required on-site hours are seven days a week for a total of 120 hours. The nursing
staff was in compliance with the contractual requirements providing 168 hours a week of on-site
coverage.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program utilizes facility operating procedures (FOP) for all health-related procedures and
protocols. During the annual compliance review period, the designated health authority (DHA)
and the facility administrator (FA) signed all respective treatment FOPs November 22, 2024,
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and the psychiatrist signed on November 30, 2024. No new or changes in policies had been
made during the annual compliance review period. FOPs and nursing protocols were reviewed
annually as required, and signed November 22, 2024. Newly employed healthcare personnel
received a comprehensive clinical orientation to the Department’s health care policies and
procedures, which was conducted by a registered nurse (RN) as evidenced in a review of their
training packets. Nursing staff reviewed, signed, and dated a cover page between the dates of
January 29, 2025, and March 7, 2025, of all medical FOP’s, treatment protocols, and other
procedures. The approval of treatment protocols or standing procedures were written and
authorized by the Designated Health Authority as evidenced by signature and date.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. Nine
youth Individual Healthcare Records (IHCR) were reviewed for AET requirements. Six of nine
IHCRs included a valid AET obtained prior to providing medical services. One contained a court
order authorizing physical and mental health care for a committed youth in the custody of the
Department of Children and Families (DCF). The remaining two records belonged to youth who
were eighteen years of age. Each of the six applicable youth’s AETs were either originals or
stamped as a “COPY” and filed in the youth’s IHCR. All six IHCRs were signed by each youth’s
parent/guardian. Each applicable AET was signed by a department representative, was valid,
and was obtained prior to the provision of medical services. The nursing staff was interviewed
and stated the AET is obtained upon intake and nursing contacts the juvenile probation officer
(JPO) to obtain signatures from the parent/guardian. For youth who are eighteen years or older,
a separate specific consent is signed by the youth.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. Nine
youth Individual Healthcare Records (IHCR) were reviewed for parental notification/consent
requirements. Three out of nine youth were found to require parental notification for
overthecounter (OTC) medications beyond those covered by the Authority for Evaluation and
Treatment (AET). All three youth IHCRs included documentation of consent provided by the
parent/guardian. All three youth IHCRs included written notification sent utilizing the
Department’s Parental Notification of Health-Related Care form. Two of the nine youth were
taking psychotropic medications upon admission. Two of the nine youth on OTC medications,
which included one also on psychotropic medications, had medications which were prescribed,
discontinued, or had a significant change in the dosage. Written notification was sent for all
three youth and telephonic contacts were witnessed by staff and recorded in the progress notes.
None of the youth IHCRs reviewed were involved/committed to the Department of Children and
Families. All nine youth’s vaccinations were verified within thirty days of the youth’s admission
with no vaccines needed. None of the youth IHCRs contained religious exemptions or refusals
of parental consent for immunizations. Nursing staff was interviewed and stated youth's
parent/guardian are notified for medication changes, off-site treatments, emergency treatments
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and any new orders. The psychiatrist obtains consent for any new medications, dosage
changes, or discontinued medications and it is witnessed by the nurse. Written consent is also
sent to the parent/guardian with a copy of page three of the Department’s Clinical Psychotropic
Progress Notes (CPPN) form. Nine youth records were reviewed and all nine immunization
records were reviewed by nursing staff within thirty days of admission.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screenings and
re-screenings each time the physical custody of the youth changes. Nine youth Individual
Healthcare Records (IHCR) were reviewed for healthcare admission screenings requirements.
All nine youth received a medical and mental health admission screening completed on the
Department’s Facility Entry Physical Health Screening (FEPHS) form on the date of admission
by a registered nurse (RN) or licensed practical nurse (LPN). One of the reviewed youths
changed physical custody since admission to the program and was rescreened on the date of
readmission to the program utilizing the FEPHS. The nurse was interviewed regarding
healthcare admission screenings and re-screenings and stated the youth are seen by medical
staff within twenty-four hours of admission to the program. At a minimum, vital signs are taken,
the youth is questioned concerning medical needs, chronic conditions, medications, and
medical complaints, and a FEPHS is completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring healthcare service orientation is provided to
all youth when admitted to the program. Nine youth Individual Healthcare Records (IHCRs)
were reviewed, confirming all youth received a general care orientation upon admission. A
review of the Health Education forms, signed by all nine youth and filed in each IHCR,
confirmed orientation discussion included access to medical care, sick call procedures, what
constitutes an emergency and when to notify staff, medication process, right to refuse care and
how it is documented, what to do in the case of a sexual assault or attempted sexual assault,
the non-disciplinary role of the healthcare providers, and Standard Universal Precautions. The
program provides the contractual frequency of health education monthly
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Nine youth
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Individual Healthcare Records (IHCRs) were reviewed, Fourof the youth were admitted with a
known or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency care upon admission. All records documented the DHA
notification in each youth’s Chronological Progress Notes, and the Chronic Conditions Log was
updated after the notification for the applicable youth. Two reviewed youths were taking
psychotropic medication upon admission, and notification to the psychiatrist was documented.
The nursing staff was interviewed and stated both the DHA and psychiatrist is notified within
twelve hours of every youth's admission to the program regardless of the youth's medical or
mental health status.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed for all youth admitted into a department program. A review of nine
youth Individual Healthcare Records (IHCRs) found each HRH was completed on the day of the
admission. All nine IHCRs indicated the HRH form was completed prior to the Comprehensive
Physical Assessment (CPA) which included date and signatures. In all IHCRs, the designated
health authority (DHA) reviewed the HRH form as evidenced by a checkbox on the CPA and a
focused note in the admission documentation. Nursing staff was interviewed and stated they are
responsible for completing the HRH upon youth admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring a Comprehensive Physical Assessment
(CPA) is completed for all youth admitted into the physical custody of a department program
within seven days of youth’s admission. A review of nine Individual Healthcare Records (IHCRs)
confirmed the program utilized the Department’s CPA form. All CPAs were completed by the
designated health authority (DHA) within seven days of each youth’s admission to the program.
All nine had the youth’s Medical Grades documented on the CPA. The program completed a
new CPA for all youths, no prior CPAs were utilized. All sections of the CPA were completed in
full utilizing “O” or “X” markings. All nine youth refused the genital exam which was documented
as “youth refused” on each CPA in the IHCRs., All nine youth signed a refusal form which
reflected the refused portion on the CPA. The CPA in all nine records included documentation of
the most recent verified Tuberculosis Skin Test (TST), which was administered within the last
year to determine exposure to tuberculosis (TB). The results of the TST were documented on
each youth’s CPA and matched the documentation on the Department’s Infectious and
Communicable Diseases (ICD) forms. The Department’s Problem List was updated for each
youth, when applicable. Nursing staff was interviewed and stated the DHA completes the CPA
within seven days of a youth's admission to the program and annually if needed. A TB
screening is completed within seventy-two hours of a youth's admission to the program.
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4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). A review of nine Individual Healthcare Records (IHCRs)
found all youth were clinically screened and evaluated for STIs on the date of admission. None
of the youth required further evaluation. All testing, screening, clinical evaluations, and
diagnoses were documented on the Department’s Infectious and Communicable Diseases
(ICD) forms and were filed in the lab section of the IHCR. Oneof the youth was out of the
Department’s physical custody; and a rescreening was required and completed.All nine youth
were offered counseling and testing and if indicated,t reatment/referral for HIV as evidenced by
documentation in all nine youth records. Twoyouth consented to receive a HIV test and
documented consents were executed. Both youthswere offered pre/post-test counseling,
testing, and referral for treatment for HIV and the pre/post-test counseling was documented on
each youth’s Individual Health Education Records. The HIV results were filed confidentially in a
sealed envelope marked “Confidential.” Both of the envelopes were signed by the designated
health authority (DHA) indicating their review. The youth’s confidentiality was protected by not
including the youth’s HIV status on the program’s internal alert system. The program’s policy
ensures the youth’s HIV test results are only disclosed to the youth’s legally authorized
representative, healthcare providers during treatment, the Department of Health for purposes of
reporting, health facility staff committees conducting facility monitoring, medical personnel who
have been subject to significant exposure, and healthcare facility personnel or agents for
healthcare provider who have a need to know during patient care. A licensed registered nurse
(RN) provides pre and post-test counseling services under the direction of the medical doctor.
Nine youth were interviewed and all nine advised they can request HIV testing. Nursing staff
was interviewed and stated youth are screened at intake for STIs and offered HIV testing. Upon
confirmation of positive testing results, the DHA is contacted, and medical orders are given.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. None of
the youth presented with a similar sick call complaint three or more times within a two-week
period. Two of nine youth had a sick call request. One additional record was requested and
provided to review. All three sick call requests were completed by the applicable youth. All three
reviewed sick call requests were addressed and completed by the licensed practical nurse
(LPN) and reviewed by the registered nurse (RN) as required. Each of the Sick Call Request
forms were filed in each youth’s Individual Healthcare Record (IHCR) in reverse chronological
order. None of the youth were in restricted housing of any kind. The Sick Call Request forms
and progress notes were documented in accordance with Health Services Rule, including vital
signs, treatment, education, and follow-up plans. Each of the sick call events was documented
on the Sick Call Index and on the program’s Sick Call Referral Log. All the dates listed on the
Sick Call Index corresponded to the completed Sick Call Request forms located in each of the
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nine youth IHCRs. Sick call occurs seven days a week, twice a day pursuant to contract
requirementsSick call hours are posted on the medical office door and in the dorms. A licensed
nurse conducts sick call and when the licensed nurse is not on-site, the program has
procedures whereby the shift supervisor reviews all sick call requests within established time
frames. Sick call forms are located on each dorm and in the cafeteria. An exam table and
equipment are used to perform sick call. Sick call was not observed during the annual
compliance review as none occurred. Nine youth were interviewed, and six youth stated upon
submission of a sick call request, they were seen by medical staff within a day, and the
remaining three youth had never submitted a sick call request. Nursing staff was interviewed
and stated sick call requests are collected twice daily, and youth are seen within twenty-four
hours of submission. All sick call forms are submitted by the youth and completed by the nurse
prior to filing in the IHCR.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure the youth have access to episodic and first-
aid care. A review of nine youth Individual Healthcare Records (IHCRs) found three youth
required on-site episodic care. In all three applicable IHCRs, the on-site care provided by a
licensed healthcare staff was documented in the problem-oriented, subjective, objective,
assessment, and plan (SOAP) elements. First aid kits are located in the barn, in each dorm, and
three in master control for transports. The program has a process for ensuring contents of the
first-aid kits are maintained and stored in accordance with guidelines to prevent expiration and
maintain the viability of each kit’s contents. An observation of three first-aid kits confirmed the
kits were fully stocked with designated health authority (DHA) approved contents. The nurse
monitors the first-aid kits monthly and checks for expired contents, which is documented on the
first-aid kits logs. The program has three automated external defibrillators (AED) located in
medical, master control and Nike dorm. The AED procedures are located with the AEDs. The
AED batteries and pads are checked by the registered nurse (RN) once a month.
Documentation confirmed the RN monitored the AEDs as required. The RN checked the
expiration dates of the AED in the presence of the Monitoring and Quality Improvement regional
monitor. The nurse conducted a self-test of the AED in front of the regional monitor, and no
issues were noted. The batteries of the AED were last changed in September 2023 and expire
in December 2030. The AED pads were changed August 2023 and expire in November 2028.
The program had a list of emergency numbers which were inaccessible to youth. The
emergency numbers are posted in master control, medical, and administration,,which are
accessible to both licensed and non-licensed program staff A review of nine training records
confirmed all staff were trained in episodic, first-aid, and emergency care, and the administration
of the epinephrine auto-injector. A review of the emergency drills confirmed the program
conducted an emergency drill to include cardiopulmonary resuscitation (CPR)/AED annually. A
video review confirmed that drills are simulated. A review of drill documentation demonstrated
that emergency medical drills were both announced and unannounced, conducted at a
minimum of quarterly on each shift and direct care staff participated in at least one drill annually
involving CPR. The completed emergency medical drills included scenarios simulating an
episodic care event which called for immediate first-aid and/or administration of CPR
techniques, and the initiation of emergency procedures to follow when a life-threatening
emergency does occur. An episodic care event was not observed while on-site as one did not
occur during the annual compliance review week. The program has a policy and procedures
regarding the use, access, and inventory of Narcan. The policy states all newly employed staff
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and admitted youth shall receive education on recognizing and treating symptoms of opioid
overdose. Training will include risk factors for overdose, strategies to prevent overdose deaths,
overdose recognition and response, and administration of Narcan. The training and prevention
plan also includes emergency response procedures. Narcan is stored in the medical cart and
inventory cabinets, and inventoried along with other medication weekly and perpetually.
Supervisors are trained on the use of Narcan. Nine staff were interviewed and all nine stated
they would either contact a supervisor or master control to call 9-1-1. Nine youth were
interviewed, and all confirmed they can see a doctor when needed. The nursing staff was
interviewed and stated the program has three AEDs which are co-located with first-aid kits in the
facility. Nursing staff perform monthly checks of the AED and the kits, which are documented in
a logbook.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure the processing of timely referrals and the
coordination of medical services to an off-site healthcare provider. A review of nine Individual
Healthcare Records (IHCRs) found five were applicable for off-site care. In all applicable IHCRs,
there was an indication the youth required off-site care. The Department’s Summary of Off-Site
Care Consultation Report form was utilized and filed in all five youth’s IHCRs and noted in the
Episodic Care Log Four IHCRs had documentation of the parent/guardian notification efforts,
one youth was in the custody of the Department of Children and Families (DCF), who was
notified. Five youth were applicable for discharge documentation and each had the applicable
documents filed in the IHCR. The designated health authority (DHA) reviewed and signed all off-
site care findings, instructions, and information in each of the five applicable IHCRs. One of the
youth required follow-up testing, referrals, or appointments. The IHCRs had documentation the
referrals were tracked, and the youth received appropriate and timely follow-up care. Nursing
staff were interviewed and stated off-site appointments are tracked through a scheduling book
and all documentation is reviewed by the nursing staff and the DHA as evidenced by signature
and date.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and any necessary follow-up
care. A review of nine youth Individual Healthcare Records (IHCRs) found three were identified
on the Department’s Facility Entry Physical Health Screening (FEPHS) form with a current
chronic condition at admission. None of the youth were identified as having a communicable
disease. One of the three applicable youth was taking prescribed medication on an on-going
basis. Two of the applicable youth were undergoing treatment for a physical health condition. All
three youth were classified with a Medical Grade of two to four and were placed on the
program’s Chronic Illness List. One youth was applicable to receive periodic evaluations at least
every ninety days and received the required periodic evaluation. The other two applicable youth
had not been at the program for ninety days at the time of the annual compliance review. None
of the youth were applicable for taking anti-tuberculosis medications. One applicable youth did
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receive a timely periodic evaluation prior to the renewal of prescription medication expiration.
None of the three youth required an off-site evaluation or off-site care. There was no evidence
of any lapses in care or missed periodic evaluations. The Department’s Problem List was
updated for each youth. The facility administrator was interviewed and stated formalized
procedures are in place for healthcare staff to review important youth medical issues during the
daily management meetings with the leadership team. The designated health authority (DHA)
was interviewed and stated a youth with a chronic condition will be seen at a minimum of every
ninety days and a medical tracker is utilized to ensure all applicable youth are seen. Nursing
staff were interviewed and stated a medical tracker is utilized to ensure youth with chronic
conditions are seen at a minimum of every ninety days by the DHA.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure the accurate and safe administration of
youth medications. A review of nine youth Facility Entry Physical Health Screening (FEPHS)
forms found two youth were taking medication at the time of admission. Both youth medications
were verified prior to the youth being admitted into the program, and the prescription notification
was documented in each youth’s Chronological Progress Notes. The designated health
authority (DHA) and, when applicable, the psychiatrist was contacted to obtain an order to
resume the specified medications prescribed prior to admission for each youth. One youth was
not admitted with medication; however, was placed on medication while at the program. Each of
the three reviewed youth Individual Healthcare Records (IHCRs) documented the youth
received medication while in the program and all medications were continued, discontinued,
changed, or new medications ordered utilizing the Practitioner Order form. Each medication had
a current and valid prescription or order. None of the youth were in restricted housing of any
kind. Three of nine youth were applicable for over –the counter (OTC) medications which were
administered according to approved protocols. The Department Medication Administration
Record (MAR) was used to document all medications and treatments for all reviewed IHCRs.
The MAR clearly indicated medication start and stop dates of all youth’s medications. In all three
applicable IHCRs, the staff and youth initialed each administered medication entry. There were
no undocumented explanations for lapses or errors in medication administration for any of the
reviewed IHCRs. The registered nurse (RN) documented side-effects monitoring weekly on
each MAR for the three applicable youth IHCRs. There were no medications administered by
non-healthcare staff. One youth had a refusal, which was clearly documented on the MAR and a
refusal form was completed. The MARs contained all the required elements. None of the nine
youth were applicable for parenteral medication. One of the nine youth was admitted to the
program on psychotropic medication and the psychiatrist was notified as evidenced by
documentation in the youth’s IHCR. The youth received a psychiatric interview within fourteen
days. One youth was applicable for psychotropic medication subsequent to admission. Upon
review of the three applicable youth IHCRs, two youth received medication monitoring/review
every thirty days as required and the third youth had not been at the program for ninety days at
the time of the annual compliance review. There were no standing orders for psychotropic
medications, emergency treatment orders for psychotropic medication, or any pro-re-nata (PRN)
orders for psychotropic medications. A medication pass was observed. The youth were escorted
by the direct care staff and approached the nurse individually. The nurse identified themself and
confirmed the reason the youth was present. The nurse prepared the medication and verified
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the youth’s allergies and alert status. No medications were pre-poured but removed from
original packaging and placed in another container for subsequent administration.The nurse and
youth initialed the MAR, and the nurse observed to ensure the medication was swallowed by
conducting a mouth check. The Six Rights of Medication Delivery/Administration were
maintained for each youth. Nine youth were interviewed and only one youth was currently taking
medication. The youth stated medication is dispensed by the nurse and could explain the
medication pass process. Nursing staff was interviewed and stated non-healthcare staff are
trained by nursing staff to dispense medications if needed. A list of trained staff is kept on the
medication cart and training is conducted annually.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as sharps
and medications are secure and inventoried utilizing a routine perpetual inventory. The program
has a procedure for reporting medication discrpencies, which includes medication recounts,
administrative notifications and notification to the Central Communication Center (CCC).
Reviewed medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory with descending count. Reviewed medications
were identified and secured in a locked, clean, and organized medication cart designated for
storage of medication, located in a secured area inaccessible to youth, with narcotics and other
controlled medications being stored behind two locks, and refrigerated medication being stored
in a secured refrigerator only used for medication. The program’s process for the destruction
and disposal of non-controlled medications is for two nurses to destroy all medication using the
chemical drug buster. Controlled medication is destroyed when the pharmacist consultant is on-
site with one registered nurse (RN). Discontinued medications which are not expired, are sent
back to the pharmacy. A review of the program’s perpetual and weekly inventory of all sharps
and stock over –the counter (OTC) medications verified completion as required with no
discrepancies. Reviewed documentation verified the nursing staff maintain a shift-to-shift
inventory of all controlled substances which is documented by each youth’s Individualized
Controlled Medication Inventory Record. Nursing staff are on-site twenty-four hours a day to
provide oversight and the delivery of medication, as such, non-healthcare staff are not trained in
the delivery and oversight of medication self-administration. Observations were conducted of
inventory counts of three controlled medications, three OTC medications, and three sharps with
no discrepancies found. The nursing staff was interviewed and confirmed controlled medication
are located behind double locks in the medical office and are destroyed as witnessed by the
pharmacist consultant and one nursing staff. The health services administrator (HSA) reported if
there is a discrepancy in the count, the nursing staff will inform the HSA and facility
administrator (FA) immediately and conduct a recount and inventory to determine where the
discrepancy originated. Once confirmed, a call to the Department’s Central Communications
Center (CCC) will be placed.
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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 has a policy and procedures related to an Infection Control and Exposure Control
Plan. The Infection Control and Exposure Control Plan is signed annually and was reviewed and
signed by the designated health authority (DHA) on November 22, 2024, facility administrator
(FA) on November 22, 2024, and provider’s corporate designee on November 22, 2024. The
policy and procedures are written in accordance to the Occupational Safety and Health
Administration (OSHA) and Center for Disease Control and Prevention guidelines. The
program’s infection control procedures include common infectious diseases of childhood, self-
limiting, episodic contagious illnesses, viral and bacterial infectious diseases, tuberculosis,
Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases caused by
blood-borne pathogens, other outbreaks or epidemics caused by any other infectious agent,
outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other
antibiotic resistant micro-organisms, food-borne illnesses, bio-terrorist agents, and chemical
exposures. The program offers Hepatitis B immunizations to staff as well as access to personal
protective equipment. The program has a comprehensive process for needle stick post-
exposure evaluation. If necessary, the program would have a separate file containing all
documents of youth and staff who have experienced a program or occupational exposure;
however, there has not been any incidents of reportable infectious disease by either staff or
youth. The interviewed FA confirmed the plan is located in medical and master control, with the
staff completing a bi-annual review of the plan. Nursing staff was interviewed and stated they
provide infection/exposure control training and education to both staff and youth.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This in an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures stating how the program shall maintain active
supervision of youth at all times. Active supervision is described as interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of youth
and changes in behavior, and consistently applying the behavior management system.
Additionally, program staff shall be able to account for the whereabouts of youth under their
supervision at all times. Observations of staff during the annual compliance review week found
staff supervising youth appropriately during all activities. Three staff were asked the number of
youths under their supervision, all three staff were able to accurately provide the number of
youth they were currently supervising. According to the policy and procedures provided during
the annual compliance review week, staff-to-youth ratios are one staff to eight youth during
awake hours, one staff to twelve youth during sleep hours, and one staff to five youth for off-site
activities. Observations made during the annual compliance review week included supervision
of youth during school hours, in the dining area, recreation, and youth movement through the
program. The daily schedules were posted in the dormitories, common areas, and cafeteria, and
was adhered to. Youth were observed to be supervised at all times during the annual
compliance review week, and positive interactions were observed between youth and staff.
Observations of the youth’s rooms confirmed there were no window coverings which would
affect direct line of sight of the youth. A review of video observations showed staff conducting
checks on the youth every eight minutes while in their sleeping rooms.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the implementation and training of the
program’s behavioral management system (BMS), which has not changed since the last
annual compliance review and contains all the required elements. The program utilizes the
iChoose System BMS which is a coordinated system of promoting, monitoring, recognizing, and
rewarding a youth’s progress. It is a program of incentives and consequences which promote
individualized skill building, appropriate behavior, and accountability. Staff use point cards to
monitor how well the youth are progressing in the program. Youth earn points daily for
complying with the program rules. At the end of each day, the points are totaled, and the youth
receive rewards based on the number of points earned. Each youth enters the program on an
orientation level prior to starting the BMS and progresses their way up the four levels. A review
of the BMS confirmed it is not used solely to increase a youth’s length of stay, deny basic rights
or services, promote the use of group punishment, allow youth to punish other youth, or include
disciplinary confinement. Youth learn about the BMS during the orientation process, and each
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youth was provided a program handbook, which describes the BMS. A review of the youth
handbook indicated the BMS is included and clearly written, A review of eighteen e staff training
records indicated staff were trained on the BMS. Education staff are Florida Virtual School
(FLVS) employees, and each educator received BMS training by the staff development
manager; however, the education staff is not responsible for the implementation of BMS, the
program staff remains responsible for the implementation of BMS throughout the school day. A
review of nine youth case management records indicated each youth participated in orientation
upon arrival to the program and received a copy of the youth handbook. Observations found the
BMS was posted throughout the program. Observations of staff and youth interactions verified
staff were adhering to the BMS by utilizing a ratio of four-to-one positive to negative
consequences when redirecting the youth as indicated in the program’s policy. A review of the
program’s BMS indicated a variety of rewards/incentives: staff versus youth kickball games,
candy, snacks, youth night outings, pizza, mega Monday, and fantastic Friday. Special
provisions were outlined in the program’s contract, assuring ongoing supportive services for the
youth who may experience relapse, incorporate principles and practices related to trauma
informed care, and will ensure positive reinforcement is implemented, and found to be adhered
to. Nine staff were interviewed, and all nine reported they were trained in the BMS, which
consists of a point system to include different levels with rewards and consequences. The
interviewed staff stated the BMS includes rewarding youth with daily and weekly incentives
including reward parties, extra snacks, hygiene, ice cream, off-site activities, and canteen. Each
of the nine interviewed staff stated nothing can be taken away from a youth as a consequence,
youth are informed of the consequences of their behavior at the time of the incident and are
able to explain their behavior. The nine interviewed staff reported the supervisors inform staff on
how the BMS should be utilized and provide feedback during shift briefings, at meetings, and
one-on-one if corrections are needed. Nine youth were interviewed, and each youth stated the
consequences included emergency treatment team, level freezes, privilege restriction, and early
bedtime. Nine youth reported they receive daily and/or weekly incentives such as special meals,
snacks, and canteen. Each youth was familiar with the program’s BMS level system stating
upon entering into the program they start as a Rookie then move up ranks upon completion of a
packet with each level to Pro, All-Star, and Hall of Fame. All nine youth reported staff use
rewards the same. An interview with the facility administrator (FA) confirmed the program
utilizes the iChoose System BMS and reiterated the program’s BMS policy. All nine interviewed
youth reported youth are not allowed to punish other youth.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
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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 policy and procedures in place to conduct and document eight-minute
checks during sleep hours or at other times, such as during an illness. The program has a total
of 125 video cameras capable of recording thirty-days of video footage. During the annual
compliance review week all 125 cameras were operational. Prior to conducting checks, staff are
positioned where they are able to see any movement within the living unit. Staff are required to
conduct room checks every eight-minutes and document the time of the check on the Eight-
Minute Check Log when youth are sleeping. The program’s practice is to complete checks at
eight-minute intervals, master control initiates the checks using radio communication, so all
dormitories are completed at the same time. Nine video reviews of ten-minute checks, including
samples from each of the living units, verified staff were conducting checks every eight minutes
and documented the times accurately on the Eight-Minute Check Log. In addition, the Ten-
Minute Check Logs since the last annual compliance review were reviewed. Thirty-one days,
times, and shifts indicated the ten-minute checks were completed within the required
frequencies. Nine interviewed staff verified room checks are conducted every eight minutes
when youth are placed in their rooms for sleeping or non-punishment reasons. In a formal
interview, the facility administrator (FA) stated the program has 125 cameras with video
recording capabilities for thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures to ensure youth are always accounted for
through a system of physically counting youth at various times throughout each day. The
program conducts formal head counts each hour and after outdoor activities. The program’s
policy indicates counts are conducted during power outages, escapes, program disturbances, or
any other disruptions which may occur. A review of the policy and procedures and well as the
Continuity of Operations Plan (COOP) verified program staff must always account for the
whereabouts of the youth in the care and custody of the program. This includes the need for
continual head counts to be conducted minimally at the beginning of each shift, during any
emergency situations, and at regular intervals. A review of twelve randomly selected dates and
times in the program’s logbook since the last annual compliance review validated head counts
were conducted at the beginning of each shift, hourly, after outdoor activities, during emergency
situations such as program disturbances, and during actual and/or simulated drills. In addition,
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the program logbooks included documentation of new admissions, releases, transfers, and
youth temporarily away from the program. Observations made during the annual compliance
review week indicated it is the program’s practice to conduct hourly youth counts and to
announce youth counts before all movement. Nine interviewed staff explained formal counts are
conducted every hour, and informal counts are conducted with every youth movement. Each
staff stated emergency counts are conducted when youth is missing, after emergency drills, and
if there is a discrepancy in the 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 has a policy and procedures to ensure the maintenance of chronological
record of events, incidents, and activities in a central logbook. The program maintains a bound
logbook with numbered pages for each month. A review of logbook entries confirmed they were
bound and contained a front and back cover, all entries were documented in ink with no
erasures or white-out areas. Errors were struck through with a single line, dated, and initialed by
the staff correcting the error. Reviewed documentation of randomly selected days within the
logbooks reflected each entry included the date and time of the event, the name of the staff and
youth involved, as well as a brief description, the name, and signature of the staff making the
entry. Logbooks included entries for emergency situations, population counts, law enforcement
access to youth, perimeter checks, and youth movement. In addition, admissions and releases
were documented, as well as transports away from the program. There were no precautionary
observations during the annual compliance review period to review. A review of the activity
schedule and logbook documentation verified there was minimal interference of education
instruction. Logbook entries for education included youth movement to and from the classrooms
and school start and end times. Logbook entries and observations verified recreation was
conducted as scheduled. A review of internal incidents reported to the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC) verified each were documented
in the logbook. The program ensures direct care staff, including each supervisor, are briefed
when coming on duty. Each staff signs the shift briefing section of the logbook to acknowledge
receiving the information. Observation of the youth living areas confirmed a copy of shift reports
were maintained in each living area for forty-eight hours.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures for assignment, inventory, tracking, and storage of
program keys. Keys are bound on a tamper resistant ring which includes a brass-colored tag
with the number of keys and a tracking number. The facility administrator (FA) is responsible for
inventory and tracking of all program keys including issuance, verification activities, and tracking
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of keys, as well as retrieval of keys from permanent staff. Shift supervisors with the assistance
of the master control operator are responsible for the inventory, issuance, and return of keys
from shift to shift. Observations verified program keys and staff personal keys are maintained in
master control in a secured cabinet with a lock. The program has a Daily Key Log to track keys.
The log indicates the name of staff and what type of key they are to be assigned according to
their position. The program maintains a master inventory list of program keys. A random check
of five different sets of program keys compared to the inventory list indicated the keys were
accounted for. The program identifies keys as active and restricted which are kept in a locked
drawer below the key cabinet in master control. Active keys are assigned to direct care staff
while restricted keys are designated for medical staff, kitchen staff, case managers, and
therapists. The program’s practice is when staff arrive at the program, personal keys are
collected by master control and placed in the key cabinet. Active program keys are given to staff
by master control who documents the provision in the key logbook. A review of the key logs
since the last annual compliance review verified this practice. In addition, the program has a list
of staff who are assigned permanent keys. Permanent keys are issued, and staff sign an
acknowledgment form indicating the key identification number and the number of keys issued. A
review of the signed acknowledgment forms indicated each staff signed for the use of
permanent keys. A random check of three staff indicated they had program keys, knew the
number of keys on the key ring, and knew the function of each key. If a key becomes damaged,
a Broken Key Report is filled out which includes the date, reporting staff, key hook number, key
number, description, and attach the broken key with tape. The shift supervisor and key control
manager sign the form and the key is replaced. A review of the Department’s Central
Communications Center (CCC) reports since the last annual compliance review indicated there
was zero reports made to the CCC for missing keys. An informal interview was conducted with
the assistant facility administrator (AFA) who reported staff keys are given to master control
upon entry into the facility, those personal keys are securely stored, and program keys are
assigned to the staff. Visitor keys are given to master control upon entry into the facility and are
given a “numbered chit” to return upon their departure, the visitors keys are placed on the
corresponding numbered hook. Observations indicated there is a daily tracking key log, and
inventory of keys. An informal interview with the program’s AFA was conducted, he stated staff
are to notify master control of missing or lost keys and when keys are damaged. Master control
notifies the facility administrator (FA), then the program’s physical plant manager (maintenance
supervisor) has the damaged/broken key replaced by a vendor. Nine interviewed staff were able
to explain the process in which personal keys and program keys are administered and tracked.
They provide master control with their personal keys upon entering the facility, the keys are kept
in a secure cabinet, and it is documented in a logbook when facility keys are provided to them.
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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 to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when youth in
the program are found
in the possession of contraband. The program has a system in place to prevent contraband
entering the facility which includes defining items/material considered contraband, as well as
exemptions, providing youth with a list of contraband, informing youth of consequences if found
with contraband, and searching the physical plant, program grounds, youth, and incoming and
outgoing mail. The facility visitor log and all nine sampled staff personnel records contained a
signed contraband attestation statement. All thirty-four new hire staff records contained the
contraband attestation statement. The attestation statement addresses any staff who is found in
possession of contraband in a program will be subject to disciplinary action up to and including
dismissal as outlined in Florida Administrative Code. The policy also states law enforcement will
be contacted if any found item is considered illegal as defined in Florida Statutes, or if there is
evidence of any type of unlawful activity. The program clearly delineates those items considered
contraband and keeps a contraband log documenting the focus of the search, items found, and
the disposition of any items found. A review of the Department’s Central Communications
Center (CCC) reports since the last annual compliance review indicated there were no incidents
reported regarding contraband. The program logbooks, search and contraband logs, and
incident reports were reviewed to determine frequency and quality of searches and the results
of each search, and each was found to be in compliance with policy. A formal interview with the
facility administrator (FA) confirmed the program’s policy and procedures on how contraband is
handled and disposed of is at the discretion of the FA. Contraband, which is not illegal shall be
discarded, returned to their original owner, mailed to the youth’s home, or stored and returned
upon release. The FA confirmed in all cases involving the confiscation of contraband, which is
illegal, the confiscated item(s) shall be turned over to law enforcement authorities, and a
criminal report is filed. Video observation was conducted on six random days in the last thirty
days. All observations showed the staff and visitors were pat searched by staff of the same
gender. A wand device designed to detect metal objects was used on all staff and visitors, and
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all bags, cups and shoes were searched. Nine staff interviews were conducted and all nine staff
stated youth room searches are conducted daily, and random searches occur one time a week.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to ensure searches, including full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-site activities, and visitation. Parents/guardians are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched after school, group, outdoor recreation, and meals. Youth who
are a new admission, readmission, returning from visitation, returning from off-site activities
and/or appointments, suspected of contraband, or are a security risk are full body searched.
Observations made throughout the annual compliance review week validated youth are
provided instructions regarding the search, youth searches were conducted by staff of the
samegender as the youth, were conducted in a manner so as not to degrade the youth, and
were
based on the Protective Action Response (PAR)/Right Interactions (RI) training manuals.
Searches observed during the annual compliance review week verified youth were searched
after every movement. Youth searches were observed upon returning from a transport and upon
intake. All observed searches were completed thoroughly and respectfully. Youth appeared to
be comfortable and accustomed to the process. Video observation was completed of staff and
visitor searches. All videos review confirmed staff and visitors are being pat searched, an
electronic wand device is used and all bags were searched. Nine staff were interviewed. All nine
of the staff stated youth are searched at every movement and returning from any transport. Nine
interviewed youth confirmed they are searched upon every movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures for transportation, operation, and maintenance of
each vehicle used to transport youth. The center has a total of three vehicles of which two are
used to transport youth. Each vehicle had an annual safety inspection conducted by a certified
automobile mechanic. Observations of the three program vehicles were conducted. Each
reviewed vehicle was locked when not in use, have the appropriate number of seatbelts, a
safety screen, a seatbelt cutter, a window punch, up-to-date fire extinguishers, and an assigned
first-aid kit with approved items by the designated health authority (DHA) which is checked out
by staff prior to departure with youth and returned to medical upon the completion of transport.
Weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventative maintenance check sheets. The two observed vehicles had
working seatbelts, and the passenger doors could not be opened from the inside. A random
check of five staff personal vehicles, found all the vehicles were locked and secured when not in
use.
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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 has a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. Reviewed documentation
verified all approved drivers had a valid driver’s license and human resources conducts a
monthly driver’s license check on all staff to ensure all staff operating a program vehicle have a
current license. The program assigns a ratio of one staff to five youth during transport, not
including the driver. An observation of a transport was conducted. there were two staff with two
youth. Logbook entries with names of staff transporting youth reflected at least one staff of the
same gender as the youth is on each transport. Nine staff were interviewed, each staff
confirmed they are not allowed to use personal vehicles to transport youth, confirmed they are
provided with a cellular telephone and two-way radio for communication during transport, and
youth are secured with shackles. Nine staff stated youth are secured in the vehicles with
seatbelts and shackles during transport, they also confirmed emergency equipment in the
transport vehicle included a first-aid kit. Nine interviewed staff confirmed the vehicle is searched
prior to and after each use for contraband. Nine interviewed staff stated in the event of an
emergency during transport, they are to pull over, contact the program, call 9-1-1, and assist the
youth if there are any injuries or illnesses. All nine staff were able to list emergency equipment
in the vehicle to include seatbelt cutter, window punch, knife-for-life, wheel lock and cones. Nine
interviewed youth stated they had never witnessed anyone placing contraband into the vehicles
and have never been handcuffed to any part of the vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures to ensure safety and security is maintained.
The policy addressed who is responsible for conducting the audits, procedures to implement
corrective actions for deficiencies, and an internal system to verify deficiencies are corrected.
Weekly safety and security audits are conducted by the facility administrator (FA) and physical
plant manager (maintenance) or designee and documented on the Safety and Security Audit
Inspection form. Any deficiencies are addressed on the form, and a work order is submitted to
the appropriate staff for corrections. In addition, deficiencies are discussed during the morning
management meeting. The weekly audit forms are reviewed by the FA. A review of the safety
and security inspection forms since the last annual compliance review indicated inspections
were completed, as required. The program’s Preventive Maintenance Checklist was reviewed to
ensure maintenance schedules and repairs were conducted as required. In a formal interview,
the assistant facility administrator (AFA) stated weekly safety and security inspections, and daily
perimeter checks are conducted, and any deficiencies identified are discussed amongst the
management team and addressed, as necessary. A review of deficiencies in the Department’s
Juvenile Justice Information System (JJIS) related to safety and security since the last annual
compliance review found there had been zero deficiencies. A formal interview with the FA
confirmed all deficiencies identified are reviewed with staff along with corrective action plans to
address the issue.
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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 to have a tool management system which
ensure youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. A review of inventory
logs and observations verified tools are securely stored when not in use, easily marked for
identification, inventoried prior to, and following work activities. All sharp edged and pointed
tools are inventoried daily when in use. A review of ten unique tools in the maintenance area
verified the inventory matched the inventory list. The maintenance staff are responsible for
conducting the inventories and securely maintaining all Class A tools and equipment. The
maintenance staff complete a tool inventory list which documents each tool in inventory. All
maintenance tools were inaccessible to youth and were observed to be secured in the
maintenance area. Observations of the tool storage area found it was organized and secure.
Class B tools including mops, brooms, and buckets are maintained in locked closets by each
dormitory and in a locked closet in the kitchen area. The items are used by staff and youth when
performing daily cleanup activities. Staff are required to complete a sign-out and sign-in log
when items are taken and are returned to the designated storage room. Reviewed
documentation verified there were no instances of missing or lost tools since the last annual
compliance review. Prohibited tools at the program include machetes, bowie knives, and other
long bladed knives. According to the program policy, if a tool is broken or inoperable, the
maintenance staff is alerted and makes a notation on the inventory log. The maintenance
manager is responsible for replacing the broken tool. If a tool is missing, staff shall notify
administration, fill out an incident report, document the incident in the logbook, place a tag on
the shadow board, call the Department’s Central Communications Center (CCC), and the
program shall be searched until the tool is found.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. A review of the program’s procedures verified staff
are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. A risk assessment is completed by the case
manager prior to youth using any tools. The program’s staff-to-youth ratio during a work project
is no less than one staff to five youth. Program staff search youth after a work detail has been
completed. Nine youth records were reviewed, all youth had risk assessments completed to use
class B tools. No youth were observed utilizing class B tools during the annual compliance
week. Nine youth were interviewed, all nine reported they use mops and brooms only. Nine staff
interviewed all stated the youth are allowed to use brooms, mops, and scrub brushes.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. The program's policy stipulates the facility administrator (FA)
is responsible for providing approval and permissions if a personal cellular telephone and/or
equipment/electronic devices capable of taking pictures and/or audio or video records, including
smart watches, are required. The program’s procedures specify tools are restricted to only the
tools needed for the job, tools are checked upon arrival and departure, and youth are restricted
from the work area. When a contractor arrives on-site, they sign the Outside Contractor On-Site
Work Project Log which includes the vendor’s name, date and time in, a list of tools needed for
the job, the beginning quantity of tools and ending quantity of tools, staff name checking the
tools, and date and time out. The form states the vendor must report any lost tools to
administration immediately. A review of vendor sign-in sheets since the last annual compliance
review confirmed tools and other equipment were inventoried when the vendor arrived and
inventoried when they left. Three reviewed project invoices showed the date of the project
matched the vendor sign-in sheets. Outside vendors are accompanied by staff to the work area
and youth access is restricted from the work area. Staff must supervise vendors in the work
area where youth are located. No observations of outside contractors were conducted, due to
no outside contractors presence at facility during the annual compliance week.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes, and the frequency of conducting drills at random times and under varied
conditions. Reviewed documentation validated emergency drills were conducted for all shifts
each month, as required. In addition, the program conducted emergency drills on each shift
ensuring fire, riot, severe weather, flooding, terrorist threats, chemical spills, medical situations,
and bomb threats were covered on a rotating basis. Drill documentation included the type of
drill, date and time, participants, a brief scenario description, deficiencies identified during the
drill, and applicable corrective actions. Observations of the program during the annual
compliance review week indicated there were thirty-eight annually inspected fire extinguishers
and egress plans are posted throughout the program. Annual inspections on the fire
extinguishers were completed in March 2025. Nine staff were interviewed, all stated they had
participated in a fire drill in the last twelve months, along with various other COOP drills. Nine
youth were interviewed and stated fire and emergency drills are conducted and each youth had
stated they have participated in drills. An interview with the facility administrator (FA) indicated
the program maintains a drill calendar which includes drills for fire prevention, Right Interaction,
medical, suicide, escapes, bomb threats, contraband, COOP, hostage, weather related
incidents, terrorist threats, and disturbances. Drills are conducted randomly on each shift and
monthly in accordance with the program’s contract.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a department approved Continuity of Operations Plan (COOP) available
for all staff to review. The COOP plan was submitted on March 10th, 2025, and approved by the
Department on March 13th, 2025. The COOP provides for basic care and custody of youth in the
event of an emergency or disaster. The COOP also addresses phases of a disaster plan as well
as emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire prevention, bomb threats, evacuations, chemical spills,
severe weather, and terrorist attacks. A review of the plan indicated alternative housing has
been identified should the program require an evacuation due to an emergency or disaster. The
program also has provisions of equipment and supplies maintained in the kitchen, the
maintenance building, and the assistant facility administrator’s (AFA) office to ensure a
continuous operation of services during emergency or disaster situations. These items include
but are not limited to; clothing, shoes, flashlights, radios, batteries, bedding, raincoats, hygiene
products and nonperishable food items. In addition, the program has a generator to provide
continuous power from ten to fourteen days. The program maintains identifying information on
each youth in the program, and in the event the program has to evacuate the youth record
accompanies the youth to the temporary location, secured in a locked storage box. A review of
nine youth records indicated each has youth’s name, Department identification number,
admission date, gender, race, contact information, emergency contact, assigned juvenile
probation officer (JPO), committing judge, victim information, physical description, health status,
and a photograph. The interviewed facility administrator (FA) reported the copy of the COOP is
maintained in master control and the FA’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures for the storage and inventory of flammable,
poisonous, and toxic materials. Toxic items are stored outside of the program in a locked
building. Cleaning supplies are located in the locked closets in each dormitory and in a locked
closet in the kitchen area. A list of staff which includes the facility administrator (FA), assistant
facility administrators (AFAs), supervisors, and maintenance staff designates they are
authorized to handle flammable, poisonous, and toxic materials. All flammable, poisonous, and
toxic materials are stored according to type and use. A Safety Data Sheet (SDS) binder is
located inside the storage area with a picture of each material and a number corresponding to
the SDS for each chemical. A perpetual chemical inventory list is maintained, and the chemicals
are checked daily. A review of the inventory list verified this practice. The perpetual inventory
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form identifies the chemical number, description, amount used, amount remaining, date
chemical is used, and initial of staff. Observations of the storage area indicated it is clearly
marked hazardous chemicals and securely locked. A review of ten unique chemical inventories
wwas compared to the actual items in the storage areas and verified the inventory was correctly
documented. The program maintains a policy and procedures to ensure all flammable, toxic,
caustic, and poisonous items are disposed of appropriately. The facility administrator (FA) or
designee and maintenance staff are responsible for the control and accountability of all caustic,
toxic, poisonous, flammable, or hazardous, fluids, substances, or chemicals used in the
program. All unused hazardous materials are kept in the locked storage shed located outside
the program and are disposed of according to the Safety Data Sheet (SDS). An interview with
the FA indicated disposal of hazardous chemicals is accomplished within parameters of state,
local and federal laws. The maintenance staff is responsible for the safe and lawful disposal of
these items and only maintenance or other trained staff who have the safety equipment for
diluting, handling, and disposing of hazardous and solid waste are responsible for disposing of
hazardous items and toxic materials. The FA stated there were no chemicals disposed of during
the annual compliance review period. Used kitchen grease and waste is stored in a large
container outside the kitchen area and is disposed of by a local vendor. All liquid waste from
work details is disposed down plumbing drains. The program’s policy states all chemical spills
are reported to master control immediately and the shift supervisor. An evacuation of the
affected area is conducted and a determination by the FA whether to contact outside assistance
to contain the spill. Staff and youth are not allowed to return to the affected area until it has been
deemed safe by a qualified professional. An interview with the FA indicated disposal of
hazardous items and toxic substances or chemicals is completed by taking them to the local
county landfill/hazardous waste collection site. Bio-hazardous waste is disposed of at the local
fire department.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Youth are not to clean, handle, or dispose of any
toxic chemicals, biohazardous bodily fluids, or human waste. Youth are strictly prohibited from
the maintenance area where toxic items and chemicals are stored. Nine youths were
interviewed, each stated they do not use any chemicals.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures for youth to have visitation and communication
with family members in order to reestablish family and community relationships. Youth are
informed of visitation upon admission during the orientation process. The program encourages
visitation from the parents/guardians by forwarding a welcome letter upon the youth’s admission
notifying the days and time of visitation, who is allowed to visit, and the corresponding rules of
visitation. A list of authorized visitors and correspondence is maintained in the youth’s case
management records and updated, as needed. A review of nine youth case management
records verified each record contained an approved correspondence, visitation, and telephone
log. Visitation is held Sundays from 2:00 p.m. through 4:00 p.m. Special visitations are also
provided for parents/guardians who are unable to participate in the regularly scheduled visitation
days. A review of the program logbooks and visitation sign-in logs since the last annual
compliance review verified visitation and special visitation are conducted. Youth are also
provided one fifteen-minute telephone call each week, writing material, and a self-addressed
and stamped envelope to talk with and send letters to approved family members. A review of
the mail logs since the last annual compliance review showed the youth were receiving and
sending mail to approved family members. Youth can have unimpeded access with the courts,
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attorneys, their juvenile probation officer (JPO), and/ or the Department of Children and Families
case worker. Nine youth were interviewed, each youth indicated they are given the opportunity
to communicate with family members by mail, telephone, and/ or visitation. In a formal interview
with the facility administrator (FA), it was confirmed the program has an agreement with an
interpreter company for youth whose primary language is not English.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a daily activity schedule which reflects the youth receive at least one hour of
recreation each day and additional time allotted for leisure activities. The program’s contract
requires one recreation therapist. The recreation therapist has the required credentials outlined
in the program’s contract. The contract does not require special provisions for the incorporation
of recreation into the youth’s performance or treatment plans. The recreation therapist created
monthly activity calendars which reflect the recreation and leisure opportunities available to
youth each day. A review of the activities confirmed they promote social and cognitive skill
development, creativity, teamwork, healthy competition, mental stimulation, and physical fitness.
Logbooks were reviewed for the annual compliance review period and recreation was
documented each day for at least one hour, as required. Recreation was observed during the
annual compliance review week at its scheduled time and staff were found to be taking
precautionary measures to ensure the health and safety of the youth. Nine youths were
interviewed,and all youth confirmed the program allows them the opportunity to exercise, play
outside, or participate in activities indoors for at least an hour every day. All nine-youth stated
they are provided various activities including basketball, football, running. Nine staff were
interviewed and reported youth are provided recreation time for a minimum of one hour every
day. Staff provided examples of indoor and activities available for the youth to include but not
limited to; football, basketball, kickball, card games and stretching exercises.
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 rooms; 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.
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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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Office of Accountability and Program Support Page 67 of 72 (Revised September 2022)
Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has a policy and procedures to implement career and technical education
services. The contract stated the program will provide cardiopulmonary resuscitation (CPR),
first-aid, Florida Ready to Work Soft Skills credentials, and Occupational Safety and Health
Administration (OSHA)-10 certifications within ninety days of a youth’s admission. The program
also provides ServSafe Food Handling certifications, EmployU curriculum, and Equine
Technical Skills training for youth who are interested, reach a certain behavioral management
system (BMS) level, and are suitable according to the risk assessment screening. The program
maintains an accurate counting of all youth who have received certifications in each skillset area
utilizing a career and technical education binder organized by certification within the annual
compliance review period. The program was able to provide documentation of 153 youth having
completed CPR and first-aid, 109 youth completing Florida Ready to Work Soft Skills
credentials with 105 earning certification, ninety-five completing OSHA-10, 127 completing
ServSafe Food Handling, three completing EmployU, and thirty-six completing equine training
during the annual compliance review period. At the time of the annual compliance review week
two of the six industry certification areas offered by the program, OSHA-10 and ServSafe Food
Handling from the master credentials list the program was not running; however, had sessions
scheduled. Forty youth were scheduled to begin OSHA-10 the third week in May of 2025 and
eight to begin ServSafe Food Handling on May 17, 2025. Career and technical education
services are provided Monday through Friday between 5:10 p.m. and 6:10 p.m. as well as
during leisure and recreation time on weekends, if the youth wish to work on it. Documentation
and credential of all staff or providers providing services were reviewed and verified they were
qualified to deliver services. Nine youth records were reviewed for contact timeframe
requirements for completion of career and technical education services. All youth were
applicable fore OSHA-10 certifications and reviewed documentation verified four youth
completed the certification. The remaining five had been scheduled for career and technical
education services with an outside provider. Eight of the nine youth obtained their CPR and
first-aid certifications within the timeframe requirements, one youth obtained their certification
nine days late due to the staff conducting CPR and first-aid being transferred to another
program, the program identified the gap, and had the staff transferred back. All youth were
applicable for Florida Ready to Work Soft Skills and four youth completed the certification. The
remaining five are scheduled to do so, as of the annual compliance review week. An interview
with nine youth verified the program is offering education services to include Florida Virtual
School (FLVS), General Education Development (GED), and EmployU. An interview with the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 72 (Revised September 2022)
program director confirmed youth have access to contracted pre-vocational and vocational
services provided by the program to include EmployU (self-advocacy training), Florida Ready to
Work, OSHA-10, Food Handling, CPR/first-aid, and equine training.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The center
provides education services through Florida Virtual School (FLVS). A review of the program’s
activity schedule and the daily academic schedule indicated the program’s activity schedule
incorporates the daily school schedule. One discrepancy was found with the ending time for
school. The program listed the ending time as 2:50 pm, but it should be 2:45 pm. Nine
interviewed youth reported there were no interruptions to school. A review of nine random days
in the logbook one day each month for the annual compliance review period indicated education
classes started on time, but showed classes ended early for lunch; however, time was all made
up at the end of the day, except on three days, one when there was no documentation of school
ending, and two additional days when documentation of the end of the school day was for only
half of the program youth. Observations of the program video was conducted for three days
regarding educational access. The footage showed the youth started school on time for two of
the three days. All three daysschool was let out early for lunch and time was made up at the end
of the school day. On the remaining day, the school did not start until 9:40 a.m. due to an
incident in one of the classrooms as school was starting.
6.03 Educational Access (Education 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.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 am through 2:45 pm with a sixty-minute lunch break from 12:05 pm through
1:05 pm, fulfilling the weekly requirement of twenty-five hours of instructional time. The interview
with the lead teacher indicated all the youths receive credit for completing a course. They also
reported the school schedule is adhered to. Observations of the program video was conducted
for three days regarding educational access. The video observation showed teachers were
present during scheduled classroom time, except on one day, when no teacher was present
until 9:40 a.m. due to an incident in one of the classrooms before school started.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures for developing and implementing a vocational
competency development program. A review of the career education program found it is
appropriate for the educational abilities and goals as well as the length of stay and classification
of the youth. The program provides a Type 2 career education development program, which
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 72 (Revised September 2022)
includes communication, interpersonal, and decision-making skills. The interviewed facility
administrator (FA) stated youth receive career education services through the education Florida
Scholars Academy (FSA), which includes digital technology instruction and life skills
assessments, as well as through program-facilitated opportunities such as Occupational Safety
and Health Administration (OSHA)-10 training, Florida Ready to Work, and cardiopulmonary
resuscitation (CPR) and first-aid certification. The FA further indicated the program provides
employment opportunities in the community for high school graduates and previously had youth
work at local fast-food restaurants, restaurants and mail service provider. The program has an
equine program unique to residential programs. Equine training provides opportunities for youth
to learn horse anatomy and care, special handling and fitting for horses, and participation in
various community service projects at local horse farms. The program partners with the local
police department at least quarterly to complete community service projects in the community
and the program teaches youth hands on skills learning to wash clothes, iron, and dress
appropriate for different settings. The interviewed lead educator stated students are provided
with Standardized Testing and Reporting (STAR) assessments to gauge the individual needs of
each youth; Florida Youth College if a youth graduates, and career and technical education
courses for all admitted youth.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
According to the contract, the educational provider must develop an Education Transition Plan
for each youth. Upon entering a residential commitment program, an Education Transition Plan
must be developed for each youth. Three closed case records were reviewed; none contained
an Education Transition Plan. Many youths entered the program prior to the new education
provider, Florida Virtual School (FLVS), started completing Education Transition Plans, so they
would not have had an Education Transition Plan developed. FLVS has recently developed an
education plan template and trained its staff to implement an Education Transition Plan for each
youth moving forward. Of the nine interviewed youth, eight reported taking part in the
development of their Education Transition Plan, and one reported not being part of the
development; however, responses indicated staff spoke with each youth about what they were
working on, what they needed to work on, future goals and what can be accomplished while at
the program, and any assistance with any of their education goals they may possibly require
versus completing an actual transition plan. All three youth’s education transition plans
contained interventions based on the youth’s educational needs and post-release plans as well
as the recommended educational placement for post-release based on the youth’s individual
needs and performance. The interview with the instructional leader indicated exceptional
student education (ESE) services are provided for students with disabilities.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 72 (Revised September 2022)
6.06 Qualified Instructional Personnel (Education Contract
Satisfactory Compliance
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has procedures in place to provide qualified instructional
personnel. In reviewing the six educational instructional staff for the facility, including two flex
teachers who provide virtual education at the program, it was indicated all the teachers have an
active certification, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects. Two teachers were
teaching in the field and out-of-field subject areas. Two of eight teachers were teaching courses
outside their field. Florida Virtual School (FLVS) provided parent notification for those teachers
who were also teaching out of the field; however, the letter did not indicate which subjects were
taught out of field. One teacher provides exceptional student education (ESE) services in the
program, and FLVS provided certification for the ESE instructor. Approval was not obtained for
any of the six teachers by the school board for out-of-field teaching.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The program has a policy and procedures for youth to be referred to Florida Youth College
(FYC) when a youth earns their high school diploma or General Education Development (GED)
diploma. A review of documentation found eight youth were referred to FYC during the annual
compliance review period by the program staff and the education provider as of July 1, 2024.
Nine youth were interviewed with only one being applicable for post-secondary education. The
youth stated he is not currently doing any school activities or certifications. When questioned
about this, the program responded the youth had just arrived at the program thirty days prior
and will have the opportunity to earn certifications in the upcoming scheduled classes.The youth
will have the opportunity once they earntheir risk assessment to gain employment. The
interviewed lead educator stated FYC is available to students once they have graduated. The
youth are also provided assistance with job acquirements as well as transition back into their
community.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 72 (Revised September 2022)
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Eight youth were referred for post-secondary provider services though Florida Youth College
(FYC). No other youth were referred during the annual compliance review period. Seven of eight
reviewed records documented the required information regarding the completed orientation.
One youth was provided the opportunity to complete orientation and declined services;
however, later agreed to services but had no orientation. Seven applicable youth records
included a career plan, the remaining youth refused services after their orientation was
completed. Two of the eight youth are currently still committed, and one youth refused services
after orientation; therefore, three youth are not applicable for required support follow-ups. Of the
five applicable youth, three had documentation, which required support follow-ups completed or
attempted in good faith within the required timeframes with no exceptions. Of the two remaining
youths, one youth had one missing contact at the thirty-day follow up, and the remaining youth
had two missing contacts at the thirty and sixty-day follow ups. A copy of admission and
registration to a postsecondary program was included in each of the two applicable youth
records. The remaining youth either declined services, refused to participate, and/or never
responded to reach out attempts. Nine youth were interviewed. Eight are currently receiving
education services. The remaining youth has graduated and will be afforded the opportunity to
participate in certification courses per the program. The graduated youth indicated he is doing
nothing in classes all day. The Florida Scholar Academy (FSA) instructors instruct and facilitate
course work in a one-to-one or group fashion to ensure the youth are receiving necessary
support in succeeding.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 72 of 72 (Revised September 2022)

report_type: QI Residential

file_name: CSIOcala-FINAL-FY2425 .pdf

program_name_raw: Center for Success and Independence Ocala