state: FL

facility_name: JoAnn Bridges Academy

summary: QI Residential - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
JoAnn Bridges Academy
Rite of Passage
(Contract Provider)
950 S.W. Greenville Hills Road
Greenville, Florida 32331
Review Date(s): November 18-21, 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:
Ken Phillips, Office of Accountability and Program Support, Lead Reviewer (Standard 1 and
Interviews)
Jamie Franz, Office of Postsecondary and Workforce Education, Deputy Director (Indicator
2.19)
Lea Herring, Office of Fidelity, Accountability, and Support, Fidelity and Support Specialist
(Standard 2)
Dehryl McCall, Office of Postsecondary and Workforce Education, Education Coordinator
(Indicator 2.19)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 1
and Interviews)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: JoAnn Bridges Acadmey MQI Program Code: 1444
Provider Name: Rite of Passage Contract Number: 10361
Location: Madison County / Circuit 3 Number of Beds: 28
Review Date(s): November 18-21, 2025 Lead Reviewer Code: 145
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 64 (Revised August 2025)
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C )* 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e P ro g ra m m in g 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS )* 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 64 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l* 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n a l A c c e s s (R e s id e n tia l C o n tra c t P ro v id e r)* 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
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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 Suicide Prevention Plan* Satisfactory
3.10 Suicide Prevention Services* Satisfactory
3.11 Secure Observation* Non-Applicable
3.12 Suicide Precaution Observation Logs* Satisfactory
3.13 Suicide Prevention Training* Satisfactory
3.14 Mental Health Crisis Intervention Services* Satisfactory
3.15 Crisis Assessments* Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services* Satisfactory
3.17 Baker and Marchman Acts* Non-Applicable
3.18 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 64 (Revised August 2025)
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 Screening & 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/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Conditions/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Psychiatric Services* Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 64 (Revised August 2025)
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* Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised August 2025)
Program Overview
The JoAnn Bridges Academy is a twenty-eight-bed program, for twelve to eighteen year old
females, located in Greenville, Florida. The program is operated by Rite of Passage, Inc.,
through a contract with the Department. The program provides the following services: mental
health overlay services (MHOS) and substance abuse education. In addition, the program
fosters each youth by providing Aggression Replacement Training (ART), Seeking Safety,
Impact of Crime, Living in Balance, Character Traits, Trauma Recovery, and Empowerment for
Adolescent Girls and Young Women (G-TREM). Additional treatment services provided include
family, individual, and recreational therapy. The program administration is comprised of a
program director (PD), an administrative assistant, and clinical director. Case management and
therapeutic services are provided by three therapeutic managers and two case managers, who
also serve as the transition coordinator. Medical services are offered daily and are provided by a
medical doctor who is the designated health authority (DHA) and two registered nurses (RNs).
The DHA is required to be on site for two hours weekly. The RNs are to be on site sixteen hours
weekly. Educational services are provided by Florida Scholars Academy and post-secondary
services are provided by Florida Youth College. The layout of the program includes one large
building consisting of two youth dorms, a gymnasium, cafeteria, and two classrooms. There are
also two portable buildings on-site, and an outdoor field for recreational activities. The program
has a total of forty-three security cameras, all of which were reported as working during the
annual compliance review week. At the time of this annual compliance review, the program
reported having the following vacant positions: one recreational therapist, one kitchen staff and
two coach counselors.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 64 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a written policy and procedures for volunteers, mentors, and interns who work
with youth less than ten hours a month, requiring sight and sound supervision. According to the
program director, there have been no volunteers, mentors, or interns who have required the
initial background screening for this annual compliance review scope. A review of the program’s
employee roster revealed there were a total of nine staff hired, requiring an initial background
screening, for the scope of the annual compliance review. Each of the nine personnel records
included evidence of an eligible background screening and a criminal history report review
completed prior to youth contact. An exemption was not applicable for any of the reviewed
records. One of the nine staff had a break in service. For this staff, there was documentation the
new background screening was completed. All staff applicable for a pre-employment
assessment tool had documentation of this tool within their personnel records, along with the
posted passing score. Each of the nine staff were added to the program’s employee roster in
Clearinghouse. All nine staff records contained a signed contraband attestation form.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
A review of the program’s employee roster found one staff eligible for five-year re-screening
requirements. The employee’s record included documentation the five-year re-screening was
completed at the five-year interval as required, which was calculated by the Clearinghouse
prints expiration date. The rescreening was submitted to the Background Screening
Unit/Clearinghouse prior to the five-year anniversary date as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (Revised August 2025)
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.
A review of five staff personnel records found evidence all five staff signed for and received the
program’s Code of Conduct. A review of the Department’s Central Communications Center
(CCC) reports and an interview with the program director (PD) revealed the program had only
two incidents of alleged abuse and neglect reported to the Florida Abuse Hotline or CCC. None
of the incidents involved potential trafficking victim, Child Sexual Exploitation, or labor trafficking.
A review of CCC incidents found only one incident with substantiated findings. For this one
record, there was evidence provided by program administration showing management took
immediate action to address the allegations. The staff received a written reprimand as a result
of the incident. The program provided documentation which indicated their Trauma Responsive
and Caring Environment (TRACE) self-assessment was completed and emailed to the
Department on May 21, 2025. Observations made during the annual compliance review week
found postings for the Florida Abuse Hotline number and CCC number throughout program
areas. The program’s written policy and procedures includes proper steps for reporting abuse or
neglect. The policy indicates staff shall provide unhindered access to report alleged abuse, and
at no time shall youth be prevented from self-reporting or making a call to the Florida Abuse
Hotline or the CCC. The PD was interviewed and stated in the event physical abuse, threats, or
profanity are used towards youth, law enforcement may be involved as well as staff may receive
suspension, or even termination as a result. The program director also stated all staff are
trained and retrained yearly on the Trauma Response Approach, which teaches staff to
communicate effectively and in a professional manner. This helps staff to interact with the youth
in a productive manner. Youth are encouraged to participate in the Trauma Response Survey to
better assist staff. These are completed monthly during their formal staffing. Facility Operating
Procedures (FOP) ensure anyone suspecting a youth has been abused will immediately contact
the Florida Abuse Hotline and make a report. Reports are called in within the two-hour window
these incidents are kept recorded on site in an effort to track. All facility staff have been trained
in the Abuse Hotline/CCC procedures. Five youth were interviewed and all reported being safe
in the program. All youth denied ever having been stopped from reporting any abuse or neglect.
Each were familiar with the location of the Florida Abuse Hotline number. All reported staff were
respectful when speaking with them. Four of five reported they have heard staff use curse
words on occasion, but in a conversational style and not in a threatening manner. One reported
they have never heard staff use curse language. Five staff were interviewed and summarized
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 64 (Revised August 2025)
the abuse reporting process. None of the five staff reported ever observing another staff telling a
youth they could not call the Florida Abuse Hotline. None reported hearing staff use profanity
when speaking with youth.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
Based on a review of the Department’s Central Communications Center (CCC), the program
had a total of six CCC reports for the scope of the annual compliance review. This number
increased by one from the last annual compliance review period. A sample of five CCCs were
reviewed for completion requirements. Four of five were found to have been reported within the
required two-hour timeframe. One of five was reported one minute late. Four of five were
documented in the program’s logbook or shift report. One incident could not be found
documented in the logbook or shift report. A review of internal incident reports and grievances
was completed, which did not reveal any additional incidents which should have been reported
to the CCC.
1.05 Right Interactions (RI) and Physical Intervention Rate Non-Applicable
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.
There have been no Protective Action Response (PAR) incidents during the annual compliance
review period; therefore, this indicator is rated non-applicable.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program submits a pre-service training plan prior to implementation which has been
approved by all required parties. The program had only one staff within the scope of the annual
compliance review which was applicable for having been at the program for 180 days since hire
and was applicable for a review of pre-service training requirements. An additional four new
staff, still within their 180 days were selected to hold a total sample size of five staff records for
review. The staff already outside of their 180 days of hire completed more than 120 hours of
pre-service training, and although the training for grievance procedures was completed one day
late, all other required trainings were completed withing the required timeframe. All five staff
records reviewed found evidence each completed all essential trainings as required, prior to
youth contact. Four of the five staff reviewed were still within their 180 days from hire and were
still working on completing all trainings outlined in their pre-service training plan. At the time of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 64 (Revised August 2025)
the annual compliance review, one of the five had completed a total of 197 hours, and the
remaining four staff had completed over 200 hours of pre-service training.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
A total of five staff training records were reviewed for in-service training requirements for
calendar year 2024. Based on trainings provided, as well as a review of the Department’s
Learning Management System (SkillPro), one of the five staff reviewed had completed seventy-
five hours of in-service training, and the remaining four staff had completed over one hundred
hours. All trainings were completed as required with only two exceptions found: one staff had
not completed active shooter preparedness training, and one staff did not complete
professionalism and ethics. Only one supervisory staff was able to be reviewed for the
additional eight hours of supervisory training required. For this staff, there was documentation of
sixteen hours of additional supervisory training found for the training year reviewed. The
program provided documentation which indicated all trainings staff were provided by qualified
staff, such as Right Interactions (RI), and cardiopulmonary resuscitation (CPR) and first-aid. The
program submitted an in-service training plan prior to implementation which was approved by all
required parties.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures regarding the grievance process. The process
includes an informal, formal, and appeal phase. The program maintains grievances for the year
in a marked binder. The program had a total of four grievances for the scope of the annual
compliance review. A review of each of the four found all contained documented complaints by
youth referencing the same staff member. All were received and reviewed by administration
within the same day. Responses were due June 30, 2025, but were received July 11, 2025, due
to an ongoing investigation regarding the alleged staff member. An interview with the program
director (PD), and documentation provided, revealed the investigation into the staff member
concluded July 8, 2025. The grievances were responded to after the conclusion of the
investigation, as authorized according to the program’s grievance policy. The program’s policy
indicated efforts will be made to conclude the grievance process within five working days. If
resolution cannot be made during this timeframe, the reason will be documented in the
response.
Five staff were interviewed were able to summarize the grievance process. Five youth were
interviewed and two stated they have never completed a grievance. Four youth were able to
summarize the grievance process and one youth stated they were not familiar with the process
or timeframes. The PD was interviewed and stated all youth are afforded the opportunity to
complete a grievance at any point. The PD summarized each phase of the grievance process.
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1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a written policy and procedures which states the program shall provide life
and social skills addressing, at a minimum, identification and avoidance of high-risk situations
which could endanger the youth or others, communication, interpersonal relationships, and
interactions, and non-violent conflict resolution, anger management, and critical thinking, to
include problem solving and decision making. Life skills provided include the ARISE curriculum,
and various group topics such as; positive skills development, body image, life skill streaming,
and positive organizational culture. The program’s designated mental health clinician authority
was interviewed and stated the program combines individual, group, and family sessions to
individualize treatment based on each youth diagnosis, history, and presenting symptoms. The
program utilizes cognitive behavior therapy to help youth identify and modify negative thought
patters and behaviors which contribute to emotional and behavioral difficulties. Therapeutic
managers work one-to-one and in groups with youth to help them recognize and challenge
irrational beliefs and replace them with healthier goal-orientated thoughts. Five youth were
interviewed and all were able to discuss various life skills/activities and therapeutic groups they
have participated in, and were able to express ways they have practiced skills learned from
these activities.
1.11 Rehabilitative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at JoAnn Bridges Academy. For details related specific to IOC service delivery,
please refer to the annual SPEP report.
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1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a written policy and procedures which addresses the internal alert system and
the Department’s Juvenile Justice Information System (JJIS) alerts. The program’s procedures
address a continually updated, internal alert system easily accessible to program staff, which
keeps staff alerted to youth who pose a risk to security or safety including escape, sexual
offending and other assaultive or violent behavior risks, suicide, other mental health as well as
health related concerns, including food allergies and special diets. When risk factors or special
needs are identified during or following the classification process, staff shall immediately update
the internal program alert information and shall enter this information into JJIS. Only appropriate
staff may recommend downgrading or discontinuing a youth’s internal alert status. Upon
recommendations from appropriate staff, JJIS alerts shall be downgraded or discontinued. Five
youth records were selected for review of alerts entered by the program staff. For the five youth,
there were a total of eighteen alerts entered. All alerts were entered appropriately and within the
required timeframe with three exceptions. Two youths’ medical alerts were entered one day late
each, and a dietary alert for a youth was entered six days late. All alerts matched the program’s
internal alerts. Five staff were interviewed and reported they are notified of alerts at the program
through avenues such as access to JJIS, logbooks, daily shift reports, meetings, and an alert
binder located in the program lobby area. An interview with the program director revealed there
is an internal alert process for the facility where alerts are updated and/or closed as appropriate
by medical and/or mental health clinical staff based on results of the assessment and nature of
the alert. Nursing staff were interviewed and reported the registered nurses at the program are
responsible for updating the medical alert system.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains youth records in a separate filing system which includes an Individual
Healthcare Record and an individual management record. The individual management records
contain all required information such as the youths name, Department identification number,
date of birth, county of residence, and committing offense. Sections in the records are divided
as required, which included a section for Legal Information, Demographics, Correspondence,
Case Management and Treatment Team Activities, and miscellaneous. All labels reviewed were
marked ‘Confidential’ and were found secured in a locked file cabinet or rooms which was also
clearly marked as “Confidential”.
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1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program provided documentation which revealed their community advisory group meets at
least every 120 days. Meeting minutes, sign-in sheets, and agendas were provided for the
scope of the annual compliance review which found meetings held June 28, 2025, and October
26, 2025. The program solicits active involvement from all required parties with the exception of
a representative from the Florida Scholar’s Academy. Contact by phone was made with a board
member who confirmed their participation in meetings. The member stated they are made
aware of meetings through email and a letter sent by the program and reported they enjoy
participation in the meetings and would like to continue doing so in the future. The program
director was interviewed and stated meetings are scheduled quarterly. During the meetings,
ideas are discussed which include positive and negative reports, as well as brainstorming new
ideas for improvement to program policies.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures for staff performance, determining the evaluation of
staff, performance standards, and frequency of evaluations. The performance evaluations are
completed annually for staff. A review of five job descriptions was completed which found each
staff performance standards were clearly identified. Five separate performance evaluations
were also reviewed confirming the program reviews staff on an annual basis. Performance
standards reviewed matched the job descriptions for each staff, and all staff whose job functions
included the implementation of the program’s behavior management system (BMS) was clearly
documented on their expectations and descriptions. The program’s contractual agreement was
reviewed to ensure all specific contractually required positions were maintained and
performance as outlined. All key staff positions were filled at the time of the annual compliance
review with the exception of the recreational therapist. The program reported the position had
been vacant since September 15, 2025; however, a candidate has been selected and will be
starting within the next two weeks. A review of the candidate’s educational records revealed
they hold the qualifications required for the position. The program director was interviewed and
stated each staff receive a ninety day and annual evaluation.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of special contract conditions was completed and found the program is implementing
items and services negotiated and outlined in the contract which are considered Special
Contract Conditions. The program provides a transportation service for parents of youth to
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specific geographic areas every month. According to the program director (PD), no youth have
accepted this service during the scope of the annual compliance review. All youth have been
afforded the opportunity and participation with enrichment activities from local volunteers to
enhance therapeutic needs. The program also offers youth with substance abuse issues the
opportunity to participate in alcoholics anonymous and narcotics anonymous (AA/NA); however,
according to the PD, no youth have accepted the opportunity. All youth have access to
appropriate reading materials and the program maintains a diverse media center. The PD was
interviewed and stated all contract negotiated items are offered at the program and provided
consistently, including mental health treatment, educational services, vocational, CTE services,
medical treatment, as well as delinquency intervention programming.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has systems to review and analyze data in decision-making practices. The
program produces monthly site operations summaries. Information includes wages, worker’s
compensation claims, budget utilization percentages, youth length of stay, admissions,
unplanned exits, planned exits, incidents, runaways, assaults and fights, medication errors and
self-harm, as well as use of restraints. The monthly operations report is posted where all staff
can access and review it, as well as information is shared in monthly staff meetings. Reviewed
documentation supported this practice. Information is forwarded by e-mail or letter to providers
and stakeholders. The program has also hosted community advisory board meetings and
community inclusive activities to include a fall festival. The provider conducts calls with their
leadership team at the program as well as utilizing multiple data systems and encouraging more
management involvement with staff by having the information posted for everyone’s access.
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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.
Five case management records were reviewed and each verified the youth’s parent/guardian
was called within twenty-four hours of the youth’s admission. All five records included written
notification of each youth’s parent/guardian within forty-eight hours of admission. Each record
reflected program staff notified the committing court and assigned juvenile probation officer
(JPO) in writing of each youth’s arrival on the day of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the youth orientation process. A program
orientation was conducted for all five reviewed youth within twenty-four hours of admission.
Orientation included expectations and responsibilities of each youth, written behavioral
management system, access to medical and mental health and substance abuse services,
access to the Department’s Central Communications Center (CCC) and Florida Abuse Hotline,
zero tolerance regarding sexual misconduct, what is considered contraband and illegal items
and consequences for having these items, performance plan process, hygiene and dress code,
procedures for visitation, mail, and telephone usage, each youth’s anticipated length of stay,
goal completion, expectations for release, access to community, grievance process, fire drills
and emergency procedures, facility tour, health education topics, services available, daily
schedule, living unit, and treatment team assignment. Five youth were interviewed and each
indicated the orientation process was completed within twenty-four hours of admission and
included program rules, procedures, schedule, and more. No youth were admitted to the
program during the annual compliance review; therefore, a youth orientation could not be
observed.
2.03 Written Consent of Youth Eighteen Years or Older Non-Applicable
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 not had any youth eighteen years of age or older during the annual
compliance review period; therefore, this indicator is rated non-applicable.
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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 outlining the classification process for youth upon
admission to the program and completion of reassessments for required activities as necessary.
The policy includes a classification system which promotes safety and security, as well as
effective delivery of treatment services, based on determination of each youth’s individual needs
and risk factors, which addresses, at a minimum, items outlined in Administrative Rule. A review
of five records found documentation in all records addressing each youth’s gender, height,
weight, physical stature, age and maturity level, special needs, history of violence, gang status,
criminal behavior, sexual aggression or vulnerability to victimization, perception of vulnerability,
potential or verified human trafficking history, and risk factors for medical, suicide, escape, and
security. All five records confirmed each youth was assigned to a living unit and room based on
the program’s classification system. Each record included the Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) documents. The program utilizes an alert system which
staff have access to and provides updated information on each youth, including medical, mental
health, suicide, sexual predator, aggression, and escape or security risks. Review of the
Department’s Juvenile Justice Information System (JJIS) alert list did not contain any
information for issues affecting classification. All five records included reclassification forms and
documented reclassification throughout the length of stay or when warranted which could be an
increase in privileges or freedom of movement, participation in work projects or off-campus
activities, a change in supervision, updated alerts, behavioral concerns, or relevant information
to ensure security.
The program director (PD) was interviewed and indicated a pre-admission staffing is held for
each youth. The case manager is responsible for assigning youth rooms. Case management is
responsible for reviewing youth records at the time of entry. Each youth is screened for
vulnerability and important factors are considered such as physical characteristics, age and
maturity, identification of special needs, gang affiliation, current offenses, criminal behavior,
history of violence, medical and mental health issues, co-offenders, suicidal ideations, sexual
aggression, education, predator behavior, separation, delinquent history, escape and risk to
public, deoxyribonucleic acid (DNA) testing, and history or potential human trafficking. The
classification is documented on the program’s classification form, with special needs and
security needs identified. The classification types include; reassessed and reclassification,
restorative process, or a reassessment of youth risks and needs.
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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 outlining the gang identification and notification of law
enforcement. None of the five reviewed case management records were applicable for gang
identification and notification. There were no additional youth applicable for gang identification
during the annual compliance review period.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to address a youth’s participation in gang prevention
and intervention activities. During this annual compliance review period, there were no youth
applicable for gang identification prevention and intervention. Any youth identified as a gang
member or having gang affiliations will participate in Impact of Crimes (IOC) groups weekly. In
addition, a goal shall be included in their individual performance plan pertaining to gang
membership and/or affiliation. The program’s policy and procedures address providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
programs gang prevention and awareness include the completion of IOC, performance plan
goals, and gang related activities prior to being released from the program. The program
director was interviewed and reported the program ensures each youth have an opportunity to
develop a plan to disaffiliate with a criminal street gang. Each youth’s performance plan
included relevant goals relating to gang intervention strategies. All staff will be required to have
training yearly on gang awareness. This training will include identification, signs and symbols,
trends, and possible gang activity in the program.
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.
A review of five youth case management records found documentation in all records verifying
the Residential Assessment for Youth (RAY) was completed within thirty days of admission. All
initial assessments were maintained in the Department’s Juvenile Justice Information System
(JJIS). All five records were applicable for ninety-day reassessments. Four of the five records
had reassessments completed every ninety days as required. One youth record completed the
ninety-day reassessment two days late. All five records were applicable for additional
reassessments deemed necessary by the intervention and treatment team. All five youth case
management records maintained all reassessment documentation as required.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
A review of five youth case management records verified each record included a Youth Needs
Assessment Summary (YNAS) completed in the Department’s Juvenile Justice Information
System (JJIS). All five case management records documented the YNAS was completed within
thirty days of each youth’s admission. Each record documented the youth’s top three
criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
Each of the five reviewed youth case management records included performance plans. All five
case management records documented the initial performance plan was completed within thirty
days of admission in the Department’s Juvenile Justice Information System (JJIS). All five
records documented the performance plan was completed after completion of the Youth Needs
Assessment Summary (YNAS). Documentation in each of the five youth case management
records indicated all required team members were present to provide input into the creation of
the youth’s performance plans. Five youth were interviewed and each confirmed they
participated in the development of their performance plan. All performance plan goals were
measurable and included target completion dates. The individualized goals were based upon
the prioritized needs reflecting the risk and protective factors identified during the initial
assessment. Performance plan goals identified responsibilities of staff and youth. The
performance plans included the top three criminogenic needs, transition goals, and targeted
court-ordered sanctions which could be reasonably initiated or completed while at the program.
All five case management records included performance plan transmittal letters which were sent
to all applicable parties within the required time frame. Performance plans were signed by the
treatment team leader, youth, and other parties who are responsible for goal completion.
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.
All five reviewed case management records were applicable for performance plan revisions.
Each youth’s treatment team was involved in determining the need for performance plan
revisions. Revisions were made based on goal progress, newly revealed information, and
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Residential Assessment for Youth (RAY) Reassessment results. All five youth records had
additional plans, including academic or treatment plans, incorporated into the performance plan.
Two youth were applicable for services with the Department of Children and Families (DCF) and
included a current behavior support plan or case plan through DCF, and no coordination with
the Agency for Persons with Disabilities (APD) was applicable or required.
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.
Four of the five reviewed case management records were applicable for Performance
Summaries and Transmittals. One youth was not applicable for a Performance Summary as
ninety-days had not passed since the signing of the initial performance plan. Each of the four
applicable records had Performance Summary’s which included the youth’s status on each
performance plan goal, overall treatment progress, behavior, academic status including grades,
credits earned in the program, if the youth was a high school student including performance and
behavior in school, significant events, interactions with peers and staff, and level of motivation
or readiness to change. All four Performance Summaries were completed within ninety days of
the performance plan signatures. Reviewed documentation in the four records indicated the
youth were allowed to read and add comments prior to signing the summary, the youth received
a copy of the summary, and the original summary was filed in the youth’s case management
record. Each Performance Summary was signed and dated by all required parties and sent
within ten business days to the committing court, juvenile probation officer, and parent/guardian.
A review of three closed case management records verified each release summary included the
justification for release, discharge, or transfer and was attached with the Pre-Release
Notification (PRN). The release summary and PRN were sent at least forty-five days prior to the
youth’s expected release. A signed copy was maintained in each youth’s record. None of the
youth records were applicable for the court objecting to PRN’s for release or needing to be
resubmitted to meet the court’s expectations. Once approved, the program provided written
notification to each youth’s parent/guardian. Each closed case management record contained
an Exit Residential Assessment for Youth (RAY). None of the youth were applicable for the
Sexually Violent Predator Program. One youth record was applicable for a required victim
notification, and the victim notification was sent out and documented. Original Performance
Summaries and copies of release summaries were in each youth case management record.
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.
Five reviewed case management records included documentation confirming program staff
attempted to involve parent/guardian in the assessment process, performance plan
development, and progress review. Parents/guardians were provided with opportunities to
attend or participate in these events. If unable to attend, the parent/guardian is provided the
opportunity to participate by telephone or video conferencing, or to provide verbal or written
input prior to the meeting. A treatment team meeting could not be observed as there was no
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treatment team meeting conducted during the annual compliance review week. The program
director (PD) interview indicated parents/guardians are included in treatment planning with
youth and offered family therapy sessions. The parents/guardians are included in weekly team
updates for formal treatment team meetings which help keep the parent/guardian involvement
high. Parents/guardians are a part of the youth’s treatment team meetings to discuss problem
behaviors and solutions which work best for the youth. Five youth were interviewed and all
reported their parent/guardian is called during treatment team meetings and one youth reported
the program contacts their grandmother regularly.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
Five youth case management records were reviewed for formal and informal treatment team
reviews. In each record, the case manager and therapist were identified as treatment team
leaders. The treatment team for each youth included the youth, administration representative,
case manager, living unit representative, education, clinical staff, medical staff, juvenile
probation officer (JPO), and parent/guardian. Participants were present and provided written
input. The youth’s JPO and parent/guardian, when able, participated by telephone. Each
reviewed case management record included formal treatment team reviews completed at least
once every thirty days as required. All five reviewed records were applicable for informal bi-
weekly treatment team meetings and included all required elements. There were fifty-four
treatment team meetings reviewed with twenty-six formal meetings and twenty-eight informal
meeting. All treatment team meetings included all required elements including the youth’s name,
review date, attendees, input from team members, how youth are progressing, youth behavior,
any physical interventions, and Residential Assessment for Youth (RAY) Reassessment results.
All treatment team documentation was maintained in each youth’s record. The youth’s treatment
team members, JPO, and parent/guardian were invited and encouraged to participate in youth
formal treatment team reviews. A treatment team meeting could not be observed as no
treatment team meetings were conducted during the week of the annual compliance review.
Each of the five interviewed youth reported they have an opportunity to demonstrate learned
skills and youth progress is discussed during formal treatment team meetings. All five youth
provided comments which demonstrate they are allowed to ask questions, request for any
additional help, and discuss their progress at the program. Two youth additionally reported their
parent/guardian and JPO discuss and ask questions during treatment team meetings.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Three closed case management records were reviewed for transition planning and the
Community Re-Entry Team (CRT) meeting. Transition conferences were conducted at least
sixty days prior to each youth’s scheduled release date. The youth, treatment team leader,
program director or designee, juvenile probation officer (JPO), parent/guardian, medical, and
education staff were invited and participated in each youth’s transition conference. During the
transition conference the team conducted a review of the transition activities on each youth’s
performance plan, revised the performance plan as necessary, identified additional transition
activities as needed, identified target completion dates, and identified persons responsible for
completion. A copy of each plan was sent to each applicable party not in attendance at the
transition conference with a request for return with a signature. The treatment team leader
obtained participant signatures or electronic acknowledgement of responsibilities. All three
closed case management records included supporting documentation indicating the program
and youth participated in the CRT meeting prior to release and an invitation sent through email
was maintained within the youth records.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management records were reviewed for Exit Portfolios. Documentation
indicated the Exit Portfolio was discussed and initiated for the youth during the transition
conference for all three youth. The three closed case management records included all required
documents including a state-issued identification card, Social Security card, and birth certificate.
The Exit Portfolio was provided to each youth and juvenile probation officer (JPO). The youth
were not applicable for requirements specific to youth in a secure maximum risk program. The
program did not have any additional requirements related to the Exit Portfolio included in their
contract. Each Exit Portfolio was verified during the exit conference.
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 for Exit Conference requirements. Exit
Conferences were conducted for each youth after notification to the juvenile probation officer
(JPO) and at least fourteen days prior to the anticipated release date. The closed case
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management records reviewed confirmed the JPO, parent/guardian, education representative,
intervention and treatment team leader, and other pertinent parties participated in each youth’s
Exit Conference. All three Exit Conferences were documented in each youth’s case
management record and held separately from the transition conference and Community Re-
Entry Team meetings. The status of transition activities established at the transition conference
and plans were finalized for the youth’s release. Review of the three youth’s dates of admission
and termination documented in the case management record did correlate within the
Department’s Juvenile Justice Information System (JJIS). The Exit Conference documents
included a review of transition conference goals, a summary of pending transition goals,
provisions for continuation of education and/or employment, evidence the youth’s case manager
and parent/guardian are aware of the plan, documents, and post-release discharge plans, and
signatures for all required parties. The youth’s JPO and parent/guardian participated by
telephone.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to promote formal constructive input by youth. The
program’s policy states there are multiple opportunities for youth input which include a student
survey, student government, Request to Speak forms, Contributor Club, safety meetings,
treatment team, townhall meetings, maintenance requests, problem resolution process, and
grievance forms. A review of program youth community meetings reflected these meetings were
held regularly. The program reports a monthly youth advisory meeting is conducted and later
provided meeting agendas to show new business discussed.
Five youth were interviewed, and three stated input is provided with “One on One” forms, two
youth mentioned weekly meetings such as Recognition Questions and Concerns, and one youth
mentioned a Positive Organizational Culture Group. The program director (PD) was interviewed
regarding any formal process to solicit youth input on systemic issues, to improve conditions, or
enhance the quality of life. The PD reported the TRACE assessment and Student Council
provide input to assist with improving the aspect of the program. “One on One” forms are
accessible for the youth to provide input as well.
2.18 Educational Access (Residential Contract Provide) 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 posts an activity schedule which reflects the education schedule and times. The
reviewed schedule coincides with the education contract provider’s schedule times. A review of
three random days of video and the logbook indicated youth were escorted to and from
education classes as scheduled with minor deviation from the posted schedule. No significant
issues were observed from the video review. Youth were receiving at least five hours of
classroom instruction totaling twenty-five hours weekly. One random day from each month of
the scope of the annual compliance review was observed in the program’s logbooks. The
logbook review revealed youth were transitioning to education classes at the scheduled times.
For two days reviewed, there was documentation the youth left ten minutes early one day, and
fifteen minutes one day, however all other days the youth left at the scheduled time. Five youth
were interviewed who reported education services are being provided. Four of five reported
there were little interruptions during school times and one youth said there were no
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interruptions. Youth gave some examples of interruptions such as some youth may be acting
out, and the staff have to remove those individual youth.
2.19 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 contract requires, the program to deliver Career and Technical Education (CTE) services
aligned with the Master Credentials List (MCL) approved by the Florida Department of
Education (FDOE). Youth are to be enrolled in a CTE program within three months of
admission. Additionally, all students must complete Florida Ready to Work, Occupational Safety
and Health Administration 10 (OSHA 10), and cardiopulmonary resuscitation (CPR)/first aid
within prescribed timelines. The review of five youth records confirmed the program consistently
delivers and documents Ready to Work, OSHA 10, and CPR/First Aid. Current CTE offerings
include Certified Nursing Assistant (CNA), hospitality, medical aid, and hair braiding. While the
SafeStaff Food Handler and hair braiding credentials are not on the MCL, both provide entry-
level employment opportunities and potential pathways to higher-level certifications in food
service and cosmetology industries, respectively. At the time of review, no youth were eligible
for the CNA program. Recognizing barriers for youth entering the healthcare field, the program
is encouraged to expand CTE offerings into additional industries such as Information
Technology, Manufacturing, and Logistics, which may provide broader employment
opportunities. Five youth were interviewed and confirmed the program is providing CTE services
in OSHA 10, Ready to Work, SafeStaff, and hair braiding. The program also has classes to
demonstrate culinary skills and crocheting. The interviewed program director stated the
vocational services offered at the program are OSHA 10, Florida Ready to Work, and SafeStaff.
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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 had three separate licensed staff serving as the designated mental health clinician
authority (DMHCA) during the annual compliance review period. Each of the licensed staff had a
valid and active license while serving as the DMHCA at the program. At a minimum, the
DMHCA was on-site forty-hours weekly and is the single licensed mental health professional
responsible for the coordination and implementation of mental health and substance abuse
services at the program. The DHMCA is also on-call to provide support services to the program
twenty-four hours a day, seven days a week. The DMHCA position description was reviewed
and confirmed the inclusion of mental health and substance abuse services to be provided at
the program. The program has a back-up DMHCA, who has a valid and active license and
provided services in the interim from the previous licensed staff to the current licensed staff. The
DMCHA was interviewed and stated they conduct crisis assessments, facilitate group therapy,
and review all assessments and treatment plans. In addition, clinical staff can discuss any
matter daily with the clinical director in-person, email, or by phone and in-preson weekly
supervision is provided every Wednesday morning.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program did not have any other licensed staff throughout the annual compliance review
period who required supervision from the designated mental health clinician authority (DMHCA).
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has three non-licensed mental health and substance abuse clinical staff. The
contract requires four non-licensed staff and the remaining fourth position has been vacant
since 2022. The most recent position was vacated August 1, 2023, and subsequently filled on
September 2, 2025. Communication with the Office of Health Services (OHS) determined the
program has combined case management and therapist positions; therefore, the fourth position
is held by a case manager approved by OHS with the understanding the case manager does
not carry a therapy case load. The designated mental health clinician authority (DMHCA)
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ensures each of the non-licensed clinical staff working under their supervision are performing
services they are qualified to provide based on education, training, and experience. A review of
direct supervision logs found face-to-face, on-site, weekly supervision occurred most of the time
for the three staff reviewed. There were two occasions in May 2025 where no weekly
supervision was found for staff. In addition, two separate occasions were found for one staff not
signing the supervision log; this staff had been out on leave for an extended period. Supervision
for each of the non-licensed mental health and substance abuse clinical staff was found
documented on the appropriate Department form. The program has a Chapter 397 license,
which expires March 22, 2026. Of the three non-licensed mental health and substance abuse
clinical staff, one holds a master’s level degree from an accredited university, the remaining two
hold a bachelor’s degree from an accredited university in a required field of counseling, with
both having over two years of experience. Each of the staff are employees of a service provider
licensed under Chapter 397. Each of the non-licensed mental health and substance abuse
clinical staff have completed twenty hours of training and supervised experience in assessing
suicide risk, mental health crisis intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
A total of five mental health and substance abuse records were reviewed for mental health and
substance abuse admission screening. The Massachusetts Youth Screening Instrument,
version-2 (MAYSI-2) is utilized by the program as a comprehensive screening tool for each
youth admitted. The program reviews available information to include the youth’s commitment
packet and reports and/or records for existing documentation of mental health or substance
abuse problems. Each reviewed screening was conducted by staff who were trained to
administer the MAYSI-2. The screenings were each conducted in the Department’s Juvenile
Justice Information System and completed in full. Each of the youth had a documented referral
reason. Appropriate referrals were made for each youth to have a comprehensive evaluation
and in addition, to ensure an assessment of suicide risk was conducted within twenty-four
hours. None of the reviewed youth required an immediate assessment for emergency services.
The program director (PD) had developed a written policy and procedures for the
implementation of a standardized admission/intake mental health and substance abuse
screening process, which addressed all necessary components. The PD was interviewed and
reported the program administers mental health screening and suicide risk screening during the
intake process. At times referrals are made for further evaluation, assessment, and clinical
services. The initial intake and screening process ensures treatment, gives priority to urgent
needs and emergency situations, and facilitates the identification of youth who have co-
occurring conditions.
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3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
A total of five youth mental health and substance abuse records were reviewed for mental
health and substance abuse assessments and evaluations. A combined mental health and
substance abuse evaluation was conducted for each of the youth within thirty calendar days of
admission. Each youth had consent obtained for substance abuse services. Four of the five
comprehensive evaluations were conducted by a non-licensed mental health clinical staff or
non-licensed substance abuse clinical staff. The remaining evaluation was conducted by a
licensed qualified professional. Three of the four evaluations completed by the non-licensed
staff were signed by the licensed qualified profession within the required ten days and one
evaluation was reviewed and signed three days late. All the new evaluations contained all
necessary and relevant information for a completed comprehensive evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
A total of five youth mental health and substance abuse records were reviewed for mental
health and substance abuse treatment. Each of the youth had a initial treatment plan developed
within seven days of initiation of treatment, or for youth prescribed psychotropic medication,
within seven days of the initial psychiatric diagnostic interview. Each initial treatment plan
included all elements as prescribed in the Department’s form. One of the five youth entered the
program with psychiatric needs and subsequently had the required information included within
the initial treatment plan. Each of the youth’s initial treatment plans were reviewed and signed
by all persons who participated in the development of the plan.
A total of five youth were reviewed for completion of an individualized treatment plan. One of the
five included psychiatric services at admission. Two youth later included the provision of
psychiatric services into the treatment plan once evaluated by the psychiatrist and prescribed
psychotropic medications. The remaining two youth never required any type of psychiatric
services. All five youth had a completed individualized treatment plan, which contained all
prescribed conditions of the Departments form, completed within thirty days of admission The
individualized treatment plans documented each youth’s prescribed services to be completed
while at the program. All individualized treatment plan reviews were completed every thirty days
as required and included signatures from all persons who participated in the development of the
plan.
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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.
A total of five youth mental health and substance abuse records were reviewed for treatment
services. All youth were assigned to a treatment team upon arrival to the program. The
multidisciplinary treatment team documented the necessary team members involved in each
youth’s treatment. Each youth was in receipt of mental health services and had the necessary
Authority for Evaluation and Treatment form authorizing treatment. The program documented
mental health treatment notes, which contained all information as required within the
Department’s Counseling/Therapy Progress Notes form. A review of each youth’s services
included individual psychotherapy/counseling and psychosocial skills, as stipulated on the
treatment plan documented on the progress notes. A total of three youth closed records were
reviewed for discharge planning. Each of the closed records indicated a discharge plan was
documented on the Department’s discharge form. None of the youth were released while on any
type of suicide alert/precautions. Each summary included future services needed. The
discharge plans documented services were discussed with the youth, juvenile probation officer
(JPO), and parents/guardians during the exit conference. In addition, a copy of the discharge
plan was provided to the youth, JPO, and parents/guardians.
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.”
Program services shall include twenty-eight nonsecure slots with Mental Health Overlay
Services (MHOS) for girls aged twelve to eighteen years old. In accordance with contract,
specialized treatment services primary clinical groups are Aggression Replacement Training
and Impact of Crime. In addition, if therapeutically diagnosed, the following supplemental
treatment services could be offered: Supplemental Services: Seeking Safety, G-TREM,
Character Traits, Dialectical Behavior Therapy, and Living in Balance. The counselor to youth
ratio is one to fourteen. The program met the following requirements while providing treatment
services: individual therapy at least once every two weeks, or more often as prescribed; family
therapy at a minimum of monthly, or as prescribed in each youth’s individualized treatment plan;
and if necessary, the psychiatrist provided services at least once every two weeks. Therapy
progress notes reflected services being provided as prescribed and documented as outlined
within each youth’s individualized treatment plan. Group therapy included mental health groups
weekly or as prescribed services outlined within each youth’s treatment plan and facilitated by
therapists as required. Fidelity monitoring was conducted monthly by the regional clinical
director.
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Five youth were interviewed, and each indicated they participate in family and/or individual
counseling. Five staff were interviewed and four staff stated they did not facilitate any mental
health or substance abuse groups. The one remaining staff was a therapeutic manger and said
they do facilitate mental health or substance abuse groups. The designated mental health
clinician authority was interviewed and confirmed services include bi-weekly individual
counseling, monthly family session, and group therapy four days a week. The program director
was interviewed and stated the program administers mental health screening, including suicide
risk screening, during a youth’s admission to the program. When indicated, referrals are made
for further evaluation, assessment, and clinical services as appropriate. The initial intake and
screening process ensures equitable treatment, gives priority to urgent needs and emergency
situations, facilitates the identification of youth who have co-occurring conditions, and supports
access to an integrated assessment process and results in timely initiation of services.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written suicide prevention plan, which safely assesses and protects youth
with elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code. The plan details suicide prevention procedures and
incorporates required elements such as identification and assessment of youth at risk of suicide,
staff training, suicide precautions, levels of supervision, referrals, communication, notifications,
documentation, immediate staff response and a review process. The plan’s review process for
suicide attempts and mortality reviews contained the required elements such as circumstances
surrounding the event, relevant facility procedures, all relevant training of involved staff,
pertinent medical and mental health services involving the victim, possible precipitating factors,
and recommendations for change in policy, training, medical or mental health services and
operating procedures if warranted. The suicide prevention plan was reviewed by both the
program director and designated mental health clinician authority on October 12, 2025.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
A total of five youth mental health and substance abuse records were reviewed for suicide
prevention services. Each youth had an assessment of suicide risk (ASR) conducted as a result
of either a self-report, staff observation, or admission screening. Each of the ASR’s were
completed on the required Department’s form. The level of supervision was annotated
according to the staff completing the ASR. In each incident, the youth’s parent/guardian, along
with juvenile probation officer, was notified of the youth’s potential suicide risk. During the
duration of time the youth was on suicide precautions, four of the five youth were provided daily
mental health supportive services. The fifth youth was placed on standard supervision upon
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admission screening. Each of the ASRs were either completed by a clinical staff under the
supervision of a licensed professional or by a licensed professional. For those ASR’s conducted
by a clinical staff under supervision, each one was subsequently reviewed by a clinical staff
within twenty-four hours or the next time the licensed staff was on-site. Each assessment was
completed within twenty-four hours of notified concerns. Appropriate documentation was found
in the program logbook for four of the five youth. The fifth youth was placed on standard
supervision at admission. There was documentation found in each ASR of the actual date/time
the clinician conferred with the program director or designee. Four of the five ASR’s were
applicable for a follow-up ASR. In each case, the follow-up ASR was completed prior to the
youth’s removal from precautionary observation. Each follow-up ASR was documented on the
required Department form. The discontinuation of supervision was documented in accordance
with the program’s suicide prevention plan. In each applicable case, a suicide risk alert was
placed in the Department’s Juvenile Justice Information System (JJIS) accordingly. While on
precautionary observation, each youth was allowed to participate in select activities with other
youth in designated safe housing/observation areas of the facility. A video review of three
separate youth on precautionary observation was reviewed; with no issues observed and all
required policies and procedures being followed.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “Non-
Applicable.”
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
A total of five youth mental health and substance abuse records were reviewed for suicide
precaution observation logs. Four of the five were applicable, the fifth youth was placed on
standard supervision at admission. A total of fourteen precaution observation logs were
reviewed from the four youth records. The observation logs were each maintained for the
duration the youth was on suicide precaution. None of the logs denoted any warning signs. Two
of the fourteen observation logs were missing a supervisor signature; all others had the required
supervisor signature. Thirteen logs had the required mental health staff signature, with one of
missing a signature. Eight observation logs documented safe housing requirements and six of
the observation logs did not document safe housing requirements. Only one of fourteen
observation logs missed one thirty-minute visual observation, all other youth behavior checks
were documented accurately and on-time.
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3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has seven suicide response kits, which include a knife-for-life, wire cutters, needle
nose pliers, and the required first aid provisions. The suicide kits are in the medical office (one
in the medication cart), supervisor office, storage closets in youth dormitories, and both program
vans. Training records were reviewed for five pre-service and five in-service staff, for
implementation of suicide prevention training. A review of mock suicide drills demonstrated drills
are held no less than quarterly on each of the programs shifts. Training included at a minimum
all staff who encounter youth, which included kitchen and maintenance staff. A review of video
on October 9, 2025, and November 5, 2025, revealed mock drills are simulated and youth do
not participate in any drills. The mock suicide drills included the use of cardiopulmonary
resuscitation at a minimum semi-annually. Staff who were not present during any mock suicide
drill has the opportunity to review drill scenario’s during briefings on their next shift.
The program director was interviewed and stated it is the policy of the program to administer
mental health screening, including suicide risk screening, during a youth’s admission to the
program. When indicated, referrals are made for further evaluation, assessment, and clinical
services as appropriate. The initial intake and screening process ensures equitable treatment,
gives priority to urgent needs and emergency situations, facilitates the identification of youth
who have co-occurring conditions, supports access to an integrated assessment process, and
results in timely initiation of services. Five staff were interviewed and stated to notify mental
health staff, provide constant sight and sound supervision, and document if a youth expresses
any suicidal thoughts.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has an integrated emergency mental health crisis intervention and emergency
mental health and substance abuse services plan. The combined plans included all necessary
elements of notification and alert system, means of referral, communication, supervision,
documentation, and review procedures.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program had only one applicable crisis assessment during the annual compliance review
period. The crisis assessment was conducted immediately based on the needs of the youth.
The crisis assessment addressed all applicable requirements necessary to assist the youth in
need. The crisis assessment was conducted by a licensed mental health professional and was
placed on standard supervision. There was no indication the youth posed a safety and security
risk to themselves or others at time of the crisis assessment. The crisis assessment was
completed in accordance with the programs integrated emergency mental health crisis
intervention and emergency mental health and substance abuse services plan. The youth did
not require off-site services or a follow-up assessment.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an integrated emergency mental health crisis intervention and emergency
mental health and substance abuse services plan. The combined plans included all necessary
elements of immediate staff response, notifications, communications, supervision, authorization
to transport for emergency mental health or substance abuse services, transport under Baker
Act, transport under Marchman Act, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Five youth mental health and substance abuse records were reviewed for safety planning
process for youth. Each of the youth’s safety plans were completed within fourteen days upon
admission to the program. The plan was jointly prepared by the youth, parent/guardian or family
member, and program clinical staff. The safety plan incorporated other recommendations from
previous and current clinical assessments and/or screening instruments. One of the five safety
plans was missing one thirty-day update, out of twenty-four total updates completed by the
program every thirty days. Each of the youth’s safety plans incorporated all pertinent strategies
in assisting the youth with any issues or triggers. Safety plans were reviewed by all staff for the
duration of the annual compliance review period, except for the month of October. Staff maintain
a binder of each youth’s safety plan, which is actively carried with staff throughout the day. Five
youth were interviewed and stated they were able to contribute to their safety plans. The
program director was interviewed and stated the youth safety plans are updated monthly and as
needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The designated health authority (DHA) is a licensed physician and holds an unrestricted license
meeting all requirements for independent and unsupervised practice in the State of Florida. The
DHA’s license expires January 31, 2026. The DHA has specialty training in family practice.
There was no indication the DHA had any disciplinary cases or public complaints on record. The
DHA has designated an advanced practice registered nurse (APRN) for clinical duties. The
APRN holds an unrestricted clear and active license to practice in Florida with an expiration
date of April 30, 2026. The APRN’s academic clinical specialty is in pediatrics. The APRN has a
Collaborative Practice Protocol (CPP) in place and is maintained on-site. The program does not
employ a physician’s assistant (PA). The contract stipulates the licensed physician (MD) must
be on-site at least once a week for a minimum duration of two hours a visit; however, the CPP
stipulates the MD will be on-site no less than once a month to provide all required clinical
services. A review of sign-in/out logs for the annual compliance review period confirmed the
DHA was on-site at least monthly, and the APRN was on-site weekly when the DHA was not, in
accordance with the CPP. There were no instances in which either provider failed to meet the
required weekly presence. The back-up DHA holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida. The back-up
medical doctor license expires March 31, 2026. The DHA conducted all administrative duties.
There was no indication the program used any type of tele-medicine services during the annual
compliance review period. An interview with the APRN confirmed the existence of a current
Collaborative Practice Protocol between the APRN and the DHA. A copy of the protocol was
available for review. The APRN stated the DHA reviews documentation during on-site visits but
does not sign-off on all entries. The APRN reported duties included conducting sick call,
completing well-care assessments for new admissions, and performing evaluations and
scheduled follow-ups for youth with chronic conditions. The APRN is on-site every seven days
and reported no concerns regarding the healthcare services provided by the program. The DHA
was interviewed and stated they perform Comprehensive Physical Assessments (CPA) as
scheduled, participate in policy and procedure development, and conduct periodic evaluations
as scheduled. The DHA also stated they provide orders for sick call which need further
evaluations. The DHA communicates by phone and in-person with staff. A medical folder is
maintained in the clinic which is reviewed at each on-site visit. The DHA reported they have a
back-up medical doctor when they are on vacation. The DHA reported having no concerns or
issues with the health care provided at the program.
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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 employs two registered nurses (RNs) for all on-site coverage. One RN resigned in
August 2025, and a replacement was hired in October 2025. All three nurses who provided
services during the annual compliance period held clear and active licenses, as verified through
the Florida Department of Health (DOH). One license is valid through April 30, 2026, and the
remaining two are valid through April 30, 2027. All nursing staff maintain current
cardiopulmonary resuscitation (CPR) certifications, both of which expire in February 2027.
According to the contract, the required on-site hours for nursing are for the RN clinical manager
to be on-site forty hours a week and additional RNs for sixteen hours a week. On-site nursing
program coverage shall be provided seven days a week for a total of fifty-six hours by RNs
licensed in the State of Florida. A review of the work schedule confirmed the hours were being
met.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) completed the annual review of all treatment facility
operating procedures (FOPs) and provided formal approval on October 29, 2025. The program
director conducted an independent review and signed the treatment FOPs on October 24, 2025.
The psychiatrist and health services administrator (HSA) completed their annual review and
signed the FOPs on October 30, 2025. The clinical director finalized their review on October 29,
2025, and the newly hired registered nurse (RN) signed on November 3, 2025. All required staff
reviewed and signed policies. Additionally, the newly hired healthcare staff member received a
comprehensive clinical orientation to the Department’s health care FOPs, facilitated by the HSA.
A review of approved treatment protocols and standing procedures was authorized by the DHA,
as required.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
an Authorization for Evaluation and Treatment (AET) form. Three of the five records included an
AET form stamped “copy” and appropriately filed within the IHCR, as required. Each of these
three forms contained the parent/guardian’s signature, with no indication of refusal to sign, and
all were signed by a Department representative and deemed valid. The remaining two youth
were under the care of the Department of Children and Families (DCF) following termination of
parental rights, with the court authorizing all treatment and procedures. Both IHCRs contained
the required court orders. In September 2025, one of these youth received a court order signed
by a judge restoring guardianship to the parent/guardian, and a new AET form was completed
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and signed by all required parties on November 19, 2025. None of the reviewed youth were
over eighteen years of age. An interview with nursing staff indicated the policy for obtaining a
new or current AET requires staff to immediately contact the juvenile probation officer (JPO) to
request assistance in obtaining consent from the parent or guardian. If the youth is under the
care of the DCF and parental rights have not been retained, and no court order is available, staff
must again contact the JPO promptly to obtain the necessary court order. For youth who are
eighteen years of age or older, the policy states they are responsible for signing their own
consent forms upon reaching their eighteenth birthday.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the parental notification/consent. Four youth required parental notification. Three youth had
documented parental notification for over-the-counter (OTC) medications not covered by the
Authorization for Evaluation and Treatment (AET) and received either parental consent or court-
authorized approval. The fourth youth was not applicable due to the termination of parental
guardianship and the issuance of a signed court order. All four youth had new medications
ordered, with corresponding documentation of parent/guardian or Department of Children and
Families (DCF) contacts within progress notes. Each youth also received written notifications
using the appropriate Department forms. Three of the four youth were applicable for
psychotropic medication. One youth was previously presecribed psychotropic medication upon
admission, two youth began psychotropic medication after admission. In each of the three
records, staff documented witnessed telephone calls, attempts, and conversations related to
psychotropic medication. Each youth prescribed psychotropic medication, whether newly
initiated, discontinued, or significantly changed, the parent/guardian verbal consent was
documented on page three of the Clinical Psychotropic Progress Note (CPPN) or had court
ordered authorization. Two of the three youth were currently or previously under DCF care.
Vaccination records were verified utilizing Florida Shots for all five youth within thirty days of
admission. No vaccinations were administered while in the program; therefore, parent/guardian
consent, including consideration of any religious exemption, was not required. An interview with
nursing staff indicated parental notification is required for several categories of care. For non-
psychotropic medications which are not covered by the AET, as well as for any newly prescribed
or discontinued medications, staff must attempt to contact the parent and document the attempt
in the IHCR progress notes, followed by written notification. When psychotropic medications are
prescribed, discontinued, or have a significant dosage change, verbal consent must be obtained
in the presence of a witness and documented by the psychiatrist on page three of the CPPN,
with written confirmation sent afterward. Parental notification, both verbal and written, is
required for any new vaccinations or immunizations which have not already been consented to
on the AET. For off-site emergency care, staff must attempt to contact the parent/guardian by
phone and then follow up in writing. Any invasive procedure or hospitalization requires both
verbal and written parental notification. Timely notification procedures include providing written
parental letters within twenty-four hours for routine visits. Verbal notification for new non-
psychotropic medications not covered by the AET occurs at the conclusion of the visit, with
written notification also being sent. In emergent situations, verbal notification is made
immediately. For psychiatric services and the initiation of psychotropic medications, verbal
consent is obtained during the on-site psychiatric visit whenever possible. When a youth’s
illness or injury requires emergency services, staff schedule follow-up with a licensed healthcare
professional during the next on-site visit. If the youth is seen off-site, the follow-up occurs at the
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next on-site provider visit. For psychotropic medications, the parent or guardian must again
provide verbal consent with a witness during the psychiatric visit, which is documented on page
three of the CPPN and followed by written confirmation. Immunization records are obtained
through commitment packets, educational records, and/or Florida Shots website, and these
records are reviewed on the day of admission. Documentation of immunization exemptions
requires religious exemptions be completed and authorized by the county health department,
with a copy filed in the IHCR. Medical exemptions must be supported by a signed letter from the
youth’s physician or a Department of Health exemption form stating the reason for the
exemption, with the documentation also being filed in the IHCR.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the healthcare admission screening and rescreening form. Each of the five IHCR’s contained a
Facility Entry Physical Health Screening (FEPHS) form, which was completed on the date of
admission. All five FEPHS were completed by a registered nurse (RN); therefore, none were
completed by direct care staff. None of the five youth were applicable for a change in custody
lasting greater than twenty-four hours. Three additional youth records were requested for
additional examples of FEPHS re-screenings for youth returning after a change in custody
greater than twenty-four hours. The program provided one additional file, as no other applicable
cases occurred during the annual compliance review period. The record reviewed showed the
youth had two rescreening’s completed on dates of readmission by an RN, one in June 2025
and another in July 2025, following required court appearances in the home county. An interview
with nursing staff indicated all newly admitted youth are seen by medical personnel upon entry
to the facility for an initial screening. The admission process begins with an email notification
from the commitment manager. A registered nurse completes the admission screening, and the
nurse documents the review on the FEPHS form within twenty-four hours.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
youth orientation to healthcare/education services. All youth had documentation for the
completion of orientation to healthcare services upon admission to the program. The youth’s
orientation included all necessary topics and was signed by each youth and healthcare staff,
acknowledging the completion of orientation. Health Education is mandated monthly and is
completed as required as supported by the sign-in sheets for the annual compliance review
period. These sessions are led by registered nurses (RNs) and cover all required topics.
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Office of Accountability and Program Support Page 39 of 64 (Revised August 2025)
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
notification to the designated health authority (DHA) and/or designee. Three of the five youth
were found applicable for having a chronic condition. None of the three youth were identified as
in-need of emergency care upon admission. All three applicable youth had documentation of a
referral being sent to the DHA within twelve hours of the youth’s admission. One of three
applicable youth was previously prescribed psychotropic medication upon admission; however,
the psychiatrist was notified for all youth at the time of their admission. An interview with nursing
staff indicated the process and timeframe for notifying the DHA vary based on the situation. For
non-emergent matters, notification occurs upon completion of the medical intake. For emergent
situations, notification is made immediately. Licensed medical staff are responsible for
completing these notifications, which are documented in the admission progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the Health-Related History (HRH) form. All five reviewed youth IHCRs contained an HRH
completed within seven calendar days of admission. Each of the five HRHs reviewed was
completed prior to completion of the Comprehensive Physical Assessment (CPA); as evidenced
by signature and date. All the HRHs were reviewed by the designated health authority (DHA);
this was indicated by the checkbox on the CPA. An interview with nursing staff indicated the
responsibility for completing the HRH lies with licensed healthcare staff and is typically required
within seven days of admission. The program’s practice is for the HRH to be completed on the
day of admission by licensed healthcare personnel.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of a
Comprehensive Physical Assessment (CPA) form. All the CPAs reviewed were completed on
the Department’s CPA form, as required. All five youth had a current CPA on file at the time of
admission; however, the program’s facility operating procedures indicate a new CPA will be
completed regardless of whether one is in the youth’s IHCR at the time of admission. All five
CPAs were completed within seven calendar days of the youth’s admission to the program.
Each CPA was completed by the designated health authority (DHA). All five CPAs documented
the correct Medical Grade. All five CPAs indicated a gynecological examination was “refused”
and a refusal form was signed by each youth and placed in the IHCR as required. Each section
of the CPA was marked respectively with an “O” or an “X” accordingly. All five youth had the
Department’s Problem List updated, as required. All five youth had at least one verified
tuberculosis skin test (TST) documented in the IHCR. All TST results matched on the CPA and
Infectious and Communicable Disease (ICD) forms. An interview with nursing staff indicated the
DHA evaluates every youth after admission, regardless of their current CPA status. Medical
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Office of Accountability and Program Support Page 40 of 64 (Revised August 2025)
assessments follow the established schedule: every two years for Grade one and annually for
Grades two through five. For tuberculosis (TB) screening, if there is no documented TB test
within the past year, the screening must be completed within seventy-two hours of admission.
The nurse also reported gynecological examinations are not routinely performed.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
sexually transmitted infections (STI) screening. All five youth were screened and evaluated for
STIs on day of admission. Each youth was applicable for further evaluation and was referred to
the designated health authority (DHA), documented on the Department STI form. Four of the
five youth had testing ordered and performed. The remaining youth refused testing and signed a
refusal form. For each applicable case, testing and results were documented on the Infectious
and Communicable Diseases (ICD) form, as required. None of the youth met criteria for
rescreening. All five youth signed the Department Human Immunodeficiency Virus (HIV) Youth
Consent form, with one youth declining consent and the remaining four providing consent. All
five youth were offered HIV counseling, testing, and treatment or referral. One youth refused
and signed a refusal form. The remaining four were referred to the Madison County Health
Department for HIV testing and counseling. Three of the four received testing, along with pre-
test and post-test counseling. The fourth youth received an alternate type of care at the Health
Department, despite the original referral for HIV pre-test counseling and testing. For the three
youth who completed HIV testing, results were filed in the IHCR, and each result included
practitioner review with signature and date. Pre-test and post-test counseling were documented
in the Individual Health Education Record for each of the three youth, as required. Youth
confidentiality was maintained by ensuring HIV status and any STI diagnoses were not recorded
in the program’s internal alert system. The program had policies and procedures which
addressed HIV testing results and results are only disclosed to youth, and statutorily identified
entities. The HIV pre and post-test counseling is provided by the Madison County Health
Department. Interviews were conducted with five youth, all of whom stated they could request
HIV and acquired immunodeficiency syndrome (AIDS) testing. An interview with nursing staff
indicated (STI screening is conducted for all youth upon admission, and youth may choose to
accept or decline testing. If further evaluation is needed, the DHA may provide specific orders
for additional testing. Youth have the right to request or decline STI testing at any time. Referrals
and testing are documented on the STI form and practitioner orders. The Office of Health
Services (OHS) recommends completion within thirty days of admission. Documentation in the
IHCR includes the STI form, ICD form, lab results, health education records, and practitioner
orders. Youth are rescreened upon readmission and offered testing if they have been out of the
program for more than thirty days or if symptoms are present. HIV consents, declinations, and
test results are maintained in the confidential medical chart and are not included on any internal
alert or problem list. HIV counseling and testing through the program are provided by the
Madison County Health Department, which conducts pre and post-test counseling as well as
testing. The process and results are documented in the ICD form within the IHCR and in the
youth’s health education record.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
sick call process. Three of five youth records were applicable for the sick call review. None of
the reviewed youth presented with similar sick call complaints three or more times within a two
week period. Seven sick calls were reviewed; the youth completed an individual Sick Call
Request form each time. All seven of the sick calls were reviewed and completed by the
registered nurse (RN). The sick calls were each found filed in the IHCR in reverse chronological
order. None of youth had been in restricted housing during the annual compliance review
period. The reviewed sick call forms were documented in accordance with the Florida
Administrative Code. Each sick call reviewed was documented on the Sick Call Index. All the
sick calls were documented on the program’s Sick Call Referral log. The dates listed on the Sick
Call Index corresponded to the completed Sick Call forms located in each IHCR. A review of the
daily schedule, along with the posted schedule and nurses’ interviews confirmed sick call was
conducted as required by contract requirements. Sick call hours were posted outside the
medical clinic and in each wing. Sick call is available seven days a week, starting at 7:15 a.m.
and as needed. Licensed nurses will conduct sick call if available; however, the program has
procedures whereby the shift supervisor reviews all sick call requests as soon as possible and
within four hours after the request is submitted. Sick call forms are available to youth in each
wing and nurse’s office. An exam table and equipment are used to perform sick calls. An
observation of sick call was unable to be observed, as there were no sick call requests during
the week of the annual compliance review. Five youth were interviewed, and all reported they
could see a nurse within one day of submitting a sick call request. Nursing staff stated sick call
is available seven days a week, beginning at 7:15 a.m. and continuing until all requests are
completed. Youth submit requests using forms available on each wing, and submission boxes
are accessible during bathroom breaks, mealtimes, after education sessions, and during free
time. RN staff routinely conduct sick call, and the designated health authority (DHA) conducts
sick call when scheduled on-site. All sick call visits take place in the medical intake area. If a
youth presents with three similar complaints within a fourteen-day period, the matter is referred
to the DHA. The program follows DHA approved treatment protocols and does not utilize
restricted housing or confinement for health-related purposes.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
an episodic, first-aid, and/or emergency care situation. Four of the five youth required on-site
episodic care. Each of the nineteen medical incidents was conducted by licensed healthcare
staff. The healthcare staff documented each case in subjective, objective, assessment, and plan
(SOAP) format. There were no cases of episodic, first-aid, or emergency care being provided by
non-healthcare staff. The program’s episodic and emergency care procedures were reviewed
and no issues were identified. The program maintains a total of nine first-aid kits, including two
designated for transportation. First-aid kits are located in both youth wings, the medical cart
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Office of Accountability and Program Support Page 42 of 64 (Revised August 2025)
closet in the gym, the kitchen, the large trailer, and the small trailer. Additionally, five suicide kits
are maintained on-site, located in each wing storage closet, the human resources office, the
gym closet, and the lead office. On-site healthcare staff conduct a monthly review of all first-aid
kits to ensure contents are complete, stored in accordance with guidelines, and replenished as
needed to prevent expiration. First-Aid Kit binder logs confirm first-aid kits, automated external
defibrillator (AED), and suicide kits are checked monthly, as evidenced by date and staff
signature. Medical staff reported if a first-aid kit is opened, staff must notify healthcare personnel
and complete the Report of On-Site Healthcare by Non-Healthcare Staff form. The form is then
filed by medical staff, and the kit is restocked and resealed. A review of three first-aid kits, in the
human resources office and both transportation vehicles, confirmed all kits were fully stocked
with designated health authority (DHA) approved contents. The program maintains one AED,
which is stored in the medical cart closet located in the gym. Operating procedures for the AED
are available both with the device and in the medical office. On-site medical staff inspect the
AED daily to ensure the batteries and pads are functional, as documented on the daily log
sheets. There is no indication the AED is monitored by an outside provider. Medical staff
conducted a self-test on the device, and no issues were identified. The AED batteries are set to
expire on April 30, 2026, and were last replaced on February 20, 2022. The AED pads are due
to expire on April 30, 2027, and were last replaced on March 20, 2025. A list of emergency
contact numbers was observed in the medical office and in the medical cart binder; they were
accessible to staff and secured from youth. A sign-in sheet confirmed the health services
administrator (HSA) provided training to direct care staff on the administration of the epinephrine
auto-injector. Five staff training records documented completion of episodic care, first-aid, and
emergency care training. A review of the program’s episodic, first-aid, and emergency care drill
documentation showed drills were completed on each of the four shifts. These drills occurred
monthly throughout the annual compliance review period and were thoroughly documented in
the medical drill binder. All direct care staff participated in at least one drill, which included
cardiopulmonary resuscitation (CPR) procedures. A video review of one medical drill confirmed
the drills are simulated. The scenarios replicate episodic care events require immediate first-aid,
the potential administration of CPR, and the initiation of emergency procedures in response to
life-threatening situations. The program maintained complete and accurate documentation for all
emergency drills, which were unannounced and conducted quarterly on each shift in
accordance with contractual requirements. No episodic care events occurred during the on-site
annual compliance review period. The program maintains Narcan policies and procedures
which address both its use and accessibility. A total of ten units of Narcan were on-site. Two
were stored in a break box in the medical cart closet, three in the medical office cabinet, and
one in each of the five suicide kits. According to facility operating procedures, Narcan
inventories are required weekly; however, the Narcan stored in suicide kits had been inventoried
monthly. Medical staff subsequently removed the Narcan from the suicide kits and placed it in
the medical office cabinet to ensure compliance with weekly inventory requirements. All staff
receive initial and annual Narcan training and are provided access to the medication. Annual
Narcan training was conducted on January 8, 2025, by the HSA, as verified by the training sign-
in sheet. An interview with five youth was conducted, and all reported they are able to see a
dentist or doctor as needed. An interview with five staff members indicated all are authorized to
call 9-1-1 in the event of a medical emergency. Staff responses also described the emergency
response process, which includes assessing the scene, notifying medical personnel, notifying a
supervisor, and calling a code over the radio. Nursing staff reported where each first-aid kits
were located. For on-site episodic care, non-healthcare staff are required to complete the
required Department form and notify licensed staff for follow-up during the next on-site visit.
Licensed staff document care using a chronological SOAP note and record it in the episodic log.
The episodic log, along with the chronic roster, is used to track youth who are sent off-site for
emergency care. The program maintains one AED located in the gym closet, which is checked
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regularly by the registered nurse. Medical staff conduct monthly emergency drills covering all
four shifts. CPR and AED demonstrations are conducted at least quarterly. A list of emergency
numbers is maintained in the Medication Administration Record (MAR) book, on the medication
cart, and in the medical office. Emergency medical drills are conducted monthly for all shifts.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
A review of five youth Individual Healthcare Records (IHCRs) was conducted to assess the
completion of off-site care referrals. Four of the five youth had a total of seventeen applicable
off-site referrals, and each of their IHCRs reflected the need for off-site services. One youth was
not applicable for off-site care. For each instance in which off-site care was provided, a
Summary of Off-Site Care Consultation Report was appropriately filed in the corresponding
IHCR. No cases required off-site emergency services. Parental notification efforts were
documented for all four youth. Discharge documents for all seventeen referrals were properly
included in the respective IHCRs, and the designated health authority (DHA) reviewed and
signed each set of off-site care findings. Additionally, all four youth required follow-up
appointments, which were appropriately tracked, scheduled, and completed. An interview with
nursing staff indicated youth sent off-site for first-aid or emergency care are tracked using off-
site summary reports, which are filed in the IHCR. Nursing staff ensure all hospital orders are
followed, and any additional orders received from the DHA after review of the Off-Site Care
report are implemented and appropriately filed in the IHCR. Charts are flagged for DHA review
during the weekly on-site visit to ensure all off-site care findings, instructions, and information
are reviewed and initialed. Nursing staff also track follow-up testing, referrals, and appointments
using the chronic roster. The program monitors youth with chronic conditions through regular
documentation and oversight using the chronic roster.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
chronic condition periodic evaluations. Three youth were identified as having a chronic
condition, all of whom were recognized during the Facility Entry Physical Health Screening
(FEPHS) at admission. None were found to have a communicable disease. Two of the three
youth were prescribed ongoing medications, and all three were receiving treatment for a
physical health condition. One youth was classified with a Medical Grade between two and four,
the remaining two were on psychotropic medication therefore had a Medical Grade of five. No
youth were identified as pregnant. All three applicable youth were placed on the chronic
condition list. Two received their required periodic evaluations within the prescribed timeframes.
The remaining youth received an evaluation six days late due to scheduling conflicts involving
multiple appointments on the same day. No youth required anti-tuberculosis medication,
prescription renewals, or off-site evaluations; therefore, a designated health authority (DHA)
follow-up was not necessary. Overall, there were no additional lapses in care or missed
evaluations. The Department’s Problem List was updated appropriately for all three youth in
accordance with Florida Administrative Code. An interview with nursing staff revealed the
program monitors youth with chronic conditions through regular documentation and oversight
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using the chronic roster. An interview with the program director indicated the facility’s nursing
staff ensure all newly admitted youth receive a preliminary screening, including a review of
medical history to assess healthcare needs. This assessment is completed as part of the initial
intake process upon program placement. Upon admission, on-duty healthcare staff review the
youth’s previous medical records, conduct a comprehensive assessment, and complete the
FEPHS. A healthcare rescreening is completed each time the youth’s physical custody changes
and they are returned or readmitted to the facility. If the initial screening is conducted by direct
care staff, it is reviewed by a nurse within twenty-four hours. The DHA was interviewed and
stated youth are seen every three months for periodic evaluations for chronic conditions and are
tracked on forms updated weekly. Coordination is done with healthcare staff to ensure the
periodic evaluations are done on time.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
medication management. Four of the five youth were found applicable for receiving medication
at the program. All five youth had a completed Facility Entry Physical Health Screening
(FEPHS) form. Two youth were admitted with medication, and prescription verification was
properly documented in their progress notes and on the Department’s Prescription Medication
Verification Checklist. The designated health authority (DHA), and the psychiatrist when
applicable, were contacted to resume the specified medications prescribed prior to admission.
All prescribed medications for the four applicable youth had current, valid orders and were
administered according to those prescriptions. Practitioner order forms were completed by the
DHA for all medications. The program does not operate restricted housing. Three youth were
authorized to receive over-the-counter (OTC) medications not listed on the Authority for
Evaluation and Treatment (AET) form; these medications were administered in accordance with
approved protocols or practitioner orders unless prohibited by a parent or guardian. The
Department Medication Administration Record (MAR) was used to document all medications
and treatments, and all required elements under Florida Administrative Code were present. Four
youth received medication from non-healthcare staff, and the program follows a policy requiring
healthcare staff, non-healthcare staff, and the youth to initial each administration entry. A review
of the MARs confirmed all entries were properly initialed, with no unexplained lapses or errors in
documentation. Weekly side-effect monitoring was recorded for all applicable youth. None of the
youth refused medication during the review period. All youth had multiple MARs completed,
each containing all required documentation elements. No youth required parenteral medication.
There were no standing orders, emergency treatment orders, or pro re nata (PRN) orders for
psychotropic medications.
A medication administration pass was observed during the annual compliance review. The youth
was escorted to the medical cart by direct care staff and approached the nurse individually. The
medical staff identified themselves, confirmed the purpose of the visit, and verified the youth’s
identity by name, date of birth, and allergies. Medications were prepared from original
packaging, and allergies and alerts were reviewed with the youth. The Six Rights of Medication
Administration were followed. The youth was provided water, took the medication, and a visual
mouth check was completed. The administration was then documented on the MAR with both
youth and staff initials. An interview was conducted with five youth regarding medication
administration. Three youth reported receiving medication from the nurse, while the remaining
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two indicated they do not take medication. An interview with nursing staff indicated each youth’s
medication regimen is verified upon admission. Verification includes reviewing physician orders
and ensuring the youth-specific label on the original packaging matches the current prescription
for administration. The DHA or psychiatrist is contacted to determine whether medications
should be continued or held. All medication verification is documented on required Department
form. Non-healthcare staff do not perform medication verification; their role is limited to
confirming medication counts during custody changes for transport. The program uses the
standard MAR. Non-healthcare staff who administer medications must be trained by the health
services administrator (HSA) through a structured, three-step process. A list of trained staff is
maintained at the front of the MAR binder. Staff must also memorize and adhere to the six rights
of medication administration during every medication pass. Medication pass times are
scheduled Monday through Friday at 7:00 a.m., noon (if applicable), and 5:00 p.m.; Saturday
and Sunday at 8:00 a.m., noon (if applicable), and 5:00 p.m. For pharmaceutical procurement,
the facility holds a modified Class II permit. Medications and prescriptions are obtained through
a contract pharmacy, with orders faxed in and delivered the next day by courier if submitted
before the cut-off time and the medication is in stock. The program also utilizes a psychiatrist,
with a separate fee generated for each youth.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
Psychiatric services are provided by a psychiatrist who holds a clear and active Florida license,
valid through January 31, 2026, in compliance with Florida Administrative Code requirements.
The psychiatrist is available for emergency consultation twenty-four hours a day, seven days a
week. For youth scheduled for treatment team review, the psychiatrist briefs a designated
treatment team representative on each youth’s current psychiatric status. The psychiatrist’s
evaluations and recommendations are incorporated into the mental health clinical staff’s
assessments and are reflected in each youth’s individualized mental health or substance abuse
treatment plan. The program does not employ a psychiatric advanced practice registered nurse
(APRN). A review of sign-in/sign-out logs confirmed the psychiatrist’s visits during the annual
compliance review period were conducted in accordance with contractual requirements. The
psychiatrist actively manages, oversees, and supervises all psychotropic medication services
within the program. No back-up psychiatrist was utilized during the review period, and the
program does not employ telepsychiatry services. An interview with the designated mental
health clinician authority (DMHCA) indicated they meet with the psychiatrist every fourteen days
to review and discuss the care of youth receiving psychiatric services. Three of the five reviewed
youth were found applicable for receiving psychotropic medication at the program. One youth
entered the program on psychotropic medications and the remaining two youth were prescribed
psychotropic medication at a later stage in the program. In accordance with program protocol,
all youth are referred for a psychiatric evaluation; therefore, all five youth received an initial
psychotropic diagnostic interview. The youth admitted on psychotropic medication continued the
prescribed medication. Two youth were not prescribed psychotropic medication at the time of
the initial psychiatric interview but were subsequently prescribed medication later in the
program. The remaining two youth were not prescribed psychotropic medication at any time.
The youth admitted on psychotropic medication received a diagnostic psychiatric interview
within fourteen days of admission, as required. All five youth received an initial diagnostic
interview regardless of medication status, and each interview included a comprehensive history
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and mental status examination. DSM-5-TR diagnoses were documented for the youth admitted
on psychotropic medication. Treatment recommendations were documented for all five youth.
For the youth admitted on psychotropic medication, documentation included the prescribed
medication(s), clinical justification linking the medication to the youth’s diagnosis, identified
target symptoms, initial treatment goals, potential side effects, risks and benefits of medication
use, and the frequency of medication monitoring and management. All five youth had
documentation completed on the Department’s Clinical Psychotropic Progress Note (CPPN),
which was clearly identified as the Initial Diagnostic Psychiatric Interview. One youth was
applicable for prescription medication at the time of the initial diagnostic interview. The youth
who continued on psychotropic medication received medication reviews every thirty days, with a
total of four reviews completed. Two additional youth were prescribed psychotropic medication
later in the program and received required thirty-day medication reviews; one youth completed
five reviews, and the other completed three reviews to date, each being completed every thirty
days as required. All thirty-day medication reviews were conducted by the program psychiatrist,
and page three of the CPPN was completed as required. No psychiatric evaluations conducted
within six months prior to the youths’ admissions were available for review. Page three of the
CPPN included the following required documentation: identifying data; diagnosis; target
symptoms; evaluation and description of the medication’s effect on target symptoms; prescribed
psychotropic medication, including name, dosage, and quantity; normal dosage range; ordered
dosage; frequency and route of administration; rationale for medication or dosage changes; side
effects; description of the youth’s response to medication, including positive and adverse effects
or documentation indicating none were present; youth adherence to the medication regimen;
height, weight, blood pressure, and most recent serum drug levels or laboratory findings when
applicable; documentation of telephone contact with the youth’s parent or guardian regarding
medication; psychiatrist’s signature and date; and monthly monitoring for Tardive Dyskinesia as
indicated on the CPPN. The program does not currently provide telepsychiatry services.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The equipment in the medical clinic classified as sharps was observed to be secured and
inventoried utilizing a routine weekly perpetual inventory. Three sharps were observed and
counted, and the totals matched the program’s documented inventory. All medications were
properly identified and secured in designated locked storage areas. The medication cart was
clean, well-organized, and maintained appropriately. Three over-the-counter (OTC) medications
were also observed and counted, with inventory totals accurately matching documentation. No
controlled medications were on-site during the annual compliance review; however, an
inspection confirmed, if present, they would be secured behind the required two locks.
Additionally, in accordance with Board of Pharmacy requirements, shift-to-shift inventory counts
of controlled substances would be documented on each youth’s Individualized Controlled
Medication Inventory Record. All medications were stored in a separate, secure area
inaccessible to youth. One medication required refrigeration, and it was stored appropriately in a
locked, medication-only refrigerator. The program’s process for destruction or disposal of
expired or discontinued medications requires pharmacy-return for medications originally
dispensed by the pharmacy. The pharmacist, who visits monthly, coordinates this process.
Medications not originating from the pharmacy are destroyed jointly by the nurse and
pharmacist with proper documentation. Perpetual and weekly inventories of sharps and stock
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OTC medications were completed as required. Supervisory-level non-healthcare staff receive
training on medication administration and oversight from the health services administrator
(HSA), with sign-in sheets confirming training occurred on January 8, 2025. If an inventory
discrepancy occurs, the nurse attempts to reconcile the count; if unresolved, the program
director is notified and the incident is reported to the Department’s Central Communications
Center (CCC). An interview with nursing staff indicated the expired medications are handled
according to type. Expired over-the-counter (OTC) medications are disposed of using a pill
buster. Expired psychotropic medications are returned to the pharmacy for credit. Expired
controlled substances are documented and destroyed in a pill buster with the pharmacist
consultant, registered nurse, and administrative staff serving as witnesses. The process for
securing controlled substances, including narcotics, involves faxing a copy of the prescription
along with the order to the pharmacy for fulfillment. The copy and the order are filed in the
youth’s Individual Healthcare Record (IHCR). The program maintains a current agreement with
a consultant pharmacist, who conducts monthly audits of the department, provides guidance,
and participates in quarterly meetings and reviews. A copy of the consultant pharmacist’s
license is maintained on-site.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program’s infection control procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to federal regulations and the
Centers for Disease Control and Prevention (CDC) guidelines. The designated health authority
(DHA) last reviewed the infection control procedures and exposure control plan on October 29,
2025. Reviews were also completed by the program director on October 24, 2025, and by the
health services administrator (HSA) on November 3, 2025. All required elements were included
in the infection control procedures. Hepatitis B immunizations and appropriate protective
equipment are available to all staff. During the annual compliance review period, there were no
incidents required notification of the local county health department, the CDC, or the
Department’s Central Communications Center (CCC). The program maintains a written
exposure control plan which incorporates all required components and specifies procedures for
post–needle-stick exposure. The plan is accessible to all staff and is kept in the medical office.
Additionally, the program director (PD) maintains a separate file for any youth or staff member
who may have experienced a facility-related or occupational exposure. An interview with the PD
indicated the exposure control plan is located in the emergency binder in the medical clinic and
is also accessible throughout the facility. The registered nurse (RN) provides infection control
training to all staff. In addition, youth receive infection control training from an RN upon
admission. Nursing staff interview confirmed a copy of the exposure control plan is available to
all staff. The RN is responsible for conducting infection control training for staff and for providing
infection control education to youth upon admission and annually, as scheduled. Medical staff
oversee training for all staff on the program’s exposure control plan.
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4.20 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for prenatal care
and education. None of the youth were applicable for completion of prenatal care or education.
Three additional youth records were requested; however, there were no pregnant youth in the
program during the annual compliance review period. Upon admission, all five youth received
pregnancy tests, and all results were negative. Each youth received the required health
education, which was appropriately documented in the Health Education section of the IHCR.
On February 12, 2025, all non-healthcare staff responsible for the supervision or treatment of
pregnant youth completed in-service training on girls’ healthcare, provided by the health
services administrator (HSA). The training included guidance on observing and monitoring for
emergency care needs and symptoms of potential miscarriage. The program maintains nursing
protocols and treatment plans specifically designed for pregnant youth. An interview with
nursing staff indicated the program routinely utilizes services provided by the county health
department, including human immunodeficiency virus (HIV) testing and treatment, sexually
transmitted infection (STI) testing and treatment (non-HIV), prenatal care, and routine
gynecological care. Services for pregnant youth include mother and baby classes. All female
youth are tested for pregnancy upon admission, as required by policy. Routine monitoring of
pregnant youth includes daily assessment of signs and symptoms, staff education on pregnancy
and miscarriage, and provision of a specialized diet. The registered nurse (RN) provides
education to non-licensed healthcare staff on girls’ healthcare, and pregnant youth receive
education on nutrition and physical changes associated with pregnancy.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains policy and procedures addressing youth supervision. The program’s
policy states program staff ensures the location of all youth, through active supervision and the
implementation, monitoring, and use of an accounting system of scheduled, unscheduled, and
emergency counts. Program staff shall maintain active supervision of youth, including
interacting positively with youth, engaging in a full schedule of constructive activities, closely
observing behavior of youth and changes in behavior and consistently applying the behavior
management system. The program has a ratio of one staff to eight youth during daytime
activities and a ratio of one staff to twelve youth during sleeping hours. During the annual
compliance review, observation of staff to youth ratio was observed each day to ensure
compliance with ratios. There were no issues observed. Staff and youth were observed during
educational hours, during line movements to and from meals, during breaks including time in
rooms, and during recreational activities. Video review of educational services also confirmed
staff to youth ratio was complying. Each observation confirmed positive interaction. Staff and
youth were following the posted daily activity schedule, which are posted in each living area.
Youth supervision was observed during movements to and from class, to and from meals, and
during searches. At no time during any observation period was staff to youth ratio out of
compliance. Positive interactions were observed between staff and youth. An interview with
three random staff was conducted to determine if staff were aware of the number of youths
actively being supervised. All staff were accurately able to provide the number of youths being
supervised. Based on review of the Department’s Central Communications Center (CCC), the
program had no reported escapes during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures to address implementation of the behavior
management system (BMS). A review of the program’s BMS was conducted to ensure
appropriate parties were involved in the development, implementation, and maintenance of the
(BMS) The program’s policy includes protocol where staff are provided feedback regarding
youth implementation of the BMS. There is a designated trainer who provides training to all staff
as well as educational staff, which included a joint plan on the program’s BMS. A total of five
pre-service records were reviewed and confirmed each had completed training in the program’s
BMS. Five youth records were reviewed to confirm the program’s BMS was included in youth
orientation. Each record contained documentation to confirm review of the program’s BMS. The
BMS is also referenced and documented in youth handbook. Visual observation confirmed the
program BMS is posted throughout the living units and hallways of the program. The program
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has not had any modifications to the BMS since the last annual compliance review period. The
program BMS includes all required. Review of the program’s BMS further confirmed it did not
contain practices of increasing length of stay, denial of a youth’s basic rights, promotion of
group punishment, punishment of youth by another youth, or disciplinary confinement. Visual
observation further confirmed staff and youth interactions were in adherence with such
practices. The program’s BMS includes a process wherein staff explains to youth reasons for
sanctions imposed while also allowing youth to explain their behaviors and further allowing
youth and staff to discuss behavioral impact on others, reparation for harm caused and alternate
acceptable behaviors. The program does provide a variety of rewards and incentives such as
fun Friday, movies, canteen, takeout meals, purple room privileges, and additional phone
privileges. Five youth were interviewed, and each was able to provide examples of
consequences the program has for negative behaviors. Each youth was also able to provide
examples of rewards earned at the program. Examples provided consisted of fun Friday, movie
night, snacks, purple room, daily rewards, and outings. Each youth also reported staff are
consistent in what behaviors they give rewards and consequences to. Each youth was able to
explain the difference between each level and how to move from level to level. Each youth
reported another youth is not allowed to punish youth. Five staff were interviewed, and each
staff was able to explain the program’s BMS. Each staff was also able to articulate types of
rewards the program provides as part of the BMS. Five of five staff reported basic rights cannot
be taken away from youth consequently. Each staff was able to articulate how youth are
informed of consequences and how youth can explain their behaviors.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program currently has a total of forty-three cameras of which all were properly functioning.
The program’s video surveillance system is currently capable of storing video recordings for a
minimum of thirty days. Observation of ten-minute check documentation confirmed checks were
documented in real time and staff completing the checks either initialed or signed the check
sheets. A total of nine thirty-minute increments of video observation was conducted. One of nine
thirty-minute increments contains two checks which were conducted one minute late. All other
checks were completed as required, Observation confirmed checks were conducted in the
required frequency and in real time. Each check was met with fidelity. A review of logs for the
span of the annual compliance review period confirmed checks were conducted as required. A
total of sixteen logs of thirty-minute increments were reviewed and documentation confirmed no
discrepancies. Five staff were interviewed and four reported room checks are conducted every
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ten minutes. The remaining staff reported room checks are conducted every eight minutes. The
program director was interviewed and reported the program has a total of forty-three cameras of
which all were operational during the annual compliance review.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures addressing census, counts, and tracking to
ensure youth are always accounted for. 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
headcounts to be conducted minimally at the beginning of each shift and during any emergency
at regular intervals. During an emergency, it is vital for all staff to be accounted for by
headcounts at regular intervals. Headcounts of youth and staff shall be conducted before and
after each use of vehicles and before and after group movements around the facility grounds.
Headcounts shall be logged in the facility logbooks. Any discrepancy in a headcount shall be
immediately reported to the shift supervisor. An observation of counts was conducted. The shift
supervisor called for a mandatory head count and all movement stopped during the call for
count. Each staff reported the number of youth under their supervision. The headcount was
cleared with all residents accounted for. Youth movement resumed upon confirming a clear
count. A sample of logbooks for the annual compliance review period was reviewed. Sampling
included a full day of each month. Documentation within logbooks confirmed counts are
conducted at the beginning of each shift. No entries contained information related to counts
after outdoor activity as none occurred for reviewed dates, and one entry contained
documentation of an emergency. Logbooks contained a total daily census, headcounts, youth
movement, and youth temporarily away from the program. Five staff were interviewed, and each
staff was able to verbalize how and when youth counts are conducted. Staff provided examples
such as any type of movement, every morning, and informal and formal every thirty minutes.
Each staff was also able to articulate procedures followed when youth count cannot be
reconciled. Examples provided consisted of no movement until count can be reconciled and
stay in place until all youth are accounted for. Each staff was also able to further articulate when
emergency counts are conducted and provided examples such as after drills, anytime there is
an issue, after outdoor activities, when a youth is unaccounted for, after an emergency event,
when counts cannot be reconciled, when a youth escapes, when a youth is missing, or the
count is off.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures addressing logbook entries and shift report
reviews. Documentation review confirmed logbooks were bound with numbered pages, and
entries were made in ink with no erasures or white-out areas. No logbook entries were
destroyed or removed. No logbook entries reviewed contained errors which were required to be
struck through with a single line or initialed by the staff. All entries included date and time of
event, with the names of the staff and youth involved, a brief description of the events, and the
names and signatures of the staff making the entries. No reviewed logbooks indicated there was
a report to the Florida Abuse Hotline or the Department’s Central Communications Center
(CCC). The activity schedule and logbook entries document minimal interference during
educational instruction. A review of logbook entries confirmed educational classes were
conducted as scheduled, youth arrived and departed school on time, and recreational activities
were conducted as scheduled. Logbooks are maintained in master control and are not
maintained in each living unit Logbooks. The program utilizes one logbook to represent each
living unit, therefore, shift reports are also utilized. Documentation review of a sample of shift
reports confirmed staff are debriefed during shift change and are given access to information
from previous shifts summarizing events and incidents documented in the program’s logbooks.
Previous shift reports are reviewed and signed by incoming staff. The program’s logbooks
contained documentation of emergency situations, special instruction for supervision and
monitoring, population counts at the beginning and end of shifts, perimeter security checks and
other security checks conducted by staff, transports away from the facility including name of
staff, youth involved and destination, and admission and releases. Based on reviewed logbook
entries, there were no incidents involving the use of mechanical restraints, no request for law
enforcement access, information relating to escapes or attempted escapes, and no youth was
removed from mainstream population. Shift reports are maintained at each living unit 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 maintains a policy and procedures addressing key control. The program’s policy
includes the control and use of keys as well as key assignment and usage, including restrictions
on usage, inventory and tracking of keys, secure storage of keys, procedures addressing
missing or lost keys, and reporting and replacement of damaged keys. Distribution of keys was
unable to be observed during the annual compliance review as distribution occurred outside of
annual compliance review hours. An informal interview with the shift supervisor and program
director (PD) was conducted. Both interviews confirmed when upon arrival to the program and
after search procedures, staff will provide their personal keys which are stored in the key
lockbox. Staff will then sign the key inventory log which indicated the key ring number and what
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keys are attached to the ring. Staff will sign to indicate they have received the assigned keys;
staff also sign the inventory log upon departure from the program confirming they have returned
the assigned key. The program’s key storage area is maintained in the program’s main
entrance. The key storage box is attached to the wall. The storage box is key and padlock
accessible as well as electronic keypad combination accessible. The key box is not easily
accessible while locked. An observation of the key inventory was conducted to ensure inventory
matched the actual key logs. All keys were in their correct location and matched the key number
and total number of keys listed. The key storage is secured when not in use. Permanent issued
keys are authorized by the PD. When permanent keys are assigned, staff receiving the keys will
sign an acknowledgement form indicating receipt and procedures to adhere to for assigned
keys. Keys are inventoried monthly to ensure accuracy. Documentation of monthly checks were
done for the scope of the annual compliance review and confirmed the program is following its
practice. Restricted keys are only accessible to authorized staff who are assigned to specific job
functions requiring restricted key use. The program’s process for reporting and replacing
damaged keys states damaged keys shall be reported to the shift supervisor and returned to the
maintenance supervisor, who will be responsible for discarding, updating inventories as
applicable and the issuance of replacement keys. A review of the Department’s Central
Communication Center (CCC) revealed the program had no incidents reported during the scope
of the annual compliance review period related to key control concerns. Three staff were
informally interviewed regarding their assigned issued work keys. Each staff was able to identify
the correct number of keys on their ring as well as identify the function of each key.
Five staff were interviewed, and each was able to articulate the process for personal and
program keys from when walking in to begin shift until departing.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures addressing illegal and prohibited items from
being introduced into the program. The program’s current system required elements such as the
program defining items which are considered contraband, providing youth with a list of
contraband items, informing youth of consequences of having contraband in their possession,
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searching the physical plant, searching the grounds of the facility, searching youth, and
searching incoming and outgoing mail. Visual observation confirmed the program’s visitor
logbook contains a contraband attestation statement. During the scope of the annual
compliance review period, the program hired a total of nine new staff members. Documentation
confirmed each staff member had a completed attestation form on record. The program’s policy
and procedures address staff who are found to be in possession of contraband in the program
and further states staff will be subject to disciplinary action up to and including dismissal. The
program policy and procedures indicate law enforcement will be contacted in the event items
considered contraband are found. The program’s policy and procedures clearly delineate items
which are considered contraband. During the scope of the annual compliance review, the
program had no items of contraband confiscated. The Department’s Central Communications
Center (CCC) website was reviewed and no reports of incidents where illegal contraband was
turned over to law enforcement was reported. The program’s logbooks, incident reports, and
search reports were reviewed to determine frequency and quality of searches as well as search
results were reviewed with no issues. Five staff were interviewed, and each was able to explain
the process for youth room searches. The program director (PD) was interviewed and reported
contraband items which are designated as contraband are prohibited on campus by staff,
volunteers, contractors, visitors, or youth. During orientation, all youth are given a handbook
which lists all items considered as contraband. There are postings of a list of contraband items
throughout the program. The program conducts contraband searches of the physical plant,
facility grounds, each youth, and incoming and outgoing mail. Program policy and procedures
address any staff who is found in possession of contraband in the program. Law enforcement is
to be contacted if any item considered illegal as defined in Florida Statutes is identified, or if
there is evidence of any type of unlawful activity. All contraband discovered or confiscated, and
is considered harmful contraband, is turned to the PD who will contact the appropriate
authorities if needed.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures addressing searches and full body visual
searches. During the annual compliance review, youth were observed being searched during
breaks, before and after line movements, and lunch breaks. Observation of searches confirmed
youth are treated with dignity and respect. Searches were conducted by the appropriate number
of staff and gender, and searches were thorough with staff providing instruction and explaining
reasons for extent of searches. During the annual compliance review, no observations of
searches during transports, after admission, visitation, following off-campus activities, or
following access to tools occurred because neither activities nor events occurred during annual
compliance review hours. Video review of staff and visitor searches was conducted. A total of
three staff and two visitor searches were reviewed with no observed issues. During the
searches, both staff and visitors were searched utilizing an electronic wand, each staff and
visitor was pat searched, and all personal property was searched. Five staff were interviewed
and each reported youth searches are conducted every movement. Five youth were
interviewed, and each was able to articulate when searches are conducted including after every
movement, every day, and every transition.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 64 (Revised August 2025)
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures to address maintenance of vehicles used for
transportation of youth. The program has two vans which are used for transportation of youth.
The program’s two transportation vehicles as well as five additional staff vehicles were randomly
checked on one day of the review to ensure the vehicles were properly secured when not in use
and each vehicle was found to be properly secured. Documentation review confirmed each
vehicle used for transportation of youth had an updated annual safety inspection documented.
One van had identified deficiencies which has been corrected. The maintenance records are
maintained by the program’s building manager. Each vehicle contained an annually inspected
fire extinguisher, approved first-aid kit, seatbelt cutter, window punch, and the appropriate
number of seatbelts. The door to the youth passenger area was not able to be opened from the
inside in either vehicle. Neither of the two transportation vehicles required a safety screen.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures for transportation of youth. Based on review of
the program’s policy, as well as an informal interview with the shift supervisor, a cell phone and
radio are issued to transporting staff. An observation of transportation was unable to be
conducted during the annual compliance review as no youth transports were schedule during
the annual compliance review week. According to the program’s policy and procedures, the ratio
for staff transporting youth is maintained at one staff to five youth for offsite transportation
however a minimum of two staff shall accompany all transports with one staff member of the
same gender as the youth. To ensure all staff transporting youth maintain a current and valid
driver’s license, the program’s human resource department obtains monthly driving record
information from the Department of Highway Safety and Motor Vehicles. No youth are allowed
to operate program or staff vehicles. Five staff were interviewed, and each staff reported youth
secured in the vehicles using seatbelts. Each staff also reported the program provides a cellular
telephone as a communication device during transports. Each staff was able to articulate types
of safety equipment within transport vehicles. All staff reported staff are not allowed to use
personal vehicles to transport youth and reported transport vehicles are searched for
contraband prior to and after each use. Each staff explained the emergency response process
during vehicle transport. Each staff was able to articulate staff to youth ratios while on transport
and provided examples of one to one, more than one youth there is two staff, two to eight, and
one to five. Five youth were interviewed, and each reported not ever being handcuffed to any
part of the van or ever seeing anyone place contraband in a transport vehicle.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 64 (Revised August 2025)
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures addressing weekly safety and security audits.
The program director (PD) is responsible for conducting the weekly security and safety
inspections, as well as developing and implementing warranted corrective action because of
safety and security deficiencies identified during internal or external review audit or inspection.
Safety and security audit documents were reviewed for the scope of the annual compliance
review and were found to be following requirements. The program’s preventive maintenance
checklist was reviewed to ensure maintenance and repairs were conducted as outlined in
Florida Administrative Code. Confirmation of safety and security audits as well as preventive
maintenance checks was affirmed by the Residential safety and security specialist. The PD was
interviewed and reported program policy and procedures include completion of a weekly safety
and security audit, the development and implementation of corrective actions warranted
because of safety and security deficiencies found during any internal or external review audit, or
inspection. If deficiencies are found the issue(s) work orders are put in place and all supervisors
are notified along with administrators.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures addressing tool inventory and management.
The program’s policy and procedures address the issuance, inventory and control of equipment
and tools. All tools are inventoried prior to and after work activities. The program building
manager conducts daily inventory of tools with sharp edges or points. Inventory of items without
sharp edges are inventoried daily and monthly. Review of the program’s inventory forms
confirmed the program’s practice. The program prohibits the use of machetes, bowie knives, or
other long blade knives. The program’s procedure for missing or lost tools dictates in the event
a tool is missing staff shall notify the program director (PD) and the tool control officer
immediately. A tag is hung on the shadow board until a replacement tool is in place. If a class A
tool is missing during a work project or activities involving youth, the PD or designee is
immediately notified and the staff member supervising the inventory writes an incident report,
document in the program’s logbook, and notifies the Department’s Central Communications
Center (CCC) within the required timeframe. If a tool is missing after a vocational education
class, all youth in class will be held in the vocational area until a thorough search has been
conducted. If a tool is missing from another area, all youth with access to the tools are held at
the work site until a thorough search of the youth and the area are conducted and all staff are
notified. The program had no instances of lost or missing tools during the scope of the annual
compliance review. If a tool is damaged it is properly disposed of and a new one acquired to
replace it. The maintenance worker, or PD in their absence, will complete inspections of all tools
weekly and submit to the PD. A total of ten tools, including kitchen tools, were reviewed to
compare with inventory. Each tool was secured, was marked for easy identification, and the
inventory observed was accurate.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 64 (Revised August 2025)
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures addressing youth tool handling and supervision
to ensure tools are used safely. The program’s policy and procedures include required elements
such as supervision requirements when youth use tools, issuing tools, established ratios, tool
distribution and collection, and search criteria during work projects, during activity. An
observation of youth utilizing tools was not able to be observed during the annual compliance
review week do to no youth handling tools during this time. The program’s policy and
procedures dictate a one staff to five youth ratio will be maintained when youth are using tools,
during searches, and tool distribution and collection. The program does not participate in
disciplinary work projects. Youth who are given permission to utilize tools have passed training
and have an approved risk assessment. Five youth records were reviewed, and each record
was found to have a completed risk assessment. One of five youth was approved for tool usage.
A request to the program was made to provide four additional records of youth who have been
approved for tool usage. Documentation review within each of the five youth records who were
approved for tool usage contained evidence of training on the intended and safe usage of tools.
Five staff were interviewed, and each reported youth are allowed to use mops and brooms. Five
youth were interviewed and found each reported they are allowed to use mops, brooms, and
scrub brushes.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures addressing outside contractors. The program’s
policy and procedures states outside contractors/services personnel shall be accompanied by
the maintenance staff or designee and will receive written instructions regarding responsibilities
for tool control and prohibition on bringing in contraband. Contractors shall limit tools to only
those necessary. Staff will check tools upon the workers arrival to and exit from the program.
Youth access will be restricted from the work area. In addition, facility staff shall supervise
outside contractors/services personnel in areas located by the youth. Immediate reporting to the
program director (PD)/on call designee shall be initiated in the event the worker identifies a
missing tool. Sign-in instructional sheets were reviewed. The contractor agreement sign-in
sheets dictates the procedures the contractor is required to follow related to tool inventory
prohibited tools and items. The sign-in sheet contains contractor name, company being
represented, and contractors signature. Tools are inventoried upon admission and upon
departure with acknowledgement confirming all tools are accounted for. The program’s
guidelines for outside contractors’ tools includes the following: tools are checked upon arrival
and departure, tool restrictions while in the facility, youth restriction from the work area and
missing tool follow-up. A review of three invoices for completed projects were reviewed and
documentation confirmed dates of invoices coincide with work projects completed at the
program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 64 (Revised August 2025)
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a policy and procedure for fire, safety and evacuation drills.
Documentation review for the scope of the annual compliance review period confirmed the
program conducts emergency and Continuity of Operations plan (COOP) drills monthly on each
shift on a rotating basis. Documentation review confirmed drills contained all required elements
such as type of drill, date and time of drill, drill participants, brief scenario, finding. and
recommendations. Visual observation confirmed fire evacuation routes and egress plans were
posted throughout the facility. Documentation review and visual observation confirmed the
program has a total of eighteen fire extinguishers in various locations and each was inspected
annually. Five staff were interviewed and reported participating in drills. Examples provided
were evacuation, fire, food and safety, medical, suicide, Right Interaction (RI), escape, and
active shooter drills. Five youth were interviewed and each reported being instructed on what to
do in case of a fire. Youth indicated various timeframes including one time a month, two times a
month, every week, and they are done often. The program director (PD) was interviewed and
reported the program conducts drills monthly, including mental health, medical, and RI drills.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a Continuity of Operations Plan (COOP) which is maintained on each
living unit and supervisor office and is readily available to all staff. The COOP was reviewed and
updated on February 12, 2025, and was approved by the Department’s Residential Services
March,12, 2025. The program’s COOP addresses alternative relocation sites approved by the
Department. The program’s Emergency Disaster Preparedness Plan and COOP is a combined
Plan. The emergency supplies are in a delegated storage closet, kitchen, and supervisors’
office. Supplies observed consists of clothing, under garments, toiletries, bedding, dry goods,
water, and batteries. The program maintains two binders representing each dormitory living unit.
Each binder contains all relevant critical identifying information for each youth. Reviewed
documentation confirmed binders contained all required elements such as youth’s full name,
Department of Juvenile Justice identification number (DJJID), admission date, date of birth,
gender, race, name, address, and telephone numbers for parent/guardian, name, address, and
telephone number of the person with whom the youth resides and his or her relationship to the
youth, emergency contact information, juvenile probation officer’s (JPO) information, names of
committing judge, state attorney, and public defender, committing offense and judicial circuit
where offense occurred, notation of whether or not the judge retains jurisdiction, victim
notification information, if required, physical description of youth, personal physician, if known,
and photograph of youth. The program director (PD) was interviewed and reported available
copies of the COOP are in each department's office and posted throughout the facility.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 64 (Revised August 2025)
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedure addressing storage, inventory, and disposal of
flammable, poisonous, and toxic items and materials. The program’s policy states caustic,
poisonous, flammable, or hazardous fluids, substances, or chemicals shall never be stored in
program living areas. All flammable, poisonous and toxic materials shall be secured in locked
storage areas when not in use. The program maintains inventory of all flammables, poisonous,
and toxic fluids used in the facility. Maintenance staff shall inspect all storage areas and
inventories monthly and note any discrepancies in a report to the program director (PD). Visual
observation confirmed flammable, poisonous, and toxic materials are stored in secure areas
inaccessible to youth and inventories were maintained. Maintenance, youth care workers,
supervisors, kitchen staff, medical staff, and PD are all authorized to handle flammable,
poisonous, and toxic materials. According to the program’s policy and procedure disposal of
hazardous chemicals is accomplished within parameters of state, local, and federal laws. Only
maintenance or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous waste and or solid waste, shall be responsible for disposing of
hazardous items and toxic materials. Hazardous items and toxic substance or chemicals will be
disposed of in accordance with Occupational Safety and Health Administration (OSHA)
Standard. The PD, maintenance staff, and supervisors are authorized to dispose of items. The
program disposes of hazardous waste by method of bio-hazardous waste contractor. An
informal interview was conducted with the program’s building manager to determine disposal
practices. The building manager reported when materials are targeted for disposal, the program
contacts the bio-hazardous waste contractor. The contractor visits the program monthly, items
targeted for disposal are stored securely until removed. The building manager further reported
the program had no items targeted for disposal for the scope of the annual compliance review
period. Hazardous liquid waste is disposed of in accordance with Safety Data Sheets (SDS).
Hazardous liquid waste is stored in a hazardous material storage area, mop water and unused
beverage waste is disposed of in the kitchen drains, and kitchen grease is stored in a separate
container for disposal. According to program policy and procedures, upon becoming aware of a
chemical spill, staff shall notify master control of the location, the shift supervisor or master
control shall direct the shutdown of all air handlers and ventilation systems and close all
windows and doors at the direction of the on-scene supervisor or PD, and assistance from
outside the facility shall be contacted as necessary. The program reported no chemical spills
during the scope of the annual compliance review period. A sampling of inventory of ten items
was conducted. Each item contained an SDS, and the inventory of each item matched the
actual items observed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 64 (Revised August 2025)
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedure addressing youth handling and supervision of
flammable, poisonous, toxic items and materials. The program’s policy states all flammable,
toxic, caustic, and poisonous materials shall be stored in secure areas inaccessible to youth.
Program youth shall not be permitted to use, handle, or clean with dangerous or hazardous
chemicals, respond to chemical spills or clean, handle, or dispose of any other person’s
biohazardous material, bodily fluids, or human waste. Visual observation confirmed the program
maintains strict control of flammable and toxic items and materials. Access to areas where
these items are used or stored is restricted for youth. An observation of youth during daily
cleaning activities were not able to be conducted during the annual compliance review. Five
youth were interviewed, and each reported never having used any chemicals or cleaning
products.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 64 (Revised August 2025)
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 water-related activities; therefore, this indicator will be rated
as non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedure addressing visitation and communication. The
program’s visitation schedule is posted on each living area, main lobby area, as well as within
youth orientation handbooks. The program’s policy and procedures related to visitation and
youth correspondence states program youth shall be provided opportunities to promote
communication and engagement which fosters family reunification and community connections.
Youth shall be provided opportunities to send and receive mail to promote communication which
fosters family reunification and community connections. Youth shall be provided the opportunity
to make outgoing phone calls to aid in family reunification, strengthen transition, and promote
successful community reintegration. Reviewed documentation confirmed visitation occurs on
Sundays from 2:00 p.m. until 5:00 p.m. Telephone and mail correspondence logs were reviewed
and confirmed youth are offered telephone calls one time a week and mail is sent two times a
week. Youth are encouraged to write at least one time a week. Each youth was offered and
given an opportunity to communicate and participate in visitation, mail correspondence, and
telephone call opportunities. An alternate visitation schedule is offered when special
circumstances arise. An informal interview with the transition coordinator confirmed there were
no youth with a history of human trafficking. An interview with the therapeutic manager
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 64 (Revised August 2025)
confirmed the program utilizes language line services as the third-party language service
provider for language translation services. According to policy and procedures, outgoing mail is
searched. Five youth were interviewed and each reported being able to call or write
parent/guardian.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program’s activity schedule documents a range of supervised and structured indoor and
outdoor recreation and leisure activities for youth to participate in for at least one hour daily. The
program’s activity schedule is posted within each living unit. Large muscle activities are
provided. A review of the program’s logbooks confirmed recreational activities were conducted
as scheduled and activities indicated promotion of social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. Observation
of recreational activities confirmed the program takes precautionary measures to prevent
overexertion, heat stress, dehydration, frostbite, hypothermia, and exacerbation of existing
illnesses or physical injury. The program’s recreation therapist position has been vacant since
September. The credentials for the previous recreation therapist’s credentials were reviewed
and met all requirements during. Five youth case management records were reviewed for
recreational therapy inclusion within their individualized performance plan. Each youth individual
performance plan contained recreational therapy. Five staff were interviewed, and each was
able to describe types of indoor and outdoor activities provided to youth at the program as well
as duration of the activities. Each staff reported activity duration time as one hour and activity
examples provided were basketball, kickball, volleyball, softball, yoga, Zumba, and dodgeball.
Five youth were interviewed, and each youth reported activities are provided for at least one
hour. Examples of activities provided were basketball, exercise, dodgeball, volleyball, softball,
calisthenics, Zumba, yoga, kickball, and soccer
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 does not utilize controlled observation; therefore, this indicator will be rated as
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 does not utilize controlled observation; therefore, this indicator will be rated as
non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 64 (Revised August 2025)
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 does not utilize controlled observation; therefore, this indicator will be rated as
non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 64 (Revised August 2025)

source: DJJ

program_name_raw: JoAnn Bridges Academy