summary: QI Residential - FY24-25 - 4 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Walton Academy for Growth and Change
Right of Passage, Inc.
(Contract Provider)
286 Gene Hurley Road
Defuniak Springs, Florida 32433
Review Date(s): May 13-16th, 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:
Rebecca Smith, Accountability and Program Support, Lead Reviewer (Standard1)
Jessica Gibson, Accountability and Program Support, Regional Monitor, Standard 2
LeAnn Gruentzel, Accountability and Program Support, Regional Deputy Supervisor, Standard 1
Patrick McKinstry, Accountability and Program Support, Regional Monitor, Standard 4
Ken Myers, Office of Education, Northwest Education Coordinator, Standard 6
Kayshala Patterson, Accountability and Program Support, Regional Monitor, Standard 5
Ken Phillips, Accountability and Program Support, Regional Monitor, Standard 5
Meghan Thrasher, Accountability and Program Support, Regional Monitor, Standard 3
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor, Standard 6
Program Name: Walton Academy for Growth and Change MQI Program Code: 1443
Provider Name: Right of Passage, Inc. Contract Number: 10358
Location: Walton County / Circuit 1 Number of Beds: 42
Review Date(s): May 13-16th, 2025 Lead Reviewer Code: 222
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.07 Residential Assessment for Youth (RAY) 6.01 Contract Specific CTE Services (Residential Contract)
5.06 Logbook Entries and Shift Report Review
6.08 Florida Youth College (Post-Secondary Contract)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 65 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 65 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Limited
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 65 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 65 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 65 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Limited
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 65 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Failed
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) 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).
Overall Rating Summary for Standard 1
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be conducted
within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 65 (Revised September 2022)
Program Overview
The Walton Academy for Growth and Change is a forty-two-bed program, for thirteen- to
eighteen-year-old males, located in DeFuniak Springs, Florida. The program is operated by Rite
of Passage, Inc., through a contract with the Department. The program provides the following
services: Substance Abuse Overlay Services (SAOS) and Mental Health Overlay Services
(MHOS), which includes innovations in delinquency programming. In addition, the program
fosters each youth by providing Aggression Replacement Training (ART), Council for Boys and
Young Men-Living Legacy, Impact of Crime, Seeking Safety, Thinking for Change (T4C), Active
Parenting, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and Skillstreaming the
Adolescent. Additional treatment services provided included family and individual therapy.
Program administration is comprised of a program director, director of group living, and director
of student services. Case management services are provided by two transitional service
coordinators and one part-time transitional service coordinator. Mental health staff at the
program includes a clinical director, who is the designated mental health clinician authority
(DMHCA), and two therapeutic managers. Medical services are offered daily from 7:00 a.m. to
5:00 p.m. by the health services administrator (HSA) and one registered nurse (RN). The
program employed a licensed practical nurse (LPN) for approximately four months during the
review period. The program has a contract with a medical doctor, who serves as the designated
health authority (DHA). The DHA is on-site a minimum of two hours per week. Educational
services are provided by Florida Virtual School. The layout of the program includes three
building structures, with one building housing most of the program operations, one building
housing the Home Builders Institute (HBI) program, and the third building is currently not in use.
The program had all eighty-four operating security cameras providing coverage. The program
had four vacant positions: one cook, two coach counselors, and one therapist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 65 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a policy and procedures addressing initial background screenings of
employees, volunteers, mentors, and interns. The program reported having had no volunteers,
interns, or mentors who required initial background screening during the annual compliance
review period. The program submitted their Annual Affidavit of Compliance with Level 2
Screening Standards to the Background Screening Unit (BSU) January 7th, 2025. Background
screening for teachers is done through Florida Virtual School, which is the statewide school
district contracted to provide educational services at the program. Based on the current staffing
roster provided, the program had a total of twenty-eight staff who required initial background
screenings during the scope of the annual compliance review. All twenty-eight records were
reviewed and found twenty- eight were screened and found eligible prior to their initial date of
hire, with one screening not being completed prior to staffs hire date; however the staff signed a
“no youth contact” agreement and the staff did not have any contact with youth prior to the
return of their background screening. Criminal history report information was reviewed and
included for all twenty-eight records reviewed. All twenty-eight staff records reviewed also
included evidence each completed the Ergometrics as their pre-employment assessment tool
and received a passing score, which was reflected and included in all records reviewed. All
twenty-eight had a signed contraband attestation form within their employee personnel record.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures which notes background re-screening/resubmission
shall be conducted for all program employees, contracted providers, volunteers, mentors, and
interns with access to youth and confidential youth records. Employees and volunteers are re-
screened every five years from the initial date of employment. The program had one applicable
staff to review for five-year rescreening requirements during the annual compliance review
period, and the rescreening was completed within the required timeframe.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 65 (Revised September 2022)
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.
Observations made found evidence of postings in various program areas for emergency
numbers to the Department’s Central Communications Center (CCC) and the Florida Abuse
Hotline. The program has a policy and procedures regarding abuse reporting which indicates all
staff, volunteers, interns, or contracted staff shall immediately report any allegations or
suspicion of an incident of abuse or harassment which has occurred in the program to the
Florida Abuse Hotline or the CCC, for youth eighteen years of age or older. If a youth refuses to
place an abuse call, staff must place the call if the staff has reasonable suspicion abuse has
occurred. Staff shall notify the program director and on duty supervisor as soon as the call has
been placed as well as the reason for the call. An internal incident report shall be completed and
forwarded to the respective supervisor once the call has been made. Based on a review of CCC
reports received for the annual compliance review period, the program had a total of thirteen
incidents related to physical, psychological, or emotional abuse. Four incidents were
documented with substantiated findings, the remaining nine incidents were unfounded. A total of
five incidents were reviewed which indicated the Florida Abuse Hotline and/or the CCC were
notified. None of the reviewed incidents included evidence there were any potential human
trafficking victim, child sexual exploitation, or labor trafficking. The program director (PD)
provided documentation indicating the Trauma Responsive and Caring Environment (TRACE)
self-assessment was completed April 28th, 2025. The PD was interviewed and
outlined/summarized the program’s Code of Conduct for staff. The program director reported
the program incorporates trauma responsive practices through their Champions Team,
completing TRACE self-assessments, staff training on trauma, and providing a voice to youth
through student government, Town Hall meetings, One-on-One Requests, and the grievance
process. The PD further explained the program’s incident reporting process by stating the
program director or designee is notified as soon as possible of an incident and an internal
incident report is completed. If reportable, the CCC and Florida Abuse Hotline are called.
Incidents are discussed daily in management meetings and daily shift briefings. Seven staff
personnel records were reviewed, all seven records contained a signed copy of the programs
code of conduct. Seven interviewed staff were able to summarize the abuse reporting process,
and each reported they have never heard another employee refusing a youth’s rights to report
abuse allegations. Three of seven interviewed staff reported never hearing another employee
using profanity when speaking to youth. One staff reported hearing another staff use profanity
one time, two staff reported they have heard other staff use profanity occasionally when
speaking to youth, and one staff reported hearing profanity often. Seven interviewed youth
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Office of Accountability and Program Support Page 12 of 65 (Revised September 2022)
reported they feel safe at the program and have never exchanged personal information (email
addresses, phone numbers, social media accounts) with program staff. Six of seven youth
stated they have never been denied access to call the CCC or the Florida Abuse Hotline. One
youth stated he was denied access to call the CCC two months ago in reference to moldy food;
however a CCC was located where the youth called and reported the incident to the CCC. Six
interviewed youth stated staff were respectful when talking with the youth, one youth reported
they were treated like animals, but did not elaborate on any examples of mistreatment and has
repeatedly spoken negative about the program with numerous unsubstantiated claims.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
A total of five incidents were reviewed which contained evidence of program management
taking immediate action and applying applicable corrective actions for incidents related to
allegations of abuse or neglect. Three of the reviewed incidents indicated the employee was
terminated. Two of the reviewed incidents indicated the employee was reprimanded. All
documentation of the corrective action was notated in the employee’s human resource record.
The program director was interviewed and stated allegations of abuse are addressed through
mandated reporting and an internal investigation, and necessary corrective action is determined
by the findings.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of fifty-nine incidents reported to the Department’s Central
Communications Center (CCC) during the annual compliance review period. There were no
additional internal incidents/grievances reviewed which should have been reported to the CCC
based on observations made. A sample of five CCCs were reviewed for incident reporting
requirements, based on the CCC information previously obtained. The review revealed all five
incidents were reported within the two-hour timeframe. All five were also documented, as
required, within the master control logbook. The number of CCCs has increased since the last
annual compliance review by one.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
During the annual compliance review period, the program experienced ninety-one Protective
Action Response (PAR) incidents, which was a significant increase from the previous year of
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Office of Accountability and Program Support Page 13 of 65 (Revised September 2022)
thirty-nine. The program maintained summaries of each incident, which were submitted to the
Department’s regional office by the fifteenth of each month. The program’s Right Interactions
(RI) plan was last updated on February 10th, 2024, and approved and signed on December 13th,
2024. The program’s PAR rate during the annual compliance review period was 7.03, which is
above the statewide Residential PAR rate of 2.41. The program director (PD) was interviewed
and stated, under the previous program administration the program experienced a significant
change in staff culture which directly impacted the youth culture. The program also takes into
account the external stressors which affect youth. As a result, the program is undergoing a
restructuring of administration staff with the hiring of a new PD and Clinical Director, and the
reorganization of both the case management and clinical department to ensure management
staff are unified in their approach and message to the youth. The PD reported administration is
notified of any use of force incident as soon as possible. Each incident is reviewed daily at
management team meetings, along with video and PAR reports. Corrective action and training
are taken as needed. The program had a total of ninety-one PAR incidents this annual
compliance review period. A sample of nine PAR reports were reviewed, which included
documentation showing a statement completed by each staff involved by the end of the staff’s
workday. None of the incidents reviewed included evidence of youth or staff injury, or usage of
mechanical restraints. No incidents included evidence of allegations for abuse, requiring contact
with the Florida Abuse Hotline. Each of the nine reports had documentation of a review by a
supervisor and a PAR-certified supervisory staff. All nine incidents had documentation the report
was reviewed by the administrator or designee within seventy-two hours of the incident. PAR
report documentation is maintained in a centralized binder within administration. Seven staff
were interviewed and all indicated they knew the process in which RI is used and were able to
articulate the different processes.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program utilizes the position of coach counselors as the primary direct care position. In
addition, shift supervisors, maintenance staff, and kitchen staff may also be utilized as direct
care if not working within their current job description. A sample of seven pre-service training
records were reviewed for pre-service training requirements. Based on a review of provided
documentation and the Department’s Learning Management System (SkillPro), one staff had
completed all required training within the one-hundred-and-eighty-day requirement. One staff
was still within one hundred and eighty days of hire; however, has completed all training with the
exception of motivational interviewing (MI). One staff was found to be missing motivational
interviewing and Human Trafficking Intervention. The remaining four employees had completed
all required training with the exception of motivational interviewing. The program director stated
a motivational interviewing class is scheduled this month to assure all employees have
completed MI training. All seven staff records reflected each staff received all essential skills
training prior to youth contact, including training for Right Interactions, Suicide Awareness and
Prevention, Emergency Procedures, Facility Operating Procedures, Child Abuse Reporting,
Prison Rape Elimination Act (PREA), and First Aid/Cardiopulmonary Resuscitation and
Automated External Defibrillator trainings. Each of the seven staff records also included
evidence of additional required trainings completed, as well as additional contractual trainings
completed as required, confirming all reviewed staff completed over the required 120 hours of
pre-service training. A review of documentation confirmed all instructors were qualified to deliver
trainings as provided.
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Office of Accountability and Program Support Page 14 of 65 (Revised September 2022)
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a policy and procedures addressing in-service training requirements.
Seven staff training records were reviewed for in-service training. Each staff completed the
required twenty-four hours of in-service training. Each staff completed in-service trainings in
active shooter preparedness, cardiopulmonary resuscitation (CPR)/First-Aid/automated external
defibrillator (AED), Human Trafficking, information security awareness, mental health and
substance abuse, Prison Rape Elimination Act (PREA), Protective Action Response
(PAR)/Right Interactions (RI), professionalism, interpersonal communication, and ethics, sexual
harassment, suicide awareness and prevention, and trauma responsive practices. Each of the
staff are currently certified in PAR/RI. Two supervisors were reviewed for additional annual
supervisory training. Each supervisory staff completed a minimum of eight additional hours of
supervisory training. Each reviewed staff completed trainings required by Florida Administrative
Rule in emergency response and emergency drills, infection control, bloodborne pathogens, and
exposure control plan. All instructors were qualified to deliver training. The program’s in-service
training calendar was submitted prior to its implementation. The training plan was approved by
the program director, the assistant secretary for the Department’s Office of Residential Services,
and the director of the Department’s Office of Talent Leadership, and Culture (TLC).
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures for the grievance process. The program’s grievance
process includes an informal, formal, and appeal phase. In addition, youth may complete one-
to-one forms which give youth opportunities to request meetings with staff to address issues
which may arise. Observations made during the annual compliance review found evidence of
grievance forms and one-to-one forms located in each of the living units. A metal drop box was
also located with the blank forms. The director of group living stated he and the program director
(PD) check the boxes daily for these completed forms. The program maintains all one-to-one
forms and grievance forms for the annual compliance review period in binders. A sample of six
grievance forms were reviewed and found each one was noted as resolved, signed by the
youth, and responded to by staff within the required timeframe. The PD was interviewed and
stated the grievance process has three phases which include the informal phase, where an
attempt is made to process the incident with the staff, the formal phase, which goes to the
supervisory staff to review and determine a resolution, and the appeal phase, which is done
when the youth did not agree with the resolution in the second phase. The program director or
designee would then review to provide a final determination. Seven interviewed staff were able
to articulate the program’s grievance process. Seven interviewed youth were able to explain the
grievance process and all phases.
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Office of Accountability and Program Support Page 15 of 65 (Revised September 2022)
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups, therefore this indicator is rated
not applicable
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing life and social skills training provided for
youth. The policy indicates life and social skills address areas such as identification and
avoidance of high-risk situations, communication and relationships, non-violent conflict
resolution, critical thinking, and anger management. Life skills interventions provided are
evidenced based and include groups such as Living in Balance, Skillstreaming, Seeking Safety,
and Aggression Replacement Training (ART). The program’s life skills offered address the
needs of the program’s targeted gender group. Sign-in sheets were reviewed and confirmed
groups are being facilitated as required. In addition, medical records included evidence of health
education provided for youth by the program’s medical staff. The program’s designated mental
health clinical authority (DMHCA) was interviewed and confirmed the groups being provided.
The DMHCA stated youth complete role play in groups and are provided the opportunity to use
the skills learned in daily interactions with others. Seven interviewed youth confirmed
participation in groups and activities at the program. The program director interview confirmed
the program addresses the needs of a targeted gender group through needs assessments and
performance/treatment planning.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Walton Academy for Growth and Change program. For details related
specific to IOC service delivery, please refer to the annual SPEP report. .
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
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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 and keeps them alerted to youth who pose a risk to security or
safety, including escape, sexual offending and other assaultive or violent behavior risks, suicide,
other mental health and health related concerns, including food allergies and special diets.
When risk factors or special needs are identified during or following the classification process,
staff shall immediately update the internal program alert information and shall enter this
information into the Department’s Juvenile Justice Information System (JJIS). Only appropriate
staff may recommend downgrading or discontinuing a youth’s internal alert status. Upon
recommendations from appropriate staff, JJIS alerts shall be downgraded or discontinued.
Seven youth were reviewed for internal alerts; five youth were applicable for alerts documented
in Department’s Juvenile Justice Information System (JJIS). All alerts were documented on the
alert list and in JJIS on the same date. All alerts matched JJIS and the internal alert system. The
program director (PD) was interviewed regarding internal alert systems and alerts. The PD
reported the program’s formalized procedures regarding review of important medical issues
pertaining to the youth, which include sharing the information during the weekly health and
wellness class. The medical department and the clinical director are responsible for entering
and closing out alerts in JJIS. Nursing staff was interviewed and reported the health services
administrator (HSA) is responsible for updating the medical alert system. Seven staff were
interviewed and reported they are informed of the youth’s alerts through daily shift briefings, and
all alerts are located in master control on a board.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains separate youth records for mental health, case management, and
medical for each youth. All youth records were labeled confidential. All records were observed
to be secured in a locked file cabinet when not being used. The cabinet and staff office door
outside the area were both labeled confidential. Youth individual management records are
divided into sections which includes the youth’s legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and miscellaneous information. Each record contained the youth’s name, Department of
Juvenile Justice identification number, date of birth, county of residence, and committing
offense.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program solicits involvement from law enforcement, community partners, school board, and
faith community; however, did not have documentation showing they attempted to solicit
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involvement from judiciary community or business community, for required representative
participation in a quarterly community advisory board meeting. Participants are emailed by the
program, inviting them to participate. Documentation of quarterly meetings was provided for the
scope of the annual compliance review period. Sign-in sheets and agendas were observed for
meetings conducted on May 23rd, 2024, August 15th, 2024, and November 7th, 2024. The next
scheduled meeting was documented to be held in the first quarter of 2025; however, was not
conducted due to a change in leadership within the program and the meetings have not
resumed. Telephone contact was made with a member of the program’s community advisory
board. The individual confirmed they do participate in the meetings and enjoy the process. They
stated they are notified of meeting dates from emails sent by the program. The program director
(PD) was interviewed and confirmed the community advisory board meetings are held quarterly.
Participants include members from areas such as law enforcement, community agency
members, education, and faith-based representation. The PD further stated they work on
recruiting and improving the attendance of members. Any recommendations provided in the
meetings are documented in the meeting minutes and utilized when appropriate.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which indicates staff are to receive evaluations on
performance annually. Three different program job descriptions were reviewed and found
evidence each staff position had clearly identified performance standards. Seven staff personnel
records were reviewed and found each had a completed annual evaluation as required.
Performance standards for all seven staff matched the job descriptions for each staff member
reviewed. A review of the provider’s contractual agreement was done in comparison with the
program’s current vacancy list and found the program had no key positions vacant. Seven
interviewed staff confirmed they receive performance evaluations. Five staff stated they receive
them annually, two stated the evaluations were done every six months, and one staff stated
they are completed monthly. The program director was interviewed and stated the program has
faced challenges with staff turnover, primarily due to burnout and competitive job markets,
which have occasionally impacted morale. To address this, the program implemented regular
staff recognition, wellness initiatives, and feedback sessions to support team engagement and
communication. The program’s staff retention plan includes offering professional development,
mentorship opportunities, and reviewing compensation packages to enhance job satisfaction
and reduce turnover.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program maintains a policy and procedure addressing special contract conditions. The
program’s contract and Memorandum of Negotiation (MON) were reviewed for special contract
conditions. The special conditions include the program providing youth with substance abuse
issues the opportunity to participate in AA/NA while in the program, ensuring youth have access
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to appropriate reading materials external to educational services and maintaining a diverse
media center, coordinating on-site enrichment activities at least monthly, which include a mentor
or volunteers, offering and coordinating Family Days six times a year, offering Family
Conferences twice a year at minimum, preferably during Family Days when education staff are
present, and providing regular, faith-based opportunities. The program must make diligent
attempts to provide religious services or education which encompass all faiths and provide
programs which allow time for the youth to address their spiritual health and inner strength.
Activities may include mentoring, time for personal reflection, cultural traditions, rituals, and
discussions. The program shall also ensure during the last sixty days in the program, all eligible
youth, will be submitted to the court for approval to participate in at least six approved off-
campus activities and have an Animal Assisted Therapy program. Documentation reviewed
indicated all special contract conditions were being provided, with the exception of not providing
off-campus activities during the annual compliance review period as required.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program reviews and analyzes data in every-day decision-making practice. The program
creates charts for each data trend topic. Topics include areas such as numbers of restraints,
youth admissions/releases, physical altercations, and Protective Action Responses (PAR). A
PowerPoint is created which is given to all staff and administration monthly during staff
meetings. Documentation reviewed supported the program’s practice. The program director
(PD) stated upon request form the Department, the provider will share this information. Program
administration also participates in monthly calls with the Department’s Residential Services staff
to discuss significant or upcoming events, youth admissions/releases, staff vacancies, PAR
incidents, pending workorders, outstanding safety and security issues, and facility maintenance
issues or concerns. Documentation of the monthly calls were observed, confirming the
program’s practice and participation. The PD stated an internal system developed by the
provider is used as well as utilization of Key Performance Indicators and maintained Excel data
to review for improvement of program processes. Changes may then be made based on trends
observed from data collected
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures in place to address initial contact with the
youth’s parent/guardian as well as the committing court. Seven youth case management
records were reviewed, and each contained documentation the parent/guardian was contacted
or attempted to be contacted by telephone on the day of admission. All records indicated the
parents/guardians were mailed a parent/guardian admission letter on the day of admission
which spoke about length of stay, visitation, and the performance planning process. Along with
the admission letter, parents/guardians also received supplemental information to include a
parent/guardian intake survey and rules for visitation. All reviewed records contained a copy of
the judge notification of admission letter sent to the committing court informing them of the
youth’s placement and was mailed on the day of admission. The documentation further
indicated the youth’s assigned juvenile probation officer was copied on the notification and, if
known at the time of admission, the youth’s post release counselor.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures in place to address youth orientation. Seven
youth case management records were reviewed, and all contain documentation showing the
youth participated in an orientation on the day of admission. An observation of a youth
orientation was conducted and verified the orientation contains all elements as outlined in the
program’s policy. Upon arrival to the program, the youth are searched, then meet with medical,
clinical, and case management staff. During the orientation, the youth’s assigned case manager
completes the orientation checklist, which addresses the program’s rules, expectations, goals,
and services applicable to the youth. The orientation conducted with each youth included all the
required topics, which were discussed with the youth by the case manager. Once all information
is reviewed, forms are signed and dated by both the youth and the case manager. All seven
records contained a signed acknowledgement showing each youth received a copy of the
program’s handbook. Additional information included a review of rewards and consequences,
Prison Rape Elimination Act (PREA) information, information on how to access outside victim
advocates for emotional support services related to sexual abuse, and items deemed
unauthorized when in possession of youth. Seven youth were interviewed and verified their
orientation to the program began within twenty-four hours of admission and included a review of
program rules, procedures, and schedules. In addition, each youth was able to articulate what
occurs and who they meet with during orientation.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures in place requiring the 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 screening, assessment, or treatment. Seven
youth case management records were reviewed to determine if the program obtained written
consent for providing youth information with the parent/guardian, Department of Children and
Families, or other applicable agencies. Three of seven reviewed records were applicable, as the
remaining four youth were under the age of eighteen. All three applicable records contained an
authorization to release information form signed by the youth on their eighteenth birthday or
upon admission to the program for those youth who were already eighteen years of age at the
time of placement.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a written policy and procedures in place which clearly addresses and outlines
a classification system implemented in accordance with Florida Administrative Code and
promotes safety and security as well as the effective delivery of treatment services based on
each youth’s individual needs and risk factors. On the day of admission, a classification meeting
is conducted to assign the youth to a living unit, sleeping room, and youth group or staff advisor.
Seven youth case management records were reviewed. Each record contained a classification
form completed on the day of the youth’s admission to the program addressing all required
components for the purpose of assigning each youth to a living area, sleeping room, and youth
group or staff advisor. In all instances, the case manager reviewed the youth’s alerts in the
Department’s Juvenile Justice Information System (JJIS) for any issues affecting classification.
In three applicable case records, medical, mental health, substance abuse, security risk factors,
and/or any special needs identified during or subsequent to the classification process were
immediately entered into the program’s internal alert system and JJIS. The program has a
system in place for reassessing youth 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 off-campus
activities. At admission, an initial youth classification form is completed. As warranted,
reassessments are completed and filed in the youth’s case management record. All seven
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reviewed records contained evidence of an initial classification, and five out of seven had
reclassification sheets which were signed and dated by members of the treatment team. An
interview with the program director (PD) confirmed all rooms at the facility are single rooms and
all youth begin in the orientation stage in order to better learn and understand the program.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures in place which outline notification of law
enforcement regarding youth entering the program with suspected gang affiliation or
documented gang membership, as well as for youth who are observed engaging in gang
activities during their commitment to the program. Seven youth case management records were
reviewed; however, only one youth was applicable for gang affiliation or membership. The
program was able to provide two additional youth records for review of gang identification and
notification. For all three reviewed youth records, there was documentation showing notifications
were made to all requisite jurisdictions. All of the three reviewed records documented
notification to local law enforcement prior to the annual compliance review notification. Each
youth had documentation of the youth’s gang status being shared with on-site education staff,
the youth’s juvenile probation officer (JPO), and the youth’s post-residential counselor (if
identified). The program’s process is to copy the educators, JPOs, and post-residential
counselors on the law enforcement notifications. In all three case records the gang alerts were
entered into the Department’s Juvenile Justice Information System (JJIS) upon identification.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures in place which address the implementation of
gang prevention and intervention strategies. During the admission process, youth are screened
for gang involvement on the youth admission classification form as well as on a separate gang
questionnaire. Youth identified as having gang involvement have an alert entered into the
Department’s Juvenile Justice Information System (JJIS) as well as the program’s internal alert
board. Youth identified as being gang members, are affiliated with any gang, or who are at a
high risk of gang involvement are required to participate in gang prevention and intervention
activities. The program uses Gang Resistance and Drug Education (GRADE) as its main gang
curriculum. The program also uses Impact of Crime (IOC) as part of its gang prevention and
intervention strategies as well as individualized goals and objectives related to gang intervention
strategies. Lastly, the program’s policy indicates a youth will be provided the opportunity to dis-
affiliate from their identified criminal street gang should they choose to do so. Seven youth case
management records were reviewed; however, only one youth was applicable for gang
involvement. The program was able to provide two additional records to review. Of the three
applicable youth, two had been admitted to the program long enough for their performance plan
to be developed and in both reviewed records the youth had gang goals listed on their
individualized performance plan. A review of the program’s gang binder found all three youth
were participating in monthly gang intervention groups as evidenced by observed sign-in
sheets. An interview with the program director (PD) confirmed if a youth has an active gang
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alert, they are placed in a monthly gang intervention group and a goal is added to their
performance plan.
2.07 Residential Assessment for Youth (RAY) Assessments and
Limited Compliance
Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures to ensure a Residential Assessment for Youth
(RAY) is completed within thirty days of the youth’s admission to the program, and the RAY
Reassessments are completed every ninety days after the completion of the initial RAY. Seven
youth case management records were reviewed, and six out of seven contained an initial RAY
completed within the required time frame. One youth’s RAY was seventeen days late. All seven
youth records had the initial assessment maintained in the Department’s Juvenile Justice
Information System (JJIS). Each youth also had a copy of their RAY overview report filed within
their individual record. Seven youth case management records were reviewed to determine
whether a RAY Reassessment was completed within ninety days. Five records were applicable
for RAY Reassessments. One record contained the required RAY Reassessment
documentation completed every ninety days, the remaining four records had reassessments
done nine, three, thirteen, and one day late out of a total of eight reassessments required
across all five applicable records. The late reassessments were all completed at the end of
March and beginning of April 2025 while the program had only one case manager on staff. The
case manager is no longer employed at the program as of April, and upon her exit, regional
compliance has been on site and immediately began to rectify this issue. The program has
since hired new case managers, and they will have their required training completed by the end
of May 2025. The updated RAY overview reports, along with the RAY comparative risk and
protective reports, were maintained in each youth case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures in place to ensure the Youth Needs
Assessment Summary (YNAS) is conducted within thirty days of the youth’s admission to the
program. Seven youth case management records were reviewed, and six of the seven records
contain a YNAS completed within the required time frame. One youth had a YNAS completed
forty-eight days late. All of the reviewed YNAS were documented in the Department’s Juvenile
Justice Information System (JJIS).
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a written policy and procedures in place to ensure all members of the
treatment team, youth, juvenile probation officer (JPO), and parents/guardians are involved in
the development of the youth’s performance plan within thirty days of admission to the program.
Seven youth case management records were reviewed, and five of seven contained
documentation of the Individualized Performance Plan (IPP) being developed within the
required time frame and developed following the youth’s initial Youth Needs Assessment
Summary (YNAS) and initial Residential Assessment for Youth (RAY), as required. Two youth
records contained an IPP completed forty-eight and two days late. Reviewed documentation in
six of seven records confirmed the youth’s intervention and treatment team were present during
the development of the IPP and included participation and signatures from the treatment team
leader (youth’s case manager), youth, program administration, direct care/living unit
representative, mental health treatment staff, education/vocation staff, and medical staff. In one
record the treatment staff and education staff did not sign the IPP indicating participation in its
development; however, there was documentation within the case record those treatment team
members were involved in the completion of the Youth Needs Assessment Summary (YNAS)
and within the IPP indicating they were able to provide input. The parent/guardian was
unavailable for participation in three of seven case management records and there was
documentation notification was sent to the youth’s parent/guardian from the assigned case
manager requesting they review and sign the signature sheet and return it in the self-addressed
stamped envelope provided by the program; however, none of the case management records
contained a returned IPP signature sheet signed by the youth’s parent/guardian. All seven
performance plans contained individualized goals based on the prioritized needs of the youth
and the top three criminogenic needs. Delinquency interventions and transition activities were
included in each performance plan. Court ordered sanctions were included in three applicable
records. Each reviewed IPP listed the responsibility of staff in completing the goal, the
responsibility of youth in completing the goal, start date, and projected completion/end date.
Upon completion of the performance plan, and after signatures by required parties, a transmittal
letter and a copy of the plan were mailed to the committing court, JPO, parent/guardian, and
Department of Children and Families (DCF) counselor, as applicable, within ten working days.
Seven interviewed youth stated they participated in the development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a written policy and procedures in place which address performance plan
revisions and incorporation of other plans into each youth’s Individualized Performance Plan
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(IPP). Seven youth case management records were reviewed and five were applicable for
having revisions completed. In all applicable records the revisions were warranted based on the
Residential Assessment of Youth (RAY) reassessments as well as any demonstrated progress
or lack of progress toward completing a goal. In one of the applicable records the youth needed
revisions in order to facilitate transition activities during the last sixty days of their stay at the
program. Seven youth case management records were reviewed, and all were applicable for
having and contained additional plans, including academic or treatment, within their IPP. Two of
the seven youth were involved with the Department of Children and Families (DCF) and had a
current behavior support or case plan through DCF which was also coordinated with each
youth’s IPP.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a written policy and procedures in place to ensure Performance Summaries
and transmittals are completed within the required time frames. Seven youth case management
records were reviewed for the completion of Performance Summaries. Only five records were
applicable and a review of the five applicable records validated each youth received a
Performance Summary; however, of the eight required summaries across all applicable records,
five were three, four, twenty-eight, forty-four, and eighteen days late; four were following the late
update to each youth’s Residential Assessment for Youth (RAY) reassessment. At the time, two
of the late summaries were completed, there was only one case manager on staff, and the case
manager is no longer employed at the program as of April. Upon her exit, regional compliance
has been on site and immediately began work to rectify this issue, including insuring the
remaining three late summaries were completed. The program has since hired new case
managers, and they will have their required training completed by the end of May 2025. The
remaining three required summaries were completed within the required timeframe following the
signing of their initial Individual Performance Plan. One of the summaries was applicable for
being prepared prior to the youth’s release from the program. All Performance Summaries
included the youth’s status on each performance/treatment plan goal, overall
adjustment/progression in the residential commitment program, overall progress during the
rating period, educational and vocational progress including credits earned and behavior in
school, transition/discharge information, and youth comments. In addition, the youth’s behavior,
level of motivation/readiness to change, interaction with peers, interaction with staff, overall
behavior adjustment to the program, and significant positive and negative events were also
addressed. Upon the youth’s assigned case manager completing the Performance Summary,
the document was signed and dated by the staff preparing the Performance Summary, the
treatment team leader, program director or designee, and the youth. There was documentation
in all applicable records showing the youth could read and add comments to each Performance
Summary prior to signing them. All case management records contained the original
Performance Summary. In all instances, within ten working days, a copy of the original
Performance Summary, along with a transmittal letter, were sent to the committing court,
juvenile probation officer (JPO), parent/guardian, and Department of Children and Families
(DCF) counselor, as applicable. Three closed records were reviewed for discharge and release
summaries. All three records contained the original release summary which included the
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justification for the youth’s release from the program. All records contained a Pre-Release
Notification (PRN), completed at least forty-five days prior to the youth’s release except for one
which was sent four days late. All summaries and PRNs were signed by the appropriate parties
and maintained in the youth’s closed case management record. All three records contained
notification to the parent/guardian confirming the youth’s release date once the program
received the approved PRN from the committing court. All three closed records contained
documentation supporting the exit Residential Assessment for Youth (RAY) was completed for
each youth following approval of their release. None of the reviewed youth were applicable for
the Sexually Violent Predator Program (SVPP) or for victim notifications.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures to encourage and facilitate the involvement of
the youth’s parent/guardian in the case management process. The program encourages
parent/guardian involvement through the assessment process, participation in the development
of the youth’s performance plan, progress reviews, and in transition planning. Additionally,
parents/guardians are provided advanced notice of formal treatment team meetings dates and
times to elicit participation. If the parent/guardian is unable to attend any of these meetings in
person, they are given the opportunity to participate by telephone and can provide verbal or
written input as well. There were no treatment team meetings scheduled to be observed during
the annual compliance review week. The program provides family visitation and continually
encourages family involvement beginning when the youth arrive to the program. The program
director (PD) was interviewed and confirmed the program encourages parental involvement by
maintaining regular communication through phone calls, emails, and scheduled meetings to
discuss their child’s progress and goals. Parents are invited to participate in case planning
conferences, treatment reviews, and family engagement events. Seven youth were interviewed,
and six stated their parents/guardians are involved in their case management through phone
calls. One youth indicated he is over the age of eighteen and his parents do not involve
themselves.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a written policy and procedures in place to ensure each youth and intervention
and treatment team meet on a bi-weekly basis (formally and informally) to review the youth’s
performance, Residential Assessment for Youth (RAY) Reassessment results, progress on
Individualized Performance Plan (IPP) goals, positive and negative behavior including behavior
resulting in physical interventions, and treatment plan progress. Seven youth case management
records were reviewed. Each record contained evidence of the youth’s parent/guardian, juvenile
probation officer (JPO), and other pertinent parties including the case manager, transition
specialist/transition services manager, medical/health services, education, administration,
mental health therapist, and youth counselor/living unit representative being invited and
encouraged through advanced notification. Each party was documented as actively participating
in treatment team progress review meetings. Formal reviews were conducted at least every
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thirty days and were appropriately documented in the youth’s case management record. Each
formal review included a review of the performance plan progress report, status of performance
plan goals and objectives, contact with parents/guardians and JPO, changes in risk level,
current level, level status, performance plan goal focus for the month, and stage of change. In
addition, physical and medical progress reports, mental health/substance abuse progress
reports, youth and/or parent/guardian progress reports, and program behavior and performance
progress report, and performance plan revisions based on results of the RAY Reassessment
were reviewed. In each of the seven case management records reviewed, there was
documentation of bi-weekly informal treatment team meetings taking place, with all required
elements being addressed and all required parties attending or providing written or verbal input.
There were no formal or informal treatment team meetings documented in any of the youth case
management records after the month of March 2025 due to a disgruntled staff disposing of the
required documentation; however, all meetings had documentation present up to this point, and
case notes were entered in the Department’s Juvenile Justice Information System (JJIS) by
each youth’s JPO and input forms by auxiliary treatment team members were present in each
case record indicating the meetings had taken place past this time. During the program’s annual
compliance review, the annual compliance review team was unable to observe treatment team
meetings as no meetings were scheduled. Seven youth were interviewed, and all youth
confirmed staff talk about their performance to include progress on performance goals, positive
and negative behaviors, and treatment progress during treatment team. All youth articulated
they demonstrate skills learned at the program by speaking about it during treatment team as
well as how they are progressing, what level they are on, and what goals they are working
towards.
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 a written policy and procedures in place addressing the program’s transitional
planning process, to include participation of the program and the youth in the Community Re-
entry Team (CRT) meeting. A review of three closed youth case management records and one
youth in the transition phase currently at the program, found documentation of the treatment
team planning for all four youth’s successful transition to the community upon release from the
program. Each record also contained evidence of a transition conference and summary being
completed at least sixty days prior to the youth’s targeted release date, except one which was
conducted four days late. Documentation confirmed each transition plan was developed by the
youth, case manager (treatment team leader), administrative representative, clinical services
representative, education representative, medical representative, juvenile probation officer
(JPO), and the youth’s parent/guardian. Documentation in all four records verified all attendees
signed and dated the transition plan. During the transition conference, the treatment team
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members reviewed transition activities listed on the youth’s Individualized Performance Plan,
identified target completion dates, and the person/persons responsible for completion. Each of
the four records showed evidence of the plan being sent with a request for return with signature
to the parent/guardian and JPO, with documentation of both participating by telephone, although
there was no evidence of the parent/guardian or JPO returning the transition conference
signature page. Documentation in each case record noted the transition plan was transmitted
electronically to the JPO, with an acknowledgement receipt printed and filed with the plan. All
four youth records contained evidence of the youth and assigned case manager participating in
the CRT meeting held prior to the youth’s release. Email invites were present in all records.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures in place addressing the program’s exit
process, to include assembling an exit portfolio for each youth to assist them once they are
released back into their home community. A review of three closed youth case management
records found all records contained an exit portfolio. Each exit portfolio was discussed and
initiated for the youth at the transition conference and then verified during the exit conference.
Each exit portfolio included a transition plan, a calendar containing the dates and times of
follow-up appointments for the youth to attend in their home community which was documented
on the A Plan for Success form, sample employment applications, résumés, vocational
certificates, educational records, and school transcripts. None of the case records contained a
copy of the youth’s birth certificate, state-issued identification, and/or Social Security cards;
however, each case record had noted various attempts to obtain these items. Upon release
from the program, the completed exit portfolio was provided to the youth and documented on
the acceptance of custody form. In addition, case management staff forwarded the exit portfolio
information to the juvenile probation officer (JPO).
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures in place which address participation of the
youth and treatment team in the exit conference. Three closed youth case management records
were reviewed for the completion of an exit conference. All three records contained
documentation of an exit conference being conducted after the juvenile probation officer (JPO)
was notified of each youth’s release. All the records reflected the exit conference was conducted
at least fourteen days prior to the youth’s release during which the status of goals developed at
the transition conference were reviewed and release plans were finalized. A summary of the
conference was found in all three records and included the date, signatures, names of
participants by phone, and a summary of pending transition goals. The individuals who
participated in the exit conferences for each youth included the case manager (treatment team
leader), education representative, mental health therapist, medical representative, program
director/designee, juvenile probation officer (JPO), and the youth. In two of the three records
reviewed, the youth’s parent/guardian participated by telephone; however, there were attempts
to include the parent/guardian in the remaining record. Exit conferences were held separately
from the transition meeting and Community Re-Entry Team (CRT) meeting. Each youth’s date of
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release and admission was verified within the Department’s Juvenile Justice Information system
(JJIS) and matched each youth’s date of admission and release documented in the case record.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process which promotes constructive input by youth as evidenced by
the policy. The program uses youth surveys, student government, requests to speak, RAMS
club, safety meetings, treatment team, townhall meetings, maintenance requests, the problem
resolution process, and grievance forms to solicit youth input. Student government and monthly
house meeting agendas, minutes, and notes were reviewed during the annual compliance
review. The program’s policy did not specify the required frequency of meetings; however, the
program documented minutes demonstrating they were held at least monthly and sometimes
more frequently. Seven youth were interviewed, with five indicating they can talk to staff, attend
group dorm meetings, town hall meetings, have one on one meetings, and submit surveys to
provide input about what happens at the program. Two youth were unsure of how they could
provide input and when asked about those responses program staff stated they would meet with
the youth and reiterate the youth input policy so the youth are fully aware of how they are able
to be heard. The program director (PD) was interviewed and confirmed the program has a
formal process which includes regularly scheduled youth forums and suggestion boxes to
gather input on systemic issues affecting the residential environment. During these forums,
youth can voice concerns and propose ideas for improving conditions, which are documented
and reviewed by management. Recommendations are evaluated and, when feasible,
implemented with follow-up communication to youth on actions taken.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program employs a designated mental health clinician authority (DMCHA) who has a clear
and valid license for the State of Florida. The license expires on March 31, 2027. There was
another DMHCA utilized during the annual compliance review who held a clear and active
license in the State of Florida, which expires on March 31, 2027. The DMHCA was on-site
weekly to ensure appropriate coordination and implementation of mental health and substance
abuse services were taking place as required. The DMHCA position description was reviewed
with no exceptions noted. The program utilizes specialized treatment services and the single
licensed mental health professional, which is the DMHCA, is responsible for the coordination
and implementation of mental health and substance abuse services. The program has a back-
up DMHCA who has a valid and active license in the State of Florida which expires on March
31, 2027. The DMHCA was interviewed regarding their position and reported they ensure each
youth is promptly assigned a therapist upon entry into the program and all required intake
assessments are completed. Based on these assessments, youth are appropriately placed into
the designated clinical track in either the mental health overlay services (MHOS) or substance
abuse overlay services (SAOS) and are assigned an evidenced based group interventions. The
DMHCA oversees the review of all clinical documentation of all evidenced-based services,
ensuring each intervention is delivered in alignment with the established curriculum and best
practice standards. The clinical services provided at the program are individual therapy, family
therapy, and group therapy. The DMHCA provides formal clinical supervision to all unlicensed
therapists on a weekly basis, as part of maintaining high standards of care and professional
development. During the sessions, they review cases of youth who may be exhibiting
challenging behaviors or requiring additional clinical interventions. This allows the clinical staff to
collaboratively identify effective strategies and ensure timely support. Beyond formal
supervision, ongoing communication is maintained throughout the day through email and in-
person, to stay aligned on emerging issues and ensure consistent, coordinated responses
across the clinical team.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program does not have any licensed clinical staff working under the designated mental
health clinician authority (DMHCA).
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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 designated mental health clinician authority (DMHCA) assures the non-licensed clinical
staff working under their supervision are performing services they are qualified to provided
based on education, training, and experience. Direct supervision was held with the non-licensed
clinical staff working under the DMHCA. The direct supervision logs were provided for review
and were documented on the Department’s Licensed Mental Health Professionals and Licensed
Substance Abuse Professionals Direct Supervision Log form. A review of the documentation
revealed supervisions were conducted a minimum of one hour a week, on-site, and face-to-face
with the non-licensed staff. The program has a Chapter 397 license. The license was observed
hanging up throughout the program; however, the date on the licenses was expired as of March
22, 2025. An informal interview with the state compliance manager revealed the program had an
audit conducted by the Department of Children and Families on February 21, 2025. The
updated license had not been provided to the program at the time of the annual compliance
review though has been requested several times. The non-licensed mental health and
substance abuse clinical staffing was in accordance with current contract to include the number
of hours. There was one vacancy in clinical staff during the annual compliance review period.
The previous DMHCA resigned and the position was filled on March 31, 2025. There were eight
non-licensed clinical staff who worked at the program during the annual compliance review
period. All eight hold a master’s-level degree from an accredited university or college in a
qualifying human services field. All staff work in a program which holds a Chapter 397 license.
Six of the eight staff were trained to conduct Assessments of Suicide Risk (ASR) and
documentation was provided for review. Two of the staff were in training to complete their
required hours for conducting ASRs.
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.
Seven youth were reviewed for mental health and substance abuse records admission
screening documentation. All seven records included the Massachusetts Youth Screening
Instruments - Second Version (MAYSI-2) documentation. There was also documentation the
screeners reviewed available information to include the commitment packet and reports and/or
records for existing documentation of mental health or substance abuse problems or history of
human trafficking. All staff who completed the MAYSI-2 screenings were trained as evidenced
by a review of the Department’s Learning Management System (Skill Pro) training records. Six
of the seven MAYSI-2 screenings were completed in the Department’s Juvenile Justice
Information System (JJIS) on the day of admission. One of the MAYSI-2 screenings were
completed on a hard copy. The JJIS document was printed out, but the front page was blank.
The program did acknowledge the blank page and hard copy being the only documentation for
the youth. All seven records included a referral for further evaluation as required by the
program’s written policy and procedures. Two of the youth were required to have an
Assessment of Suicide Risk (ASR) completed due to “suicide ideation” being a risk factor as a
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result of the MAYSI-2 assessment. The program’s written policy and procedures indicate all
youth receive an ASR upon intake. One youth was applicable for an immediate assessment due
to being released from the detention center prior to receiving the required twenty-four hour ASR
at the detention center. Three of the seven youth were placed on precautionary observation
during the intake process and all documentation was included in the youth records. All seven
youth were referred for a comprehensive assessment and all referrals included the reasons for
referral as a result of the MAYSI-2 screening.
The program maintains a written policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. A review of the policy
included the following elements: a standardized screening process which included a review of
commitment packet information, reports, and records, administration of the MAYSI-2 in JJIS or a
clinical mental health screening by a licensed mental health professional and clinical substance
abuse screening by a qualified professional and referral of juvenile offenders identified by
screenings as in-need of further evaluation or immediate attention. It also included staff training
in mental health and substance abuse issues and administration of the MAYSI-2 and a
standardized process for referral of youth identified as in-need of further mental health and/or
substance abuse evaluation to an appropriate services provider and/or professional or, when
immediate attention is needed, to a hospital or Baker Act or Marchman Act receiving facility. The
program director was interviewed regarding the screening process and identifying the youth at
risk for mental health and substance abuse problems and suicide. The program director
reported the screening process includes the initial assessments being conducted upon intake,
which uses standardized tools to identify signs of mental health issues, substance abuse, and
suicide risk. Youth are then referred to mental health professionals for further evaluation, if
necessary. Ongoing monitoring and regular check-ins to ensure any emerging concerns are
addressed promptly, and appropriate services are put in place.
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 designated mental health clinician authority (DMHCA) was interviewed regarding how the
program conducts the initial screenings and completing the comprehensive mental health and/or
substance abuse assessment. The DMHCA reported the clinical staff reviews all intake
materials, including the Department’s Electronic Commitment Packet and associated
assessments prior to completing the comprehensive assessment. A thorough interview is then
conducted with both youth and their parent/guardian to gather additional context, identify
specific needs, and establish a baseline for treatment planning. This process ensures the
recommended services are tailored to support the youth's successful engagement and progress
within the program. Seven youth mental health and substance abuse records were reviewed for
mental health and substance abuse evaluation. All seven records included documentation of a
combined mental health and substance abuse evaluation. All evaluations were completed within
thirty calendar days of admission. All records included a consent for substance abuse services.
All seven comprehensive assessments were completed by a non-licensed clinical staff and all
seven were reviewed and signed by the DMHCA within ten days of the evaluation being
conducted. All seven evaluations were new and included the following elements: identifying
information, reason for evaluation, relevant background information, behavioral observations,
mental status examination, interview information, discussion findings, patterns of alcohol and
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other drug abuse, impact of alcohol and other drug abuse on major life areas, risk factors of
continued alcohol and other drug abuse, and recommendations. Six of the seven assessments
included the diagnostic impression/formulation including the Diagnostic and Statistical Manual of
Mental Disorders – Version Five (DSM-V) and one evaluation did not include the diagnosis.
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 had an open deficiency for treatment plans and treatment team meetings;
therefore, none of the selected youth were reviewed. The last verification for the deficiency was
on May 8, 2025 with one youth being admitted since this date and applicable for review. The
initial treatment plan was developed within seven days of initiation of treatment and included all
required elements of the Department’s Initial Mental Health and Substance Abuse Treatment
Plan form as well as the youth’s psychiatric needs. The initial treatment plan was signed by the
following: mental health staff, youth, treatment team leader, program management, living unit,
and education. The parent/guardian and juvenile probation officer (JPO) did not sign the initial
treatment plan. These individuals are called during the initial treatment team when the initial
individual treatment plan is finalized and signed by all parties. The youth had not been at the
program long enough to receive a treatment plan and/or reviews.
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.
Seven youth mental health and substance abuse records were reviewed for treatment planning.
All seven youth were assigned to a treatment team upon arrival to the program as evidenced by
a treatment team form located in the records. Reviewed documentation in all seven records
reflected the following team members were in attendance: youth, program administration,
residential living unit, education staff, medical staff, clinical staff, and parents/guardians. All
records included documentation of properly executed Authority for Evaluation of Treatment
(AET) forms and a consent for substance abuse treatment. The youth determined to be in need
of substance abuse treatment were unable to be reviewed due to the open deficiency. The
clinical treatment notes were not reviewed as well. Three closed mental health and substance
abuse records were reviewed for discharge planning. All three discharge plans were
documented on the Department’s Mental Health and Substance Abuse Treatment Discharge
Summary and located in the closed records. None of the youth released were on suicide
alert/precautions when discharged. The Discharge Summaries documented the need for future
services. The Discharge Summaries also included documentation they were discussed with the
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youth, parent/guardian, and juvenile probation officer (JPO) at the exit conferences. There was
also documentation a copy of the Discharge Summary was provided to the youth, JPO, and
parents/guardians
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program’s required clinical groups include Aggression Replacement Training (ART) and
Seeking Safety. Both services are designated as primary services and are reviewed by the
fidelity support specialists. Seven youth were interviewed regarding family and individual
counseling sessions provided at the program. All seven youth reported they receive family and
individual counseling sessions. The youth also included how often each of them receive
services. Seven staff were interviewed regarding group facilitation for mental health or
substance abuse groups. All seven staff reported they do not facilitate mental health or
substance abuse groups. Two staff did report they facilitate Impact of Crime groups, which are
non-clinical. The designated mental health clinician authority (DMHCA) was interviewed
regarding mental health and substance abuse services. The DMCHA reported the program
provides Skillstreaming the Adolescent, Trauma-Focused Cognitive Behavioral Therapy, and
Aggression Replacement Training for mental health overlay services (MHOS), and Seeking
Safety and Living in Balance for substance abuse overlay services (SAOS). The program
director (PD) was interviewed regarding specialized treatment services. The PD reported the
program provides specialized treatment services for mental health and substance abuse. These
services are delivered by licensed professionals who provide individual and group therapy
tailored to the needs of the youth. Treatment plans are developed in collaboration with case
managers and reviewed regularly to ensure they are meeting the youth's specific therapeutic
needs. The DMHCA is on-site for forty-hours each week and the therapist’s caseloads are
between eight and fourteen youth. All non-licensed staff held a master’s-level degree, and all
qualification documentation was provided for review with no exceptions. The program meets the
following requirements: individual therapy at least once every two weeks or more often as
needed, family therapy provided at least monthly, and psychiatric services at least once every
two weeks, or per contract. The licensed mental health counselor provides on-site services
which includes provision of therapeutic services, involvement in treatment planning, and staff
training and consultation. Four mental health and substance abuse groups are held each week
for the applicable youth, as evidenced by a review of the group schedule.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program’s psychiatric services are provided by a psychiatrist with a clear and active license
in the State of Florida. The license was provided for review and expires on March 31, 2026. The
psychiatrist is on-call twenty-four hours a day, seven days a week. The psychiatrist briefs a
representative of the treatment team regarding the psychiatric status of each youth receiving
psychiatric services and provides evaluation and recommendation updates for each youth’s
treatment plan. The program does not employ a psychiatric advanced practice registered nurse
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(APRN). A review of the psychiatric sign-in and out logs revealed the psychiatrist was on-site bi-
weekly for the duration of the annual compliance review period. Documentation showed the
psychiatrist actively participated in, managed, and supervised psychotropic medication services
in the program. The program has a back-up psychiatrist who has a clear and active license in
the State of Florida which expires on January 31, 2026. The back-up psychiatrist was not
utilized during the annual compliance review period. The contract was reviewed and does not
include tele-psychiatry. The psychiatrist was interviewed regarding their position and job
requirements. The psychiatrist engages youth in psychiatric services, typically medication
management with some supportive treatment and psychoeducation. The psychiatrist sees all
new youth admissions and accepts referrals from therapists on an as-needed basis. The
psychiatrist meets with the designated mental health clinician authority (DMCHA) and the
program director as needed. The therapists will complete referrals to the psychiatrist when
concerns arise. The psychiatrist conducts face-to-face and/or telephonic communication with
representatives of the treatment team. The psychiatrist reported not having any concerns with
the mental health or substance abuse services at the program. The designated mental health
clinician authority (DMHCA) reported there is a psychiatrist on-site four hours every other week.
There is also a back-up psychiatrist who is on-call as needed. The youth are discussed with the
psychiatrist when on-site.
Seven youth mental health and substance abuse records were reviewed for psychiatric
services. Two of the seven youth entered the program on psychotropic medications. All youth
were referred for a psychiatric interview upon admission which corresponds with the program’s
policy and procedures. The two youth who entered the program on psychotropic medications
received a diagnostic interview within fourteen days of admission. A review of the initial
diagnostic interviews included the youth’s history, mental status examination, the youth’s
Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-V) diagnosis,
treatment recommendations, and initial treatment goals. Two of the seven initial interview
documentation included prescribed medications, explanation of the need for psychotropic
medication, target symptoms, potential side effects, risks and benefits of taking the medication,
and frequency of medication monitoring. No other youth were prescribed or continued on
medications during their initial interviews. The initial diagnostic interviews were documented on
the Department’s Clinical Psychotropic Progress form and included all required information on
the clinical psychotropic progress notes (CPPN). As a result of the initial interview, one youth
had a change in the existing prescription medication regiment as was indicated on page three of
the CPPN. Six of the seven youth were placed on psychotropic medications during the annual
compliance review period and after their initial psychiatric interview. Each record included
documentation the youth received a medication review every thirty days by the psychiatrist. One
youth started on medications and then was removed from the medication due to the youth not
experiencing any perceived benefit of the medication. Documentation reviewed also included an
updated CPPN if the youth’s medication changed. A review of the CPPNs revealed the following
elements were included: identifying data, diagnosis, target symptoms of each medication,
evaluation and description of effects of the prescribed medications on target symptoms, and the
name, dosage, frequency, route of administration of medication, side effects, youth’s adherence
to the medication regime, height, weight, and blood pressure, whether there was telephone
contact with the parents/guardians, signature of the psychiatrist, and date of signature. Two of
the seven youth were applicable for Tardive Dyskinesia monitoring on a monthly basis which
was indicated on both reviewed CPPNs.
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3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a written plan which details the suicide prevention procedures. The plan
was provided for review and included the following elements: identification and assessment of
youth at risk of suicide, staff training, suicide precautions, levels of supervision, referrals,
communication, notification, documentation, immediate staff response, and a review process.
The plan also included all elements for the processes for suicide attempts and a mortality
review. The written suicide prevention plan was reviewed by the designated mental health
clinician authority (DMCHA) and program director on January 6, 2025.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Seven youth mental health and substance abuse records were provided for a review of suicide
prevention services. Five of the seven youth were determined to be at-risk upon admission to
the program. The two remaining youth were determined to be at risk through staff observations.
All Assessment of Suicide Risks (ASR) were documented on the Department’s form. Three of
the youth were placed on constant supervision and precautionary observations (PO) and four
were placed on standard supervision as a result of the ASR. All seven reviewed ASRs
documented a notification to the parents/guardians and juvenile probation officer (JPO) was
made, as required. The mental health staff provided supportive services for all the youth. Six of
the seven reviewed ASRs were completed by a trained non-licensed clinical staff and were
reviewed by a trained, licensed staff. One of the seven ASRs was completed by a licensed staff.
All of the reviewed ASRs were completed within twenty-four hours of the intake screening or
documented concerns. The discontinuation of PO was documented by a non-licensed staff and
reviewed by a licensed staff. Two of the seven youth were applicable to be stepped down from
close supervision as required. The close supervision discontinuation was documented in the
master control logbook. None of the youth were transitioned to a lower supervision level without
the consent of the designated mental health clinician authority (DMCHA) and the program
director or designee. The ASRs documented the actual dates and times the clinician conferred
with the program director or designee and the DMHCA. None of the youth were determined to
be in crisis. Two of the youth required a Follow-Up ASR be completed prior to the removal of the
youth from PO. The Follow-Up ASR was documented on the required form. Both youth were
maintained on suicide precautions and constant supervision until the Follow-up ASR indicated
suicide precautions could be discontinued. Both youth were stepped down to close supervision
prior to standard supervision, as required. A review of close supervision logs revealed one of the
two youth were maintained on close supervision until it was determined no longer necessary by
the clinical staff. One close supervision log showed a gap for one hour and ten minutes The
program was made aware of the gap and reported the youth was out of their room during this
time; however, there was no documentation on the close supervision logs to indicate this
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information. The discontinuation of close supervision for both youth was documented in
accordance with the program’s suicide prevention plan and after a conference was held by the
program director and licensed clinical staff. Four of the seven suicide alerts were documented in
the Department’s Juvenile Justice Information System (JJIS) and accurately closed following the
recommendations of the ASR and Follow-up ASR. Two of the youth were only on PO during
their intake with clinical staff and a JJIS alert was not required. There was no documentation in
the master control logbooks indicating three of the youth were placed on PO. The program was
made aware of the missing documentation. All PO logs included documentation of the youth’s
participation in select activities with other youth in the designated safe housing/observation
section of the PO logs. There were no youth on PO during the last thirty days; therefore, video
review could not be completed.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Seven youth mental health and substance abuse records were reviewed for suicide precaution
documentation. Four of the seven were applicable for review. Three of the four had Suicide
Precaution Observation (PO) logs maintained for the duration the youth were on suicide
precautions. One youth had a gap of time in the PO logs for two hours and thirty-six minutes
The program was made aware of the gap in time on the reviewed PO logs. All four records
included documentation the youth had an appropriate level of supervision and information
regarding the youth’s behaviors which were documented in real time and did not exceed the
required thirty-minute intervals, with the exception of the missed time previously mentioned. Two
of the four youth had warning signs documented on the reviewed PO logs. All reviewed PO logs
included all shift supervisor and mental health clinical health signatures and documented safe
housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Seven pre-service and seven in-service employee training records were reviewed and all staff
completed suicide prevention training during the annual compliance review period. The program
maintains five suicide response kits. All the suicide response kits are located in Master Control
and are co-located with the first-aid kits. The program conducted the required mock suicide drills
each quarter, with the exception of the fourth quarter. The program made the Monitoring and
Quality Improvement team aware there were two missing drills for the A day shift and the B day
shift for February 2025. A suicide drill was observed on video and it was simulated with no youth
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being involved in the drill. All mock mental health drills included a response to a suicide attempt
and/or incident of serious self-injury. The use of cardiopulmonary resuscitation was only
practiced once during the annual compliance review period. The staff who were not present
during the drills had an opportunity to review each drill. All drills included signature pages for
staff. The program director was interviewed regarding drills. The program provides regular
training and mock drills for staff on emergency response procedures related to suicide attempts
and self-inflicted injuries. The drills are conducted monthly and include role-playing scenarios,
de-escalation techniques, and proper use of emergency protocols. The goal is to ensure all staff
are prepared to respond quickly and effectively to protect youth and secure the environment.
Seven staff were interviewed regarding medical emergency and suicide drills being conducted
at the program. Five staff reported they are conducted once a month and two staff reported they
are conducted twice a month.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written crisis intervention plan. The plan was provided for review and
included the following required elements: notification and alert system, means of referral,
communication, supervision, documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Seven youth mental health and substance abuse records were reviewed for crisis assessment
documentation. One of the seven records was applicable for review. Two additional records
were provided for review for a total of three records. All three youth had a crisis assessment
conducted immediately based upon each youth’s needs. All three crisis assessments included
the following elements: reason for assessment, mental status examination and interview,
determination of danger to self and others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up, and notification
to parents/guardians of the follow-up treatment. The crisis assessments were conducted by a
non-licensed mental health professional who was working directly under a licensed mental
health professional. None of the youth were placed on precautionary observation as a result of
the crisis assessment. One of the three incidents included a Prison Rape Elimination Act
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(PREA) event. A Mental Health and Substance Abuse Referral Summary was completed
immediately for a crisis assessment and ongoing mental health treatment services was
provided.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written emergency mental health and substance abuse plan. A review
of the plan revealed the following elements were included: immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services, transport for emergency mental health evaluation under
Chapter 394 (Baker Act), transport for emergency substance abuse assessment and treatment
under Chapter 397 (Marchman Act), documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth mental health and substance abuse records were reviewed for Baker and
Marchman Act documentation. None of the selected youth were applicable. The program had
one youth applicable for a Baker Act during the annual compliance review period and the record
was provided for review. The youth was placed on one-to-one supervision at the time of
discovery of suicidal behaviors. Mental health staff was involved and contacted. The youth was
sent out for a Baker Act. The youth was placed on precautionary observation when they
returned to the program and a Mental Status Examination was conducted. A non-licensed
clinical staff completed the Assessment of Suicide Risk (ASR), which was reviewed and signed
by a licensed clinical staff. The youth’s supervision level was maintained until an appropriate
assessment was conducted.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Seven youth mental health and substance abuse records were reviewed for safety plans and
the safety planning process. Six of the seven youth had a safety plan completed within fourteen
days of admission. One youth’s safety plan was completed thirty-four days late. Four youth
initial safety plans were applicable for parent/guardian participation in the development of the
safety plans. Three youth were eighteen at the time of admission and did not require parental
involvement. All four applicable records included documentation the plan was jointly prepared by
the youth and clinical staff; however, only two of the four applicable youth safety plans included
parent/guardian involvement, with no written documentation as to why the other two
parent/guardians did not participate. All seven reviewed initial safety plans incorporated
recommendations from previous and current assessments and screening instruments. Six of the
seven records included documentation the safety plans were reviewed and updated, as
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necessary every thirty days. One youth was missing two monthly updates. Six of the seven
records had updated safety plans completed following any significant behavioral or mental
health event. One youth had a mental health incident and a safety plan was not updated. All
safety plans included the following required elements: warning signs, baseline behaviors, crisis
recognition, jointly developed coping strategies, intervention strategies, and debriefing process.
Current safety plans are located in a binder in Master Control for staff to review. Seven youth
were interviewed regarding safety plans and each reported they contributed to their safety
plans. The program director was interviewed regarding the updates to safety plans and reported
they are updated monthly or as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a designated health authority (DHA) who is clinically responsible for the
medical care of all youth at the program. The DHA holds an unrestricted license and meets all
requirements for independent and unsupervised practice in Florida. The DHA’s licensure
expires January 31, 2026. The DHA’s specialty training is family practice with experience in
adolescent health. A review of the Department of Health medical quality assurance website
revealed no disciplinary cases or public complaints on record for the DHA. There was no
indication of the program employing a physician assistant or advanced practice registered
nurse. A review of logs document the DHA was on-site once a week for a minimum of two
hours. There was no indication the program utilized telemedicine during the annual compliance
review period. A survey was completed by the DHA. The DHA supports the claim of conducting
periodic reviews, being on-site weekly, and the availability to be contacted by the program
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has two registered nurses (RN), who provide nursing coverage. Each RN license
was reviewed and were found to have clear and active licenses in accordance with Florida
Department of Health medical quality assurance web site. Nursing staff had current
certifications in cardiopulmonary resuscitation (CPR). Nursing coverage meets contract
requirements for a minimum of eighty hours a week. One RN is designated as the health service
administrator (HSA). The HSA is on-site, for a minimum of forty hours per week.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program had facility operating procedures (FOP) for health-related procedures and
protocols utilized at the program. All respective treatment FOPs were reviewed and signed
annually by each required person. Each nurse reviewed, signed, and dated all FOPs and
healthcare protocols. There was no indication for any new policies or changes occurring over
the review period. The program had one part time nurse hired, who later resigned during the
annual compliance review period. This nurse was in receipt of a comprehensive clinical
orientation to the Department’s health care policies and procedures, which was given by the
program’s health service administrator. The designated health authority approves all treatment
protocols or standing procedures for the program.
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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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed to ensure completion of the
authority for evaluation and treatment (AET) form. Six of the seven youth had a legible copy of
an AET filed in the IHCR. The one remaining youth was eighteen years old. Each of the
applicable AET forms were signed by the youth’s parent or guardian. Each of the applicable
forms weas signed by a department representative. The reviewed AET’s were each valid at the
time of the youth’s admission to the program. Two of the seven youth reviewed turned eighteen
while in the program and one youth was eighteen prior to being admitted. Each of the three
youth had a documented release of information signed in their respective IHCR’s. An interview
with nursing staff revealed the program reaches out to the juvenile probation officer to request
contact be made with the parent to obtain new or current AET information.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for parental notification for
medication and treatment prescribed. Five of the seven youth were applicable for parental
notification concerning over-the-counter (OTC) medications beyond those covered by an
authority for evaluation and treatment (AET) form. Each applicable youth had documentation of
consent provided for by the parent or guardian. Notifications were found documented on the
appropriate Department form and filed in the youths IHCR. One of the seven youth was taking
psychotropic medication at admission. Five youth were later prescribed psychotropic medication
after admission. Each youth on psychotropic medication had necessary parental or guardian
consent documented. All the youth had a shot record which was verified within thirty days of the
youth’s admission to the program. There was no indication of any youth requiring an exemption
for religious beliefs. Documentation of immunizations demonstrates the program uses
MyFloridaShots to verify youth immunizations at admission. An interview with nursing staff
identifies when parental notifications are to be made and for what situations. Additionally,
medical staff will notify parents or guardian, in writing, within twenty-four hours for routine
medical visits and verbally for any new medications not covered by the AET.
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.
Seven reviewed youth Individual Healthcare Records (IHCRs) had documention reflecting all
seven youth were screened at admission for any healthcare concerns utilizing a Facility Entry
Physical Health Screening (FEPHS) form. Each of the screenings was completed by a
registered nurse (RN). There was no indication any of the youth had been out of the physical
custody of the program for greater than twenty-four hours. An interview with nursing staff
identified all newly admitted youth are seen by medical upon entering the facility for screening. If
there is a change in physical custody of a youth, a rescreen is completed.
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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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and confirmed each of the
youth were oriented to the general process of health care delivery services at the program. All
seven youth signed a completion of health care education/orientation at admission which
included/covered all required topic.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for notification of the
designated health authority (DHA) or designee upon admission. An informal interview with
medical staff revealed the DHA is notified of all youth within twelve hours of admission to the
program. None of the youth reviewed required any emergency care upon admission.
Documentation within the youth’s IHCR confirmed the DHA was notified of each youth’s
admission to the program. In one of the seven youth reviewed, the youth was taking
psychotropic medication upon admission. In this case, the psychiatrist was notified. An interview
with nursing staff identified any youth admitted with serious chronic condition, the DHA is
notified.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and each documented a
Department Health-Related History (HRH) form completed upon admission to the program.
Each of the HRH forms were completed prior to the completion of the comprehensive physical
assessment (CPA). The designated health authority (DHA) indicated the review of the HRH
form for each youth. An interview with nursing staff identified the HRH is completed within seven
days of a youth’s admission by a licensed healthcare staff.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and each documented a
new Department Comprehensive Physical Assessment (CPA) form was completed within seven
days of admission to the program. All the CPAs were completed by the program’s designated
health authority (DHA). All sections of the CPA were marked appropriately. The one part of the
CPA specifically dealing with genital examination for male youth was annotated accordingly and
a youth refusal form was signed and located in each of the reviewed IHCRs. When necessary,
the youth’s problem list was updated as required. Each IHCR contained at least one verified
tuberculosis skin test (TST) with results documented on the CPA. An interview with nursing staff
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identified if there is no documented TST within the year of admission, one will be completed
within seventy-two hours of admission.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for evaluation and treatment
(if necessary) for sexually transmitted infections (STIs). Five of the seven youth reviewed were
applicable for having been sexually active. Each of the youth were subsequently referred to the
designated health authority (DHA) for further evaluation. Each of the referrals was documented
on the STI screening tool. Three of the five youth signed a refusal for any further STI testing.
The remaining two youth had testing ordered, where the screening, clinical evaluation, and
diagnosis were documented on the Department’s infectious and communicable disease (ICD)
form. There was no indication any youth had been out of the physical custody of the program.
Seven youth were offered counseling, testing, and if indicated, treatment/referral for human
immunodeficiency virus (HIV). Four of the seven youth were in receipt of HIV testing. The three
remaining youth had refused HIV testing. The four youth receiving HIV testing had results filed
in accordance with Florida Administrative Code. Each youth had documentation of pre/post-test
counseling being completed. There was no indication for any results found posted of a youth’s
HIV status. The program has a written policy and procedures, which identifies only HIV test
results are disclosed to youth and those entities addressed in accordance with Chapter 381,
Florida Statute. The program has an agreement to utilize Oasis for any HIV testing and
education needs for youth. Seven youth were interviewed, each said they can have an HIV test
if they wanted. An interview with nursing staff indicates youth are screened at admission for
STI’s. In addition, the DHA can provide orders for testing. Youth have the right to request or
decline testing. STI screening, evaluations, referrals, and testing are documented in the IHCR.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sick call processes.
There was a total of forty-two sick call complaints between the seven youth reviewed. None of
the youth presented with a similar sick call compliant three or more times within a two-week
period. Each of the sick call requests were completed by the youth. Each of the sick call request
were completed by a registered nurse (RN) and filed within the IHCR in reverse chronological
order. The program does not employ a licensed practical nurse (LPN). There was no indication
any of the youth were in restricted housing. The sick call forms were each documented in
accordance with Florida Administrative Code. The sick calls were documented on each youth’s
sick call index. In addition, the sick calls were documented in the sick call referral log. The dates
listed on the sick call index were found to correspond with the completed sick call forms.
A review of the daily schedule, posted schedule, and nurse interview confirm sick call was
conducted daily. Sick call hours were posted in the medical clinic area. The review of forty-two
sick call complaints affirmed only licensed nurses conduct sick call. The program has written
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policy and procedures which addresses practices necessary when nursing staff are not
available to conduct sick call. Sick call forms were found in a box inside the youth’s dormitories.
An exam table was observed to be used to perform sick calls. Seven youth were interviewed,
whereas one youth stated they can see a nurse immediately when a sick call request is made.
Five youth said they are seen within a day of the sick call request. The remaining one youth said
they had never requested a sick call. An interview with nursing staff confirmed the programs
hours and frequency for conducting sick call.
A sick call was observed during the on-site annual compliance review. The youth was escorted
to medical by direct care staff. The RN identified themselves and the purpose as to why the
youth was there. No other youth were present to hear or see the examination. The staff present
was standing in the hallway during the examination process, which did not afford complete
privacy to the youth.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and five were appliable for
the provision of episodic, first-aid, and emergency care. There was a total of fifteen separate
episodic or first aid events reviewed. Each event was completed by a licensed healthcare staff
and completed in problem-oriented charting. The program has a written policy and procedures
addressing episodic and emergency care. There was a total of eight first aid kits on-site, two of
which are used for transportation. Medical staff check first aid kits monthly. Three separate kits
were reviewed with the assistance of medical staff; there were no observed issues.
The program has one automated external defibrillator (AED) located in master control. The AED
is checked monthly by medical staff. The batteries and pads are operable, with clearly marked
expiration dates. A test of the AED was completed by medical staff with no observed issues.
The program had a list of emergency numbers posted for staff, which were inaccessible to
youth. Non-healthcare staff training was observed for administering the epinephrine auto-
injector. Training is completed by the health service administrator who is a registered nurse
(RN). A total of fourteen pre/in-service training records were reviewed for episodic, first-aid, and
emergency care; all staff have completed training requirements. There are two separate
locations in which Narcan is stored. One is in the locked medical office and the other is in
master control in a locked box. Training for Narcan access and usage indicated only nurses and
supervisory staff may assist in administering Narcan. Narcan is inventoried weekly by medical
staff.
The program has conducted monthly announced/unannounced medical drills for each shift over
the past twelve months. Drills simulate an episodic event which calls for immediate first aid
and/or administration cardiopulmonary resuscitation (CPR). A video review of a medical drills
was reviewed and were observed to be simulated. The inclusion of CPR skills into medical drills
was documented quarterly. Direct care staff participate in at least one medical drill which
included CPR at a minimum annually. An episodic care event was not able to be observed for
one did not present itself while the annual compliance team was on-site.
Seven youth were interviewed, and each stated they can see a dentist or doctor if needed.
Seven staff were interviewed; each stated they are able to personally call 9-1-1 if youth have a
medical emergency. An interview with the nurse supported the program’s location and number
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of first aid kits and AED. The nurse was also able to articulate the process for on-site care to
youth and documentation requirements.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and five were applicable for
any medical services to an off-site health care provider. There was a total of eight events
reviewed of youth requiring off-site care. A summary of off-site care consultation report form
was completed for each of the eight events reviewed. In each event, the program provided
parental notification and documented with the IHCR. Each of the discharge instructions were
filed in the IHCR and signed off by the designated health authority (DHA). The one applicable
youth requiring emergency care was documented on the Episodic Care log. There were only
two youth requiring any additional follow-up appointments. Each youth had the necessary
treatment completed and documented accordingly in the IHCR. An interview with nursing staff
identified the tracking process for off-site medical care. The practices also include documenting,
notification, and follow-up medical treatment.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for youth identified with a
chronic condition. Three of the seven youth were identified on the facility entry physical health
screening (FEPHS) form with a chronic condition. Two of the three youth being reviewed were
also later identified with a body mass index increase/decrease and subsequently placed on the
chronic illness list. All three youth were placed on the chronic illness list once identified with an
issue. The three youth were in receipt of periodic evaluations at least every ninety-days. There
was no indication of a lapse in care or missed periodic evaluations. The Department’s problem
list was update in accordance with Florida Administrative Code. None of the youth were
applicable for taking antituberculosis medications, nor were any periodic evaluations done off-
site. An interview with the program director addressed a daily morning meeting and treatment
team are where discussions are held with healthcare staff to review youth medical issues. An
interview with the designated health authority (DHA) states periodic evaluations for youth with
chronic conditions occurs every ninety-days or less. Additionally, the nurse tracks this
information and an interview with nursing staff states a chronic roster is used to monitor youth
with chronic conditions.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication
management. One of the seven youth were admitted to the program with medication. The
medication was verified prior to admission into the program and documented within the IHCR.
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The designated health authority (DHA), along with the psychiatrist, were contacted. Five youth
were later prescribed medication after admission to the program. The one remaining youth was
never prescribed any medications. All reviewed medications for each youth, had a current, valid
order, which were administered pursuant to observed prescriptions. All reviewed medications
contained an order on the practitioner order form. Over-the-counter (OTC) medications not
listed on the authority for evaluation and treatment (AET) form were administered according to
approved protocols. Each youth had a medication administration record (MAR), which indicated
start and stop times/dates for each medication. Each of the MARs reviewed also contained all
required elements with no exceptions. Five of the six youth on medications had occurrences
where non-healthcare staff assisted in the delivery of medications. In these instances of non-
healthcare staff administering medications, each medication entry had a staff initial documented
on the MAR. Training was reviewed for each non-healthcare staff administering medication;
each of these staff had been in receipt of medication training conducted by a registered nurse
(RN). All MARs reviewed had at a minimum weekly side-effect monitoring completed by an RN.
Four youth had documented instances of having refused medication. Each occurrence was
clearly documented on the youth’s MAR and a signed refusal form was filed in each IHCR. One
of the seven youth was prescribed psychotropic medication at admission to the program. Five
additional youth were subsequently referred and prescribed psychotropic medication. Each of
these youth on psychotropic medication, were in receipt of medication monitoring every thirty
days. There was no indication of any standing orders, emergency treatment protocols, or pro re
nata (PRN) orders for psychotropic medication. A medication pass was observed, whereas a
direct care staff escorted the youth to the medical clinic. All required procedures for medication
pass were followed with no noted exceptions. The RN conducting the administering of
medications went through the six rights of medication administration. The nurse does not
conduct or supervise any other program activities while administering medication. Seven youth
were interviewed and those taking medications agreed either nursing staff or the DHA
administers medications. An interview with the nurse relayed the process for verifying a youth’s
medication regimen, the protocol for non-healthcare administering medication, and nursing
accountability for medications. In addition, the nurse verified the use of MARs along with
medication pass times and dates for administering medications.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
An observation of the medical clinic was conducted for the accountability of medical equipment,
sharps, and medications on-site. The program has a routine perpetual count for all sharps and
medications, with a shift-to-shift inventory for controlled substances. Sharps and medications
were observed secured in a locked area inaccessible to youth. The medication cart was clean
and organized, with controlled substances being stored separately behind two locks.
Medications which might require refrigeration, would be stored in a refrigerator, which was
observed to be secured and noted for medication use only. The program uses pill buster (RX
destroyer) to destroy medication when required. This process is conducted by two registered
nurses and documented in medication disposal log. Controlled medications are destroyed with
the pharmacist once a month, if needed. Medications which are discontinued can be returned to
the pharmacy. A count of three controlled medications, over-the-counter (OTC) medications,
and sharps was conducted with no discrepancies noted. The program maintained and
documented all counts for each area observed. An interview with the health service
administrator revealed if there is a discrepancy with inventory, a count will be conducted again
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and if the count is not reconciled within thirty minutes, then a report is generated to the
designated health authority (DHA) and program director. The Department’s central
communication center (CCC) would be contacted within two hours. If a medication error has
occurred which impacted a youth, the parent/guardian would be contacted.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has written infection control procedures including prevention, containment,
treatment, and reporting requirements related to infectious diseases, Occupational Safety and
Health Administration (OSHA) federal regulations, and the Centers for Disease Control and
Prevention (CDC) guidelines. The infection and exposure control plan were reviewed and
signed annually by the program. The plan and procedures included all required elements.
Safety and protective equipment are available for staff to utilize. There have been no instances
in which the local county health department, CDC, and/or the Department’s Central
Communications Center (CCC), have been notified for infectious diseases. The program has an
established binder, which is maintained for any youth or staff who have experienced an
occupational exposure. An interview with the program director confirmed the exposure and
infection control plans are located in medical and updated yearly. An interview with nursing
confirmed the exposure and infection control plans are located in medical, program director
office, and master control. Nursing staff stated infection control training for youth is provided by
a registered nurse upon admission and infection control training for staff is conducted by the
health service administrator.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures addressing youth supervision. The
policy states program staff shall maintain active supervision of youth, including interacting
positively with youth, engaging in a full schedule of constructive activities, closely observing the
behavior of youth and changes in behavior, and consistently applying the behavior management
system. The program’s staff-to-youth ratio is one-to-eight during the daytime hours and one-to-
twelve during nighttime hours. The supervision of youth was observed each day during the
annual compliance review week. There were no discrepancies in youth and staff ratios and
positive interactions were observed between youth and staff. The youth were observed to be in
a full schedule of activities each day during the annual compliance review week. Three staff
were informally interviewed, and each was able to provide an accurate count of youth they were
supervising without having to physically count them. Observation of youth rooms confirmed
windows were not covered by any means which would affect the direct line of sight of youth.
Staff did observe youth while they were sleeping in their rooms.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation of the
behavior management system (BMS) and staff training. Reviewed documentation confirmed
appropriate parties were involved in the development, implementation and on-going
maintenance of the BMS. There are protocols in the program’s BMS where staff are provided
feedback regarding the implementation of the BMS. The program has a trainer who trains all
staff and education staff on the program’s BMS. Seven youth case management records were
reviewed and revealed youth orientation included a review of the program’s BMS. Three staff
positions were reviewed, which included the coach counselor, senior coach counselor, and shift
supervisor. Each of these position descriptions detailed job functions which included
implementation of the program’s BMS. Seven staff records were reviewed, and each staff
completed training in the program’s BMS, as required. The program’s BMS was observed to be
documented within the program’s policy and procedures and youth handbook and seen posted
on walls in living areas. The program’s BMS has not changed from the previous year. The
program’s written BMS policy includes promoting safety, respect, and fairness, promoting and
protecting youth rights, positive and negative consequences, constructive disciplinary
actions/non-punitive, opportunities for positive reinforcement, recognition of accomplishments
and positive behaviors at a four-to-one ratio, promoting socially acceptable means for youth to
meet their needs, process for explaining to youth the reasons for sanctions imposed, youth
having the opportunity to explain his/her behavior, opportunities for staff and youth to discuss
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the impact of behaviors on others, reasonable reparations for harm caused to others,
discussions of alternate behaviors, promoting of positive dialogue and peaceful conflict
resolution, and separation of youth from population is minimized. Additionally, the BMS policy
states the length of stay is not increased because of performance plan revisions or the addition
of performance plan goals. The BMS policy opposes denial of youth’s basic rights, promotion of
group discipline, punishment of youth by other youth, and disciplinary confinement. Staff and
youth interactions were observed and were not in adherence to the above elements of the BMS,
including rewards and negative consequences. A review of the BMS process revealed staff
explain to the youth the reason for any sanction imposed prior to the end of the staff’s workday,
the youth is given an opportunity to explain his or her behavior, and staff and the youth discuss
the behavior’s impact on others, reasonable reparations for harm caused to others, and
alternative acceptable behavior. Youth and staff indicated rewards/incentive are not currently
being provided as required by the BMS. An informal interview with the program director
revealed due to a change in program leadership, the monthly incentive/rewards and activities
calendar ceased in January 2025 and is currently being revised. A definitive date in which the
calendar will resume was not provided by the program. Seven youth were interviewed. All seven
youth were able to summarize the consequences and process used when receiving
consequences. Five youth indicated rewards/incentives are currently not being provided by the
program. Two youth indicated an increase in levels. One youth indicated additional television
time as an incentive/reward. Five youth indicated staff are consistent in what behaviors they
give rewards and consequences; two youth indicated staff are not. Each youth was able to
explain the difference between each level and how to move from level to level. Each youth
stated they are not allowed to punish other youth. The program director was interviewed and
indicated the program utilizes a BMS responsive to the characteristics of the program’s
population. The system is designed to maintain order and security fostering compliance with the
program rules teaching youth alternative pro-social methods of dealing with problems using both
rewards and a system of progressive discipline. It promotes safety, respect, fairness and
protection of rights within the community, provides for constructive discipline and a system of
positive and negative logical consequences to encourage youth in meeting expectations for
behavior, provides for positive reinforcement and recognition for accomplishments and positive
behaviors at a minimum ratio of five-to-one positive to negative consequences, promotes
socially acceptable means for youth to meet their needs, and includes processes addressing the
needs of and cognitive capacity of youth. Direct care staff provide immediate feedback on
behavior and response to interventions and share information with the youth on a daily and
weekly basis.
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 does not utilize room restriction; therefore, this indicator is rated as non-applicable
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
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The program maintains a written policy and procedures to conduct and document ten-minute
checks during sleeping hours or at other times. The program has a total of eighty-four cameras
and all of them were operational during the annual compliance review week. Video recordings
are stored for up to thirty days. The above was also confirmed in an interview with the program
director. Video observations of nine thirty-minute period increments were conducted during the
annual compliance review week and revealed four of the ten-minute checks were conducted in
the required frequency, in real time, and the checks were met with fidelity. Four of the ten-
minute checks were conducted in the required frequency, in real time; however, the checks
were not consistently met with fidelity. The remaining ten-minute check was not conducted in
the required frequency and not consistently met with fidelity. A sample of nine logs during the
applicable review period was reviewed to verify ten-minute checks and revealed eight of the
thirty-minute increments from each shift from each month were initialed and conducted as
required. The remaining thirty-minute increment revealed one entry was missing and was not
initialed. Seven staff were interviewed. All staff stated room checks are conducted in ten-minute
intervals when youth are placed in their room for sleeping.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a written policy and procedures addressing census, counting and
tracking of youth. The policy states staff shall conduct and document counts minimally at the
beginning of each shift, after each outdoor activity, and during emergency situations such as
escapes or riots. Observations of formal headcounts were made during the annual compliance
review week. The master control operator called for a headcount. All movement of youth ceased
and a headcount for each area containing youth was conducted. The headcount was tallied and
an “all clear” was given. A logbook review was conducted for one day each month of the annual
compliance review period and found one exception. Documentation included any applicable
admissions, releases, youth movement, emergency situations, and formal headcounts. Seven
staff were interviewed. Each staff was able to articulate the youth census, youth counts are
conducted every thirty minutes and every movement, and when emergency counts are
conducted. Additionally, each staff was able to articulate the procedures when a youth count
cannot be reconciled, per the program’s policy.
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.
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The program maintains a written policy and procedures addressing logbook entries and shift
reports. A review of one full day each month during the annual compliance review period
revealed master control logbooks were bound with pages numbered. All entries were made in
ink with no erasures or white-out areas. There was no indication of logbook entries being
destroyed or removed. Three noted errors were struck through with one line and initialed by
staff as required; however four errors were not struck through with one line and/or initialed by
the staff correcting the error, with three errors being written over. All master logbooks included
dates, times, events, names of staff and youth, if applicable, brief description of events, and
names and signatures of staff making entries. The logbook was reviewed for incidents reported
to the Department’s Central Communications Center, and all were found to be documented in
the master control logbook. According to the program director, the program does not maintain
living unit logbooks. A review of shift reports maintained during the annual compliance review
period indicated incidents, events, and activities were documented in eleven out of twelve shift
reports. For one month only one shift report was provided. In three of the twelve reviewed shift
reports, incoming staff signed and dated the shift reports for the previous shift. The remaining
nine reports were missing signatures indicating being briefed of the previous shift’s contents. A
review of the master logbook indicated staff documented emergency situations, incidents,
special instructions, population counts, perimeter and security checks, transports, requests by
law enforcement to access any youth, removal of any youth from mainstream population,
admission and releases, and information relating to escapes or attempted escape incidents, as
required. A copy of the shift report was maintained in living units for at least forty-eight hours.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures which address key control. A review of
the program’s policy includes 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, reporting, and replacement of damaged keys. On-site observations of the
distribution and collection of keys indicated personal keys are turned in before entering the
program. Master control handles inventory, issuance, and return of keys from shift to shift. A
review of the key inventory indicated the inventory matched the actual key rings in use. The
keys were secured in a key storage box behind a combination lock when not in use. The
process for permanent key assignment includes signing the permanent key assignment
acknowledgement form. Restricted keys were observed to be locked and secured or assigned
to a staff member. The program’s practice for reporting and replacing damaged keys is for the
staff member to complete the damaged keys and tools form and submit a work order. The key
box was observed to be inaccessible when locked. During the annual compliance review period,
the program had zero incidents reported to the Department’s Central Communications Center or
any Program Monitoring and Management (PMM) deficiencies related to key control concerns.
An informal interview with the director of group living revealed all restricted keys are stored in
administration in a closed combination box, and staff members are provided restricted keys at
the start of their shift. The program’s method for the daily tracking and reconciliation of keys is to
keep daily sign-in and out logs. A sampling of five key rings was observed and compared with
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the inventory and key log, which confirmed all keys were in their required location and matched
the key number and total number of keys listed. Three random staff were informally interviewed
regarding their work issued keys. Each staff had the correct keys as noted on their signed key
log and were able to articulate the function of each key. Seven staff were interviewed. All staff
were able to summarize the program’s key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures for contraband procedures. The
program’s policy clearly delineates items/materials considered contraband, as well as
exemptions. The program provides youth with a list of items which are considered contraband
and informs youth of consequences if found with contraband, which are also listed within the
youth handbook provided during orientation. The policy outlines searches of the physical plant,
facility grounds, youth, incoming mail in the presence of youth, and outgoing mail. The facility
visitor log does contain a contraband attestation statement. A review of thirty-one new staff
hired since the last annual compliance review indicated all staff completed the attestation form.
The program’s policy and procedures address any staff who is found in possession of
contraband in the program will be subject to disciplinary action up to and including dismissal.
Law enforcement is contacted in the event any item found would be considered illegal as
defined in Florida Statutes, which was confirmed with the review of two incidents of contraband
being found and turned over to law enforcement, as well as the program contacting the
Department’s Central Communication Center. Facility logbooks, incident reports, and search
reports were reviewed to determine the frequency and quality of searches and there were no
issues. The program director was interviewed and articulated the contraband procedures are
aligned with the program’s contraband policy. Seven staff were interviewed, and each staff was
able to articulate the program’s process for room searches.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures outlining searches of the youth, staff,
and facility grounds for contraband items. Youth searches were observed during the annual
compliance review week prior to and returning from school, after transport, during admission,
and following access or ability to obtain tools or other equipment. Youth were treated with
dignity and respect to minimize the youth’s stress and embarrassment. Searches were
conducted by same gender staff. Observations revealed searches were thoroughly completed,
gave clear instructions, and were conducted as required by the Right Interactions (RI) training
manual. Searches before and after visitation and upon return from off-campus activities were
unable to be observed during the annual compliance review week. A video review of nine staff
searches was completed and there were no issues with eight of the searches. The remaining
search indicated one staff did not remove their shoes. A review of ten visitor searches was
completed. No major issues were observed. Seven staff were interviewed. All staff were able to
articulate when and how youth searches are conducted. Seven youth were interviewed. Each
youth stated they are searched at each youth 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 maintains a written policy and procedures regarding the transportation of youth
and the maintenance of vehicles used in transports. The program has two vehicles used to
transport youth. Five staff vehicles and two program vehicles were checked to ensure the
vehicles were locked when not in use. One of the five staff vehicles was observed to be
unlocked. Program administration was notified, and this was corrected. The two program
vehicles were properly secured and locked when not in use. There was documented evidence
which confirmed an annual inspection of each vehicle, identified and corrected deficiencies, and
each contained maintenance records. A visual observation confirmed each vehicle contained an
approved first-aid kit, seatbelt cutter, window punch, appropriate number of seatbelts, the door
could not be opened from the inside, and a safety screen was installed. One vehicle contained a
fire extinguisher. The remaining vehicle did not contain a fire extinguisher. This was immediately
corrected and an extinguisher was placed in the vehicle by program administration upon being
notified. Additionally, the emergency kit box in the rear of one of the vans had a lock on it;
however, at the time of review, program administration was unable to open the box with the van
keys.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures regarding transportation of youth,
ensuring staff-to-youth ratio, and safety and security of staff and youth. The program’s policy
ensures compliance with all requirements outlined by the Department relating to transportation
of youth and driver eligibility. The supervisor cellular telephone is issued by the program to the
transporter according to the program director and policy. The one staff to five youth ratio is used
during all transports as required (excluding driver). Visual observation following a transport
confirmed the appropriate staff-to-youth ratio and there was one staff of the same gender on the
transport. A staff was also observed riding in the back with the youth. Youth and staff were
observed wearing seatbelts and no youth were attached to any part of the vehicle. The
program’s practice to ensure staff operating a vehicle have a current and valid driver’s license
consists of human resources (HR) obtaining monthly driving record information from the
Department of Highway Safety and Motor Vehicles for all staff who are in the Department’s Staff
Verification System (SVS). HR shall notate designated transportation staff within SVS. The
program’s policy and procedures do not allow for youth to operate program or staff vehicles. An
interview with the program director revealed each vehicle used to transport youth has a safety
screen. Seven staff were interviewed. Three staff indicated youth are placed in the back of the
transport vehicle. All seven staff indicated youth are shackled and handcuffed and placed in
seat belts. Four of seven staff reported having a radio or program issued cellular telephone
during transport. One staff stated their personal phone is used. The remaining two staff stated
they have never completed a transport; therefore, they were unsure. All staff stated first-aid kits
were placed in transport vehicles as safety equipment. In addition, three staff members stated a
window/windshield breaker are placed in the transport vehicle. Four staff members stated a seat
belt cutter is placed in the transport vehicle. Also, one staff member stated a fire extinguisher is
placed in the transport vehicle. All staff stated youth are not allowed to be transported in
personal vehicles. All staff stated transport vehicles are searched for contraband prior to and
after each use. All staff were able to summarize the emergency response process during
vehicle transport. Four staff stated the staff-to-youth ratios were two staff and one youth. Three
staff stated the staff-to-youth ratio is one staff and five youth. All seven staff stated the vehicles
have a safety screen in the back. One staff also indicated the van has a cage. Seven youth
were interviewed. Four youth stated they have never been handcuffed to any part of the vehicle.
The remaining three youth stated they have not been on a transport. Additionally, all seven
youth stated they have not seen anyone place contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures outlining the weekly safety and security
audit inspection process. The director of group living is responsible for conducting the weekly
security audits and safety inspections. The development and implementation of any corrective
actions warranted for areas of concern were observed to be documented on the Department’s
Facility Security Audit and Safety Inspection form. A review of this documentation was done for
the annual compliance review period which confirmed the program’s practice. The safety and
security specialist confirmed the program provides all required documentation weekly and
responds to any actions needed. The program also had one outstanding minor deficiency at the
time of the annual compliance review week. An interview with the program director revealed the
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process of identifying and tracking safety and security deficiencies involves weekly safety and
security audits, daily perimeter checks, and findings documented.
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 has a policy and procedures which address the program’s tool inventory and
management, as well as the issuance and control of equipment and tools. All tools are
inventoried prior to being issued for work and work activities. Kitchen staff documents all sharps
daily as evident from the inventory forms observed. Machetes, bowie knives, and other long
blade knives are prohibited. In the event a tool is missing staff shall notify administration and the
tool control officer immediately. A tag is hung on the shadow board until a replacement tool is in
place. If a Class A tool is missing, during a work project or activities involving youth, the facility
director or designee is immediately notified and the staff member supervising the inventory
writes an incident report, documented in the facility's logbook, and notify the Central
Communications Center (CCC) within the required time frame. A review of ten total tools, which
included five kitchen knives and five maintenance tools, was completed to verify the inventories
present. All tools were accounted for as indicated on the inventory forms. All tools were also
observed secured and inaccessible to youth. One meat cleaver, located in the locked knives
cabinet in the kitchen, had some denting in the blade edge and replacement was
recommended. All items were marked for easy identification, and each matched the
corresponding number on the inventory forms.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures which outlines requirements for youth tool handling
and supervision of youth when using tools. The policy includes a system of tool issuance and
assessment to determine a youth’s risk to self and others, and an established ratio requirement
of one staff to five youth when using tools. Youth using tools was unable to be observed during
the annual compliance review week; however, youth were observed on a video review being
searched by staff prior to leaving the vocational class. Seven youth case management records
were reviewed and found each youth was trained on the intended and safe use of tools. Each
youth also had a risk assessment completed prior to tool usage. Seven staff were interviewed.
All seven staff stated youth could use mops and brooms. In addition, one staff stated youth can
use knives and four stated youth can use specific tools when in the Home Builders Institute
(HBI) vocational class. Seven youth were also interviewed about tool usage. Six of seven youth
indicated they are allowed to use mops and brooms. Additionally, four of seven indicated youth
are allowed to use other tools such as vacuum, washing machine, kitchen, HBI tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures outlining established guidelines required
for outside contractors, which includes information regarding tool control and restrictions. The
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program has separate sign in/out procedures for outside contractors. This information was
observed to be maintained in a binder and included guidelines such as tools being checked
upon arrival and departure, restrictions in the facility, restrictions of youth from the work areas,
and missing tool follow-up. Procedures also include program staff accompanying outside
contractors when they are in the secured areas, which was observed being done during the
annual compliance review week. A sample of three project invoices was obtained and compared
with sign in/out forms for outside vendors/contractors. Two of the three invoices reviewed
matched the sign in and out outside contractor log. One of the three was from Stanley Steamer,
and the program was unable to locate where the vendor signed the log.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program conducts fire drills monthly for each shift. A review of fire drill documentation found
drills completed monthly and on each shift as required. Drill documentation included the type of
drill, date and time, list of participants, brief scenario, and findings and recommendations.
Observations made during the annual compliance review found evacuation and egress routes
clearly posted in program areas. The program has a total of twenty-one fire extinguishers, all of
which were inspected annually based on the last inspection done December 5, 2024, by B & C
Fire Safety. Seven staff were interviewed. Four staff stated they have participated in fire and
code drills within the last twelve months. Three staff stated they have participated in suicide,
medical, and Continuity of Operations Plan (COOP) drills. Seven interviewed youth all reported
they have been instructed as to what to do in the event of a fire, as fire drills are conducted
monthly. The program director was interviewed and stated fire, COOP, and medical drills are
completed monthly.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a Continuity of Operations Plan (COOP), which is located in the master
control room and the program director’s office. The plan was reviewed and approved annually,
as required by the Department’s Residential Operations regional director. The plan was last
approved March 17, 2025. The plan addresses alternative relocation sites approved by the
Department. A stock of emergency supplies, including food and assorted canned goods, was
located in the kitchen supply cabinet, clearly marked for emergency usage. Other supplies
include medical, special diet information, and bedding. Per an interview with the program
administration, in the event of an evacuation, the program takes with them all youth records,
which include mental health, medical, and case management. A review of seven youth case
management records found each contained all the required information concerning the youth
needed to assist with identification of the youth and provision of special instructions in the event
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of an emergency evacuation. In addition to the youth records, the program has a COOP binder
used during an evacuation, which includes the Juvenile Justice information System (JJIS)
expanded face sheet for all youth and contains all demographic and contact information. The
program director was interviewed and confirmed the COOP is located in the administration
office and master control and is available for all staff.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a written policy and procedures which details storage, inventory, youth
handling, and disposal of flammable, poisonous, and toxic items and materials. The procedures
indicate all these materials shall be stored in secure areas inaccessible to youth. These
substances shall be kept under strict control. Observations made during the annual compliance
review week found all chemicals and toxic items were stored securely and inaccessible to youth.
The director of group living was interviewed and stated all staff are able to handle toxic,
poisonous, and cleaning items, and staff are trained in chemical control. A review of seven staff
training records revealed each staff had received chemical and tool control training. Disposal
practices are done in accordance with Occupational Safety and Health Administration (OSHA)
requirements. A grease container is maintained outside the kitchen and grease disposal is done
through an agreement with BHT Resources. The program’s medical office maintains a disposal
log of all biohazardous waste. The waste is picked up monthly by an agreement with Stericycle.
The program administration was interviewed and stated there have been no flammables
disposed of during the scope of the annual compliance review. In addition, the program has had
no reported chemical spills for the review period. A review of ten total chemicals found in
storage revealed all were noted on an inventory form. Nine of ten items’ ending counts on the
inventory forms matched their number of actual counts for those reviewed items. One item,
Windex Window Cleaner, located secured in the master control room contained a discrepancy.
The inventory noted there were two bottles, but the actual number of bottles found to contain
some level of the chemical was three. All had a corresponding Safety Data Sheet (SDS)
present.
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).
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The program has a written policy and procedures which details storage, inventory, youth
handling, and disposal of flammable, poisonous, and toxic items and materials. The procedures
indicate all these materials shall be stored in secure areas inaccessible to youth. These
substances shall be kept under strict control. Observations made during the annual compliance
review week found no chemicals unsecured or accessible to youth. Youth are not authorized to
directly handle any poisonous or toxic chemicals in the program. No youth were able to be
observed during daily cleaning activities for the annual compliance review week. Seven youth
were interviewed. One youth stated he has poured laundry soap with staff watching. One youth
reported he has used paint in the program while working in the Home Builders Institute
vocational class. Two youth reported staff pour or spray the chemicals when the youth clean.
Three youth reported never using any chemicals.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a visitation schedule posted in the lobby of the facility as well as the youth
handbook. Visitation is held the third Saturday of each month from 11:00 a.m. until 3:00 p.m.
Alternative visitation arrangements may be made if necessary, according to program
administration. The program has a written policy and procedures addressing visitation and
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communicating for youth, which indicates youth will be provided at a minimum at least one
telephone call per week by the program. Based on the youth’s level, according to the program’s
Behavior Management System, the youth may be allowed more. Youth with hearing or speech
disabilities and youth who wish to communicate with parties who have disabilities shall be
afforded access to necessary equipment to promote effective communication. Outgoing calls
may include calls to parent/guardians, family members, and others identified on the youth's
approved correspondence list. Outgoing calls are also permitted to the attorney of record,
juvenile probation officer, and, if applicable, dependency case manager. Outgoing calls to
officials are not limited. The program’s director of group living was interviewed and stated they
and other designated staff facilitate youth calls on a rotating basis daily for youth. Youth also are
allowed to mail unlimited letters to individuals on their approved correspondence list weekly,
Monday through Friday. All outgoing and incoming mail is searched according to the program’s
operating procedures. The program utilizes Language Line Solutions as the agreement with
third party language services if needed. The case manager develops the approved contact list
for each youth at intake, along with the youth’s assigned juvenile probation officer. An interview
with the case management staff revealed the program has no youth present at this time with a
history of human trafficking. Seven interviewed youth all confirmed they call and send letters to
their family while in the program.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program posts an activity schedule which documents a range of structured indoor and
outdoor recreation and leisure activities for youth at least one hour each day, as well as large
muscle activities being provided. A review of logbook entries for the scope of the annual
compliance review found recreation activities are provided daily. Recreational activities were
also observed during the annual compliance review week. Staff were observed providing direct
supervision for youth. Recreational activities promote social and cognitive skill development,
creativity, teamwork, health competition, mental stimulation and physical fitness. The program
also takes precautionary measures to prevent overexertion, heat stress, dehydration, frostbite,
hypothermia, and exacerbation of existing illness or physical injury. The program has a
recreational therapist who holds the required education and credentials needed to provide
recreational therapeutic services. Seven youth case management records reviewed found each
included recreational therapy as part of the youth’s plans. Seven youth were interviewed. Six
youth reported physical activities are provided for at least one hour. Activities were described as
football, basketball, and soccer. The one remaining youth reported physical activities are not
provided for at least one hour, and stated he just goes outside and is not allowed to access the
balls. Seven interviewed staff all reported indoor and outdoor activities are provided for youth at
least one hour daily. Staff gave examples of activities to include soccer, workouts, television,
football, basketball, and cards.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a written policy and procedures which addresses controlled observation
procedures, as well as the searches and inspections of the controlled observation room.
According to the program administration, the youth individual rooms are to be used in the event
a youth is to be placed in controlled observation. The youth rooms meet required parameters for
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controlled observation, with no electrical outlets, a minimum of thirty-five unencumbered square
feet, vents not easily accessible, fire-retardant mattresses, and shatter-resistant windows.
According to the program administration, there have been no incidents involving youth
placement in controlled observation for the scope of this annual compliance review.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a written policy and procedures which addresses controlled observation safety
checks and release procedures, as well as staff responsibilities for youth on controlled
observation status. The program director or designee approves any releases when it is
determined, based on the behavior of the youth. According to the program administration, there
have been no incidents involving youth placement in controlled observation for the scope of this
annual compliance review.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a written policy and procedures which addresses controlled observation safety
checks and release procedures, as well as staff responsibilities for youth on controlled
observation status. The program director or designee approves any releases when it is
determined, based on the behavior of the youth. According to the program administration, there
have been no incidents involving youth placement in controlled observation for the scope of this
annual compliance review.
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Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education Services
Failed Compliance
(Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The career and technical education (CTE) services required to be provided by the program per
contract are Florida Ready to Work (FRTW) Soft Skills, Occupational Safety and Health
Administration (OSHA-10), Cardiopulmonary Resuscitation and First Aid (CPR/FA), Certified
Nursing Assistant (CNA), Entrepreneurial Program/Club, and Junior Achievement program.
During the annual compliance review period, the program delivered two of the six required
services. Forty-eight youth participated in OSHA-10, with sixteen earning certificates.
Additionally, eleven youth received CPR/FA training, and all received certifications. During the
annual compliance review week, the director of group living registered two youth for the FRTW
program and was in the process of enrolling more. The statewide compliance director was
actively seeking information on the Junior Achievement program to initiate its implementation.
No documentation or updates were provided for the CNA or Entrepreneurial Program/Club. An
informal interview with the statewide compliance director revealed the program is now under the
direction of a newly appointed program director and in the process of updating the program
schedule. As a result, no finalized schedule with CTE services was available for review. There
are two instructors responsible for delivering CTE services. One is a shift supervisor, and the
other a nurse; both are certified to provide CPR/First Aid/AED instruction. Observations of CTE
services were not conducted during the review week, as no relevant sessions occurred on-site
during the review. Furthermore, no data regarding industry-recognized certifications was
provided. Seven youth were interviewed; all reported educational services are available and
being delivered. Additional programs mentioned included Home Builders Institute and CPR as
part of non-classroom educational offerings. An interview with the program director confirmed
educational services are provided, with a high rate of completion for daily and weekly
assignments and few behavioral incidents. A review of seven youth case records revealed none
participated in FRTW or OSHA-10, and only one youth was documented as having received
CPR/First Aid training.
6.02 Educational Access (Residential Contract Provider) <---Update--->
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.
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Educational services are provided by Florida Virtual School (FLVS). A review of the facilities'
activity schedule and the daily academic schedule indicated the program’s activity schedule
incorporates the daily school schedule. No discrepancies were found. Seven youth were
interviewed; five reported there were no interruptions during school; the remaining two reported
there were interruptions due to other youth horseplaying. A review of twelve randomly selected
days in the logbook throughout the past year indicated education classes started on time for ten
of the twelve days reviewed and ended on time for all twelve days. The two days which started
late, started twenty and twenty-two minutes late. Observations of educational video for three
days revealed there were no issues found.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 a.m. through 2:45 p.m. with a sixty-minute lunch break from 12:05 p.m. to
1:05 p.m., fulfilling the weekly requirement of twenty-five hours of instructional time. The
interview with the lead teacher indicated all youth received credit for completing a course. They
also reported the school schedule is adhered to. Observations of educational video for three
days revealed there were no issues found. The video observation showed teachers were
present during scheduled classroom time.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The career education program is not appropriate for the educational abilities, goals, length of
stay, and classification of the youth in the program. The residential juvenile justice education
program includes a contracted minimum stay of nine months, offering CAPE courses leading to
pre-apprentice certifications and industry-recognized credentials; fowever, the program has not
yet been compliant with Type 3 requirements, as Home Builders Institute (HBI) is not available
to all youth. The career education programming includes essential skills such as
communication, interpersonal skills, and decision-making, as required. An interview with the
program director confirmed the specific pre-vocational and vocational services provided include
, Florida Ready to Work (FRTW). Soft Skills,Additionally, an interview with the lead instructor
revealed career education services and assessments are provided in partnership with the
Florida Youth College.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The educational provider is responsible for developing an Education Transition Plan for each
youth upon entering a residential commitment program. Three closed youth case records were
reviewed; none contained an education transition plan. The program’s education services are
provided by Florida Virtual School (FLVS), which began their contract on July 1, 2024. None of
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the closed youth records were applicable for the current provider as they entered the program
prior to July 1, 2024. Additionally, none of the current program youth had an Education
Transition Plan initiated, as required, by the FLVS staff. It was reported FLVS has recently
created an Education Plan template and trained their staff to implement the development of a
plan for each youth moving forward. The interview with the instructional leader indicated
Exceptional Student Education (ESE) services are provided for students with disabilities,
English Language Learners (ELL) services for language learners, and intervention groups for
those youth below grade level in reading and/or math. The instructional leader reported an
Educational Transition Upon Entry form is completed with each student discussing their
educational needs and goals before leaving the program. All seven interviewed youth stated
they participated in the development of their education transition plan. One interviewed youth
stated “very well,” and six youth stated “well” regarding how well they think the program is
preparing them for high school, high school equivalency diploma (GED), vocational school,
employment, and/or college.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider, Florida Virtual School (FLVS), has procedures in place to
provide qualified instructional personnel. In reviewing the educational instructional staff for the
program, including flex teachers who provide virtual education at the program, documentation
indicated all teachers have an active certification, according to the Florida Department of
Education website and provide appropriate coverage as provided for in the Course Code
Directory. Flex teacher certifications suggest all are currently certified in their teaching subjects.
One teacher was teaching in their field. Two teachers were teaching out of field courses. The
classes taught out of field were Science, Social Studies, and English. FLVS provided parent
notification for those teachers who are teaching out of field; however, the letter did not indicate
which subjects were being taught out of field. Three teachers are providing Exceptional Student
Education (ESE) services at the program, and FLVS has provided their certification as ESE
instructors.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
Three youth records were reviewed for the Florida Youth College (FYC) referral process. Each
of the three youth were referred to FYC as required. Seven youth were interviewed, and none of
the youth are applicable for post-secondary education.
6.08 Florida Youth College (Post-Secondary Contract Provider) Limited Compliance
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
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to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Three youth records were reviewed to assess the post-secondary services provided following
referral to Florida Youth College (FYC). Each of the records contained documentation verifying
the day, date, and time of the youth’s FYC orientation. Additionally, all records included a career
plan tailored to the youth’s individual interests and aptitudes. No follow-up services were
documented, as one youth relocated out of state and the remaining two youth chose not to
continue participating in the program. The program currently has an open Outcome-Based
Corrective Action Plan (OBCAP).
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report_type: QI Residential

rule: Indicator 2.07

rating: Limited Compliance

rule: Indicator 5.06

excerpt: Logbook Entries and Shift Report Review

rule: Indicator 6.01

rating: Failed Compliance

rule: Indicator 6.08