summary: QI Residential - FY25-26 - 8 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Jacksonville Youth Academy
Wayne Halfway House
(Contract Provider)
4501 Lannie Road
Jacksonville, Florida 32218
Review Date(s): August 26, 2025-August 29, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Michele Maynard, Office of Accountability and Program Support, Lead Reviewer ([Standard1])
Jeff Campbell, Office of Education, Northeast Education Coordinator, (Standard 2, Education
Standard 1)
Jamie Franz, Office of Postsecondary and Workforce Education, Deputy Director (Standard 2
and Education Standard 1)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Ben Marrufo, Office of Fidelity, Accountability and Support, Director (Standard 2)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Jacksonville Youth Academy MQI Program Code: 1293
Provider Name: Wayne Halfway House Contract Number: 10833
Location: Duval County / Circuit 4 Number of Beds: 24
Review Date(s): 8/26/25-8/29/25 Lead Reviewer Code: 224
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), 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 69 (Revised August 2025)
2.19 C ontract S
T h e fo llo w in g lim ite d a n d /o r fa ile d in d
Lim ited R atings
2.18 E ducational A ccess (R esidential C ontract P rovider)*
pecific C areer and Technical E ducation S ervices (R esidential C ontract P rovider)
5.01 Y outh S upervision*
5.06 Logbook E ntries and S hift R eport R eview
5.16 Fire, S afety, and E vacuation D rills
ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n .
Failed R atings
5.04 Ten M inute C hecks*
5.09 S earches and Full B ody V isual S earches
5.12 W eekly S afety and S ecurity A udit
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 69 (Revised August 2025)
In d ic a t o r R a t in g s
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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
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Assessments and Reassessments Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals, and Transmittal* Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
2.18 Educational Access (Residential Contract Provider)* Limited
2.19 Contract Specific Career and Technical Education Services (Residential Contract Provider) Limited
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 69 (Revised August 2025)
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* Satisfactory
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* Satisfactory
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 69 (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 Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 69 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision* Limited
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* Failed
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Limited
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Failed
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Failed
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 Limited
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 69 (Revised August 2025)
Program Overview
The Jacksonville Youth Academy is a twenty-four-bed program, for fourteen to nineteen-year-
old males, located in Jacksonville, Florida. The program is operated by Wayne Halfway House,
LLC, through a contract with the Department. The program provides the following services:
Mental Health Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services
(SAOS). In addition, the program fosters each youth by providing Impact of Crime, Cannabis
Youth Treatment, Aggression Replacement Training, Dialectical Behavior Skills for Adolescents,
and Living in Balance. Additional treatment services provided includes individual, family, and
group therapy sessions, recreation therapy, and restorative justice programming. Program
administration is comprised of a facility administrator, an assistant facility administrator, and a
human resources generalist. Case management services are provided by transition services
manager and two case managers. Mental health staff at the program includes the clinical
director, who also serves as the designated mental health clinician authority, two therapists, and
one recreational therapist. Medical services are offered seven days a week from 7:00 a.m. to
7:00 p.m. and are provided by a health services administrator and two registered nurses.
Educational services are provided by the Florida Scholars Academy and Florida Youth College.
The layout of the program includes one building which contains the dormitory, kitchen, cafeteria,
medical unit, case management, mental health, and administrative offices, and maintenance
building. Additionally, there are three portable buildings which serve as two education
classrooms and the third as a planning and workspace for educational staff. The program has
thirty-two operating security cameras providing coverage with one camera currently being
offline. At the time of the annual compliance review, the program had no vacant positions.
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.
Twenty staff were hired during the annual compliance review period. The program had no new
volunteers requiring a background screening during the annual compliance review period. The
program has facility operating procedures (FOPs) for volunteers, mentors, and interns who work
with youth less than ten hours a month requiring sight and sound supervision. A background
screening was completed for each of the twenty staff prior to contact with youth and access to
confidential youth records. A criminal history report was reviewed for each staff. Each staff
received an eligible rating on the background screening and did not require an exemption. A
pre-employment assessment tool was administered to all twenty of the direct care staff and
twelve received a “preferred” or “review” score. Eight staff received a score of “caution.” The
program stated the assessment is used as a tool to identify strengths and areas of
improvement. Those areas of improvement are intended to be enhanced through training or
monitoring, but the assessment does not necessarily provide a “pass/fail” score. The program
added each staff to their Clearinghouse employment roster. An Annual Affidavit of Compliance
with Level 2 Screening Standards was completed and sent to the Department’s Background
Screening Unit (BSU) on December 19, 2024.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has policy and procedure which outlines the requirements for staff five-year
rescreening. The program did not have any staff applicable for a five-year rescreening during
the annual compliance review period due to a new contract beginning October 1, 2024.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has facility operating procedures (FOPs) in place to promote an environment of
physical, psychological, and emotional safety. All staff, volunteers, interns, and contracted staff
who have knowledge, or reasonable cause to suspect a youth of being abused or neglected are
to report the information to the Florida Abuse Hotline or the Department’s Central
Communications Center (CCC), for youth eighteen years or older. All allegations are reviewed
by the facility administrator (FA). A review of five staff personnel records revealed staff sign and
adhere to a code of conduct. During the annual compliance review period, the program had a
total of two alleged incidents related to physical, psychological, or emotional abuse reported to
the CCC. Both incidents, though management took immediate action to address the allegations,
were unsubstantiated and neither involved potential human trafficking, child sexual exploitation
or labor trafficking. A tour of the program found the Florida Abuse Hotline and CCC numbers
posted throughout the facility. When a youth requests to make an abuse report, staff will
facilitate an abuse call and notify administration. The program completed a Trauma Responsive
and Caring Environment (TRACE) self-assessment on May 10, 2025.
Five youth were interviewed. All five youth confirmed they felt safe at the program and denied
ever being stopped from reporting abuse. All five youth were able to articulate the location of the
CCC and Florida Abuse Hotline phone numbers. All five youth reported the staff are respectful
when speaking to them and other youth. Four out of five youth stated staff do not use curse
words when speaking to youth, and one youth said staff use curse words occasionally when
youth are being disrespectful using curse words and the staff will respond with curse words.
This issue was discussed with the program’s administration and though they were aware of an
incident which was previously addressed, a shift briefing reminder was conducted while the
team was on-site. None of the five youth have ever exchanged emails, telephone numbers, or
social media contact information with staff. Five staff were interviewed and asked to explain the
process for allowing youth or staff to call the Florida Abuse Hotline or CCC to report suspected
abuse. All five staff stated youth are allowed to call the abuse hotline if they request. All five
reported the supervisor is notified when a call is made and two of the five reported the FA is
notified. An interview with the FA confirmed the program has policy and procedures to include
timeframes, documentation and follow-up for abuse allegations.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 69 (Revised August 2025)
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.
The program had a total of eighteen reports to the Department’s Central Communications
Center (CCC) during the annual compliance review period. Five reports were selected for
review. All of the incidents were reported within the required two-hour time frame. Each of the
incidents were documented in the logbook, with no exceptions. A review of the program’s
internal incidents and grievances found there were no additional incidents which should have
been reported to the CCC and were not. Given the program is under a new contract effective
October 1, 2024, there is no comparative data from previous years to determine whether an
increase or decrease in reportable incidents has occurred.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had two Protective Action Response/Right Interactions model (PAR/RI) incidents
during the annual compliance review period, and both were reviewed. Each report was
completed by the end of the staff’s workday and both records included statements from all staff
involved. Both reports reflected reviews by a supervisor and a RI instructor or RI-certified
supervisor. All RI incident reports were reviewed by the administrator, or designee, within
seventy-two hours of the incident. None of the reports involved mechanical restraint, injuries, or
allegations of abuse. Monthly summaries were maintained by the program of all RI incidents
and were submitted to the Department’s regional office by the fifteenth of each month. The
program’s RI plan was updated by the provider on August 15, 2025, and approved by the
Department’s regional director on August 17, 2025. The program’s RI rate during the previous
quarter was .26 which is below the state Residential average RI rate of 2.41. The facility
administrator (FA) was interviewed and confirmed the program’s policy and procedures for
PAR/RI. All five interviewed staff reported they are trained to utilize RI and could explain the
process. One staff stated they were involved in an incident where the use of RI was required.
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 has facility operating procedures (FOPs) for pre-service and certification
requirements for new staff during the first 180 days of employment. Staff in the positions of
youth care worker, shift supervisors, maintenance, kitchen staff and administrators are
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 69 (Revised August 2025)
considered direct-care staff and are counted in the youth-to-staff ratio. Documentation
confirmed all instructors were qualified to deliver training as provided in Right Interactions (RI),
First-Aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED) use.
The program’s training plan was signed and approved by the facility administrator, the assistant
secretary for Residential Services, and the director of Talent, Leadership, and Development.
Five staff records were reviewed in the Department’s Learning Management System (SkillPro).
Three of the five staff had not completed 120 hours of training within the 180 days of hire but
completed all outstanding trainings after the program received the notice of annual compliance
review. The remaining two staff members completed 120 hours of training within 180 days of
hire. All five records had the essential skills of CPR, First-Aid, AED, Emergency Procedures,
Facility operating procedures (FOPs), Prison Rape Elimination Act, Child Abuse Recognition,
Reporting and Prevention, Professionalism, Interpersonal Communication, and Ethics,
Standards of Conduct, RI, and Suicide Awareness and Prevention completed prior to youth
contact. Two of the staff were supervisors and each staff had the required sixteen additional
hours of training in the topic areas of Coaching, Leadership, and Personal Accountability. The
program had no applicable returning direct care staff having less than two years from
separation. Three additional training records in SkillPro were reviewed for staff with less than
180 days from hire and all three staff completed all required training prior to being in the
presence of youth.
1.07 In-Service Training Non-Applicable
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has facility operating procedures (FOPs) relating to the completion of annual in-
service training. Due the start of the new contract on October 1, 2024, this indicator is rated as
non-applicable.
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 facility operating procedures (FOPs) which outline the grievance process and
required staff training. The program’s grievance process includes informal, formal, and appeal
phases and associated timelines. The program’s informal phase of the process is documented
as a discussion with the supervisor and the youth, and the program’s practice correlates with
their process. A review of the program’s grievance documentation confirmed the program
maintains grievances for the past eleven months, which included eight grievances for the annual
compliance review period. Six of the grievances were reviewed, and all of the grievances were
responded to within the required time frame. Each grievance was resolved during the formal
phase. All five interviewed youth were familiar with how to submit a grievance, from locating the
form on the wall of the dormitory, to submitting it to the grievance box. All five youth stated they
could get help completing the grievance, if needed. Five interviewed staff were asked about the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 69 (Revised August 2025)
grievance process. All five were aware grievance forms are placed throughout the program, four
of five reported the supervisor reviews grievances, one said the facility administrator (FA)
reviews the grievances, and all five staff were aware youth could request assistance in
completing the form. The FA was interviewed and confirmed the program’s policy and
procedures for grievances.
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 as 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 provides instruction and activities focusing on developing life and social skill
competencies in youth. Youth are provided the opportunity to volunteer for community services
projects inside and outside of the program. The youth most recently volunteered at a local food
bank, car washes to benefit nonprofit organizations, and visits to a local nursing home to visit
with the residents. The youth are provided health and wellness training from the nursing staff
regularly. The youth participated in a college tour at Edward Waters University, trips to Golden
Corral to practice restaurant etiquette, and engaged with volunteers presenting professional
dress etiquette to include tying a bow tie and necktie. The recreational therapist facilitated a
"Good Winners and Good Losers" series to demonstrate appropriate sportsmanship while
participating in or spectating at a sporting event. Staff model effective communication skills and
have youth practice these strategies during daily interactions. Guest speakers with learned
experience have volunteered at the program to discuss the importance of making good choices.
Documentation, including sign in sheets, agendas, photos, press releases, awards, and
certificates of participation were observed. Five interviewed youth report they have participated
in Cannabis Youth Treatment groups where they talk about their substance abuse, how it
affected their lives, and coping skills to stay drug free upon release. The facility administrator
was interviewed and confirmed the youth’s involvement in community service and life and social
skill activities. The designated mental health clinician authority was interviewed and stated youth
can practice new skills they have learned in group during recreation time, during school, at any
time they are with their peers/staff, and during family sessions/visitations.
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Office of Accountability and Program Support Page 14 of 69 (Revised August 2025)
1.11 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Jacksonville Youth Academy. For details related to IOC service delivery,
please refer to the annual SPEP report.
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 established a continually updated internal alert system which is easily
accessible to program staff, which keeps them alerted to youth who pose a risk to security or
safety, including escape, suicide, other mental health, medical, sexual offender, and other
assaultive or violent behavior risks. All alerts are documented on an internal alert form with
accompanying supportive documentation, including the youth’s alert in the Department’s
Juvenile Justice Information System (JJIS), if applicable, internal incident documentation,
Assessment of Suicide Risk or Crisis Assessment, and/or youth’s classification or re-
classification form. Open internal alerts are posted on the alert board in a prominent location
available to staff, identifying which youth are on specific alerts. Additionally, alerts are updated
on a daily report and distributed electronically to administration, shift supervisors, case
management, and mental health and medical staff. This daily report is utilized to inform direct
care staff at shift briefings, conducted by the shift supervisor before each shift. Youth alerts
regarding diet and food allergies were found posted in the kitchen and shielded from view of
other youth. Seventeen alerts across five youth records were reviewed. All seventeen of the
alerts were entered or updated as required. All alerts matched in JJIS with the internal alert
system and were all found to be noted in either the logbook or shift report. An interview with the
facility administrator confirmed the program has a policy and procedure outlining the
expectations for JJIS and internal alerts, and explained it is the responsibility of the facility
administrator and/or designee, clinical director, director of nursing, and shift supervisors to
ensure compliance. An interview with the program’s nurse confirmed the nurses are responsible
for updating medical alerts. Five staff were interviewed and stated they are informed of youth’s
alerts at shift briefing, through email, or by the alert board.
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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 an Individual Healthcare Record and a separate individual management
record. The reviewed individual management records contained the youth’s name, Department
identification number, date of birth, county of residence, and committing offense. The individual
management records contained sections labeled legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and miscellaneous. All reviewed youth records were labeled confidential and secured in a
locked file cabinet labeled confidential.
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 has facility operating procedures (FOPs) to ensure the program has a community
advisory board meeting at least every ninety to 120 days. Sign-in sheets and agendas were
reviewed for the advisory board meetings, and documentation confirmed board meetings have
been at a minimum of every 120 days. A review of the list of attendees, the board roster, and
letters from the program found the facility administrator (FA) solicited involvement from all
required parties. The FA actively solicits involvement of interested community partners
including, but not limited to, representatives from law enforcement, the judiciary, the school
board or district, the business community, faith community, victim, victim advocate, or other
victim services community representative, and a parent whose child was previously involved in
the juvenile justice system. All meetings are available for members to attend virtually. Meetings
are held quarterly, and board members are frequently involved in the program. A member of the
board was interviewed and expressed involvement and interest in the well-being of youth at the
program. The interviewed FA confirmed the process for advisory board meetings and
involvement of its members.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has facility operating procedures (FOPs) to ensure staff are evaluated, at least
annually, based on established performance standards. Three position descriptions were
reviewed, and staff performance standards were clearly identified in each. Ninety-day
probationary performance evaluations were reviewed for five staff, and each was completed as
outlined in the program’s policy, and the performance standards for each evaluation matched
the job description for each staff. Each of the three staff position descriptions reviewed were for
staff implementing the program’s behavior management system (BMS). Staff records were not
reviewed for annual evaluations due to the new program contract which started October 1,
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2024, as such, no staff were applicable. The program’s contractual key positions were reviewed,
and all were maintained by the program. The program contract requires a recreational therapist,
and the current staff member’s credentials were approved by the Department’s Bureau of
Contract Management. The facility administrator was interviewed and stated the program
conducts ninety-day probationary and annual evaluations for staff. The program’s position
descriptions for each staff member's performance standards are clearly identified. Three of five
interviewed staff report they receive evaluations of their performance every ninety days. Two
staff revealed they have only been at the program for a couple of months, and therefore, have
not had an evaluation completed.
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.
The program’s special contract conditions include providing peer to peer mentoring and regular
faith-based opportunities. Youth having reached the highest levels of the behavior management
system (BMS) and those youth currently in transition are paired with youth just entering the
program or at lower levels of the BMS. Youth facilitate a daily meeting on the youth dormitory,
which is attended by program administration, education, mental health, case management, shift
supervisor, and direct care staff dependent on schedule. The compliance review team attended
this meeting while on-site for the annual compliance review. Faith-based activities are provided
to the youth weekly on Monday and Thursday evenings and Sunday mornings, as evidenced by
logbook entries and supported in the youth interviews. The facility administrator was interviewed
and stated all contract negotiated items are offered at the program and provided consistently.
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’s practice for data trend analysis involves a quarterly quality improvement process
across all Wayne Halfway House programs. The quality improvement committee reviews key
program functions to include youth case management records, incident reporting by category,
use of physical restraints, satisfaction surveys from youth, staff and professional staff, ongoing
maintenance projects, program strengths, and areas of positive practice across all programs.
The process is utilized to identify trends, reallocate resources, and ready programs for the
Department of Juvenile Justice annual compliance reviews. The information is shared quarterly
with stakeholders and staff across all programs. Program and corporate leadership meetings
include monthly quality assurance review processes which incorporate reviews of facility data,
surveys, and findings of formal monitoring and verification activities. Within each meeting,
progress to date, program strengths, improvement needs, and corrective action are discussed.
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Recommendations are made by the team with ongoing review, follow-up, and technical
assistance provided as required. Meeting invites and agendas for the quarterly meetings were
reviewed as well as program-level meeting minutes to support the ongoing process.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has facility operating procedures (FOPs) to address initial contact with a youth’s
parent/guardian and for court notification upon a youth’s admission to the program. The policy
requires telephonic contact with the parent/guardian within twenty-four hours of admission. The
policy further requires the program’s assigned case manager to send written notification and
specific program information within forty-eight hours of admission. Five case management
records were reviewed. Each record contained documentation of telephone contact with the
youth’s parent/guardian on the day of the youth’s admission to the program. Four of the five
youth records reviewed included a letter to the youth’s parent/guardian within forty-eight hours
of admission. One of the five youth case management records reviewed contained
documentation the youth’s written parental notification letter was sent six days late. The
program also notified each youth’s juvenile probation officers/post-residential services counselor
and the committing court within five working days of admission to the program.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has facility operating procedures (FOPs) to address the youth orientation process.
The program shall begin the orientation process for each youth admitted to the program prior to,
or the day of admission to the program. The case manager and/or designee will review and
provide a resident handbook to allow easy access for youth, including rules governing conduct
and positive and negative consequences for behavior. The case manager and/or designee will
orient the youth to the services at the program. The program’s orientation process includes the
following topics: review of the daily schedule; review services available; expectations and
responsibilities of youth; availability of and access to medical and mental health services;
access to the Florida Abuse Hotline, or if the youth is eighteen years or older, the Department’s
Central Communications Center (CCC); zero-tolerance policy regarding sexual misconduct,
including how to report incidents or suspicions of sexual misconduct; special accommodations
are available to ensure all written information about sexual misconduct policies, including how to
report sexual misconduct, is conveyed verbally to youth with limited reading skills or who are
visually impaired, deaf, or otherwise disabled; right to be free from sexual misconduct, free from
retaliation for reporting misconduct, and the agency’s response; items considered contraband,
including illegal contraband and prohibited items, possession of which may result in the youth
being prosecuted; performance planning process; dress code and hygiene practices;
procedures on visitation, mail, and use of the telephone; expectations for release from the
program, including the youth’s successful completion of individual performance plan goals, the
program’s recommendation to the court for release based on the youth’s performance in the
program, and the court’s decision to release; community access; grievance procedures;
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emergency procedures, including procedures for fire drills and building evacuation; and the
physical design of the facility, including those areas not accessible to youth. The program will
assign each youth to a living unit and room, treatment team and, if applicable, a staff advisor or
youth group. Five case management records were reviewed. Each record contained
documentation to show the youth received an orientation on the day of admission to the
program. Each record documented the orientation process, expectations, and responsibilities of
each youth. Each youth signed a form to document their review of the orientation checklist and
all covered topics. Daily schedules were posted in multiple locations. There were no admissions
during the annual compliance review week to observe a youth orientation. Five youth were
interviewed and each reported having orientation on the date of admission to the program.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has facility operating procedures (FOPs) to address consents for youth who are
eighteen years of age or older, which requires the program to obtain written consent of any
youth eighteen prior to providing or discussing any information with the youth’s parent/guardian.
Five youth case management records reviewed and two were applicable of being eighteen
years of age. The program provided one additional record for review. Two of the three
applicable records contained the signed written consent of the eighteen-year-old youth on the
day the youth turned eighteen. One of the three youth case management records had a signed
consent form, but the youth signed the consent form two days after the youth turned eighteen.
The program provided chronological notes which showed the program did not discuss any
confidential information with the youth’s family until after the youth signed the release form.
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 facility operating procedures (FOPs) to address the classification process and
reassessment for activities. The program’s classification includes a review of the following
factors: physical characteristics, age and maturity level; identified special needs, including
mental, developmental, intellectual, and physical disabilities; history of violence; applicable gang
affiliation; criminal behavior; sexual aggression, vulnerability to victimization, and youth’s
perception of vulnerability; history of potential or verified human trafficking; identified or
suspected medical, suicide, escape, or security risk; substance abuse history, and any other
specific information about individual youth which may indicate heightened needs for supervision,
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additional safety precautions, or separation from certain other youth. On the day of a youth’s
admission, the program conducts an admission classification meeting to discuss classification
factors, which is attended by the youth, case manager, and program administration. The
program’s policy also states the treatment team reassess and reclassify the youth’s
classification when warranted prior to considering an increase of privilege or freedom of
movement, to participate in work projects or other activities involving tools or instruments which
may be used as a potential weapon or means of escape, and/or participation in off-campus
activities.
Five youth case management records were reviewed. Each youth record contained a
classification form completed by program staff with all required elements notated. Living unit
and room assignments were derived from the information gathered from the classification
process and a review of the Department’s Juvenile Justice Information System alert list. Each
youth received a classification reassessment for increase of privilege or freedom of movement,
to participate in work projects, and/or participation in off-campus activities. The facility
administrator was interviewed and reported the classification procedures ensure the youth's
safety and security and provisions for an effective delivery of services. The case manager is
responsible for assigning each youth to a dormitory. A pre-admission staffing is held, case
management reviews the youth's records at the time of entry, each youth is screened for
vulnerability, 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
process is documented on the program's classification form, special needs identified, security
needs, reassessed and reclassification, restorative process, and a reassessment of youth risks
and needs. If a room and/or dormitory change is warranted, the direct care staff complete a
reclassification form and submit it to the case managers for appropriate action.
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 facility operating procedures (FOPs) to address gang identification, which
includes notification of law enforcement. Five case management records were reviewed, and
none were applicable for gang involvement. The program provided three addition records which
were applicable for gang involvement for review. In all three applicable records, the program
notified local law enforcement regarding the youth’s gang status. Two of the three youth’s case
management records documented the juvenile probation officer entered the gang alert into the
Department’s Juvenile Justice Information System (JJIS) prior to the youth being admitted to the
program; therefore, the youth’s juvenile probation officer was already notified. The third youth’s
case management record did not have documentation the program created a gang alert in JJIS
within twenty-four hours of upon identification but did contain notification to the youth’s juvenile
probation officer. The program added the gang alert for the youth during the annual compliance
review. All three youth’s records documented the program provided notification to each youth’s
local school district and law enforcement in each youth’s home county. The program also
maintains a binder with gang information for youth in the program, gang curriculum, and gang
curriculum attendance sheets.
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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 facility operating procedures (FOPs) to address a youth’s participation in gang
prevention and/or intervention activities. All staff will be required to have at least one training
yearly on gang awareness. This training will include identification, signs and symbols, trends,
and possible gang activity in the program. Three youth case management records were
reviewed, and none were applicable for gang involvement. The program provided three addition
records which were applicable for gang involvement for review. In review of the gang binder, the
three gang identified youth participated in monthly gang prevention and intervention
strategies/interventions and have performance plans which addressed gang interventions. The
program’s gang prevention/intervention strategies are Impact of Crime (IOC) and Gangs: 50+
Stories of Fractured Lives. The program’s facility administrator stated the program has a written
policy and procedures for youth who are considered to be affiliated with a gang. If a youth is
identified as having gang affiliation, they will receive gang educational services and will receive
the IOC curriculum. The policy and procedures ensure the youth have an opportunity to develop
a plan to dis-affiliate with a criminal street gang. Each youth's performance plan included
relevant goals relating to gang intervention strategies.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has facility operating procedures (FOPs) to address the completion of the
Residential Assessment for Youth (RAY) and reassessments. The policy requires the
completion of an initial RAY within thirty days of admission to the program and the completion of
a reassessment every ninety days. Five youth case management records were reviewed. Four
of the five youth case management records documented the initial RAY assessment was
completed within thirty days of admission. One youth’s initial RAY assessment was completed
nine days late. Three out of five case management records had RAY reassessments completed
within ninety days of the initial RAY assessment. One youth’s RAY reassessment was
completed one day late, and another youth’s RAY reassessment was completed thirteen days
late. All RAY assessments and RAY reassessments were completed in the Department’s
Juvenile Justice Information System (JJIS) and documented in the youth’s case record.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has facility operating procedures (FOPs) to address the completion of a Youth
Needs Assessment Summary (YNAS) within thirty days of admission. Five case management
records were reviewed, and each contained a YNAS. Four of the five YNAS were completed
within thirty days of admission to the program. One youth’s YNAS was completed twenty-three
days late. Each YNAS was documented in the Department’s Juvenile Justice Information
System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has facility operating procedures (FOPs) to address the intervention and treatment
team. The intervention and treatment teams are required to develop an individualized
performance plan (IPP) within thirty days of admission to the program. Five case management
records were reviewed. Performance plans were completed for each youth, with four of the five
completed by the program within thirty days of the youth’s admission. One plan was completed
twelve days late. Four of the five performance plans were developed after the initial RAY and
YNAS. One youth’s IPP was completed before the YNAS. The youth was transferred from
another program and had a completed YNAS from the prior program. Each performance plan
was developed by the treatment team, and all relevant members participated during the
development, including parents/guardians.
All five IPPs contained target dates for completion of goals, youth responsibility to accomplish
goals, and the program’s responsibilities to assist the youth to achieve the goals. Four of the
five plans did not have targeted court-ordered sanctions reasonably able to be completed in the
program; however, court ordered sanctions were added to one of the four youth’s revised
performance plans. One youth did not have court ordered sanctions listed on the court order.
Four of the five IPPs listed delinquency interventions, and one did not. Each plan included
transition goals for the youth to complete prior to release from the program. The goals were
individualized and based on prioritized needs reflecting the risk and protective factors identified
during the initial assessment. Each IPP included the top three criminogenic needs to be
addressed. Each of the performance plans were signed by the youth, treatment team leader,
and all parties who had significant responsibilities in goal completion. None of the five
performance plans were signed by the parents/guardians; however, the program did mail out
the performance plan to all parents/guardians with a request to sign and return the signature
page. Each performance plan was sent to the committing court, juvenile probation officer (JPO),
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and parent/guardian within ten working days of the plan being completed. All five interviewed
youth reported they participated in the development of their performance plan, knew their
current performance plan goals, and had a copy of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has facility operating procedures (FOPs) to address revisions to individualized
performance plans, when determined necessary, by the intervention and treatment team. The
policy requires revisions when new criminogenic needs are identified during the Residential
Assessment for Youth (RAY) reassessments, when the youth demonstrate progress or lack of
progress toward completing a goal, or when new information is acquired or revealed. Five youth
case management records were reviewed. All five had performance plan revisions. There had
been at least one monthly review of each youth due to RAY reassessments, newly acquired
information, progress towards completing goals, and/or lack of progress toward goal completion.
The two applicable youth’s IPP revisions were complete to facilitate activities during the last
sixty days in the program. All five youth’s performance plans referenced the additional treatment
and academic plans. None of the youth reviewed were applicable for a behavior support or case
plan.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has facility operating procedures (FOPs) to address the requirements for
completion of performance summaries every ninety days. The performance summaries are due
within ninety days of the signing of the youth’s individual performance plan (IPP), or at shorter
intervals, if requested by the committing court. The policy further requires the treatment team to
prepare a performance summary prior to the youth’s release, discharge, or transfer from the
program. The performance summary provides information to the youth, parent/guardian,
juvenile probation officer (JPO), and other parties related to the status of each performance goal
and describes the youth’s overall adjustment to and performance in the program. Five youth
case management records were reviewed, four of which were applicable for the completion of at
least one performance summary and transmittal. Three of the four performance summaries
were completed within ninety days of the IPP. One of the four performance summaries was
completed three days late. Each of the four summaries contained the following required
elements including the youth’s status on each goal, treatment progress, behavior, level of
motivation/readiness to change, interaction with peers, interaction with staff, adjustment to the
program, and positive/negative events. Only three of the four performance summaries
documented the youth’s academic status, grades, and credits earned at the program. Each of
the four summaries were signed by the applicable treatment team members, including each
youth, who was given the opportunity to read and add comments prior to signing. Each
summary was filed in the case management record. Each of the four summaries were sent to
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the committing court, juvenile probation officer (JPO), and parent/guardian within ten working
days of completion. Each youth was provided a copy of the summary.
The program had only one closed record applicable for release summaries during the annual
compliance review period. One of the five reviewed open case management records was
applicable for a release summary and was reviewed for any applicable information. Both
applicable records contained a signed copy of the original summary sent to the JPO along with
the Pre-Release Notifications (PRN) at least forty-five days prior to the youth’s anticipated
release date. Each summary contained the justification for release. One summary was
applicable for a direct discharge and a discharge summary was sent. Neither record was
applicable for the Sexually Violent Predator Program (SVPP). The program provided written
notification to the parent/guardian of the approval for release. The program completed an exit
RAY in the one applicable closed youth’s record, for the open would be applicable for an exit
RAY. Neither record was applicable for victim notifications being mailed.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has facility operating procedures (FOPs) to address the inclusion of
parents/guardians in the case management process. Five case management records were
reviewed. In each of the case management records, the case manager sent an admission letter
to the parent/guardian, which included the dates/times for treatment team meetings. If unable to
attend treatment team, the program gives the parent an opportunity to participate by telephone
or providing verbal/written input prior to the meeting. Each record had documentation to show
the parent/guardian was involved in the assessment process and participation in the
development of the individual performance plan (IPP). A copy of the IPP was mailed to each
parent/guardian with a request to sign and return the signature page. There was documentation
to show the parent/guardian was called for each treatment team meeting. Documentation
verified the program has family days quarterly and case managers keep in contact with
parents/guardians and promote involvement. The program director was interviewed and
reported the program recognizes the importance of family involvement and relationship building
between parents, the youth, and their siblings. Youth are provided with the means to write and
telephone home on a consistent basis; it is important to utilize all other resources available to
encourage and support family involvement. The program sends parent notification letters to
encourage family participation and tells the parents when the treatment team meetings are so
they can participate with their youth and the team in developing a treatment plan. The family is
also encouraged to participate in transition planning through phone calls and formal transition
and exit conference meetings. Five youth were interviewed. All five interviewed youth report
their parent/guardians are involved in their case management by participating in treatment
teams.
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2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has facility operating procedures (FOPs) to address the members of the treatment
team and meetings. The policy identifies the case manager to be the treatment team leader.
The program’s treatment team members consist of the case manager/treatment team leader,
youth, and representatives from program administration, education, the youth’s living unit,
mental health treatment, education, and medical. The juvenile probation officer (JPO) is also
part of the treatment team, and, when applicable, the transition case manager, and the youth’s
parent/guardian, or the Department of Children and Families (DCF) case worker are included.
Five case management records were reviewed. Each of the records documented the notification
to the required participants of the treatment team meetings and who attended. If the
parent/guardian and/or JPO did not participate in the treatment team meeting, there was
documentation to show attempts to contact. Five reviewed youth’s case management records
documented nineteen formal treatment teams were held as required and eight formal treatment
teams were held either two, four, five, or six days late. Four of the five reviewed case
management records held informal treatment reviews as required. One of the five youth’s case
management records documented informal reviews were not being held bi-weekly alternating
formal treatment team meetings but being held the same day. All forms contained all required
elements and signatures from all required team members. All five youth case management
records documented comments from treatment team members, a brief synopsis of the youth’s
progress in the program, youth’s progress on performance plan goals, the youth’s positive and
negative behaviors, any skills acquired in the program, behaviors resulting in physical
intervention, treatment progress, and Residential Assessment for Youth reassessment results.
The youth’s JPO, parent/guardian, and any other pertinent parties, when applicable, were
invited and encouraged to attend treatment teams. Five youth were interviewed. All five youth
reported staff talk to them about their performance to include progress on performance plan
goals, positive and negative behavior, and treatment progress. Each of the five youth reported
they are able to discuss what goals they are working on, their behavior in the program, their
education status, and what level they are currently on in the program.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has facility operating procedures (FOPs) to ensure the treatment team plans for
the youth’s successful transition to the community upon release from the program. Five youth
records were reviewed, and one record was applicable for transition planning. The program
provided the only one additional applicable closed record for review during the annual
compliance review period. Documentation in both applicable records confirmed transition
conferences were conducted at least sixty days prior to the youth’s release from the program.
Both case management records documented the required participants were invited for each
transition conference. All required participants were invited to participate by telephone or in
person. If participation was not possible, the members were invited to provide written input prior
to the meeting. The treatment team reviewed transition activities on all performance plans,
revised performance plans, if necessary, identified transitional activities, identified target
completion dates, and identified persons responsible for completion. The treatment team leader
obtained signatures of all applicable members. One of two records documented a copy of the
transition plan was sent or the plan was transmitted electronically to the juvenile probation
officer, and one did not. In both records, there was documentation to reflect a Community Re-
Entry Team (CRT) meeting invite and verified a CRT meeting was conducted prior to the youth’s
release along with youth and case manager participation.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has facility operating procedures (FOPs) to ensure an exit portfolio is assembled
for all youth. The program only had one applicable closed record during the annual compliance
review period. The exit portfolio was discussed during transition. The closed youth’s exit
portfolio contained a copy of the transition plan, education and/or vocational certifications, and
sample employment applications. Documentation could not verify if the portfolio included a
calendar with all dates/time/locations of the upcoming community appointments, résumé, a
State of Florida identification card, birth certificate, or social security card, though
documentation and program policy confirmed the parent/guardian was sent letters requesting
the required elements to obtain an identification card.
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2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has facility operating procedures (FOPs) to address youth exit conferences. Five
youth records were reviewed, and one record was applicable for transition planning. The
program provided the only one additional applicable closed record for review during the annual
compliance review period. Both applicable records documented an exit conference was held at
least fourteen days prior to the release date. Each exit conference was conducted after the
juvenile probation officer (JPO) was notified of the release. Each record had documentation of
the exit conference date, signatures, and a summary pending transition goals. Each record had
documentation to show the treatment team leader, parent/guardian, education representative,
therapist, JPO, youth, and other pertinent parties participated in the exit conference. Each
record had documentation of the status of transition activities and finalized plans for the youth’s
release, provisions for continuation of education and/or employment, and exit portfolios were all
reviewed during the exit conference. For the one applicable closed record, the parent/guardian
and JPO are aware of the youth’s vocational plan and the date of admission and date of release
correlated with the Department’s Juvenile Justice Information System (JJIS). Each exit
conference was held separate from the transition and Community Re-Entry Team meetings
(CRT).
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has facility operating procedures (FOPs) in place to address youth input. The
program’s FOPs included soliciting input from youth through multiple avenues of communication
including grievances, Request to Talk forms, and regular living unit meetings. This gives the
youth experience in identifying systemic issues impacting their residential community and
making recommendations for resolution to improve conditions and enhance the quality of life for
staff and youth in the program. Reviewed documentation verified youth advisory boards and
monthly house meetings were completed as required. The facility administrator was interviewed
and reported the program has a formal process to promote constructive input by youth. Youth
are encouraged to participate in the program’s Trauma Responsive and Caring Environment
(TRACE) Survey. Also, the program has a questionnaire which asks the youth about their
satisfaction with the program every thirty days during formal treatment team reviews. The
program has a youth advisory board to discuss and plan events. Each dormitory has suggestion
forms for the youth to complete and submit. Five youth were interviewed. All five youth reported
they can provide input about what happens at the program through the youth advisory board
meetings, with one youth stating youth are the voice of the program.
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2.18 Educational Access (Residential Contract Provide) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has written facility operating procedures (FOPs) to provide educational access. A
review of the program’s activity schedule and the daily academic schedule revealed the
program activity schedule aligns with the daily school schedule. Five interviewed youth reported
they are receiving education services and there are no educational interruptions. A review of
randomly selected days in the logbook for eight months during the annual compliance review
period indicated education classes started on time with the exception of two months, which
started seven and ten minutes late, however one of the days made up the time through staying
over at the end of the day. Two days also revealed students returned from morning break six
and twenty-three minutes late. Observations of the program's video were conducted for three
days. The footage showed school started three, eleven and thirteen minutes late respectively.
The morning break went over twenty to thirty-eight minutes for all three days, which was longer
than the scheduled fifteen minutes. Lunch period started six to nine minutes early, and school
ended four to fourteen minutes early for all three days reviewed. The average loss of
educational time for all three days ranged from thirty-four minutes to one hour and thirteen
minutes.
2.19 Contract Specific Career and Technical Education
Limited 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.
Under the executed contract, the program is required to deliver Career and Technical Education
(CTE) services which lead to career pathways and student outcomes, including instruction
toward an Industry Certification from the Master Credentials List, as approved by the Florida
Department of Education. The contract further requires youth be enrolled in a CTE training
program or program of study within the first three months of admission into the programs.
Additionally, all youth must complete Florida Ready to Work (Soft Skills Credential),
Occupational Safety and Health Association Outreach Training Program (OSHA-10), and
cardiopulmonary resuscitation (CPR) and First-Aid certifications within the prescribed timelines.
Reviewed documentation verified the program is delivering and documenting OSHA-10 and
CPR/First-Aid certifications. The review also confirmed documentation for SafeServ, which,
while not a contractual requirement, represents a valuable credential for youth. However, no
documentation was available to verify Florida Ready to Work Soft Skills was being offered.
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Office of Accountability and Program Support Page 29 of 69 (Revised August 2025)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program maintains facility operating procedures (FOPs) ensuring a State of Florida licensed
clinician will serve as the designated mental health clinician authority (DMHCA) and will be
responsible for providing the coordination and implementation of mental health and substance
abuse service delivery. The program has a licensed mental health counselor (LMHC), who
serves as the program’s DMHCA and clinical director. The DMHCA has a clear and active
license which expires on March 31, 2027. Documentation showed the current DMHCA is a full-
time staff and was on-site during the annual compliance review period for forty hours a week
and on call twenty-four hours a day or as needed as contractually required. The program
provided the license and position description for review. The program has a back-up DMHCA
who has a clear and active license with an expiration date of March 31, 2027. The DMHCA was
interviewed and reported they provide clinical oversight and supervision of the mental health
professionals at the program. The DMHCA indicated they conduct groups and individual/family
sessions as needed based on the program needs and are on-call for any mental health issues
which may arise day or night. The DMHCA maintains clinical trackers, conducts monthly fidelity
checks, and completes other various monthly reports. The DMHC also reported they maintain
constant contact with clinical staff by weekly clinical supervision, electronic communication, and
maintain an open-door policy for all staff.
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 has facility operating procedures (FOPs) to ensure mental health and substance
abuse services are provided by staff with the appropriate qualifications. The designated mental
health clinician authority (DMHCA) and the back-up DMHCA are the only licensed mental health
providers at the program. Substance abuse services are provided by the DMHCA whose license
expires on March 31, 2027, and a back-up DMHCA if needed, whose license also expires on
March 31, 2027.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has facility operating procedures (FOPs) to ensure mental health and substance
abuse services are provided by individuals with appropriate qualifications. The program has two
non-licensed mental health and substance abuse clinical staff. There were no mental health
clinical staff vacancies during the annual compliance review period. Each of the two non-
licensed clinical staff hold a master’s-level degree in the field of counseling, psychology, social
work, or a related human services field. The designated mental health clinician authority
(DMHCA) assures the non-licensed clinical staff are performing services they are qualified to
provide based on education, training, and experience. A review of weekly clinical supervision
confirmed each non-licensed clinical staff received one hour a week of on-site, face-to-face
direct supervision by the licensed mental health professional during the annual compliance
review period. Each clinical supervision was documented on the Department’s Licensed Mental
Health Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision
Log form. The program currently utilizes a Chapter 397 license, which is posted in the program
lobby. Substance abuse services are conducted by the DMHCA whose license expires on
March 31, 2027. The non-licensed clinical staff are on-site forty hours a week. Each of the two
non-licensed clinical staff completed twenty hours of Assessment of Suicide Risk 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.
The program has facility operating procedures (FOPs) to ensure 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, or when immediate attention is needed, to a hospital or
Baker Act or Marchman Ace receiving facility. The program’s policy and procedures include staff
training in mental health and substance abuse issues and administration of all screening tools.
The program screens all youth utilizing the Massachusetts Youth Screening Instrument-Second
Version (MAYSI-2) in the Department’s Juvenile Justice Information System (JJIS). Five youth
mental health and substance abuse records were reviewed and all five reflected a MAYSI-2 was
completed for each youth in full on the day of admission by a staff member qualified to complete
the screening. Documentation confirmed staff reviewed all available information for each youth
to include commitment packet, and reports and/or records for existing documentation of mental
health or substance abuse problems or history of human trafficking. All five reviewed records
indicated the MAYSI-2 as completed in JJIS on the day of admission. Three of the five reviewed
youth’s MAYSI-2 indicated further assessment was needed due to indications of suicide ideation
and the reason for the referral was documented. Each of the three youth were referred for an
Assessment of Suicide Risk (ASR) and a Comprehensive Evaluation. The program’s policy
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Office of Accountability and Program Support Page 31 of 69 (Revised August 2025)
requires all youth have a Comprehensive Evaluation completed upon admission to the program.
The facility administrator (FA) and designated mental health clinician authority (DMHCA) were
notified of the need for an assessment in each of the three applicable youth records as
documented on the mental health and substance abuse referral form. The ASR was completed
on the day of admission for each youth, with one being completed immediately due to an
incident while in a detention center. Two of the three youth requiring an ASR were placed on
precautionary observation, and one youth was in the presence of the mental health staff at all
times before being stepped down to standard. An interview with the facility administrator
confirmed the program conducts a Mental Health Screening upon the youth’s admission to the
program. Additionally, 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 the timely
initiation of services.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains facility operating procedures (FOPs) to address the provision of mental
health and substance abuse assessments/evaluations. Five youth individual healthcare records
were reviewed for mental health and substance abuse assessments and evaluations and each
included documentation the program completed a new combined mental health and substance
abuse evaluation by a licensed mental health staff. All evaluations were completed within thirty
calendar days of admission, and none were late. All five youth mental health and substance
abuse records included a consent form obtained for substance abuse services. Each of the five
reviewed mental health and substance abuse records included documentation which included
demographics, reason for assessment, relevant background information, behavioral
observations, mental status examinations, an interview or procedures administered, discussion
of findings, methods of assessment, patterns, impact of alcohol and drug abuse, risk factors of
continued alcohol and other drug abuse, clinical impression, original referral reason, and
recommendations. None of the five youth required an updated comprehensive evaluation. An
interview with the designated mental health clinician authority (DMHCA) confirmed during the
intake process youth will complete multiple assessments including the Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2), the Victimization and Sexually Aggressive
Behavior (VSAB), the Substance Abuse Subtle Screening Inventory (SASSI-3), an Assessment
of Suicide Risk (ASR), the General Anxiety Disorder assessment (GA-7), and the Beck
Depression Inventory II (BDI-II). Based on these results, the youth will complete a Mental
Health/Substance Abuse assessment within twenty-one days of entering the program. During
the first thirty days in the program, each youth has a clinical interview with a therapist,
behavioral observations are provided by direct care staff, staff monitors point cards, and juvenile
probation officer (JPO) and parents are contacted for input.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has facility operating procedures (FOPs) in place outlining the program’s mental
health and substance abuse services. Five youth records were reviewed for Initial Mental Health
or Substance Abuse Treatment Plans. All five records reflect an initial treatment plan was
developed within seven days of the initiation of treatment and documented on the Initial Mental
Health/Substance Abuse Treatment Plan form. Two of the five youth required psychiatric care,
which was included in their plans. All five youth initial treatment plans were completed by the
licensed mental health clinician, and signed by the mental health staff, the case manager or
treatment team leader, and the youth. Documentation of each youth’s parent/guardian
participation was also present.
All five of the individualized treatment plans were completed within the required timeframe. Two
of the five individual treatment plans included the type of intervention (individual, group, and/or
family therapy), methods, and frequency of services, which were evaluated monthly during
treatment plan reviews. The remaining three records did not include specific type and frequency
of interventions on the individual treatment plans; however, these details were included on all
the subsequent treatment plan reviews. Each of the five records included monthly individual
treatment plan reviews, all of which were completed on the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form and signed by all the necessary parties.
In an interview, the designated mental health clinician authority (DMHCA) explained they
complete regular fidelity checks, weekly clinical supervision, and chart reviews to ensure all
services are being provided as prescribed. Additionally, the DMHCA and therapists meet with
the assistant facility administrator and other management team members for daily updates,
monthly supervision, and coaching sessions as needed. The facility administrator is available for
regular consultation as needed, either by phone or face-to face.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has facility operating procedures (FOPs) addressing mental health and substance
abuse treatment and discharge planning. Five youth mental health and substance abuse
records were reviewed and each youth was assigned to a multidisciplinary treatment team upon
admission to the program. Reviewed documentation revealed each treatment team was
comprised of the youth, program administration, residential living unit staff, education, medical
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staff, mental health staff, substance abuse staff, and the parent/guardian. All five youth who
received mental health treatment had a properly executed Authority for Evaluation and
Treatment (AET) form. Each of the five youth were receiving substance abuse treatment, and all
five provided consent through a signed Youth Consent for Substance Abuse Treatment. Mental
health treatment notes and substance abuse treatment notes in all five youth records were
documented on the Department’s Counseling/Therapy Progress Notes form. All mental health
and substance abuse therapy included individual psychotherapy or counseling and psychosocial
skills training. Reviewed progress notes determined all five youth received the services as
stipulated on their treatment plans. The designated mental health clinician authority (DMHCA)
stated the therapists gather information from youth, parent/guardian, juvenile probation officer
(JPO) and direct care staff to develop youth treatment plans. Three closed files were reviewed
for discharge planning. In each of the three records, the discharge plan was documented on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. All three
discharge summaries documented the future services needed, evidence the discharge plan was
discussed with the youth, parent/guardian, and JPO during the exit conference, and a record
each was provided a copy.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains facility operating procedures (FOPs) to establish a delivery protocol for
Substance Abuse Treatment Overlay Services (SAOS) programming and Mental Health Overlay
Services (MHOS). The focus of substance abuse and mental health treatment is to target and
reduce/alleviate the youth’s symptoms of substance related disorder and/or mental disorder to
improve youth functioning within the program, and ultimately the community. The program
provides SAOS and MHOS services through group therapy, individual therapy, family therapy,
and psychiatric services. The designated mental health clinician authority (DMHCA), a licensed
mental health counselor, provides on-site services, as needed. The policy indicated therapy
models utilized include Cannabis Youth Treatment, Aggression Replacement Training, Living in
Balance, and Dialectical Behavioral Therapy. The non-clinical group provided is Impact of Crime
(IOC). Caseload sizes were reviewed and reflected the average caseload for each program
therapist was twelve youth, which is below the contractual maximum. The two non-licensed
therapists hold a master’s-level degree in counseling. Individual therapy is provided at least
once every two weeks, or more often as needed.
The reviewed sign-in sheets verified mental health groups consisted of ten or fewer participants
and substance abuse groups consisted of fifteen or fewer participants. A review of mental health
groups since the start of the contract confirmed four mental health groups were being held each
week for all youth. The program has a Chapter 397 license through the Department of Children
and Families to provide substance abuse treatment services to adolescents. All mental health
clinicians working at the program were qualified to provide substance abuse treatment and
education services. No youth missed services due to being on a medical quarantine since the
last annual compliance review.
The facility administrator was interviewed and reported the focus of treatment services includes
targeting and reducing/alleviating the youth’s risk and needs allowing youth to improve
functioning and reintegrate within the community. The program has two therapists who provide
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individual, group, and family counseling. A psychiatrist is onsite at least twice a month to
conduct evaluations, medication management, and provides information for the treatment
teams. The program utilizes individualized treatment tools to target the areas identified as high
risk. All groups are evidence-based and are specific to the needs of the youth. The DMHCA was
interviewed and explained all youth are provided individual, family and group therapy services,
and crisis intervention as needed. Five staff were interviewed. Four of the five staff reported
they do not conduct any mental health or substance abuse groups. One staff, who was the
mental health therapist, said they facilitate groups Monday through Thursday, and make-up any
missed groups on Friday. Five youth were interviewed. All five youth stated they are
participating in family and individual counseling. All five youth said family counseling is held
once a month. Three youth stated individual counseling is held every two weeks, and two youth
stated it is held weekly.
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 facility operating procedures (FOPs) to address suicide prevention planning
which includes identification and assessment of youth at risk of suicide, staff training to include
six hours annually, suicide precautions, levels of supervision (one-to-one, constant, close),
referrals, communication, notification, documentation, immediate staff response, and a review
process. The review process includes circumstances surrounding the event, program
procedures relevant to the incident, all relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations. The plan was reviewed and signed by the facility administrator on October
16, 2024, the designated mental health clinician authority on October 1, 2024, and the
psychiatrist on October 9, 2024.
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.
The program has facility operating procedures (FOPs) for suicide prevention services. The
program’s process is to complete an Assessment of Suicide Risk (ASR) for each youth during
the admission process. Three records were reviewed for suicide prevention services. Three
youth were determined be at risk during admission;. Two of the three youth were placed on
precautionary observation. The third youth reviewed was referred by direct care staff. The
precautionary observation placement start date and ASR referral date were the same date for
all three youth. All three records contained an ASR completed on the Department’s Assessment
of Suicide Risk form. Each of the three youth records documented the youth was placed on
suicide precautionary observation. Each ASR documented the parent/guardian and juvenile
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probation officer (JPO) for each youth was notified. The mental health staff provided supportive
services for all three youth. The ASR for each youth was completed by the licensed mental
health counselor (LMHC) within twenty-four hours, which was documented on each ASR,
including the date and time. The completion of the suicide risk assessments resulted in all three
youth being placed on standard supervision. None of the three youth required a follow-up ASR.
The discontinuation of precautionary supervision was documented in accordance with the
program’s suicide prevention plan in all three instances. A suicide alert in the Departments
Juvenile Justice Information System (JJIS) was initiated for each of the three youth when they
were placed on suicide precautions, and each alert was accurately closed following the
recommendations of the ASR. While on precautionary observation, each youth was allowed to
participate in select activities with other youth in designated safe housing/observation areas of
the program. The program indicated they did not have any youth placed on precautionary
observation for the past thirty days; therefore, video observation was unable to be completed.
The designated mental health clinician authority (DMHCA) was interviewed and confirmed the
program’s suicide prevention services procedures. All youth are screened for suicide risk upon
admission. At any time following admission, staff can refer youth by completing a Mental
Health/Substance Abuse referral form to initiate referral for an ASR. Mental health professionals
are notified of the referral by email, telephone, or face-to-face during normal operating hours.
The DMHCA is on-call at night and on weekends to accept any notifications. The program’s
mental health professionals initiate the precautionary observation (PO) log, constant
supervision, and the completion of the ASR. Notifications are made to the facility administration,
the parent or guardian, and the JPO, which is documented on the ASR. Should a youth be
unable to contract for safety, a Baker Act would be initiated. Staff are verbally notified by mental
health professionals when a youth has been placed on precautionary observation and are
provided with a PO log. The alert board is updated, as well as the logbook, to communicate a
youth's change in status. Prior to revising a youth's supervision level, a meeting is conducted
with the facility administrator/designee, which is documented on the ASR and any change in
level is then documented in JJIS and the facility logbook.
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.
This program does not utilize secure observations; 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.
The program has facility operating procedures (FOPs) for youth placed on suicide precaution.
Three youth records were observed for Suicide Precaution Observation Logs. Each of the three
records confirmed logs were maintained for the duration the youth was on precautionary
observation. A review of precautionary observation forms confirmed the appropriate level of
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supervision, and observations of the youth’s behavior was documented in real time and did not
exceed thirty-minute intervals. Warning signs were not observed in any of the three records, so
no notification to required parties was necessary. Suicide Precaution Observation Logs for each
of the three records were reviewed and each were signed by the shift supervisor and the mental
health clinical staff. Each of the three Suicide Precaution Observation Logs documented safe
housing requirements.
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 facility operating procedures (FOPs) addressing suicide prevention training
plans stating 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. A
review of five pre-service training records documented staff did receive the internal mental
health and substance abuse training as documented on the staff individual training plans. The
program had no in-service records to review, as the contact began in October 2024. The
program had two suicide response kits, which included the knife-for-life, wire cutters, and needle
nose pliers. One kit is located in master control and one kit is in the medical office. The suicide
response kits are co-located with first-aid kits.
The program conducted twenty drills on each of the two shifts during the annual compliance
review period which exceed the quarterly expectation. The training included mock suicide drills
for all staff who encounter youth, including the kitchen and maintenance staff. Each of the mock
mental health drills simulated the response to a suicide attempt and/or incident of serious self-
injury, and no youth were used in the drill. Of the forty drills conducted, eighteen indicated
cardiopulmonary resuscitation (CPR) and/or the automated external defibrator (AED) was
utilized. A video review was not available for observation because the drills conducted in July
were completed more than thirty days prior to the review. The program provided semi-annual
training on emergency response procedures and provided staff who were not present during a
monthly drill the opportunity to review each drill scenario and procedures. The program
conducts these drills twice a month on each shift to ensure all program staff have a chance to
participate. The facility administrator (FA) reported in an interview the program conducts mock
drills to prepare staff for appropriate responses during emergency situations including mental
health, medical, fire, escape, and other Continuity of Operations Planning drills. Staff are trained
on how to respond to youth in crisis in the least restrictive means possible to protect the safety
of the youth and others, while maintaining safety, security, and control of the facility. All staff
who work with youth are trained to recognize verbal and behavioral cues indicating suicide risk,
suicide prevention, and implementation of suicide precautions. The program has a written crisis
intervention plan and emergency mental health and substance abuse plan, which addresses
those practices necessary to effectively handle youth in need of a mental status exam and a
crisis assessment. Five staff were interviewed. Two staff stated drills are conducted four times a
month, two said once a month, and one said every other month.
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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 a written crisis intervention plan which includes a notification and alert system,
means of referral including youth self-referral, communication, supervision, documentation, and
review. The plan was reviewed and signed by the facility administrator on October 16, 2024, the
designated mental health clinician authority on October 1, 2024, and the psychiatrist on October
9, 2024.Five staff were interviewed. All five staff stated they are to notify mental health when a
youth expresses suicidal thoughts. Two of the five staff said they notify the supervisor
immediately. One of the five, who was the mental health therapist, said they discuss the youth’s
situation with their clinical supervisor, complete an Assessment of Suicide Risk (ASR), and if
need be, place the youth on Precautionary Observation (PO). All five of the interviewed staff
knew there was a knife-for-life in master control. Two of the five staff reported there is another
knife-for-life in the medical office.
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 has facility operating procedures (FOPs) addressing crisis assessments and
utilizes the Department’s form. Two records were available for review for the annual compliance
review period. Both crisis assessments were conducted immediately based on the needs of the
youth. The crisis assessment documented the reason for the assessment, a Mental Status
Examination and Interview, the determination of danger to self and/or others (including
imminence of behavior, intent of behavior, clarity of danger, lethality of behavior), initial clinical
impressions, supervision and treatment recommendations, recommendations for follow-up or
further evaluation, and notification to the youth’s parent/guardian of follow-up treatment. The
crisis assessments were conducted by a licensed mental health professional, and neither was
required to be entered into the Department’s Juvenile Justice Information System (JJIS) as
neither youth were placed on precautions after the completion of the crisis assessment. Prior to
the crisis assessment, both youth were on one-to-one supervision, which was documented on
the Department’s Mental Health Alert Observation Log. One of the two youth was a victim in a
Prison Rape Elimination Act (PREA) incident and was offered on-going mental health treatment
services.
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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 facility operating procedures (FOPs) addressing the emergency mental health
and substance abuse plan which includes immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for emergency mental health evaluation and treatment
under Baker Act, transport for emergency substance abuse assessment and treatment under
Marchman Act, documentation, training, and review. Reviewed documentation confirmed the
facility administrator reviewed and signed the policy and procedures on October 16, 2024, the
designated mental health clinician authority on October 1, 2024, and the psychiatrist on October
9, 2024.
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.
This indicator is rated “non-applicable”, as the program has not had any Baker or Marchman
Acts during the annual compliance review period.
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.
The program maintains facility operating procedures (FOPs) to address the safety planning
process for each youth. The safety plan shall be designed to identify stimuli which have both
positive and negative effects on youth. Five youth mental health and substance abuse records
were reviewed for the safety planning process for each youth. The initial planning process was
initiated by each youth’s therapist within fourteen days of the youth’s admission to the program.
Reviewed documentation found the plan was jointly prepared by the youth,
parent(s)/guardian(s), and the program’s clinical staff. All five records reflect the safety plans
incorporated recommendations from previous and current clinical assessments and screening
instruments, and incorporated trauma responsive practices. Each of the five records
documented the plans were reviewed and updated at least every thirty days. The program’s
Safety Plan form included each youth’s warning signs, baseline behaviors gathered from
collateral contacts, crisis recognition, jointly developed coping strategies, intervention strategies,
and debriefing preferences. All five youth safety plans documented warning signs, youth’s
baseline behaviors and crisis recognition, jointly developed coping strategies, intervention
strategies, and a debriefing process. The plans are reviewed and signed by all staff involved in
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the development of the plan and each youth. The safety plans were maintained in each youth’s
mental health and substance abuse records and within a centralized binder inside master
control, easily accessible by all staff. All five interviewed youth stated they participated in the
development of their safety plan. The facility administrator stated in an interview the program
provides on-going safety planning for each youth. Each of the safety plans highlight the youth’s
warning signs, behavior, crisis recognition, and coping and intervention strategies and is
updated each month. The initial planning is complete upon admission to the program for each
youth and is developed with the youth, parent(s)/guardian(s), and program’s clinical staff. The
safety plan is reviewed and signed by each staff who had contact with each of the youth.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA license expires on January 31, 2026, with specialty training in family practice.
The DHA does not have any disciplinary cases or public health complaints on record. According
to the contract, the DHA is required to be on-site weekly and a review of the sign-in sheets for
the annual compliance review period indicated the DHA was on-site as required. If the DHA has
a scheduled absence, the program has an agreement with a team of three other licensed
physicians who can serve as back-up DHA across all the provider’s programs within the region
and who provide medical care to the youth. The back-up licensed physicians hold clear and
active unrestricted licenses, two expire on January 31, 2026, and one expires January 31, 2027.
The physicians utilized for back-up meet all requirements for independent and unsupervised
practice in the State of Florida. The back-up physicians did not provide services to the youth
during the annual compliance review period. The DHA does not utilize an advanced practice
registered nurse (APRN) or physician’s assistant (PA). The program does not utilize tele-
medicine or tele-health.
The DHA was interviewed and reported their role in the program is to conduct Comprehensive
Physical Assessments (CPAs) of youth, conduct periodic evaluations, follow-up on sick calls as
needed, and conduct policy and procedure development. The DHA confirmed they are on-site at
least once each week and will communicate with program staff regarding youth medical needs
while there, as well as being available to them when not on-site, twenty-four hours a day, seven
days a week by telephone. The DHA confirmed they provide on-site medical services and
ensure all off-site care findings, instructions, and information is reviewed while on-site and is
updated by telephone shortly after any off-site visits. The DHA also stated nursing staff track
acute and chronic issues and ensure any follow-up orders are adhered to. There is weekly
discussion with the healthcare staff when the DHA is on-site as needed for any questions or
clarification. If for any reason the DHA is unable to be on-site, back up coverage is arranged
through the statewide nursing clinical director.
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 (FOPs) and nursing protocols approved by the DHA.
The program has three registered nurses (RNs) and no licensed practical nurses (LPNs) on
staff. One of the RNs serves as the health services administrator (HSA). A review of each RN’s
license credentials reflected each of the nurses have a clear and active license, in the State of
Florida, according to the Florida Department of Health Medical Quality Assurance website. One
license is valid through April 30, 2026, one through July 3, 2026, and the remaining license is
valid through April 30, 2027. In addition, each of the RNs have current cardiopulmonary
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resuscitation (CPR) certifications. The required on-site hours according to the contract are
seven days a week for a total of eighty hours. The nursing staff are in compliance with the
contractual requirements.
4.03 Facility operating procedures (FOPs) Satisfactory Compliance
The program shall have facility operating procedures (FOPs) (FOP) for all health-related
procedures and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related protocols utilized at
the program. The designated health authority (DHA) and facility administrator (FA) signed and
dated all treatment protocols. The DHA and FA reviewed and signed protocols and FOPs on
October 24, 2024, and January 25, 2025. FOPs and protocols related to psychiatric services
and psychotropic medication management are developed and reviewed by the program’s
psychiatrist. The psychiatrist reviewed and signed the psychiatric protocols on October 23,
2024. The nursing protocols were signed by the nursing staff on October 24, 2024, and
November 22, 2024. There were updates to policy made during the annual compliance review
period and nursing staff signed they were reviewed on January 25, 2025. An annual review of
all FOPs and protocols were signed by the respective individuals from each discipline on May
24, 2025, signifying their understanding of the FOPs and any new health-related Department
policies with the exception of one RN who is newly hired and currently undergoing on the job
training. All newly hired medical staff receive a comprehensive clinical orientation to the
Department’s healthcare policies and procedures conducted by the registered nurse (RN). The
DHA had written and authorized approval of treatment protocols and standing procedures which
were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has facility operating procedures (FOPs) ensuring the completion of the
Department’s Authority for Evaluation and Treatment (AET), authorizing treatment of youth in
the program’s custody. A review of five youth Individual Healthcare Records (IHCRs) found four
were applicable for the AET forms. Each of the applicable youth had a signed AET form filed in
the record with the word “Copy” legibly stamped on it. The AET is valid for as long as the youth
is in the program or until the youth’s eighteenth birthday. One youth was eighteen and had a
documented release of information completed the day of admission. The nursing staff was
interviewed and reported the current policy for obtaining a new or current AET was to retrieve it
from the Department’s Juvenile Justice Information System (JJIS) or the youth’s IHCR sent to
the program. If the AET is more than one year old, staff notify the juvenile probation officer to
assist in obtaining a current AET; however, the AET is valid for as long as the youth is under
any type of supervision by the Department. If the youth is in Department of Children and
Families custody, then a court order must be signed by the committing court. If a youth is over
the age of eighteen, the nursing staff reported they may sign a Release of Information form.
Staff also keep the original signed AET in the chart. Medical treatment is discussed with the
youth by the nurses and the doctors. Youth are educated on the treatment and provide consent
if they decide to comply with the treatment.
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4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has facility operating procedures (FOPs) to ensure the parent/guardian is notified
of any changes in the youth’s condition and to document informed consent for youth healthcare.
Five youth Individual Healthcare Records (IHCRs) were reviewed for parental notifications and
four were applicable for requiring consent or notification for medical treatment, for one youth
was over the age of eighteen. Each of the applicable IHCRs documented the program received
consent from the youth’s parent/guardian for all new medications, over-the-counter medications
beyond those covered by the Authority for Evaluation and Treatment (AET), or new
psychotropic medications prior to administration. All applicable youth IHCRs documented the
program sent the required Department forms and documentation of the newly prescribed
medications were located on the Clinical Psychological Progress Note (CPPN). Witness
signatures were found for consent for psychotropic medication as required. Each of the five
reviewed IHCRs documented the program received and verified the youth’s vaccination records
within the required thirty days of admission. None of the youth were applicable for requiring new
vaccinations or requesting religious exemption.
Nursing staff were interviewed and stated notifications to parents/guardians are required when
there are changes in the youth’s health condition, when there is new medication or changes in
the medication or treatment prescribed, when there is recommended treatment by a medical
provider, and when dental treatment is recommended. As soon as the order is received by a
nurse, the parent/guardian is called and witnessed by a fellow staff then documented on a
phone log. A written notification is mailed as well. When a youth is in need of emergency
medical services, the DHA is notified immediately. Verbal notification is made to the
parent/guardian, followed by written notification. A call to the Department’s Central
Communications Center (CCC) must be made within two hours of the incident. Once treatment
is obtained, the DHA is notified, and orders are received and approved regarding care. The
parent/guardian is notified through verbal and written notice of the youth’s status and any new
orders. The CCC is called and updated as to the youth’s status. When a youth is prescribed
new psychotropic medications, medication is discontinued, or there are any psychotropic
medication adjustments verbal contact by the psychiatrist to the parent/guardian is made and is
witnessed by the nurse or staff. If youth are in need of vaccinations, they are sent to the health
department once written consent is received from the parent and an order is retrieved from the
DHA. Vaccination records are obtained through JJIS or each youth's previous medical records.
If records are not available, the nurse will obtain shot records through Florida Shots online.
Immunization records are reviewed during the admission process and reviewed by the DHA
during the youth's CPA. If a parent claims exemption and does not give consent for
vaccinations, then they complete the Religious Exemption from Immunizations form, sign and
submit it to program.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has facility operating procedures (FOPs) regarding youth healthcare admission
screening and rescreening each time the physical custody of the youth changes. Five youth
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Individual Healthcare Records (IHCRs) were reviewed, and each contained a Facility Entry
Physical Health Screening (FEPHS) form completed by a registered nurse (RN) on the day of
the youth’s admission. None of the youth were applicable for a change in custody greater than
twenty-four hours. The nursing staff were interviewed and verified FEPHS forms are completed
by RNs who see each youth immediately upon admission. When the FEPHS is completed by
non-healthcare staff, it is reviewed by a RN utilizing the FEPHS form. A new FEPHS form will be
completed by the RN as well as a body observation checklist, and a urine drug screen is also
completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has facility operating procedures (FOPs) ensuring all youth admitted to the
program are provided an orientation to healthcare services. Five youth Individual Healthcare
Records (IHCRs) were reviewed and each contained documentation the youth was oriented to
healthcare services at the program upon admission. Each youth’s orientation included all
required topics and was documented on the Department’s Health Education form as well as an
orientation sheet which listed all reviewed topics and was signed, and dated, by the youth.
Health education is to be given monthly as required by the program’s contract. A review of
documentation indicated this was being completed with the required health topics being
covered.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has facility operating procedures (FOPs) requiring notification be sent to the DHA
of all youth admissions including youth with chronic conditions, medical concerns, or any youth
admitted on psychotropic medications. Five youth Individual Healthcare Records (IHCRs) were
reviewed. One of the five youth were admitted with a known or suspected chronic condition or
required a referral to the DHA. The program provided an additional two records for review
totaling three applicable youth admitted with chronic conditions. None of the youth were
identified as in need of an emergency response upon admission. All records documented the
DHA was notified within the required timeframe and the notification was documented in the
youth’s Chronological Progress Notes as well as updated in the Chronic Conditions Log. None
of the reviewed youth were applicable for taking psychotropic medication upon admission;
however, it is the program’s practice to notify the psychiatrist of all newly admitted youth for
evaluation and notification to the psychiatrist documented according to program policy and
procedure. According to an interview with the registered nurse (RN), the DHA is notified of all
new admissions and any chronic conditions on the day of admission immediately after the RN
assessment by the nurse and also notated on the progress note and DHA notification form.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has facility operating procedures (FOPs) ensuring the Department’s Health-
Related History (HRH) form is completed prior to the Department’s Comprehensive Physical
Assessment (CPA) and healthcare needs are identified. Five youth Individual Healthcare
Records (IHCRs) were reviewed, and each contained a HRH completed by a registered nurse
(RN) on the day of admission and prior to completion of the CPA, as evidenced by the date and
signatures on both the HRH and CPA. There was documentation on each youth’s CPA the
designated health authority (DHA) reviewed the HRH. The nursing staff was interviewed and
reported the healthcare staff are responsible for completing the HRH immediately upon
admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has facility operating procedures (FOPs) ensuring the acute and chronic
healthcare needs of the youth are addressed by completing a Department Comprehensive
Physical Assessment (CPA) within seven days of youth admission. Five youth Individual
Healthcare Records (IHCRs) were reviewed and each contained a new CPA completed by the
designated health authority (DHA) within seven days of admission on the CPA. Each CPA was
completed in its entirety as required, including Medical Grade, and any parts of the exam
deferred by the physician were documented as such. In addition, each of the youth refused
parts of the exam and the DHA indicated such on the form as well as the youth signed indicating
their refusal. The program is an all-male program; therefore, none of the youth were applicable
for a gynecological exam. All of the five youth’s Department Problem List were updated as
required. Each of the five youth had a Tuberculosis Skin Test (TST) documented in the IHCR
within the last year with their results found on the Department’s Infectious and Communicable
Disease (ICD) form. Nursing staff were interviewed and reported all youth receive a CPA within
seven days of admission and annually thereafter. The nursing staff also verified the process for
ensuring each youth has a valid TST within the last year and confirming youth are screened for
sexually transmitted infections utilizing the STI screening form upon admission. The DHA then
reviews the screening form and indicates if testing is needed during their initial comprehensive
evaluation. Youth are able to consent or decline STI testing.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has facility operating procedures (FOPs) (FOPs) to ensure all youth admitted to
the program are screened, evaluated, and treated, if applicable, for sexually transmitted
infections (STIs) and human immunodeficiency virus (HIV). The designated health authority
(DHA) determines, based on the youth’s risk factors, screening tool, and evaluation, whether to
order testing for STIs. A review of five Individual Healthcare Records (IHCRs) found all youth
were clinically screened and evaluated for STIs on the date of admission. Two of the IHCRs
were applicable for further evaluation or referred to the DHA and were all documented on the
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Department’s Sexually Transmitted Infections form. All testing, screening, clinical evaluations,
and diagnoses were documented on the Department’s Infectious and Communicable Diseases
(ICD) forms, excluding the HIV results, and were filed in the lab section of the IHCR. None of
the youth were out of the Department’s physical custody; therefore, a rescreening was not
applicable. All five youth were offered pre/post-test counseling, testing, and referral for
treatment for HIV. One of the youth consented to receive an HIV test. The program’s policy
ensures the youth’s HIV test results are only disclosed to the youth’s legally authorized
representative, healthcare providers during treatment, the Department of Health for purposes of
reporting, health facility staff committees conducting program monitoring, medical personnel
who have been subject to significant exposure, and health care facility personnel or agents for
healthcare provider who have a need to know during patient care. The tested youth’s HIV
results were filed confidentially in a sealed envelope within the youth’s IHCR and the youth
received pre-/post-test counseling as indicated on the Individual Health Education Record. Pre
and post-test counseling services are provided by the DHA. The youth’s confidentiality was
protected to include not listing the youth’s STI diagnosis on any alert system.
Five youth were interviewed, all reported they are able to request an HIV test. An interview with
the registered nurse (RN) confirmed all youth are screened at admission using the appropriate
Department form and results are provided to the DHA. The DHA reviews if testing is needed
during the initial comprehensive evaluation. Youth are able to consent or decline STI testing.
STI results are filed in the lab section of the chart. Testing documentation is noted on the
Department’s Infectious and Communicable Disease Form and STI screening form. If a youth
has been out of the program for more than thirty days. the STI form is completed again, and/or
will complete a test or retest if any symptoms are present. The nursing staff confirmed all
counseling is provided by the DHA, and is documented under education in each youth’s IHCR,
with HIV results being located within the labs section of the IHCR in a sealed envelope labeled
as confidential. An HIV consent is reviewed with youth at admission and youth can be tested.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has facility operating procedures (FOPs) addressing the program’s sick call
process. A review of five Individual Healthcare Records (IHCRs) found all five youth had sick
call requests, addressed by the registered nurse (RN). Each of the Sick Call Request forms
were filed in the youth’s Individual Healthcare Record (IHCR) in reverse chronological order.
None of the youth were in restricted housing of any kind. The sick call request forms and
progress notes were documented in accordance with Florida Administrative Code, including vital
signs, treatment, education, and follow-up plans. Each of the sick call events were documented
on the Sick Call Index and on the program’s Sick Call Referral Log. All the dates listed on the
Sick Call Index corresponded to the completed Sick Call Request forms located in the youth
IHCRs. One of the youth presented with a similar sick call complaint three or more times within
a two-week period and a referral was made to the designated health authority (DHA) who did
follow up with the youth. The situation was not deemed an emergency. Sick call occurs twice a
day, seven days a week at 10:00 a.m. and 3:00 p.m. Sick call hours are posted on the medical
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office door and sick call forms are located on the living unit. An exam table and equipment are
used to perform sick call.
Five youth were interviewed, and they all reported they are seen immediately when requesting a
sick call. An interview with the nurse advised the youth completes a sick call form and put it in
the secured sick call box. The sick call boxes are located on the living unit and checked twice
daily. Sick calls are routinely conducted by the RNs or the DHA if they are on-site in the medical
clinic. According to nursing staff, sick calls are checked for urgency and can be completed
anytime within the day but are scheduled daily at 10:00 a.m. and 3:00 p.m. while youth are on
breaks. If a youth presents the same complaint three or more times within a two-week period,
the youth must be referred to the DHA. Nursing staff confirmed the program has DHA approved
treatment protocols and the program does not utilize restricted housing. An observation of a sick
call was able to be conducted during the annual compliance review week. The youth was
escorted to the sick call by a direct care staff member. The RN examining the youth identified
themselves prior to beginning the sick call with the youth and confirmed the reason for the
youth’s request. The sick call was conducted in a private area with no other youth present to
hear or see the examination; however, the direct care staff was present within sight and sound.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has facility operating procedures (FOPs) to ensure the youth have access to
episodic and first-aid care. A review of five youth Individual Healthcare Records (IHCRs) found
four youth required on-site episodic care. In the four applicable IHCRs, the on-site care was
provided by a licensed healthcare staff documented in the problem-oriented subjective,
objective, assessment, and plan (SOAP) elements. The program has a total of nine first-aid kits
located in designated areas throughout the program. The kits are in the medical clinic, master
control. kitchen, two in maintenance, two in the classrooms, and there is one kit in each
transport bag for the two transport vans. The program has a process for ensuring contents of
the first-aid kits are maintained and stored in accordance with guidelines to prevent expiration or
deterioration. An observation of two first-aid kits confirmed the kits were fully stocked with
designated health authority (DHA) approved contents. The nurse monitors the first-aid kits
weekly and checks for expired contents, which is documented on the first-aid kits logs. The
program has one automated external defibrillator (AED) located in the administrative hallway.
The AED procedures are located with the AED. The AED batteries and pads are checked by the
registered nurse (RN) once a month. Documentation confirmed the RN monitored the AED as
required. The RN checked the expiration dates and completed a self-test of the AED in the
presence of the Monitoring and Quality Improvement regional monitor, with no issues noted.
The batteries of the AED were last changed in April 2023 and expire in May 2028. The AED
pads were changed July 2025 and expire in January 2026. A list of emergency numbers
including the Poison Information Control Center was posted and accessible for non-licensed
and licensed staff, inaccessible to youth, posted in medical, master control, and inside the non-
healthcare binder inside the medical clinic. There was documentation indicating authorized
direct care staff are appropriately trained on the administration of the epinephrine auto-injector
and a review of eight staff training indicated the requirements were met regarding episodic, first-
aid, and emergency care.
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A review of the emergency drills confirmed the program conducted an emergency drill to include
cardiopulmonary resuscitation (CPR) annually with drills being conducted every month on each
shift. The emergency medical drills simulated an episodic care event which called for immediate
first aid, and/or administration of CPR techniques, and the initiation of emergency procedures to
follow when a life-threatening emergency does occur. A video observation of drills was
conducted. In the most recent drill completed at the program, on both shifts, the drill did not
appear to be simulated but taught. The statewide nursing director stated this was a trend
administration has noticed and is working with staff to correct the issue. The Department’s
Office of Health Services was also informed and reported they would be providing further
technical assistance on the matter. An episodic care event was not conducted during the annual
compliance review week. The program has FOPs regarding Narcan. The policy states all newly
employed provider staff shall receive education on recognizing and treating symptoms of opioid
overdose. Training shall include recognition of symptoms of an overdose, training on proper
administration of Naloxone, actions to follow after the administration of Naloxone, recording use
of Naloxone on the Medication Administration Record (MAR), and how to report the use to
nursing staff so a replacement can be ordered. The training shall also include educating staff
regarding the risk of overdoes, including having a lower tolerance for opioids if the individual is
participating in an abstinence-based treatment program or is being discharged from a
medication-assisted treatment program. Narcan is stored in medical, inside the locked
medication cart, and inventoried along with other medication. All staff are trained on the use of
Narcan; however, only medical and supervisory staff are permitted to administer it.
Three of five interviewed staff stated they can call 9-1-1 if a youth has a medical emergency.
Two of the five said they cannot call 9-1-1, with one saying they notify a supervisor and the
supervisor can call, and one saying they notify medical and medical will make the call. All five
interviewed youth stated they can see a dentist or doctor if they need to. Nursing staff confirmed
the process for providing episodic care. Episodic care is provided by the RN. A SOAP note is
placed in the chart. If episodic care is conducted by non-healthcare staff, the Department’s
Report of On-Site Health Care by Non-Health Care Staff form is completed and a follow up is
conducted by the RN within twenty-four hours. Nursing staff conduct drills monthly with CPR
being included quarterly, if not more frequent.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has facility operating procedures (FOPs) to ensure timely referrals and
coordination of medical services to an off-site health care provider. A review of five youth
Individual Healthcare Records (IHCRs) found four applicable for off-site care. In each of the four
applicable IHCRs, there was an indication the youth required off-site first-aid or emergency
care. The Department’s Summary of Off-Site Care Consultation Report form was utilized and
filed in the youth’s IHCR. Three of the IHCRs had documentation of the parent/guardian
notification efforts, the remaining youth was over the age of eighteen and provided his own
consent. All four youth had discharge and/or other applicable documents filed in the IHCR. The
DHA reviewed and signed all off-site care findings, instructions, and information in each of the
four IHCRs. Three of the youth required follow-up testing, referrals, or appointments. There was
evidence indicating the referrals were tracked and youth received appropriate follow-up care as
documented in the IHCR. The interviewed registered nurse (RN) confirmed the youth are
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tracked utilizing an appointment log, episodic log, appointment tracker, and calendar. Once the
off-site information is received, the RN notifies the DHA of any orders or instructions. Off-site
summaries with all attachments are placed in the DHA’s book to review and signed during their
next visit to the program. When hospital orders are received, the RN calls the DHA for a
telephone order to continue the prescribed orders. The orders are then faxed to the pharmacy
and transcribed to the Medication Administration Record (MAR). The medication pass list,
utilized to help track which youth are on medications, is updated and the parent/guardian is
notified with notification mailed
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has facility operating procedures (FOPs) to ensure any youth admitted to the
program who has chronic conditions receive regularly scheduled evaluations and any as
needed follow-up care. A review of five youth Individual Healthcare Records (IHCRs) found one
was identified on the Department’s Facility Entry Physical Health Screening (FEPHS) form with
a chronic condition at admission. The program provided two additional youth healthcare records
with chronic conditions identified through the Comprehensive Physical Assessment (CPA) with
the designated health authority (DHA). None of the youth were identified as having a
communicable disease. Two youth were taking prescribed medication on an on-going basis. All
three youth were classified with a Medical Grade of two to four and were placed on the
program’s Chronic Illness List. All three youth received periodic evaluations at least every ninety
days. None of the youth were applicable for taking anti-tuberculosis medications. One youth
required an evaluation in order to renew a prescription. Two of the youth had an evaluation
conducted off-site and the evaluation was documented on the summary of off-site care form and
filed in the IHCR. The DHA followed up with each youth after the off-site care and signed off on
the discharge and/or other documents. There was no evidence of any lapses in care or missed
periodic evaluations. The Department’s Problem List was updated for each youth.
An interview with the facility administrator (FA) indicated the health services administrator (HSA)
will ensure all admitted youth receive a preliminary screening including review of medical history
to assess medical needs. The assessment is conducted within initial intake processes upon
program placement. Upon admission, the on-duty health care staff shall review the youth’s
previous medical records, conduct a thorough assessment of the youth, and complete the
Facility Entry Physical Health Screening (FEPHS) form. The DHA interview confirmed the youth
with chronic conditions are seen every thirty to ninety days depending on the youth’s condition.
Nursing staff track each youth’s chronic condition and ensure the appropriate follow-up based
on the follow-up schedule determined by the DHA. The nurse confirmed in the interview the
youth are seen by the DHA every ninety days or more frequently if requested by the DHA and is
tracked by the nurses using the chronic conditions tracker.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has facility operating procedures (FOPs) to ensure the accurate and safe
administration of youth medications. A review of five youth Facility Entry Physical Health
Screening (FEPHS) forms found one youth was taking medication at the time of admission.
Each of the youth’s medications were verified prior to the youth being admitted into the program,
and the prescription notification was documented in the youth’s Chronological Progress Notes.
The designated health authority (DHA), and when applicable the psychiatrist, was contacted to
obtain an order to resume the specified medications prescribed prior to admission for each
youth. A review of the five youth IHCRs found four youth were applicable for current
medications to be continued, discontinued, changed, or for new medications to be ordered.
Each of the four applicable youth IHCRs included a Practitioner Order form indicating the DHA,
or psychiatrist, ordered the prescription for the youth. None of the youth were in restricted
housing of any kind. All five of the youth were applicable for over-the-counter (OTC)
medications, which were administered according to approved protocols. The Department’s
Medication Administration Record (MAR) was used to document all medications and treatments
for all reviewed IHCRs. The MAR clearly indicated medication start and stop dates. In all
applicable IHCRs, the staff initialed each administered medication entry. There were no
undocumented explanations for lapses or errors in medication administration for any of the
reviewed IHCRs. The registered nurse (RN) documented side-effects monitoring weekly on the
MAR for all five reviewed IHCRs. The MAR contains all required elements. In all reviewed
healthcare records, only licensed staff were giving youth their medications. There were no
indications of lapses or errors in medication administration. One youth had indication they
refused medication and in each instance the youth signed a Refusal of Treatment form
indicating the refusal and the refusal was clearly documented in the MAR. There were no
standing orders for psychotropic medications, emergency treatment orders for psychotropic
medication, or any pro-re-nata (PRN) orders for psychotropic medications. A medication pass
was observed. The youth were escorted by direct care staff and approached the nurse
individually. The medical provider identified themselves and confirmed the reason youth was
present. The medical provider prepared the medication and verified the youth’s allergies and
alert status. The medical provider initialed the MAR, and the medical provider observed to
ensure the medication was swallowed. The Six Rights of Medication Delivery/Administration
was maintained in each of the youth records.
Five youth were interviewed, one of the five interviewed youth reported taking medications. The
youth indicated his medications are given by the nurse. The youth was able to explain the
process which included waiting in line for his name to be called, walking up to the cart, and
providing the nurse with his name and date of birth, prior to taking medicine, the nurse inspects
youth’s mouth, then he takes his medications, and the nurse inspects his mouth once more to
make sure he has taken his medications. An interview with the nurse indicated all youth’s
medication is verified upon admission and the program utilizes a pre-printed pharmacy MAR.
Non-healthcare staff do provide medications; however, there is a training curriculum in place.
Staff are trained by the nurse. The approved list of non-healthcare staff is located in the MAR
book and in the non-health care medical binder. Non-healthcare staff only give medications
when a nurse is not on-site. Medication is given three times a day and the program obtains
youth medications through a modified class II permit. The nurse confirmed the program utilizes
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the services of a psychiatrist weekly on-site and on-call twenty-four hours a day, seven days a
week.
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.
The program has facility operating procedures (FOPs) to address the psychiatric services
provided to the youth in the program. The program maintains an independent contractor
agreement with a board-certified licensed psychiatrist who has a clear and active license in the
State of Florida, which expires on January 31, 2027. The psychiatrist is scheduled to be on-site
weekly and available for emergency consultation twenty-four hours a day, seven days a week. A
review of sign-in documentation indicated the psychiatrist was on-site delivering services weekly
in excess of what is required by contract. An interview with the psychiatrist confirmed they are
on-site each week and on-call twenty-four hours a day, seven days a week. The psychiatrist
conducts psychiatric evaluations on all youth upon admission to the program, follow-up
appointments for all youth on psychotropic medication at least monthly and determine treatment
needs and staff concerns for all youth in the program with the clinical director, therapists, and
nursing staff. The psychiatrist expressed a concern regarding bettering residential services by
equipping the programs with trauma informed and behavioral modification interventions
provided by trained staff for more positive outcomes. The program does not utilize an advanced
practice registered nurse (APRN). An interview with the designated mental health clinician
authority (DMHCA) confirmed meetings with the psychiatrist occur weekly while they are on-site.
Five youth mental health and substance abuse records were reviewed; none of the youth were
applicable for having psychiatric medication prescribed upon admission, although it is standard
practice in accordance with the program’s policy and procedures to conduct a psychiatric
evaluation with all youth within fourteen days of admission. All five youth received psychiatric
evaluations which included documentation of youth history, Mental Status Examination,
treatment recommendations, and a Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis. Three youth were applicable to being prescribed psychotropic
medications. In the applicable three records, the evaluation included prescribed medications,
explanation of need, target symptoms, treatment goals, potential side effects, risks and benefits,
and frequency of medication monitoring. Each reviewed record documented the Initial
Diagnostic Psychiatric Interview on the Department’s Clinical Psychotropic Progress Note
(CPPN) form; and each contained page three of the CPPN. Each of the three mental health and
substance abuse records verified three of the five youth were put on psychotropic medications
after the psychiatric evaluation. Each applicable youth record documented the youth was
evaluated by the psychiatrist every thirty days. Each assessment was documented on the
Department’s form, including page three of the CPPN, and was completed in full. There were no
documented lapses in psychiatric services for the records reviewed. Reviewed documentation
supported there were no standing, pro re nata, and/or emergency treatment orders for
psychotropic medications. A review of three applicable psychiatric progress notes verified the
psychiatrist included the youth’s identifying data, diagnosis, target symptoms of each
medication, and description of the effect of prescribed medication on target symptoms. In
addition, the psychiatrist included the name of the prescribed psychotropic medication, quantity
of medication, normal dosage range, ordered dosage, frequency and route administration,
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reasons for any changes in medication, and/or dosage and side effects. The CPPN included the
youth’s adherence to the medication regime, vital signs, notification to the parent/guardian,
signature and date of the psychiatrist, and applicable monitoring for Tardive Dyskinesia monthly.
The program’s contract does not include the use of telepsychiatry.
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 program has facility operating procedures (FOPs) to ensure medical equipment classified
as sharps/medications are secure and inventoried utilizing a routine perpetual inventory. A
review of the medical equipment classified as sharps confirmed the items were securely stored
and inventoried utilizing a routine perpetual inventory descending count. All medications were
identified and secured in a locked medication cart designated for storage of medications. The
medication cart was secured, clean, and organized with stock items separate from youth
specific medications. The program had no controlled medication during the annual compliance
review week. All medications were stored in a separate, secured area, inaccessible to the youth.
Narcotics and other controlled medications are stored behind two locks, and refrigerated
medication are stored in a secured refrigerator only used for medication; however, at the time of
the review the program did not have any on-site. The program’s process for the destruction and
disposal or return of expired or discontinued medications involves a registered nurse (RN) and
one other staff using Drug Buster fluid. Controlled narcotics are disposed of in the same
manner; however, a pharmacy consultant must be present with the RN. All destroyed or
disposed medications are logged in a tracking binder. The program conducts a perpetual and
weekly inventory of all sharps and stock over-the-counter (OTC) medications which did not
indicate any discrepancies. The nursing staff maintain a shift-to-shift inventory of all controlled
substances, in the event a youth is prescribed a controlled substance and documented this on
the youth’s Individualized Controlled Medication Inventory Record. The number of pills, tablets,
or dosages remaining were documented on the youth’s Individualized Controlled Medication
Inventory Record after each administered dosage. Nine supervisory level staff were trained in
the delivery and oversight of medication self-administration. The training was provided by the
registered nurse (RN). Observations were conducted of inventory counts of three OTC
medications and three sharps. All inventories were correct with no discrepancies. The registered
nurse (RN) reported if there is a discrepancy in the count, the health services administrator
(HSA), designated health authority (DHA), and facility administrator (FA) shall be notified. The
program shall report and investigate unexplained losses of controlled substances and report as
required by Florida Administrative Code. The interview with the nurse confirmed their process
for destroying and/or disposing of expired medications as well as the processes for storage of
medications including controlled substances and narcotics. The nurse indicated the program’s
pharmacy consultant is on site monthly for inspections and monitoring of the medication cart,
Medication Administration Reports (MAR), medication disposals, and storage of medications. A
copy of the pharmacy consultant’s license is on-site.
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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 has facility operating procedures (FOPs) for infection control which include an
exposure control plan and are written in accordance with Occupational Safety and Health
Administration (OSHA) and Center for Disease Control and Prevention (CDC) guidelines. The
infection control policy was last reviewed and signed by the designated health authority (DHA)
on January 21, 2025, and the facility administrator (FA) on October 24, 2024. The infection
control procedures include all required elements and specify staff have access to protective
equipment and Hepatitis B immunizations. The program maintains a separate file for any
instances of facility or occupational exposure, which is kept for a period of ten years; however,
the program has not had an exposure incident during the annual compliance review period. The
exposure control plan was written in accordance with OSHA standards and was last reviewed
and signed by the DHA on January 21, 2025, and FA on October 24, 2024. The plan includes a
process for needle stick post-exposure evaluation. The program has not had any instances of
infectious diseases or quarantining/hospitalization of at least ten percent of youth and/or staff
which needed to be reported to all required parties during the annual compliance review period.
The FA and nursing staff were interviewed and stated the infection control and exposure plan is
made available to all staff located in the break room and in the medical office. Medical staff train
all other staff on the combined plan annually and as needed, and education is also provided to
each youth upon admission as well as during health education class.
4.20 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Limited 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’s staff to youth contract required ratio is one to eight youth during daytime
activities and one staff to twelve youth during nighttime sleep. Youth were observed each day of
the annual compliance review week in various activities: education, searches, daily youth
meeting, sick call, youth graduation, Impact of Crime group, recreation, and counts. All
interactions observed were positive between the youth and staff. Three staff were informally
interviewed and were able to indicate how many youth they were supervising at the time. The
program maintains a written policy and procedures for active supervision of youth. The policy
and procedures include interacting positively with the youth, engaging youth in a full schedule of
constructive activities, closely observing behavior of youth and changes in behavior, and
consistently applying the program’s behavior management system. The daily schedule was
observed to be posted throughout the program, including in the dormitory. The youth were
engaged in a full schedule of activities as evidenced by daily observations and video review.
Staff did not consistently observe the youth while they were sleeping. Ten-minute checks were
not conducted with fidelity. The youth room door windows were not covered by any items. There
was one escape during the annual compliance review period and there is an open deficiency for
this incident.
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.
A review of the program’s behavior management system (BMS) was conducted to ensure the
appropriate parties were involved in the development, implementation, and on-going
maintenance of the BMS. The program’s facility operating procedures (FOPs) include a protocol
where staff are provided with feedback regarding the implementation of the BMS. There is an
agreement between the program and the school related to the BMS. The education staff are
trained in the BMS and there are rules and guidelines for the BMS on the walls in each
classroom. Five youth case management records were reviewed and confirmed the orientation
provided to each youth included a review of the program’s BMS. Three position descriptions
were reviewed and all three included the implementation of the program’s BMS. Five staff
training records were reviewed, and all were trained in the program’s BMS. Postings of the BMS
were observed in classrooms and dormitory. The grievance procedure is addressed as part of
the BMS. Youth can earn certificates to hang in their rooms to award youth for having the
cleanest room. The phase sheets and how to earn the next level in the program were observed
in the dormitory. The grievance forms and box were in a central location for the youth. The BMS
was in the student handbook the youth receive at orientation and was confirmed during the
annual compliance review. The BMS has not been changed and was not in the process of being
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changed during the annual compliance review period. The BMS included all the required
elements including youth recognition of accomplishment and positive behaviors using a four-
positives-to-one negative ratio. The BMS does not include added length of stay, denial of basic
rights or services, promotion of group discipline, punishment of youth by other youth, or
disciplinary confinement. Staff and youth positive interactions were observed throughout the
week of the annual compliance review. There were no negative interactions observed during the
week of the review. The program provides a variety of incentives for the youth; recognition for
no physical restraints for each month, a youth room is recognized as “Room of the Month” and
the youth receives a certificate to hang in their room, special meals each week for youth who
reach phases four and five, administration periodically provides unscheduled recognition and
rewards for youth and groups of youth who have demonstrated extraordinary teamwork,
cleanliness, and culture. The youth are also able to earn “Administrative Points” which are more
than their 285 points they can earn daily, and the program provides a game room for youth who
are on phases four and five.
Five staff were interviewed and all five were familiar with the BMS used in the program. Each
understood the level expectations, timeframes, and point system. The five staff reported youth
rewards include group outings and snack attack, which is a store containing upgraded hygiene
items and snacks. All five staff confirmed basic rights cannot be taken away from youth as a
consequence. Three of the five interviewed staff explained the youth are informed of the
consequences of their behavior and are provided an opportunity to explain their behaviors. One
of those three staff stated this can occur in a special treatment team meeting. The remaining
two staff did not know the process of the youth being informed of their consequences.
Five youth were interviewed and asked about rewards and consequences in the program. Four
of five youth reported the consequences they can get are write-ups, taking points away on their
point sheets, lose incentives, and receive added time. One youth said if the violation is severe
enough, your level in the program can decrease. All five youth said rewards for positive
behavior include the “snack attack store” and going on outings. All five youth reported staff are
consistent in what behaviors they give rewards and consequences for. All five interviewed youth
were familiar with the level/point system used at the program. Each youth was able to explain, in
detail, each level’s expectations and how to progress in the behavior management system. All
five stated, youth are never allowed to punish other youth.
The facility administrator (FA) was interviewed and reported the BMS utilized at the program
ensures the youth are held accountable for their behavior either positive or negative. The rules
governing conduct and positive and negative consequences are posted in the student handbook
in which the youth can access daily. The FA ensured the BMS is based upon the youth’s status
progression, daily progress notes, and code of conduct. Recognitions of accomplishments and
positive behaviors of a five-to-one ratio is documented in the dormitory on the wall. All staff have
received training on the BMS during the first phase of employment. Youth are rewarded for
positive behavior. When a youth consistently displays positive behavior, they can earn
incentives including off-site trips, restaurant outings, personal items, and other rewards. The FA
went on to report, consequences are monitored through the program’s code of conduct and the
BMS. Program staff and education staff are trained in the implementation of the program’s BMS.
The shift supervisors and youth care workers provide feedback regarding the implementation of
the BMS during staff briefings, shift meetings, and random conversation throughout the day.
The youth are informed of their consequences and are allowed an opportunity to explain their
behavior. The staff implementation of the BMS is monitored through performance evaluations
and annual evaluations.
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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 facility operating procedures (FOPs) indicate the program is allowed to utilize
room restriction. However, the facility administrator reported the program does not utilize room
restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Failed Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has thirty-two cameras, and thirty-one cameras were operational during the annual
compliance review week. The video recordings are stored between thirty and forty-five days.
After review of ten-minute checks sheets and video review, it was determined the checks are
not being documented in real time. The ten-minute sheets were being filled out prior to and not
during ten-minute checks. The staff who completed the ten-minute check sheets did not initial
and/or sign them consistently. Each of the reviewed check sheets were documented on the ten-
minute mark for each hour. Video review further confirmed the ten-minute checks were being
falsified. The program reported the falsification to the Department’s Central Communications
Center when the issue was identified during video review.
Three different times for three different days to total nine thirty-minute increments were
observed on video. Two out of nine video reviews showed staff conducting checks every ten
minutes. Seven of the nine checks were not conducted every ten minutes though they were
documented as being completed every ten minutes on the logs. One increment showed two
checks were being denoted as being conducted on time; however, video showed the checks
were not completed. Out of the seven thirty-minute increments, one check was eighteen
minutes late, one was ten minutes late, one was seven minutes late, two were three minutes
late, three were one minute late, and one check was not conducted. All of the ten minute check
logs were documented with the times being conducted on the ten-minute mark instead of in real
time.
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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’s facility operating procedures (FOPs) ensure the safety and security of the
program follows the program’s mission, goals, and outcomes which are achieved by maintaining
active supervision of youth to include interacting positively with youth, engaging youth in a full
schedule of constructive activities, closely observing behavior of youth and changes in behavior,
and consistently applying the program’s behavior management system. The program will also
ensure proper staffing ratios are maintained based upon the Department’s and the program’s
contract. The ratios for the youth and staff are also included: one staff to eight youth during
awake hours, one staff to twelve youth during non-awake hours, and one staff to five youth for
work projects and off campus trips. The procedures also indicate resident counts will be
conducted at the beginning of each shift, several times daily to include after each outdoor
activity and during any emergency situations, escape incident or riot. The program tracks daily
census information, including, at minimum, the total daily census counts, new admissions,
releases, or direct discharges, transfers, and youth temporarily away from the program. All
counts shall be documented in the logbook. The procedures include staff observing youth at
least every ten minutes while they are in their sleeping quarters, and either during an illness or
room restriction. Staff conduct observations in a manner which ensures the safety and security
of each youth and manually document real time observation. The facility administrator reviews
the ten-minute checks by reviewing video recording during sleep hours weekly to ensure
compliance with this standard and to ensure the checks are met with fidelity. An observation of
a count was observed to be conducted from master control. There were no issues with the
count, and it was documented as required. Five interviewed staff stated census counts are
conducted hourly by master control. If the count cannot be reconciled, all five staff reported
youth movement is stopped and there is a recount until it is reconciled. All five staff reported
emergency checks are conducted after emergencies, drills, and when regular counts are not
reconciled. Logbooks were reviewed for one day of each month of the annual compliance
review period. The logbooks included all required documentation for census, counts, and
tracking. None of the dates reviewed included an emergency or transfers. One date reviewed
included a discrepancy in the number of youth in the program but was able to be reconciled.
The program reported a staff had not been hired for master control at the time of the entry in the
logbook and the counts were not updated as required.
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5.06 Logbook Entries and Shift Report Review Limited Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a chronological record of events in the facility logbook. One full day
each month of the annual compliance review period was reviewed in the facility logbook for
entries and shift reports. The program reported the shift reports are documented and maintained
within the facility logbooks. All observed logbooks were bound with numbered pages. All
reviewed dates included the following required elements: entries were made in ink with no
erasures or white-out, no logbook entries were observed to be destroyed or removed, and any
errors were struck through with a single line and initialed by the staff correcting the error. Six of
the nine dates reviewed did not include the dates, times of events, the names of the staff and
youth involved, brief descriptions of the events, or the names and signatures of the staff making
entries. Three reviewed days did include all required information. Three of the nine shift reports
in the program’s logbook did not include a summary of events, incidents, and activities. Four out
of nine reviewed shift reports did not include the incoming or outgoing staff signatures and
dates. There was also no documentation for the four reviewed dates of staff being verbally
briefed on the shift reports. There were no emergency situations or incidents identified during
the annual compliance review period, which included mechanical restraints or special
instructions for supervision and monitoring of youth. All reviewed dates included population
counts at the beginning and end of each shift, along with any additional population counts
conducted during a shift. The perimeter security checks were also documented. Three of the
reviewed dates included documentation of transports away from the facility and included names
of staff and youth, and the destination.
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 facility operating procedures (FOPs) which include the control and use
of keys. The FOPs included 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. During the annual
compliance review week, the review team was able to observe a distribution of keys conducted
by master control. Observations confirmed after a therapist entered the facility, they turned in
their personal keys, and obtained their assigned facility keys. The program’s FOPs include the
processes for permanently issued keys. These keys must be authorized in writing by the facility
administrator (FA). Department heads, facility nurse, and clinicians will have permanent issued
keys. The use of permanent keys must be limited to those individuals to whom the keys were
issued for necessary security and programming purposes. The permanent keys may be taken
off facility grounds at the discretion of the FA and are relinquished at the end of employment or
by the request of the FA. Any employee who is issued permanent keys will sign a copy of the
“Key Responsibilities” form during orientation which will be maintained in the Key Reference
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Office of Accountability and Program Support Page 58 of 69 (Revised August 2025)
File. The following keys are restricted in the facility: personnel records of staff, pharmacy
cabinet, medical department offices, facility administrator’s office, clinical/case manager office
areas and file cabinets, administrative suite of offices, maintenance manager’s storage shed for
tools, and the shift supervisor’s master key set. Restricted keys were clearly separated from
active keys by being maintained in a separate lock box within the main lock box. The key for the
restricted box is on the shift supervisor’s key ring. Documentation of staff assigned permanent
keys was reviewed. The documentation is maintained in a binder just outside master control.
The staff assigned permanent keys signed and dated the “Key Responsibilities” form, which was
evidenced by a review of the forms. These are maintained in the human resources office.
The program’s FOPs also included the process for reporting and replacement of damage keys.
If a key is lost or missing, the shift supervisor and FA must be notified immediately. A facility-
wide search of all program areas and youth will take place immediately to locate the keys. Staff
will ensure during the search the facility is placed on the highest security alert until the keys are
found, and youth will be in their sleeping rooms until the search is completed. A shift supervisor
will document the incident in the facility logbook and complete an incident report outlining how
the keys were lost and any investigation details. The program also makes reports to the
Department’s Central Communications Center (CCC), as necessary. The key replacement
FOPs included staff who damage or break a key are responsible to report this to the shift
supervisor and a Maintenance Request form is to be completed. Any keys which are broken or
need to be replaced will be given to the physical plant manager. Any extra replacement keys will
be kept secured in the Emergency/Restricted Key Box and shall be issued only with the
authorization of the FA and this shall be reflected in the documentation within the Key Log.
There were no incidents reported to the CCC or deficiencies documented in the Department’s
Program Monitoring and Management (PMM) system during the annual compliance review
period. An informal interview with the master control operator was conducted. The restricted
keys were observed to be in a small lock box inside of the large lock box. There is also a daily
sign-in/out log kept in master control for all keys coming in and going out of the facility. A review
of weekly key inventory sheets was conducted with no discrepancies noted. The key box, which
is in master control, was not easily accessible while locked. The key inventory was also
reviewed with no discrepancies noted. A sample of five key rings was observed and compared
to the inventory and key log. There were no discrepancies noted. Three staff were informally
interviewed about the number and function of each key on their key ring. All three staff were
able to state how many keys were present and what were the assigned functions of the keys.
Five staff were formally interviewed regarding key control. Each of the five staff reported their
keys are given to master control upon entry, their personal keys are securely stored, there is a
daily tracking of keys with a key log, there is inventory of keys, and program keys are assigned
to staff. Two of the five staff reported youth do not have access to keys.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 69 (Revised August 2025)
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system in place for contraband, which is documented within their facility
operating procedures (FOPs). The FOPs include a definition of items and materials considered
contraband and exemptions. The FOPs also included all mandatory requirements. The youth
are provided with a list of items considered to be contraband and consequences if found with
contraband within the student handbook they receive during orientation. The FOPs also include
procedures for searching the physical plant, facility grounds, youth, incoming mail, and outgoing
mail for contraband. The facility visitor log contains a contraband attestation statement as
observed while signing into the facility. Twenty new staff have been hired since the last annual
compliance review and all new staff signed an attestation form, which is maintained in their
personnel files. Two incidents regarding contraband, which had been reported to the
Department’s Central Communications Center (CCC), were reviewed and both incidents
included non-illegal contraband. All non-illegal contraband was disposed of appropriately, if
applicable. Facility logbooks and incident reports were reviewed to determine the frequency and
quality of searches and the result of each search. The program did not maintain search reports.
The facility administrator was interviewed and was able to summarize the FOPs for contraband
procedures. Five staff were interviewed for youth room searches. Two staff reported searches
are conducted once a month. One staff reported searches are conducted weekly. One staff
reported searches are conducted daily. The final staff stated the supervisor will tell them when
to conduct a search. Three of the five staff were able to explain the process of searching a
youth’s room, which includes searching the bed, pillows, behind the bed, underneath the bed,
and in the youth’s bins where they keep their personal/hygiene items.
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Office of Accountability and Program Support Page 60 of 69 (Revised August 2025)
5.09 Searches and Full Body Visual Searches Failed Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
During the week of the annual compliance review, youth searches were observed to be
completed when going into case management, prior to transport, and to and from treatment
team meetings. One youth was searched prior to transport. The staff were observed to pat down
the youth prior to leaving the building and prior to getting into the transport van. Staff explained
the procedures required for the youth to be searched prior to leaving the area they are in, prior
to leaving the building, and prior to getting in the van. The staff conducted a pat down search of
the youth, placed leg shackles on the youth, the youth entered the van after staff conducted a
search, and staff verified the youth put on a seatbelt. The youth was treated with dignity and
respect to minimize stress and embarrassment. The search was conducted by the appropriate
number of staff and gender. Observations determined searches were thorough and conducted
as required by the Right Interactions model (RI) training manual. Video review was conducted of
visitor and staff searches. Two visitor searches were observed with no discrepancies noted. A
review of staff searches was conducted with a total of nine staff being observed. Seven staff did
not receive a pat-down search. Two of the nine staff were not searched with an electronic wand.
Eight of the nine staff did not remove their shoes. Two of the nine staff were not searched at all
and were able to enter the secured area of the facility. One staff entered the facility with a bag,
which was not searched. A video review of three days of education movement was observed.
There were eighteen opportunities for the youth to be searched. Out of the eighteen
movements, the youth were searched once. Five interviewed staff reported youth searches are
conducted prior to all movements. All five staff were able to describe the search process of the
youth which includes starting at their collar, moving down their sides, going to their waist, and
then their legs and feet. Five interviewed youth stated they are searched prior to and after any
movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program utilizes two vans to transport youth. Documentation for the vans was provided for
review. Both vehicles had an annual safety inspection completed with no deficiencies noted and
maintenance records were documented and reviewed. Both vans were secured when checked
by review team members. Both vehicles had fire extinguishers, seatbelt cutters, window
punches, and the appropriate number of seat belts. The door to the youth passenger area
cannot be opened from the inside. Each van has a backpack for the staff to take with them.
Each backpack has a first-aid kit, the book for the van to document travel information, and hand
cuffs. The backpack does not stay in the vehicles. Five staff vehicles parked in the program
parking lot were checked by review team members during one day of the annual compliance
review week. Four out of the five vehicles were locked when checked. The staff member had
unlocked the vehicle to get food out for a potluck lunch at the program. The staff was observed
in the lobby going out to their vehicle and the vehicle was locked upon return into the program.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains facility operating procedures (FOPs) to ensure the safety and security of
youth and the community when youth are transported outside the program. A review of the
program’s FOPs, as well as interviews and observations, reflected staff transporting youth are
given a radio and program cellular telephone. Reviewed documentation verified all approved
drivers had a valid driver’s license. The program assigns a ratio of one staff to five youth during
transport, not including the driver. A transport was able to be observed during the annual
compliance review week. It was confirmed the one to five staff to youth ratio, not including the
driver, was followed with no issues. Both staff transporting the youth were of the same sex as
the youth. The youth got into the vehicle and fastened the seatbelt. The staff riding in the back
of the vehicle also got into the back of the vehicle and fastened a seatbelt. Youth are not
permitted to drive program or staff vehicles.
Five interviewed staff report youth are secured with seat belts within the vehicle. Five
interviewed staff stated they are provided with two-way radios and program cell phones during a
transport. All five staff report there are first-aid kits, fire extinguishers, seat belt cutters, and
window breaks in the transport vehicles. All five staff said transport vehicles are searched
before and after each use and youth are not allowed to be transported in personal vehicles. All
five staff reported if there is an emergency, they would notify the facility and call law
enforcement and/or emergency services if needed. All five staff stated the staff to youth ratios
during a transport are two to five. None of the five interviewed youth stated they have been
handcuffed to a transport vehicle, and none have witnessed anyone placing contraband in a
transport vehicle.
5.12 Weekly Safety and Security Audits Failed Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has facility operating procedures (FOPs) for weekly safety and security audits. The
facility administrator or the facility plant manager is responsible for conducting the weekly
security audits and safety inspections. If a deficiency is found during an internal or external
review, audit, or inspection, a corrective action plan is developed and noted on the Safety and
Security Audit Tool. The facility administrator (FA) will follow up on a weekly basis to ensure the
corrective action plan is followed thoroughly to correct the deficiency. The program provided
eight Safety and Security Audit Tool forms for review for the eight months of the annual
compliance review period. Additional Safety and Security Audit Tools were not provided to
determine if weekly audits were being completed as required. The audits reviewed had a
different facility administrator’s name on them. Items listed on the Inspection forms were not
from this facility. The program uses an Items Need Correction form. The pages of this form
provided to the review team were pages from a different program and a different provider. There
were four deficiencies located in the Program and Monitoring and Maintenance (PMM) module
of the Department’s Juvenile Justice Information System (JJIS). All four deficiencies were
assigned by Residential Services and have since been closed. The program did not provide any
Preventative Maintenance Checklists for review. The FA was interviewed and reported the
program has FOPs in place to ensure the program maintains a safe and secure physical plant,
grounds, and perimeter. The FOPs 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) will be discussed during the daily department head meetings
and during all site meetings when staff from both shifts are present.
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 facility operating procedures (FOPs) for tool inventory and management
and included the issuance, inventory, and control of equipment and tools. Five tools from the
maintenance building and the kitchen were observed. All tools were secured, had identifying
marks on them, and all inventories were accurate. All tools were being consistently inventoried
prior to and after work activities. Daily inventories were being kept for all sharp-edged tools and
monthly inventories were reviewed for tools which don’t have sharp edges or points. All
machetes, bowie knives, or other long blade knives are prohibited in the program. If a tool
becomes missing from the program, the facility administration and shift supervisor will be
notified immediately. The incident is to be logged in the facility logbook, all youth movement will
be halted until a thorough search is completed or the tool is found. The missing tool will be
documented on an incident report before the end of the shift, and the incident report will be
circulated to all department heads for review and notification. Any results of the search shall
also be documented in the logbook and discussed in shift briefings for the purpose of alerting
incoming staff to security concerns, identifying the missing item for continued search, or
indicating an item was missing and then located. If a tool is missing, a red tag will be placed on
the shadow board in the tool’s spot until the missing tool is found or replaced. One tool was
dysfunctional and in process of being replaced. The physical plant manager reported one
handsaw was damaged and taken off property for proper disposal. The physical plant manager
is in process of buying a new saw. All inventories were reviewed. The physical plant manager
completes a new inventory sheet every day as the tools are counted and checked each day.
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’s facility operating procedures (FOPs) was reviewed and included all required
elements regarding youth tool handling and supervision. Youth were unable to be observed
using tools during the annual compliance review. Once a youth is assessed for risk and
approved for tool usage, they are trained and work with the physical plant manager to learn the
tools. Five youth records were reviewed and all of the youth received training on use of tools. All
five interviewed staff reported youth are allowed to use mops and brooms. Two of five staff
reported youth are allowed to use a scrub brush. All five interviewed youth report they are
allowed to use mops and brooms. Three of the five youth report they can use a scrub brush,
and one reported they can use a rake to help with yard clean-up.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains facility operating procedures (FOPs) for outside contractors visiting the
program. The program’s FOPs included the processes for tools brought on-site from the
outside. When a repair person or other worker comes on-site from the outside community with
the tools of their trade, program staff should alert them to the potential danger of tools used on
grounds and request them to: limit the tools used to only those necessary to complete the job;
check tools when they arrive and leave; keep close track of tools while working on-site; and
immediately notify program staff if any tool missing. The outside worker or repairman will sign
an acknowledgement form indicating all tools must be inventoried upon entry into the program
and exit from the program. This acknowledgement shall be recorded on the appropriate
inventory form. When outside workers are on-site with tools, program staff should restrict
youths’ access to the work area to the extent possible, closely monitor the situation, and
vigilantly supervise youth at all times. When the work is completed, staff should check the work
area to ensure the repairman takes all tools with them when they leave. If any tool brought on-
site under these types of circumstances is found to be missing, staff shall take immediate action
according to the program’s FOPs. Seven Written Notification to Outside Contractors/Vendors
forms were reviewed. All seven forms were signed and dated by the vendor and program staff.
A tool inventory was also documented with each contractor form. The guidelines for repairment
and external workers included: tools are to be checked upon arrival and departure, tool
restrictions while in the program, youth are restricted from the work area, and missing tool follow
up. All seven forms included the invoices for the projects conducted. An inventory was kept for
all tools entering and exiting the program.
5.16 Fire, Safety, and Evacuation Drills Limited Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
Drill documentation was provided for review. A total of twelve drills were reviewed. Six of the
reviewed drills did not have a.m. or p.m. noted on the drill form; therefore, it was unable to be
determined what shift it was conducted. For the drills dated the same date, the same staff
signed and dated both drill forms. All drills did document the type of drill, dates, participants,
brief scenario, findings, and recommendations. Six months of drills for the second shift were not
provided for review. Fire evacuation and egress plans were observed posted throughout the
program. The program has thirteen fire extinguishers which were observed. All of the fire
extinguishers had been inspected annually. Four of five interviewed staff reported participating
in fire drills and medical drills and one stated they had not participated in either. Three of five
staff reported participating in mental health drills and escape drills and two stated they had not
participated. All five interviewed youth stated they have been instructed on what to do in case of
a fire, and each report they have participated in monthly fire drills. The facility administrator was
interviewed and reported facility operating procedures (FOPs) staff participate in the following
drills: fire, suicide, medical, active shooter, and weather. The program conducts drills throughout
the year. A drill schedule is given to staff to show when and which drills are to be conducted.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 69 (Revised August 2025)
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 Continuity of Operations Planning (COOP) was observed to be located in the facility
administrator’s (FA) office. There was a sign posted outside the FA’s door for staff to quickly
locate the COOP book. The COOP was last reviewed and updated on March 11, 2025. A review
of the COOP showed addresses of the alternative relocation sites approved by the applicable
Department regional director. The Emergency Disaster Preparedness Plan and COOP were
combined into one plan. The COOP was submitted to the Department for approval on March 13,
2025. Equipment and supplies required for continuous operation and services during an
emergency or disaster was observed to be located in the dry storage areas. The supplies
observed to be included were dry storage food, COOP van books, canned goods, and
flashlights. The program maintains two binders labeled for each transport van. Both binders
included facesheets and an admission card with all required information. All required information
for each youth was included in each van binder. The FA was interviewed and reported the
program has a combined coordinated disaster and COOP. The plan addressed alternative
housing plans approved by the Department’s regional director or designee. The COOP is
accessible to all staff in a clearly marked binder in the facility administrator’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains facility operating procedures (FOPs) indicating the physical plant
manager will maintain inventories of all flammables, poisonous, and toxic fluids used at the
program. All fluids shall be signed out when used and signed back in or noted as destroyed
when returned or disposed of and the corresponding inventory shall be updated. Only
authorized staff may pour the flammable, poisonous, or toxic fluid. The authorized staff includes
the physical plant manager, facility administrator (FA), shift supervisors, and dietary workers.
Youth are not allowed to handle these items and will not have access to where these items are
being used and stored. No youth will be permitted to clean, handle, or dispose of any other
person’s biohazardous material, bodily fluids, or human waste. All items must be secured when
not in use. All flammable items are to be stored in a fireproof safety secured locker. All
hazardous chemicals no longer used or outdated will be disposed of by returning them back to
the vendors or hazardous waste center in accordance with the Safety Data Sheets (SDS).
Observations made during the annual compliance review week confirmed all flammable,
poisonous, and toxic items were located in the maintenance building in a locked storage
cabinet. The storage cabinet is located behind two additional locked doors. All inventories were
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Office of Accountability and Program Support Page 65 of 69 (Revised August 2025)
observed and are being maintained for all items. The physical plant manager, under the
supervision of the FA, are authorized to handle the items. The facility operating procedures
(FOPs) included the procedures on the disposal of flammable, toxic, caustic, and poisonous
items. The FOPs also included processes if there is a chemical spill within the program, to
include notifying the shift supervisor of the location of the spill, the supervisor is to shut-down air
handlers and ventilation systems, close all windows and doors, and assistance from outside the
program is to be conducted consistent with emergency procedures. Liquid waste not resulting
from work details shall be disposed of in the drain of the cleaning supply closet. Kitchen liquid
waste, except of grease, shall be disposed of in the kitchen drain. Grease shall be placed in a
separate container for disposal. The program disposes of hazardous waste through a bio-
hazardous waste contractor. A review of the program’s disposal log determined when, how
often, and by what means the material was disposed. An informal interview with the physical
plant manager was conducted and revealed if a chemical needs to be destroyed, the physical
plant manager disposes of the item in accordance with Occupational Safety and Health
Administration (OSHA) Standard 29. Items are taken to the Union County Solid Waste site. The
FA was interviewed and reported there are procedures in place on the disposal of flammable,
toxic, caustic, and poisonous items. The plant manager is authorized to dispose these items.
The disposal procedures are in accordance with OSHA Standard 29. Disposal of items are
taken to the Union County Solid Waste site. When bio-hazardous materials need to be disposed
of, the physical plant manager will contact a bio-hazardous company who will come and retrieve
the items from medical and dispose of them. The physical plant manager has been trained on
disposing hazardous items and toxic materials. The SDSs were compared to the inventories
reviewed and it was determined the facility maintains SDS binders on-site for all materials. A
review of ten chemicals along with their SDS was completed. All ten chemicals were secured as
required by the FOPs and no discrepancies were noted. All chemicals are maintained in the
maintenance building.
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 facility operating procedures (FOPs) for youth handling and supervision
of flammable, poisonous, toxic items and materials. The program’s FOPs state staff are
authorized to handle the pre-mixed chemical solutions used for general cleaning of windows,
toilets, and sinks on the dormitory. Youth are not allowed to handle flammable, poisonous, or
toxic fluids and will not have access to these items being used or stored. The program maintains
strict control of flammable, poisonous, and toxic items and materials. The youth do not use,
handle, or clean-up dangerous or hazardous chemicals. Youth do not clean, handle, or dispose
of any person’s bio-hazardous materials, bodily fluids, or human waste. Youth do not have
access to areas where these items are stored. An observation of youth cleaning was unable to
be conducted during the annual compliance review week. Five youth were interviewed. Four of
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Office of Accountability and Program Support Page 66 of 69 (Revised August 2025)
five interviewed youth reported they do not handle chemicals. One youth stated he was able to
use paint when he helped paint the walls of the dormitory with a staff present.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
as non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program’s visitation schedule is included on the daily activity schedule posted throughout
the program as observed during the facility tour. The program’s facility operating procedures
(FOPs) include who is considered authorized visitors, visitation times, visitor sign-in, visitor
approval, visitation rules, what is considered a special visit, denial of visitation, volunteers,
searches of visitors, visitation area, termination of a visit, and supervision of visits. The FOPs
also include procedures for all forms of correspondence. Visitation logs were provided for review
and confirmed visitation is held on Sundays between 10:00 a.m. and 11:00 a.m. Telephone logs
were also reviewed, and it was determined phone calls are taking place on Saturdays between
4:00 p.m. to 5:30 p.m. Mail can be sent any day of the week while case management staff is on-
site, which was confirmed by a review of the correspondence logs. The program’s practice is to
have the youth provide written letters to case management staff to review prior to being mailed
out. The youth are given opportunities to communicate with family members through mail and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 69 (Revised August 2025)
telephone calls. If needed, alternate visitation arrangements can be made for the youth and
family members. The program utilizes a language transition service for any youth who present
the need for it. Five youth were interviewed, and all five reported they can call their
parent/guardian or send a letter. The facility administrator was interviewed and reported the
program utilizes a language transition service for all youth who presents a need. This service is
provided in all areas of treatment, including individual and family therapy and formal and
informal treatment team meetings.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The activity schedule for the program documents a range of supervised and structured indoor
and outdoor recreation and leisure activities for the youth for at least one hour daily. Large
muscle activity is provided by the program on a daily basis. A review of the program’s logbooks
indicated recreation was conducted daily. A review of the activity schedule indicated the
program promotes social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. During the annual compliance review
week, youth were observed playing basketball. The youth were observed to have water and
could take breaks when they got hot and/or thirsty. The staff to youth ratio was maintained
throughout the outdoor activities. The program’s contract requires a recreational therapist to be
on the staff roster. The recreational therapist was terminated in June 2025. The new
recreational therapist was hired during the week of the annual compliance review. However, the
reviewed individualized performance plans and treatment plans did not incorporate recreational
therapy prior to June 2025. Five youth were interviewed and each reported they get at least one
hour of recreation time where they play football, basketball, and soccer. They also get to watch
television, play board games, and play video games. Five interviewed staff stated youth are
given an hour or more of recreation time every day. The staff communicated youth participate in
basketball, football, soccer, volleyball, playing board games and card games, and playing video
games during this time.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s facility operating procedures (FOPs) confirm the program does not use
controlled observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s facility operating procedures (FOPs) confirmed the program does not use
controlled observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 69 (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’s facility operating procedures (FOPs) confirmed the program does not use
controlled observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 69 (Revised August 2025)

report_type: QI Residential

program_name_raw: Jacksonville Youth Academy

rule: Indicator 2.18

rating: Limited Compliance

rule: Indicator 2.19

rule: Indicator 5.01

excerpt: Youth Supervision (CRITICAL)

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)

rating: Failed Compliance

rule: Indicator 5.06

excerpt: Logbook Entries and Shift Report Review

rule: Indicator 5.09

excerpt: Searches and Full Body Visual Searches

rule: Indicator 5.12

excerpt: Weekly Safety and Security Audits

rule: Indicator 5.16

excerpt: Fire, Safety, and Evacuation Drills