state: FL

facility_name: Everglades Youth Academy

summary: QI Residential - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Everglades Youth Academy- Sex Offender Program
Youth Opportunity Investments, LLC
(Contract Provider)
5050 NE 168th St.
Okeechobee, Florida 34972
Review Date(s): September 30-October 3, 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:
Rondarrell George, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Central Education Coordinator, (Standard 2, 2.18)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Interviews)
Lidia Lanns Clarke, Office of Post Secondary & Workforce Education, Regional Workforce
Education Coordinator South (Standard 2, 2.19)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Everglades Youth Academy - Sex Offender Program
MQI Program Code: 1481
Provider Name: Youth Opportunity Investments, LLC. Contract Number: 10289
Location: Okeechobee County / Circuit 19 Number of Beds: 16
Review Date(s): September 30 - October 3, 2025, Lead Reviewer Code: 179
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 67 (Revised August 2025)
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 67 (Revised August 2025)
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In c id e n t R e p o rtin g (C C C )* 1 .0 4
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P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Assessments and Reassessments Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals, and Transmittal* Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
2.18 Educational Access (Residential Contract Provider)* Satisfactory
2.19 Contract Specific Career and Technical Education Services (Residential Contract Provider) 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 67 (Revised August 2025)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff* Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning* Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Suicide Prevention Plan* Satisfactory
3.10 Suicide Prevention Services* Satisfactory
3.11 Secure Observation* Non-Applicable
3.12 Suicide Precaution Observation Logs* Satisfactory
3.13 Suicide Prevention Training* Satisfactory
3.14 Mental Health Crisis Intervention Services* Satisfactory
3.15 Crisis Assessments* Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services* Satisfactory
3.17 Baker and Marchman Acts* Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 67 (Revised August 2025)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission Screening & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First-Aid/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Conditions/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Psychiatric Services* Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 67 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 67 (Revised August 2025)
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Program Overview
The Everglades Youth Academy - Sex Offender Program (SOP) is a sixteen-bed program, for
thirteen to twenty-one-year-old males, located in Okeechobee, Florida. The program is operated
by Youth Opportunity Investments, LLC., through a contract with the Department. The program
provides Juvenile Sexual Offender Treatment Services. The program is co-located with the
Everglades Youth Academy – Maximum/High-Risk program under the same contract on the
same campus. The program fosters each youth by providing Impact of Crime (IOC), Living in
Balance (LIB), and Skillstreaming the Adolescent. An additional treatment service provided
includes Juvenile Sexual Offender curriculum Pathways: A Guided Workbook for Youth
Beginning Treatment. The program administration includes one facility administrator (FA), four
assistant facility administrators (AFAs), one human resource manager, and one administrative
assistant. Case management services are provided by one director of case management, five
case managers, and two transition services managers. Medical services are accessible twenty-
four hours a day, seven days a week and are provided by a registered nurse (RN) serving as
the health services administrator, four licensed practical nurses (LPNs), a contracted physician,
a contracted optometrist, a contracted dentist, and a contracted psychiatrist. Mental health staff
at the program shall include one designated mental health clinician authority (DMHCA), one
licensed assistant clinical director, and eight non-licensed therapists. Educational services are
overseen by the Florida Scholars Academy and provided by Florida Virtual School, and Florida
Youth College for career and technical education. The building is designed with two wings, each
containing three separate living units. Everglades Youth Academy - SOP occupies one living
unit on the east wing. The living unit has sixteen individual sleeping rooms, a case management
office, an open-concept day room, and an adjoining classroom. The program has one main
master control and two sub-control stations, seven therapist offices, education offices, program
administration offices, a maintenance office and storage areas, one large recreation field, six
small recreation courts, a kitchen, a medical clinic, two medication pass rooms, and an
automotive sally port. The program has 113 video security cameras monitored by master control
staff and all cameras were operational at the time of the annual compliance review. The video
surveillance system is capable of recording thirty days of video footage. At the time of the
annual compliance review, the program had fourteen vacancies consisting of two case
managers, one intake coordinator, one food service worker, two master control technicians,
three safety security specialists, four therapists, and one transition services manager.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 67 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a written policy and procedures to ensure all newly hired staff and volunteers
receive an initial background screening. The program had thirty-one newly hired staff since the
last annual compliance review. A review of the staff records found each received a background
screening prior to contact with youth and confidential records. Reviewed documentation
reflected a criminal history report was reviewed and the Department’s Staff Verification System
(SVS) module was updated for each staff. None of the reviewed records were applicable for
obtaining an exemption prior to working with youth and none of the reviewed staff had a break in
service as indicated in SVS. The program utilizes a pre-employment assessment tool for all
direct care staff. Reviewed documentation reflected each of the applicable newly hired staff
received a passing score on the pre-employment assessment tool prior to hire. There were no
volunteers, contracted staff, or/or interns applicable for an initial background screening since the
last annual compliance review. The Annual Affidavit of Compliance with Level 2 Screening
Standards was submitted to the Department’s Background Screening Unit (BSU) on January 7,
2025, meeting the annual requirement.
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 written policy and procedures to ensure all staff and volunteers receive
background rescreening every five years from their initial date of hire. The program’s
administrator tracks each staff’s hire date and volunteer start dates to determine when the five-
year rescreenings should be submitted. The program had a total of fifteen staff applicable for a
five-year re-screening since the last annual compliance review. Each staff’s rescreening was
completed and submitted to the Department’s Background Screening Unit prior to their
anniversary date. Each rescreening was completed at least ten business days prior to each
staff’s five-year anniversary. The program did not have any volunteers or interns applicable for a
five-year re-screening since the last annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 67 (Revised August 2025)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a written policy and procedures to ensure a safe and secure environment for
staff, youth, and others to feel safe and secure from any form of abuse or harassment. The
program’s policy is to promote an environment of physical, psychological, and emotional safety.
Child abuse is not tolerated within the program. Staff shall immediately report all allegations of
abuse, neglect, or sexual harassment. Any incident or suspected incident of retaliation against
youth or staff who reported an allegation of abuse must be reported immediately. Staff are
required to report any alleged neglect or violation of responsibilities which may have contributed
to an incident or retaliation. All staff, volunteers, interns, and contracted staff who have
knowledge, or reasonable cause to suspect a youth is being abused or neglected, shall report
the information to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC), if the youth is eighteen years of age or older. Once the call has been completed,
staff must notify the facility administrator (FA) or supervisor on duty as soon as possible. The FA
or supervisor shall then begin an immediate review. The program had no CCC allegations or
incidents related to physical, psychological, and/or emotional abuse during the annual
compliance review period. There were no human trafficking victims, child sexual exploitation, or
labor trafficking reported by the program. A tour of the program confirmed the Florida Abuse
Hotline and the Department’s CCC telephone numbers were posted throughout the program.
The program’s steps for reporting abuse include the program conducting pre-service and in-
service annual training with staff to review incident reporting. The Florida Abuse Hotline and
CCC reports are reviewed during monthly staff meetings and staff are educated as needed
during monthly coaching sessions. All incidents are reported to the CCC within two hours of the
program becoming aware. Youth and staff have unlimited access to the Florida Abuse Hotline
and CCC. The program completed the Trauma Responsive and Caring Environment (TRACE)
self-assessment on April 22, 2025. The FA was interviewed and stated staff are always
expected to maintain ethical and professional behavior. Expectations are for staff to interact with
youth in a manner promoting their emotional and physical safety. Additionally, any employee
who deviates from these rules and standards will be subject to corrective action, up to, and
including termination of employment. This includes the expectation for staff to interact with youth
in a manner promoting their emotional and physical safety while incorporating trauma
responsive practices. The FA reported all staff complete TRACE training during pre-service
orientation training and annually.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 67 (Revised August 2025)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a written policy and procedures for documenting and reporting incidents. The
program’s policy and procedures require the program to notify the Department's Central
Communications Center (CCC) within two hours of gaining knowledge of the incident. The
program had two CCC incidents reported during the annual compliance review period, and each
was reviewed. A review of the master control logbook confirmed all incidents were documented.
There were no incidents reported late. A review of the program’s internal incident reports and
youth grievances reflected there were no additional incidents which should have been reported
to the CCC. The program maintains a separate record for all incident reports and has an
established system to track all incidents. The program did experience a decrease in the number
of reportable incidents to the CCC in comparison to the previous annual compliance review
period.
1.05 Right Interactions (RI) and Physical Intervention Rate Non-Applicable
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
There have been no Right Interactions (RI) incidents during the annual compliance review
period; therefore, this indicator is rated non-applicable.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a written policy and procedures which state provider staff will satisfy pre-
service/certification requirements as outlined by Florida Administrative Code within 180 days of
hire. The program’s policy requires all full time and part time staff and volunteers to receive a
minimum of 120 hours of pre-service training during their first 180 days of employment.
Volunteers receive training appropriate to their assignments. All supervisors, the facility
administrator (FA), the assistant facility administrator (AFA), and any other staff in management
positions shall complete sixteen additional hours of supervisor specific pre-service training
within ninety-days of employment. Only supervisors and direct care staff are counted in youth-
to-staff ratio. An informal interview with the FA reported case managers, therapists, the AFA,
maintenance staff, kitchen staff and operations managers can supervise youth; however,
maintenance staff and kitchen staff are not considered to be direct care staff and are not
counted in the staff-to-youth ratio. All instructors were qualified to deliver trainings. The
program’s pre-service training plan and calendar was approved by the FA, assistant secretary
for residential services, and the director of the Department’s Office of Talent, Leadership, and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 67 (Revised August 2025)
Culture. Five reviewed staff training records provided evidence of each staff completing their
required training within 180 days of hire. A review of the staff records showed three were direct
care staff, one was a supervisor, and one was upper management. Each direct care staff
training record confirmed the staff completed the required training to have contact with youth
and confidential youth records. Each direct care staff met the required training requirements to
include abuse recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR)
certification, first-aid certification, automated external defibrillator (AED), emergency
procedures, program operating procedures, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, ethics including standards of conduct, Right
Interactions model training, and suicide awareness and prevention training. Additional trainings
completed within the 180 days of hire, after having contact with youth, were active shooter
preparedness, adolescent development and behavior, balanced approach to rehabilitative
justice, the Department’s Central Communications Center incident reporting, civil rights,
communication, confidentiality/Health Insurance Portability and Accountability Act (HIPAA),
Department of Juvenile Justice (DJJ) legacy/history, equal employment opportunity, gang
awareness, human trafficking, infection control, information security awareness, the
Department’s Juvenile Justice Information System (JJIS), mental health and substance abuse,
Motivational Interviewing, quality report writing, safety, security, and supervision of youth, sexual
harassment, effective and respectful treatment of youth, and trauma responsive practices. All
five staff completed training in the grievance process, infection control, the Exposure Control
Plan, behavior management system, the intent and safe use of tools as required by the
program’s manual, and specialized services training. Additionally, training included Mental
Health Overlay Services, Substance Abuse Treatment Services, and Juvenile Sexual Offender
training. A review of two applicable pre-service supervisory training records confirmed the
required sixteen hours of supervisory training was done. Documentation for three staff within
their first 180 days of hire confirmed completion of all mandatory training.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written policy and procedures regarding in-service training for all staff. The
program’s policy requires all full-time and part-time staff to complete a minimum of twenty-four
hours of in-service training and supervisory staff will complete an additional eight hours of
training in the areas of coaching, leadership, or personal accountability annually. Five staff
records were reviewed for in-service training and each training record documented staff
exceeded the twenty-four hours of annual in-service training requirements. All five staff had
current certifications in Right Interactions (RI). Each staff had certification in first-aid, automatic
external defibrillator (AED), and cardiopulmonary resuscitation (CPR). All five in-service training
records contained documentation showing all additional required trainings were completed.
Each of the three applicable supervisory staff exceeded eight hours of management/supervisory
training in the areas of coaching, leadership, and personal accountability. The program has a
training calendar which is updated as changes occur. All training was delivered by qualified
trainers and was documented in the Department’s Learning Management System (SkillPro).
The program maintains a written in-service training plan which was submitted and approved by
the facility administrator, assistant secretary for the Office of Residential Services and the
director of the Department’s Office of Talent, Leadership, and Culture prior to implementation.
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1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures regarding their grievance process. Based on
the program’s policy, procedures are in place to confirm each youth’s right to grieve and to
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. The program’s grievance procedures include informal, formal, and appeal phases
with a time frame of two days to provide feedback to the youth and to correct the grieved
situation or condition. Youth are provided with the opportunity to file an alternate informal
request by using a Request to Speak form as their first option to voice an objection and
informally resolve a complaint. The grievance and Request to Speak forms were available to the
youth and present on each living unit as observed during the program tour. A review of the
documentation found there were five grievances and several Request to Speak forms submitted
by youth since the last annual compliance review. A review of each formal grievance revealed
the youth’s grievances were resolved at the formal phase. Five staff records were reviewed for
in-service and pre-service training. Each staff received the required training on the program’s
grievance process and procedures. Five youth and five staff were interviewed during the annual
compliance review. All youth and staff were able to explain the grievance process. An interview
was completed with the facility administrator (FA). According to the FA, all grievances received
will be reviewed in the daily management meeting and will be assigned to an appropriate staff
member for investigation. The assigned grievances will be reviewed and investigated by the
assigned staff member within two days of the assignment. If the grievance is not resolved at this
level, a supervisory level staff will investigate the grievance and respond within two days. The
person investigating a grievance will never be the subject of the youth's grievance. If the FA is
the subject of the grievance, the FA's supervisor will determine the most appropriate steps
towards resolution of the grievance. Efforts will be made to conclude the grievance process
within five working days. If resolution cannot be obtained within the timeframe, documentation of
the reason will be included within the response.
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a written policy and procedures in place to address life skills training for youth.
The life and social skills training is provided utilizing the Skillstreaming the Adolescent and
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Living in Balance (LIB) curricula. The groups specifically address communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking. A review of the program’s activity schedule confirmed each group is provided to the
youth once to twice a week by the therapists. All staff conducting groups received formal and
on-the-job training from a certified trainer to deliver the curriculum. Skillstreaming the
Adolescent groups incorporate hygiene and health skills. A review of five youth case
management records and group sign-in sheets indicated services were delivered as required.
Five youth were interviewed and reported they participate in life skills groups while at the
program. All five-youth reported they were able to demonstrate the skills during role playing
activities in groups. An informal interview with the clinical director indicated youth can practice
skills in group, role play activities, learn how to handle situations in a positive way, and how to
interact better with staff and other youth daily while at the program. An interview with the facility
administrator (FA) indicated all youth participate in daily mental health groups and life and social
skills groups.
1.11 Rehabilitative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s contract requires youth to participate in activities to promote awareness of crime
victims. The program’s rehabilitative justice programming includes Impact of Crime (IOC)
groups, which is a primary service. Youth participate in reparation activities at the program. The
program offers rehabilitative justice and community service opportunities for all youth, which
allow youth to complete community service through canteen points, assisting in the kitchen,
participating in community service projects, through faith-based activities, assisting maintenance
staff with cleaning of the program’s recreation yard, assembling hygiene packages/kits for the
local homeless and domestic violence shelters, and listening to guest speakers as part of their
rehabilitative justice activities. The youth have participated in activities which included animal
husbandry through raising chickens and donating the eggs to the local domestic abuse shelter,
assisting maintenance staff, making posters and cards, food collection and can drives, and
participation in greenhouse projects. At the time of the annual compliance review, the animal
husbandry project was under repair and there were no chickens present due to an incident with
raccoons. The groups and activities are designed to assist youth in accepting responsibilities for
harm they have caused by their past criminal actions, challenging them to recognize and modify
their irresponsible thinking such as denying, minimizing, rationalizing, and blaming victims, and
expose youth to victims’ perspectives through victim speakers. The interviewed facility
administrator (FA) reported rehabilitative justice programming included working on the
vegetable garden and chicken coop, through the donation of food and holiday gifts, through
program renovation projects, and youth support initiatives. An interview with the designated
mental health clinician authority explained rehabilitative justice is provided throughout the week
through different group projects or activities at the program. The program did not have youth
participating in rehabilitative justice activities during the week of the annual compliance review;
therefore, an observation was not made. Five youth were interviewed, and they reported they
participate in rehabilitative justice groups/activities while at the program.
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1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a written policy and procedures for updating the internal alert system and the
Department's Juvenile Justice Information System (JJIS) for easy access to alerts for program
staff. The program’s policy requires risk factors or special needs identified during the admission
process to be updated in the program’s internal alert system and/or JJIS. The process of
updating alerts is for the direct care staff, case managers, and clinical staff to place a youth on
alert status if youth meet the criteria for a new alert. A review of the program's internal alerts
binder confirmed it corresponded with JJIS for updated youth alerts. Staff are informed about
youth alert updates or changes during shift briefings and through the alert board located in the
conference room. Medical and kitchen staff are informed through the same internal alert
process and are provided with the necessary documentation. A review of five youth records
showed youth identified with alerts were placed in the alert system. None of the alerts observed
were entered late. All appropriate alerts were observed in the alert logbook and shift reports.
The interviewed nurse reported the medical staff are responsible for updating alerts and closing
alerts. The interviewed facility administrator (FA) explained the process for updating the youth
alerts in JJIS and which program staff were responsible for updating the alerts. The FA reported
all JJIS alerts must be consistent with internal alerts and will be entered/updated in the JJIS
alert system. Alerts shall be completed upon initiation of the alert and when the alert is updated
or closed. Only the licensed mental health professional, mental health clinical staff, or medical
staff may downgrade or discontinue alerts. Nursing staff should verify all alerts in the medical
alert system are accurate and up to date. The FA, assistant facility administrator, or on-site
supervisor, may update security alerts. Five interviewed staff reported they are informed of all
youth alerts during shift briefing meetings, supervisor/management meetings, and through the
alert board.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, the company philosophy, goals, objectives, and the
legal and contractual requirements. A review of five youth healthcare, mental health and
substance abuse, and case management records showed each was marked “Confidential” and
each record documented the youth’s name, Department identification number (DJJID), the
youth’s date of birth, youth’s county of residence, date of admission, and committing offenses.
Observations during the annual compliance review week found all Individual Healthcare
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Records, mental health and substance abuse records, and case management records were
secured in a locked room, which was not accessible to youth.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a written policy and procedures regarding an advisory board. The program
has a community advisory board which meets on a quarterly basis. The reviewed
documentation supported the program’s community advisory board meets at least quarterly.
The reviewed meeting minutes, sign-in sheets, and agendas documented the meetings
occurred on February 28, May 20, and September 29, 2025. The meeting on September 29,
2025, was held in person and the documentation showed the remaining two community
advisory board meetings were held virtually, with a standing conference call in number. The
advisory board members consisted of a member from the law enforcement community, a
judiciary community member, interested community partners, a community business member, a
school board member, a victim advocate, a parent/guardian whose child was previously
involved in the juvenile justice system, and a faith-based community member. A review of
community advisory board agendas and meeting minutes documented the program provides the
board members with information regarding program updates, community updates, and
community service activities. An interview with the facility administrator (FA) reported the
program’s meetings are held quarterly. The program’s FA reported invitations are sent to
community members by mail and email with a calendar invite, and a follow-up call for
confirmation is made if a response is not received from the invites. There is an established
recruitment effort to increase attendance. A community advisory board member was interviewed
by phone during the annual compliance review. The board member is an active member of the
community and has been an active member of the advisory board for several years.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures regarding performance evaluations. The
program completes ninety-day performance evaluations for newly hired staff and annual
evaluations for all staff thereafter. The administrative staff reported they provide coaching
sessions as needed. The program maintains a detailed position description for all staff and a
written agreement outlining duties for all contracted staff. Five staff personnel records were
reviewed, and the performance evaluations were specific to each staff’s job description. All five
reviewed performance evaluations found each staff’s evaluation was based on the performance
standards for their position. The evaluations rated the staff’s quality of work, modeling of
appropriate behavior, positive reinforcement in a four-to-one ratio, and each evaluation included
ratings on the staff’s job-specific responsibilities. Five staff were interviewed regarding their
performance evaluations. All five reported they had received a ninety-day performance
evaluation. The facility administrator (FA) was interviewed and reported staff are evaluated after
their first ninety days and annually, thereafter, on their job performance. A morale committee
was developed to increase staff morale. Events such as spirit week and staff appreciation week
were implemented to increase staff retention. Referral bonuses, retention bonuses, and
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stipends were implemented to lower staff turnover. Additionally, virtual job fairs were conducted
to have a larger outreach to surrounding communities.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program is required to implement all items and 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 simply listed in contract. The program tracks
measurable contract conditions through outcome measures entered in the Department’s
Juvenile Justice Information System (JJIS), which are administratively monitored by the
assigned contract manager. The program’s contract contains site-specific requirements to
include diverse media, faith-based opportunities, rehabilitative justice and community service
offerings, parenting education, motivation, achievements, and reward activities. A review of
documentation, on-site observations, and an interview with the facility administrator (FA)
validated the program provided special contract conditions, as required. The program has a
partnership with a community prison ministry representative who leads religious activities for
youth desiring to participate. The program offers rehabilitative justice and community service
opportunities for all youth in which the youth are allowed to complete community service through
canteen points, assisting in the kitchen, assisting maintenance, assisting with the animal
husbandry program, making posters and cards, food collection and can drives, and participation
with the greenhouse. The program has an animal husbandry program, however there are no
chickens currently on-site. The chicken coop at the program is currently under repair. The
program’s greenhouse has been updated and repaired since the last annual compliance review.
The program provides education and support for youth who are expecting a child during the
transition phase. The program’s registered nurse provides instruction on developmental
milestones, shaken baby syndrome, car seats, and water safety to the confirmed fathers. The
youth coordinate with their therapists regarding specific family therapy and expectant fathers are
provided additional materials such as books, brochures, and mentoring opportunities during
their stay and special visitations are coordinated, when appropriate. An informal interview with
the program’s compliance manager confirmed the program had a total of eight applicable youth
who received parental resources and education. Observations in the youth’s living units showed
books and other publications were provided. The educational and fictional reading materials for
youth to sign out and specific requests are accommodated as appropriate. Materials are
screened and vetted through the lead teacher for appropriateness and media donations are
encouraged by parents/guardians and community stakeholders. On-site observations and
informal interviews confirmed the youth have access to a variety of reading materials in addition
to tablet access. The program participates with drives for the donation of clothing, shoes,
hygiene items, food, and engage in holiday celebrations with the youth. The youth with
community service requirements coordinate with their assigned case manager to ensure
performance planning reflects the need, and all eligible youth completed all their community
service hours while at the program. The community service hours are tracked on logs and
provided to the assigned juvenile probation officer. The program utilizes trained volunteers,
mentors, and other members from the community to provide positive modeling and experiences
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with the youth and has a partnership with the community and local church volunteers, nonprofit
agencies, to include a domestic violence shelter, professional athletes, the local sheriff’s office,
and staff mentors to speak and model experiences with youth. The on-site observations
reflected the youth were wearing their assigned uniforms and were observed to be appropriately
dressed. Some of the program’s activities include sport competitions, training camps, and other
achievement celebrations. Incentives and celebrations for positive behavior and youth success
include honor roll, graduations, student of the month, classroom of the week, daily, weekly, and
monthly incentives, a football team, inter-program sports tournaments, movie nights, music
studio access, canteen, gym access, quarterly dinners with administration, academic
competitions, cook-off competitions, student council, carnival/field days, family days, holiday
celebrations, and pizza parties. The program has implemented an on-site barbershop in which
the youth are provided an opportunity to showcase their creativity by participating with the
incentivized barbershop program. The barbershop opened on September 17, 2025. An interview
was completed with the facility administrator (FA) and confirmed the program offers greenhouse
activities, cleanup details, and maintenance and food service assistance opportunities. Incentive
celebrations are held in addition to the daily and weekly incentives for academic and behavioral
achievements.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a written policy and procedures which addresses data trend analysis
components. The program’s administration and management policy addresses research efforts
to enhance operations and contribute to the base knowledge of juvenile justice. The program’s
quality assurance and program planning policy detailed a formal process for monitoring and
evaluating quality, compliance, fidelity, appropriateness, safety, and effectiveness of all program
services utilizing a framework for measurement and evaluation of outcomes and process
measures. The program conducts weekly security audits, and the report identifies any
deficiencies and potential issues within the program and anticipated resolution dates. A review
of the weekly security audits confirmed the audits were conducted and completed on a weekly
basis as required. An interview with the program’s compliance manager explained the
program’s efforts to collect and analyze data. Additionally, the program participates in monthly
compliance reviews to discuss accomplishments, the facility administrator’s (FA’s) plan of
action, any corrective actions put in place, monthly staff and youth survey responses relating to
perceptions of program safety, living environment, treatment environment, whether youth
community meetings are occurring, and monthly incidents. The program conducts interviews
with families and youth on a quarterly basis, tracks outcome measures, monitors incident
reports, conducts internal fidelity monitoring, tracks evidence-based services, incidents, and
quality improvement audits. The program discusses scores, results, and findings in the morning
management meetings, monthly management meetings, community advisory board meetings,
and during the program’s all-staff meetings.
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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 to address required initial contact with each
youth’s parent/guardian and court notification upon each youth’s admission. A review of five
youth case management records validated the program notified each parent/guardian by
telephone within twenty-four hours of admission and sent written notification of the youth’s
admission to each parent/guardian in writing within forty-eight hours of admission. All five
reviewed case management records documented notifications were made to the court and
assigned juvenile probation officer (JPO) within five working days of each youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures requiring each youth to be oriented to the
program’s rules, expectations, goals of the program, and services applicable to the youth
beginning no later than the day of the youth’s admission to the program. A review of five youth
case management records validated the program provided each youth an orientation on their
day of admission. The program’s orientation addressed available services, the daily activity
schedule, expectations and responsibilities for youth, the behavior management system, the
availability of and access to medical, mental health, substance abuse services, unimpeded
access to the Florida Abuse Hotline, zero-tolerance for sexual misconduct, incident reporting,
youth rights, contraband, the program’s performance planning process, dress code, hygiene
practices, visitation, incoming and outgoing mail, use of the telephone, expectations for release
from the program, grievance and emergency procedures, and assignment to a living unit,
sleeping room, and treatment team. The program did not have an admission during the annual
compliance review week; therefore, an observation of a youth admission was not able to be
completed. Reviewed documentation verified the youth orientation included all required topics.
Five youth were interviewed, and each reported their orientation process began within twenty-
four hours of their admission and covered all required topics.
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 requiring consent for any youth eighteen
years of age or older. A review of five youth case management records reflected two were
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applicable for being over the age of eighteen. Both applicable case management records
included a signed consent form allowing the program to discuss information related to the
youth’s physical or mental health screening, assessment, or treatment. There were no other
youth over the age of eighteen in the program.
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 for the use of a classification system, in
accordance with Florida Administrative Code, which promotes safety and security, and the
effective delivery of treatment services. The program’s policy requires the initial classification to
be utilized for the purposes of assigning each newly admitted youth to a living unit, sleeping
room, and youth group or staff advisor. Each admitted youth is to be screened for vulnerability
to victimization and sexually aggressive behavior prior to room assignment. Staff are to ensure
a youth’s potential for victimization or predatory risk has been considered when making room
assignments. A review of the program’s classification form indicated it includes notation of the
physical characteristics of the youth, age and maturity level, identified special needs, history of
violence, gang affiliation, criminal behavior, sexual aggression or vulnerability to victimization,
the youth’s perception of vulnerability, the youth’s history of potential or verified human
trafficking, suicide risk, medical risk, escape risk, and security risk. A review of five youth case
management records reflected each classification form identified the youth’s physical
characteristics, gender, height, weight, general physical stature, age, maturity level, identified
special needs including medical, mental health, escape risk, security risk, development,
intellectual, and physical disabilities, history of violence, gang affiliation, and criminal behavior.
Each youth’s applicable risk factors were identified, and a review of the Department's Juvenile
Justice Information System (JJIS) alert list was documented to assist in assigning the youth to
living, sleeping, and staff advisor. All five reviewed youth records included reclassifications for
an increase in the youth’s privileges or freedom of movement, and/or participation in a work
project. An interview with the program’s compliance manager indicated the program’s practice it
to complete a monthly security risk assessment on each youth to ensure the current or any
changed status is identified. None of the reviewed youth were applicable for off-campus
activities. The interviewed facility administrator reported the program’s case manager or
designee facilitates an admission classification meeting for all youth immediately following the
initial intake screening process. Meeting outcomes are documented and a justification for room
placement is identified on the Admission Classification form.
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2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures regarding gang identification and notification
to law enforcement. The program’s policy requires staff to review each youth’s Department Face
Sheet prior to arrival at the program to identify alerts, including gang involvement, if known. If a
youth is admitted without having been previously identified as a gang member, and discloses
they are a gang member during intake, the case manager is to notify the facility administrator
(FA) and the program’s gang specialist. Five youth case management records were reviewed,
and none were identified as being potentially involved in gang activity. The program had no
youth in the program since the last annual compliance review who had been identified or
suspected of having been involved with a gang.
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 regarding gang prevention and intervention
strategies. The program’s policy requires implementation of gang prevention and intervention
activities through the Impact of Crime curriculum when youth are identified as a criminal street
gang member, affiliated with a criminal street gang, or at high-risk of gang involvement. Each
applicable youth’s performance plan is to include goals and objectives relating to gang activities
and, if the youth desires, a plan to disaffiliate from the gang prior to the youth’s release from the
program. Five youth case management records were reviewed, and none were applicable for
gang identification prevention and intervention activities. The program had no youth who had
been identified or suspected as having been involved with a gang since the last annual
compliance review. An interview with the facility administrator (FA) indicated gang intervention
and prevention strategies are provided to applicable youth monthly. The program utilizes the
ARISE Foundation’s Life Skills Gangs: 50+ Stories of Fractured Lives as the selected gang
prevention and awareness curriculum.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a written policy and procedures requiring the individualized needs of each
admitted youth to be identified and prioritized through a comprehensive assessment process by
a multidisciplinary intervention and treatment team. As part of the needs assessment process,
the treatment team is to identify each youth’s criminogenic risk and protective factors, prioritize
needs, and determine the youth’s risk to reoffend. The program’s policy requires the Residential
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Assessment for Youth (RAY) to be completed within thirty days of each youth’s admission to the
program. The program must complete reassessments for each youth at least every ninety days
from the initial assessment. A review of five youth case management records validated each
initial RAY was completed within thirty days of each youth’s admission and maintained in the
Department's Juvenile Justice Information System (JJIS). Four reviewed records were
applicable for RAY Reassessments, all of which were completed at least every ninety days, and
one youth had not been in the program for ninety days at the time of the annual compliance
review. All initial RAYs and completed reassessments were maintained in each youth’s 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 requiring the Youth Needs Assessment
Summary (YNAS) process to be completed within thirty days of each youth’s admission. A
review of five youth case management records confirmed each contained a YNAS completed
within thirty days of the youth’s admission to the program. Each YNAS was documented in the
Department's Juvenile Justice Information System (JJIS), included the signature of each
treatment team member, identified each youth’s top three criminogenic needs, and a copy was
maintained in each youth’s case management record.
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 requiring development of an Individualized
Performance Plan (IPP) with individualized goals based on the findings of each youth’s initial
assessment, within thirty days of admission. A transmittal letter and copy of the performance
plan must be sent 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, when
applicable. A review of five applicable plans showed the plan was developed within thirty days
of each youth’s admission. The program’s policy requires each plan to be developed after the
initial Residential Assessment for Youth (RAY) and Youth Needs Assessment Summary
(YNAS). Each reviewed plan was developed and signed by the treatment team leader, the
youth, a program administration representative, living unit representative, treatment staff,
education staff, and other parties with significant responsibility for goal completion. There were
no youth applicable for current involvement with the DCF or the Agency for Persons with
Disabilities (APD). Each signature sheet was included with the original plan in the youth’s official
case record. Each reviewed plan included goals based upon the youth’s prioritized needs, the
risk and protective factors identified during the initial assessment process, and each youth’s top
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three criminogenic needs. Each plan included transition activities and set target dates for the
youth’s final sixty days in the program. Each plan identified the youth’s responsibilities for
accomplishing the goals, staff responsibilities for aiding youth in completing their goals, and
each goal had a targeted completion date. Documentation indicated the program sent a
transmittal letter and a copy of the plan to each youth’s committing court, assigned JPO, and
parent/guardian within ten working days of the completion of each plan. Five youth were
interviewed, and each stated they participated in the development of their IPP.
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 requiring each youth’s Individualized
Performance Plan (IPP) to be revised when determined necessary by the intervention and
treatment team. Five youth case management records were reviewed, and four were applicable
for IPP revisions based upon the youth’s demonstrated progress towards goal completion. None
of the five reviewed case management records were applicable for youth in transition; therefore,
they did not contain information needed to facilitate transition activities for the last sixty days of
the youth’s stay in the program. Each reviewed plan included and referenced academic,
wellness, and treatment goals which were incorporated into each youth’s plan. None of the
reviewed case management records were applicable for youth currently involved with the
Department of Children and Families (DCF) or the Agency for Persons with Disabilities (APD).
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 requiring Performance Summaries. The
program’s policy states the intervention and treatment team shall complete a Performance
Summary for each youth every ninety days after the development of the Individualized
Performance Plan (IPP), unless the committing court requests shorter intervals. A review of five
youth case management records revealed four were applicable for Performance Summaries to
be complete every ninety calendar days. One youth had not yet been in the program for ninety
days during the annual compliance review week. There were no youth applicable for needing a
Performance Summary prepared prior to the youth’s release, discharge, or transfer from the
program. Each reviewed Performance Summary addressed the youth’s status on goals, overall
treatment progress, academic status, behavior, level of motivation and readiness to change,
interaction with peers and staff, overall behavior adjustment to the program, and significant
positive and negative events. Reviewed documentation reflected each youth was allowed to
read and add comments prior to signing and receiving a copy of their summary, and the original
summary was filed in each youth’s case management record. Each Performance Summary was
signed and dated by the treatment team leader, the staff preparing the summary, facility
administrator or designee, and the youth. Reviewed documentation indicated a copy of each
summary was sent to the committing court, the youth’s assigned juvenile probation officer
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(JPO), and the parent/guardian within ten working days of completing the summary. Three
closed records were reviewed for a release summary. Each release summary included the
original summary, justification for release, and a Pre-Release Notification (PRN) sent to the
assigned JPO. Each release summary and PRN were sent at least ninety days prior to the
youth’s release as required based upon each youth’s non-qualifying status for the Sexually
Violent Predator Program (SVPP). Each reviewed case management record included a signed
copy of the summary. One record indicated the court objected to the youth’s release and the
program resubmitted a PRN and Performance Summary after the youth made progress towards
meeting the court’s expectations. Each closed record documented written notification of the
youth’s release date was sent to the youth’s parent/guardian once the program obtained the
approved PRN from the committing court. Each reviewed closed record contained a Residential
Assessment for Youth (RAY) exit assessment. Three youth were applicable for referral to the
SVPP. Each youth’s JPO was provided the SVPP eligibility form, the youth’s IPP and transition
plan, a physical health summary, and applicable psychological or psychiatric reports conducted
while the youth was in the program: however, none of the reviewed youth were deemed eligible
for the SVPP. Two youth were applicable for required victim notification, and the program
mailed the Victim Notification of Release letter to the victim or designee at least ten days prior to
the youth’s release. The third youth’s record documented no victim notification was required.
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 requiring encouragement and facilitation of
parent/guardian involvement in case management services. Reviewed records documented the
program’s efforts to include the parent/guardian in the assessment process, development of the
youth’s performance plan, progress reviews, formal treatment team meetings, and transition
planning. When a parent/guardian was unable to attend the meetings in person, they were
afforded the opportunity to participate by telephone or could provide verbal or written input prior
to the meeting. The program sends email invitations to the parents/guardians each month in
advance of the treatment team meeting. Observation of a formal treatment team meeting was
conducted during the week of the annual compliance review. The program’s case manager
contacted each youth’s parent/guardian and assigned juvenile probation officer (JPO) for them
to participate in the meeting by telephone. An interview was conducted with the facility
administrator (FA), who indicated all parents/guardians are provided a handbook upon
admission, and the parents/guardians are encouraged to participate in monthly treatment team
meetings and family sessions. Five youth were interviewed, and each confirmed their
parents/guardians participate in the monthly treatment meetings and family sessions.
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 to address the requirements for
multidisciplinary intervention and treatment team members and treatment team meetings. The
treatment team is responsible for developing, reviewing and updating each youth’s
Individualized Performance Plan (IPP) and the Initial and Individualized Mental Health and
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Substance Abuse Treatment Plans for youth receiving mental health and/or substance abuse
treatment while in the program. At a minimum, the treatment team must be composed of the
youth, the youth’s assigned therapist, representatives from the program’s administration and
residential living unit, educational staff, medical staff, the youth’s assigned juvenile probation
officer (JPO), and the youth’s parent/guardian, if available. When applicable, the gang
prevention specialist is to participate. Treatment team meetings are coordinated by case
management staff and are to be held at least once every thirty days. Five youth case
management records were reviewed, and each record included documentation of formal
treatment team reviews which were held at least once every thirty days. Reviewed treatment
team meeting documentation included the youth’s name, date of the review, all required
attendees, comments from treatment team members, a brief synopsis of the youth’s progress at
the program, and positive and negative behaviors. Each youth was provided with an opportunity
to demonstrate skills acquired in the program and comment on their own treatment progress. All
Residential Assessment for Youth (RAY) Reassessment results were discussed, and each
formal treatment team’s documentation was maintained in the youth’s record. Documentation
confirmed each youth’s assigned JPO, parent/guardian, and other pertinent parties were invited
in advance and encouraged to attend the meetings or to provide verbal or written input. A
treatment team meeting was observed during the annual compliance review week with all
required staff present except educational staff; however, written educational information was
sent to the case manager in advance of the meeting. Five youth were interviewed, and four
stated the staff talk about each youth’s progress goals, positive and negative behaviors, and
treatment progress and they can demonstrate the skills they have learned in the program. One
interviewed youth had not yet participated in treatment team as their performance plan was still
being developed.
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 specifying requirements for transition
planning, transition conferences, and Community Re-Entry Team (CRT) meetings to plan for
each youth’s successful transition to the community upon release from the program. A review of
three closed youth case management records indicated each youth had a transition conference
held at least ninety days prior to their targeted release date. Documentation validated the youth,
treatment team leader, facility administrator or designee, and other team members attended
each transition conference. The program documented attempts to facilitate involvement from the
youth’s assigned juvenile probation officer (JPO), parent/guardian, education staff, and other
pertinent parties and noted their input in the transition conference documentation.
Documentation showed the participants reviewed transition activities during the transition
conference on the youth’s performance plan, revised the performance plan and identified
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additional transition activities, when necessary, and identified target completion dates and those
responsible for completion. Attendees dated their signatures and those who participated over
the telephone or through writing were documented. A copy of the plan was sent to anyone not in
attendance who had responsibility for completion of transition goals, and the applicable record
included the email acknowledgment filed with the plan. Reviewed documentation confirmed the
CRT meeting was conducted prior to each youth’s release and all required parties participated.
Each youth case management record contained copies of email invitations to participate in the
CRT meetings.
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 requiring the assembly of an exit portfolio to
assist each youth once they are released back into the community. Three closed youth case
management records were reviewed, and each documented an exit portfolio was discussed and
initiated for the youth’s transition conference. Two of three reviewed exit portfolios did not
include a copy of a state issued identification, Social Security card, or birth certificate; however,
the records documented the program’s efforts to obtain the items prior to the youth’s release.
The third exit portfolio contained all the required items. All three reviewed records included
education and/or vocational certificates earned in the program, a resume, and a completed
sample employment application. Documentation validated the exit portfolio was completed and
provided to the youth, and program staff sent the exit portfolio information to each youth’s
assigned juvenile probation officer (JPO) upon release. Two of three youth were provided with
completed forms and clear instructions as to how to obtain information necessary for
employment and one was not applicable. During the transition conference, documentation
indicated the plans were put in place and identified those responsible for working with the youth
to obtain the needed information.
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 detailing requirements for exit conferences.
An exit conference is to be conducted for each youth prior to release from the program to review
the status of the youth’s transition goals established at the transition conference and to finalize
release planning and preparation for community reintegration. A review of three closed youth
case management records was completed. Each reviewed record validated an exit conference
was held after the program notified the assigned juvenile probation officer (JPO) of the youth’s
release. Two exit conferences were conducted at least fourteen days prior to release. One
youth’s exit conference was conducted only eight days before the youth was released as
jurisdiction was lost on the youth’s twenty-first birthday. All three reviewed records documented
the date of the exit conference, participant signatures, and a summary of pending transition
goals. Each youth’s date of admission and date of termination recorded in the case
management record correlated with the Department's Juvenile Justice Information System
(JJIS). Each youth’s exit conference included a review of transition activities established at the
transition conference, and plans were finalized for the youth’s release, with provisions for
continuation of education and/or employment. Documentation showed each youth’s
parent/guardian and JPO were aware of the youth’s vocational plan. Reviewed documentation
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showed the intervention and treatment team leader, parent/guardian, education representative,
JPO, the youth, and other pertinent parties were included in each exit conference, which were
conducted separately from the transition and Community Re-Entry Team (CRT) meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures addressing channels of communication which
requires the facility administrator (FA) to ensure youth have a voice within the program, an
opportunity to be part of program decision making, be part of planning and preparation for
reparation activities, recreational activities and incentives, and establish a forum to
communicate directly with representatives of the program management team. The program has
a formal process to promote constructive input by youth, using Request to Speak forms located
on each living unit at the program, which are completed and submitted by the youth.
Additionally, documentation supported the program hosts town hall meetings and student
advisory board meetings, which are held monthly on each living unit. It is the program's practice
to have the youth advisory board meet once a month, town hall meetings are conducted at least
once a month, and youth complete surveys monthly in which they may communicate their
concerns. An interview with five youth indicated youth may request to speak to a supervisor or
the FA, if needed. The youth stated they can participate in town hall meetings to provide input
about what happens at the program. An interview with the FA indicated monthly surveys are
completed by youth, and biweekly town hall meetings and monthly student advisory council
meetings are conducted to allow youth to provide input and communicate concerns they may
have.
2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures ensuring education access. The program
integrates education into the daily schedule. A review of three videos and three logbooks
reported youth arriving to class and returning from class on time. In addition, randomly selected
logbook entries over the past year were reviewed and reported youth were moved accordingly
with little deviation. Five interviewed youth reported there were no interruptions during the
school day.
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2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has written policies and procedures related to implementation of career and
technical education services. The provider’s contract states Florida Ready to Work Soft Skills
certification, Occupational Safety and Health Administration ten-hour (OSHA-10) certification,
and cardiopulmonary resuscitation (CPR) certifications are to be completed by each youth
within three months of program entry. Additionally, youth shall complete certification training
from the Master Credential List (MCL) prior to release. Career and technical education
certifications were received for 122 youth. Five youth earned certifications in culinary arts,
sixteen youth in digital and interactive media, twenty-four in OSHA, thirty-four in CPR,
seventeen in Florida Ready to Work Soft Skills, nine earned academic certifications, and twenty-
earned food handler’s certifications. Services are provided Monday through Friday from 3:15
p.m. to 5:00 p.m. The provider’s contract states youth will have the opportunity to offer training
in culinary arts through the Florida Safe Staff Food Handler program certification and earn
career and technical industry certifications in telecommunications technologies, network cabling,
wireless systems, and grounding and bonding. These certifications are expected to be initiated
within the first three months of program entry. Youth in high and maximum-risk programs are
expected to obtain an industry certification from the MCL prior to release; however, no evidence
of earned industry certifications from the MCL or provider contract was observed during the
review. Six closed case management records were reviewed, documenting none of the youth
earned the Florida Ready to Work Soft Skills certification, three did not earn the OSHA-10
certification, one did not earn a CPR certification, and three did not complete the Florida Safe
Staff Food Handler certification during the review period. The program reported these issues
were identified during an internal quarterly review and a corrective action plan has been
implemented, with full compliance expected by October 31, 2025.The interviewed facility
administrator reported the program was providing career and technical education. Five
interviewed youth stated they were working with the Home Builder’s Institute or food service,
taking steps to enroll at a community college, studying for business, and obtaining their general
high school equivalency diploma (GED).
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a policy and procedures requiring a single licensed mental health professional
to be designated as the designated mental health clinician authority (DMHCA). The program’s
clinical director (CD) is a licensed clinical social worker with an active license which expires on
March 31, 2027. The CD is a full-time employee who works forty hours a week on-site with a
Juvenile Sexual Offender Treatment Services certification. The CD is responsible for
coordinating and overseeing mental health/substance abuse services. The assistant CD acts as
the back-up when required. The assistant CD is a licensed marriage and family therapist with an
active license expiring March 31, 2027. The interviewed DMHCA indicated their role in the
coordination and implementation of mental health services at the program includes the provision
of clinical supervision, fidelity monitoring, oversight of service tracking, and the facilitation of
group, family, and individual counseling. The CD meets daily with the management team to
ensure all departments are working together, to address any needs as they arise, or help
prevent any potential complications.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures requiring all substance abuse and mental health
services to be provided by licensed and/or non-licensed clinical staff. The clinical director (CD)
makes sure the licensed clinical staff working under their supervision are performing services
they are qualified to provide based on education, training, and experience. A review of their job
descriptions, and an informal discussion with the designated mental health clinician authority
(DMHCA) confirmed this requirement. The licensed mental health and substance abuse clinical
staffing is in accordance with the current contract and Florida Administrative Code. The program
has one licensed CD, one licensed assistant CD, and one additional licensed therapist. During
the annual compliance review week, copies of the licenses of all mental health professionals
were examined, with no issues noted. Observations of the Chapter 397 license confirmed it was
posted at the entrance of the program. Treatment shall be provided by individuals meeting
qualifications.
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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 clinical supervisor assures the non-licensed clinical staff working under their supervision
are performing services they are qualified to provide based on education, training, and
experience. Reviewed documentation reflected each non-licensed mental health clinical staff
working under the direct supervision of a licensed mental health professional received a
minimum of one hour a week of on-site, face-to-face direct supervision by a licensed mental
health professional for the purpose of overseeing and directing the mental health services
provided in the program during the annual compliance review period, as required. The
program’s contract requires one licensed designated mental health clinician (DMHCA), one
licensed assistant clinical director, and eight therapists. At the time of the annual compliance
review the program reported having four non-licensed therapist vacancies, with the dates of the
vacancies being October 11, 2023, July 23, 2024, May 7, 2025, and August 1, 2025. A review of
direct supervision logs for three non-licensed staff since the last annual compliance review
reflected each staff received face-to-face clinical supervision for the weeks in which services
were provided without exception. Supervision was documented on the program’s form and
included all elements of the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. A review of the
non-licensed staff’s experience and education indicated one staff held a master’s-level degree
and two held a bachelor’s-level degree. Both staff with bachelor’s-level degrees had fifty-two
hours of pre-service training to include sixteen hours of training in their duties and
responsibilities. Reviewed documentation confirmed all non-licensed clinicians hold a degree
from an accredited university or college in counseling, social work, psychology, or a related
human services field. Non-licensed mental health clinical staff who conducted Assessments of
Suicide Risk completed a minimum of twenty hours of training and supervised experience in
suicide risk assessment, mental health crisis intervention, and emergency mental health
services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process which includes a
review of commitment packet information, reports, and records, administration of the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) in the Department’s
Juvenile Justice Information System (JJIS), and a referral process for youth identified by
screenings as in need of further evaluation or immediate attention. A review of five mental
health and substance abuse records indicated the program completed a MAYSI-2 on the day of
admission. The program documented the review of information to include the commitment
packet and existing documentation of mental health and substance abuse problems or history of
human trafficking. Each reviewed MAYSI-2 was completed in full in JJIS and documented the
date of completion and the name of the staff completing the screening. Four of the five youth
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MAYSI-2 records indicated the need for further assessment; however, it is the program’s
practice to complete an Assessment of Suicide Risk and a comprehensive evaluation for all
youth regardless of screening results. Each youth was referred for further assessment in
accordance with the program’s policy. None of the reviewed records were applicable for
emergency procedures or the youth being in crisis. The reviewed screening policy indicates the
facility administrator (FA) holds responsibility for implementing a standardized mental health and
substance abuse screening process. The procedures require a review of available information,
completion of the MAYSI-2 assessment, staff training in screening administration, and a
protocol for addressing youth in crisis who require immediate attention. According to the
interviewed FA, the case manager or designee facilitates an admission classification meeting for
all newly admitted youth immediately following the initial intake screening. Outcomes of the
meeting are documented, and justification for room placement is recorded on the Admission
Classification form. Staff receive information on referrals and recommendations made during the
meeting through verbal communication, updates to the alert communication board, entries in the
program’s logbook, and email correspondence.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures to address the provision of mental health and
substance abuse assessments/evaluations. Youth identified by screening or staff observation as
in need of further evaluation must be referred for a comprehensive mental health and/or
substance abuse evaluation. The evaluation and assessment process is completed by licensed
mental health professionals or mental health clinical staff working under the direct supervision of
the licensed mental health professional. The program’s practice is to refer and assess all youth
regardless of intake screening outcomes. Five youth records were reviewed for mental health
and substance abuse evaluations. The program completed a new, combined mental health and
substance abuse evaluation for all five youth on the day of admission. All five youth’s mental
health and substance abuse evaluations contained all required elements including relevant
background information, behavioral observations, a Mental Status Examination, procedures
administered, discussion of findings, diagnostic impression, patterns, impact, and risk factors of
alcohol and drug abuse, and recommendations. Each evaluation was completed within thirty
days of admission, and each youth consented to substance abuse services prior to the
evaluation. The program is licensed under Chapter 397 to provide substance abuse treatment to
adolescents.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures in place requiring an initial or individualized mental
health or substance abuse treatment plan for youth determined to have a serious mental
disorder or substance abuse impairment and are receiving mental health or substance abuse
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treatment in a program. Five youth mental health and substance records were reviewed, and in
all records an initial treatment plan was developed within seven days of treatment initiation on a
form which contained all elements of the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form. All five initial treatment plans were signed by the licensed clinical staff
completing the form, all treatment team members who participated in the development of the
plan, and each youth. The parent/guardian signed as allowed, the plan was mailed out for
signature, or the parent/guardian participated by telephone. The initial treatment plan included
the youth’s psychiatric needs in all five applicable records and a psychiatric evaluation was to
be completed as it is the program’s policy. One of five reviewed youth records was applicable
for having psychiatric needs and the plan included youth’s psychiatric needs, as well as
medication and frequency of monitoring by the psychiatrist. The individualized treatment plan
was developed for the youth within thirty days of admission in all five records on a form which
contained all the elements of the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan Form. Treatment plan reviews were completed every thirty days, as required.
Reviews were completed on the program’s form and contained all elements on the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form.
Goals and objectives were individualized for each youth. Reviews included participation of the
youth, parent/guardian, the youth’s assigned juvenile probation officer (JPO), treatment team
leader, program management, living unit, education staff, and other pertinent members.
Treatment plans and reviews documented prescribed services for each youth.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
Five youth mental health and substance abuse records were reviewed for treatment planning.
All five 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 five records reflected
team members in attendance included the youth, program administration, residential living unit,
education staff, medical staff, clinical staff, and parents/guardians. All records included
documentation of a properly executed Authority for Evaluation of Treatment (AET) form and a
consent for substance abuse treatment. Reviewed progress notes verified treatment included
individual psychotherapy and psychosocial skills. Each reviewed record verified services were
provided as stipulated in the youth’s treatment plan. Mental health and substance abuse
treatment notes were documented on the program’s form and included all elements on the
Department’s Counseling/Therapy Progress Notes form. 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 form and were 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 included documentation they were discussed with the
youth, parent/guardian, and assigned juvenile probation officer (JPO) at the exit conferences.
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There was documentation to support 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 has a policy and procedures which requires mental health and substance abuse
treatment services to be provided to youth with co-occurring disorders. The program provides
Juvenile Sexual Offender Treatment Services (JSO). The designated mental health clinician
authority (DMHCA) is on-site for forty hours each week. A review of the therapist to youth
caseload ratio documentation confirmed each therapist was assigned to ten youth. During the
review, it was concluded no youth missed services due to being on medical quarantine.
Individual therapy was provided at least once every two weeks or more often as needed. Family
therapy was provided at least once every two weeks, as applicable. The psychiatrist provided
services at least once every two weeks. The program had a contract with a board-certified
behavior analyst, who provided on-site services as needed. Group therapy included four total
mental health/substance abuse groups each week, with a minimum of three JSO groups
weekly. The program had two certified JSO clinicians, which was confirmed with the
Department’s Office of Health Services. Five youth were interviewed, and all reported
participating in both family and individual counseling, attending one family session and two
individual sessions each month. Five staff were interviewed, and all reported only therapists
conduct mental health and substance abuse groups, not direct care staff. The DMHCA was
interviewed and explained the mental health department provides individualized treatment
through individual, family, and group therapy services to address the mental health and
substance abuse concerns of the youth. The interviewed facility administrator stated the
program provides specialized treatment services as identified by contract.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a Suicide Prevention Plan in place, which received an annual review by the
designated mental health clinician authority and the facility administrator on August 4, 2025. The
plan included procedures for identification and assessment of youth at risk of suicide, staff
training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and a review process. The review process for suicide
attempts included circumstances surrounding the event, procedures relevant to the incident,
relevant training received by involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations for operational
changes. Documentation supported the Suicide Prevention Plan was reviewed annually.
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3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a policy and procedures which governs suicide prevention services. The
policy defines suicide precautions as 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 are to be placed on
suicide precautions, and a minimum of constant supervision. A review of five youth records
indicated each was applicable for an Assessment of Suicide Risk (ASR) to be completed upon
admission as part of the program’s standardized practice. A review of five ASRs which were
completed as part of the admission process indicated each was completed in full and each
youth was transitioned to standard supervision after a conference was documented with the
designated mental health clinician authority (DMHCA) and the facility administrator (FA). No
youth were placed on precautionary observation during the annual compliance review period;
therefore, no youth documentation was reviewed for precautionary observation.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program did not utilize secure observation since the last annual compliance review;
therefore, this indicator is rated non-applicable.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision for youth placed on suicide precautions. The program has not placed any youth on
precautionary observation during the annual compliance review period; therefore, no youth
mental health and substance abuse record documentation was reviewed.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures outlining suicide prevention training. A review of five
pre-service and five in-service staff training records confirmed completion of suicide prevention
training. The program has three suicide response kits which are co-located with first-aid kits and
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contain a rescue tool, a needle nose plier, and wire cutters. The suicide kits are in master
control, west wing and east wing of the program. All staff who work with youth must be trained in
suicide precautions and emergency response procedures and participate in mock suicide drills
quarterly, on each of the program’s two shifts. The drills are designed to practice responses to a
suicide attempt or incident of serious self-injury and include methods for contacting other
programs for back-up support, medical personnel, and emergency medical services. Drills
include the provision of life saving measures such as cardiopulmonary resuscitation (CPR) and
use of a suicide response kit. A review of mock suicide drills indicated the program completed at
least one drill on each shift quarterly. Drills included the provision of life-saving measures for
acutely suicidal youth or youth in crisis. A review of a mock suicide drill video confirmed drills
were simulated and staff acted out and then debriefed scenarios. The program does not use
program youth in drill simulations. The program reviews drills during staff meetings to give staff
who are not present during drills the opportunity to review each drill scenario and procedures.
The interviewed facility administrator (FA) reported the program conducts suicide drills monthly
on each shift. Five staff were interviewed and reported if a youth expresses suicidal thoughts,
direct care staff are responsible for notifying mental health staff. Staff reported the suicide
response kits were located in master control, sub control, medical, and the supervisor’s office.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written policy and procedures regarding crisis intervention and has
developed a Crisis Intervention Plan to ensure the protection of youth. The Crisis Intervention
Plan is reviewed annually by the facility administrator and designated mental health clinician
authority. A review of the program’s Crisis Intervention Plan indicated it contained all required
elements, to include a notification and alert system, means of referral, including youth self-
referral, communication, supervision, documentation, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program maintains a written Crisis Intervention Plan addressing mental health crisis
intervention services and Crisis Assessments. A review of five youth records indicated one
youth was applicable for a Crisis Assessment. A review of the assessments was completed and
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indicated the youth was assessed within two hours on the same day the youth was determined
to be in crisis. The assessment documented the reason for the assessment, a Mental Status
Examination, determination of danger, initial clinical impressions, supervision recommendations,
treatment recommendations, recommendations for follow-up, and notification to the
parent/guardian. The assessment was completed by the designated mental health clinician
authority (DMHCA). The youth was deemed appropriate for standard supervision and did not
require an alert in the Department’s Juvenile Justice Information System. No youth were
applicable for a follow-up assessment. The program only had one Crisis Assessment completed
since the last annual compliance review.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written Emergency Response Plan to establish the method in which
emergency mental health and substance abuse services will be provided to all youth. The
reviewed plan included services for immediate staff response, notification, communication,
supervision, transport for emergency services, documentation, training, and review. The plan is
maintained and annually reviewed by the facility administrator (FA) and the designated mental
health clinician authority (DMHCA).
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures for identifying stimuli which have both
positive and negative effects on the youth. The program recognizes when youth do not feel safe
and/or are triggered, they need to learn how to effectively communicate, in a proactive manner,
to ensure the physical and emotional safety of themselves and their community. The Safety
Plans are utilized to assist youth in regulating their emotions and to develop healthy coping
strategies which will assist them in day-to-day programming and their community upon
discharge from the program. The Safety Plans shall be jointly prepared by the youth,
parent/guardian or family member, program clinical staff, and applicable behavioral specialist.
The plan shall be updated every thirty days or following any significant behavioral or mental
health event identified by the treatment team. A review of five youth records indicated each had
a Safety Plan created within fourteen days of admission and reviewed every thirty days. Each
plan documented warning signs, youth baseline behavior, crisis recognition, jointly developed
coping strategies, preferred intervention strategies, and a debriefing process. Each plan was
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jointly prepared with the youth, parent/guardian, and mental health staff. Four out of five plans
were jointly prepared with the youth, parent/guardian, and mental health staff. One plan was
missing parent/guardian participation due to the parent not being available at the time the plan
was prepared. Each plan incorporated information from previous assessments and interviews.
The program’s practice is to store the Safety Plans in each sub-control room which is accessible
to all staff. Additionally, the plans are discussed and revised during each staff meeting and each
treatment team meeting to ensure the youth and supervisory staff are aware of the plan details.
Each plan clearly documented regular revisions and updates. The five reviewed records
contained forty safety plan reviews. The facility administrator (FA) indicated Safety Plans are
updated at a minimum every thirty days and correspond with treatment plan reviews and formal
treatment team meetings. Five interviewed youth confirmed they participated in the
development of their Safety Plan.
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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 written policy and procedures which require a contracted health authority to
provide on-site medical services to youth in the program. The program maintains a contract with
a State of Florida board-certified licensed medical doctor (MD) who serves as the designated
health authority (DHA). The DHA has a clear and active license in the State of Florida, expiring
on January 31, 2026, with specialty training in pediatrics. A review of the Florida Department of
Health records supported the DHA had no current disciplinary cases and/or public complaints
on record. The program has an advanced practice registered nurse (APRN), who holds a clear
and active license in the State of Florida, which expires on July 31, 2026, with specialty training
in family health. The APRN has a Collaborative Practice Protocol (CPP) in place with the
physician signed by both parties on August 28, 2025. Reviewed documentation during the
annual compliance review period found the APRN had not been utilized for clinical duties. A
review of the sign-in and sign-out logs during the annual compliance review period confirmed
the DHA was on-site at minimum once each week, with a week defined as the seven-day period
beginning on Sunday and ending on Saturday. The program has a back-up DHA who is a
licensed physician with a clear and active license in the State of Florida expiring on March 31,
2026. Reviewed documentation found the back-up DHA was utilized on two occasions during
the month of December, when the DHA was not on-site. Reviewed documentation confirmed
the program received approval from the Department’s Office of Health Services for tele-
medicine/tele-health services. Reviewed documentation found the psychiatrist utilized tele-
health to provide mental health services. Tele-health was only utilized for youth who agreed to
participate in tele-health sessions. There were no instances of tele-health being used to perform
a Comprehensive Physical Assessment (CPA), and all medical services were provided in-
person. The DHA reported their role in the program is to conduct CPAs, periodic evaluations
every ninety days for youth on medication or with chronic conditions, to evaluate and approve
nursing protocols, assess youth with a sickness, and provide oversight of medical staff. The
DHA confirmed being on-site once a week and being available by telephone twenty-four hours a
day. An interview with the APRN confirmed the program’s practice.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a written policy and procedures in place for licensed medical staff. The
program’s on-site nursing coverage is provided by one full-time registered nurse (RN), who
serves as the health services administrator (HSA) and is contractually required to be on-site
forty hours a week. In addition, there are four full-time licensed practical nurses (LPN) on-site. A
review of nurse licensure credentials for nurses who provided services during the annual
compliance review period confirmed licenses were clear and active. Each held a current
certification in cardiopulmonary resuscitation (CPR) and first- aid.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) and the facility
administrator (FA) signed and dated all respective treatment FOPs on September 24, 2025. The
psychiatrist reviewed and signed the FOPs on September 25, 2025. The nursing staff signed a
cover page acknowledging review of all FOPs and treatment protocols on January 2, 2025. The
annual review of medical FOPs and protocols was conducted on September 24, 2025.
Reviewed documentation confirmed all newly employed healthcare personnel received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse or designated healthcare professional. All approvals of treatment
protocols or standing procedures were written and were authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures to ensure the completion of the Authorization
for Evaluation and Treatment (AET) for all youth admitted into the program. The program utilizes
a separate form for youth eighteen years of age or older providing consent for release of
specific information as noted on the Release of Information Authorization for Youth Eighteen
Years of Age and Older form and to whom the information can be released and shared. Five
youth Individual Healthcare Records (IHCRs) were reviewed for an AET. Three youth records
included a valid and legible copy of an AET and the word, “Copy” was clearly stamped on each
AET. Each applicable AET form was signed by the youth’s parent/guardian. None of the
reviewed IHCRs were applicable for an additional court order filed. Each applicable reviewed
AET form was signed by a Department representative. Two of the five reviewed youth IHCRs
were applicable for the youth being eighteen years of age or older. Documentation supported
the youth signed a Release of Information Authorization for Youth Eighteen Years of Age or
Older form. An interview with the program’s registered nurse (RN) confirmed the program’s
practice.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures to inform the parent/guardian of significant
changes in the youth’s condition and obtain consent when new medications and treatments are
prescribed. Five youth Individual Healthcare Records (IHCRs) were reviewed for
parent/guardian notifications. Two youth were eighteen years of age or older and signed a
Release of Information Authorization for Youth Eighteen Years of Age or Older form. Three
youth were applicable for consent from the youth’s parent/guardian for all new medications,
over-the-counter medications beyond those covered by the Authority for Evaluation and
Treatment (AET), or new psychotropic medications prior to administration. Parent/guardian
consent was provided for the three applicable youth and written notifications were sent utilizing
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the Department’s Parental Notification of Health-Related Care form. None of the youth were
applicable for taking psychotropic medication at admission. None of the reviewed youth were in
the care of the Department of Children and Families (DCF). Each of the five reviewed IHCRs
confirmed vaccinations were verified within thirty days of the youth’s admission; however, one
youth was eighteen years old and did not consent to various immunizations. Reviewed
documentation found the youth was from another country and did not have any other adults in
the country. The program reported they did not have any youth applicable for religious
exemptions for immunizations. The nurse reported immunization verification occurs during the
initial intake. The nurse reported utilizing school records and the Florida Shots website.
Additionally, the nurse explained the process for obtaining parent/guardian consent for
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.
The program has a written policy and procedures outlining youth healthcare admission
screening and rescreening each time the physical custody of the youth changes. Five youth
Individual Healthcare Records (IHCRs) were reviewed. All five youth had a Facility Entry
Physical Health Screening (FEPHS) completed on the date of admission. Two of the screenings
were completed by the licensed practical nurse (LPN) and the remaining three were completed
by the registered nurse (RN). One youth’s IHCR indicated the youth left the physical custody of
the program for over twenty-four hours and a new FEPHS form was completed by the RN. An
interview with the nursing staff indicated youth are seen by the nurse upon admission. Nurses
are made aware of new admissions during the morning management team meetings and email.
Medical staff complete the FEPHS form, and if a youth does leave for over twenty-four hours, a
new FEPHS form and a urine drug screening are completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures for educating youth on the delivery of
healthcare services. The program’s policy requires each youth to be orientated on the general
process of the healthcare services the youth will receive at the program. A review of five youth
records confirmed each youth received a general healthcare admission orientation. The
orientation included sick call, access to medical care, medication process including side effect
monitoring, what constitutes an “emergency” and when to notify staff, the right to refuse care
and how it is documented, non-disciplinary role of the healthcare providers, and standard
universal precautions. The program maintains an education/orientation binder for youth who
refuse to sign the orientation sheet. A review of the Health Education sign-in sheets confirmed
various healthcare topics were discussed with the youth from January to September 2025.
Youth were informed on seatbelt usage, alcohol and drug related problems, sexually transmitted
disease/infections, tobacco products, including smoking, dental and basic personal hygiene,
immunizations, infection control, prevention of sexual and other physical violence, nutrition,
physical fitness, testicular self-examination, and chronic conditions monthly.
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4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures to ensure the designated health authority
(DHA) is notified when youth are admitted into the program. Five youth Individual Healthcare
Records (IHCRs) were reviewed and three were applicable for a known or suspected chronic
condition upon admission. Reviewed documentation confirmed the program’s practice is to
notify the DHA of all newly admitted youth regardless of the youth’s status. The DHA was
notified within twelve hours for each applicable youth. One reviewed record indicated the youth
had a history of taking psychotropic medication and the psychiatrist was notified. During an
interview, the nurse reported medical staff are responsible for notifying the DHA and
documenting the notification in the progress notes.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission into the program. Five youth Individual Healthcare Records
(IHCRs) were reviewed, and each contained an HRH completed by a registered nurse (RN) on
the day of admission. Each HRH was reviewed by the designated health authority (DHA) as
indicated by a checkbox on the CPA. An interview with the nurse confirmed the practice of
completing the HRH upon admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures to ensure each youth in the program receives
and/or shall have on record a current Comprehensive Physical Assessment (CPA) upon their
admission into the center. Five youth Individual Healthcare Records (IHCRs) were reviewed,
and each contained a new CPA completed by the designated health authority (DHA) within
seven days of admission. Each of the CPAs documented the appropriate Medical Grade for the
reviewed youth. There was no indication of any missing or incomplete elements on any of the
reviewed CPAs, which were completed on the Department’s form. Four youth refused part of
the examination, and each CPA documented the refusal and included the youth’s signature by
the applicable portion of the CPA examination. One youth completed all applicable sections of
the CPA. All sections of the CPA were completed in full utilizing an “O” and/or applicable “X”.
The Department’s Problem List was updated for each youth. The results of each youth’s
Tuberculosis Skin Test (TST) were documented on the CPA, and on the Department’s
Infectious and Communicable Disease (ICD) form. Reviewed documentation confirmed the
Department’s Problem List was updated as needed. An interview with the program’s nurse
confirmed a CPA is completed within seven days of a youth’s admission and annually.
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4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures requiring all admitted youth to be clinically
screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). Five youth Individual Healthcare Records (IHCRs) were
reviewed, and each documented the youth was clinically screened for STIs. Each of the youth
were applicable for further evaluation and were referred to the DHA. Each youth’s IHCR
documented testing had been ordered and performed. Testing, screening, clinical evaluations,
and diagnoses were documented accordingly on the Department’s Infectious and
Communicable Disease (ICD) form, excluding HIV results, and filed within the lab section of the
IHCR. None of the records were applicable for a re-screening to be completed. The program’s
policy outlines HIV test results are only disclosed to the youth and the youth’s legally authorized
representative, healthcare providers during the course of consultation, diagnosis, or treatment of
the individual, the Department of Health for purposes of reporting and control of spread of
disease, health facility staff committees conducting program monitoring, evaluation, and service
reviews, medical personnel who have been subject to a significant exposure, and healthcare
facility personnel or agents for the healthcare provider who have a need to know in the course
of patient care activities or administrative operations. A review of five youth IHCRs found each
youth was offered the opportunity to receive counseling and testing for HIV. None of the
reviewed youth consented to HIV testing. Five interviewed youth reported they can request a
HIV test if needed. An interview with the nurse confirmed the screening process and access for
HIV testing. Additionally, they reported the pre and post-test counseling services are provided
by the designated health authority (DHA).
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures ensuring all youth shall be able to make sick
call requests and have their complaints treated appropriately through the sick call system. Sick
call care is provided by licensed healthcare professionals pursuant to their scope of practice and
according to protocols approved by the designated health authority (DHA). When a licensed
healthcare professional is not on-site, the shift supervisor shall review all sick call requests
within the required timeframe. Five youth Individual Healthcare Records (IHCRs) were
reviewed, and two were applicable for sick call requests. One additional record was requested
and reviewed to meet the sample size. None of the applicable youth presented with a similar
sick call complaint three or more times within a two-week period. A Sick Call Request form was
completed for each of the sick call requests reviewed. Each of the Sick Call Request forms were
completed by a registered nurse (RN). All sick calls were documented on the Department’s Sick
Call Index, Sick Call Referral Log, and filed within each youth’s IHCR in reverse chronological
order. None of the reviewed sick call instances were for youth in restricted housing, as the
program does not utilize restricted housing. Observations made during the program tour found
Sick Call Request forms were located on the living modules where the youth are housed. Sick
call is provided daily by the registered nurse (RN) at 10:15 a.m. and 3:15 p.m. The sick call
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hours are posted on the living modules and medical office. Observations made validated the
program has an exam table and equipment to perform sick calls. During the week of the annual
compliance review a sick call was observed. Observations made at the time of the sick call
being conducted validated all elements were covered in accordance with the program’s policy.
An interview with the nurse confirmed the program’s practice. Five interviewed youth reported
they can see a doctor or dentist if needed. Five youth were asked how quickly they can see a
nurse once the youth make a sick call request. Each youth reported within one day.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures regarding the provision of episodic and
emergency care. Five youth Individual Healthcare Records (IHCRs) were reviewed and two
were applicable for episodic care encounters. One additional record was requested and
reviewed to meet the sample size. Two reviewed IHCRs documented first-aid/episodic care was
provided by a licensed healthcare staff and was documented in the progress notes under the
notation of episodic care. All notes were completed in subjective, objective, assessment, and
plan (SOAP) format. One youth’s record was applicable for a non-healthcare staff providing
episodic or first-aid care. Reviewed documentation confirmed a follow-up evaluation from a
licensed healthcare staff was conducted within the required timeframe. The program has a total
of eight first-aid kits located in medical, one for each of the program’s two transport vans, in the
Home Builder’s Institute (HBI) workshop, master control, east wing living module, west wing
living module, and one in the kitchen. The first-aid kits for the vans are stored in master control
until the vans are used for transport. The program has a process for ensuring contents are
maintained and stored in accordance with guidelines to prevent expiration or deterioration are to
replenish them as needed. Reviewed documentation indicated the nurse checks the first-aid kits
monthly. Observations of three first-aid kits found each was fully stocked with the required
items. A review of the first-aid kit binder confirmed the first-aid kits were being monitored as
required. The program has two automated external defibrillators (AED) which are in the medical
office and master control. The AEDs provide audio instructions on step-by-step procedures.
Written procedures are attached to the AEDs. An observation of the AED in comparison with an
informal interview with the nursing staff confirmed the AED had a blinking green light which
indicates the device is functioning adequately. Nurses check to ensure the AED batteries and
pads are operable. During the annual compliance review week, the nurse conducted a self-test
of the AEDs in front of the regional monitor. There were no issues observed. The expiration
dates of the AED batteries were October 31, 2027, for the AED stored in medical and August 2,
2027, for the AED stored in master control. The batteries were changed on June 5, 2025, for the
AED located in medical and August 2, 2023, for the AED located in master control. The
expiration date for each of the AED pads was May 13, 2026, for the AED in medical and
November 17, 2025, for the AED stored in master control. The pads were last changed on June
30, 2023, for the AED in master control and June 5, 2025, for the AED in medical. A list of
emergency numbers was posted and accessible for non-licensed and licensed staff and these
numbers were inaccessible to all youth in the program. A review of five staff training records
confirmed they met episodic, first-aid, and emergency care training requirements. A review of
the program’s emergency medical drills since the last annual compliance review confirmed
medical drills were conducted on each shift monthly. Emergency medical drills which include the
demonstration of cardiopulmonary resuscitation (CPR), first-aid, and AED are conducted at a
minimum of quarterly. The emergency medical drills consisted of both announced and
unannounced drills and were conducted at least monthly on each shift. A review of the
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program’s logbooks showed direct care staff had the opportunity to participate in at least one
drill which included the use of CPR annually. A video observation review of drills confirmed drills
simulated episodic care events which called for immediate first-aid and/or the administration of
CPR techniques and the initiation of the emergency procedures to follow when there was a life
threatening-emergency. The program had no episodic care events to observe during the week
of the annual compliance review. The program maintains a written policy and procedures for the
use, access, and inventory of NARCAN® by licensed healthcare staff and non-healthcare staff
trained by the RN to administer medication. The program stores the NARCAN® in a locked box
behind a locked door. The program’s inventory process of NARCAN® is for weekly counts to be
conducted by medical staff. Five interviewed youth reported they can request to see a doctor or
a dentist if needed. Five interviewed staff reported they are able to call 9-1-1 if a youth has a
medical emergency. The nurse reported drills are conducted monthly on each shift. The nurse
confirmed the program’s practice regarding episodic care events.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site healthcare provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a written policy and procedures to provide timely referrals, coordination, and
documentation of medical services to off-site health providers for youth with emergent or
nonemergent needs. The designated health authority (DHA) reviews, signs, and dates the off-
site care instructions. A review of five youth Individual Healthcare Records (IHCRs) found four
youth were applicable for off-site care. When applicable, the youth’s parent/guardian was
notified of the off-site care. None of the applicable youth required emergency off-site care. Each
of the three applicable IHCRs had a Summary of Off-Site Care Consultation Report which was
filed in the IHCR with additional documents when applicable. The DHA reviewed, signed, and
dated the off-site care documents, as required. Two of the four applicable youth required follow-
up care, and each was scheduled. The nurse was interviewed and reported medical staff track
follow-ups utilizing the off-site transport log, DHA tracking log, and a calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures ensuring youth who have chronic illnesses
receive regularly scheduled evaluations with the required follow-up. A review of five youth
Individual Healthcare Records (IHCRs) showed three youth were identified on their Facility
Entry Physical Health Screening Form (FEPHS) with a chronic condition after being admitted
into the program. Another youth was identified with a chronic condition after admission into the
program. None of the youth were identified as having a communicable disease. Each youth was
taking prescribed medication on an ongoing basis. One applicable youth was undergoing
treatment for a physical health condition. Each youth was classified with an appropriate Medical
Grade. Each applicable youth was placed on the chronic conditions list and periodic evaluations
were conducted every ninety days. The designated health authority (DHA) reported chronic
evaluations are conducted every ninety days and are tracked utilizing a calendar. None of the
applicable youth were taking anti-tuberculosis medications. Periodic evaluations were
conducted prior to a prescription renewal, change, or expiration, when applicable. None of the
reviewed youth were applicable for an off-site evaluation. There were no indications of lapses in
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care or missed periodic evaluations in each of the reviewed records. The Department’s Problem
List for each youth was updated in accordance with policy. The nurse reported nursing staff
track follow-up testing, referrals, and appointments with a calendar. The facility administrator
(FA) reported meeting with medical staff during morning meetings to discuss any medical issues
or concerns. Additionally, the FA reported weekly meetings with the DHA occur.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a written policy and procedures which detail the process for the receipt,
storage, inventory and administration of medication in a safe and effective manner. Five youth
Individual Healthcare Records (IHCRs) were reviewed and all five were applicable for taking
medication during the annual compliance review period. Two of the youth were applicable for
having been admitted to the program with medication. Review documentation confirmed youth
medication was verified prior to being accepted into the program. Each applicable youth’s
prescription verification was included in the chronological progress note. Reviewed
documentation supported all medications had a current, valid order, and were given pursuant to
a current practitioner’s order. Documentation confirmed the designated health authority
(DHA)/designee and psychiatrist were contacted to obtain the order to resume the specified
medications prescribed prior to admission. The program utilizes a pre-printed Medication
Administration Record (MAR) to document all medication and treatment. Each of the reviewed
MARs met all requirements. Reviewed documentation confirmed nursing staff documented
weekly side-effect monitoring on the MAR. One youth was applicable and signed the Refusal of
Treatment form indicating the refusal of medication. The MAR clearly documented the refusal.
None of the five reviewed youth records were applicable for trained non-healthcare staff
assistance in the delivery of medications when licensed staff were not on-site. None of the
reviewed youth were applicable for parenteral medication. The program’s practice is to provide
each youth an Initial Diagnostic Psychiatric Interview within fourteen days of admission. There
was no indication of any type of standing orders for psychotropic medications, emergency
treatment orders for psychotropic medication, or indication of pro re nata (PRN) orders for
psychotropic medications. During the annual compliance review week, one medication
administration was observed with no issues noted. The youth was escorted to the medical office
by a supervisor. The staff remained on the outside of the door to ensure the youth’s privacy.
The Six Rights of Medication Administration were verified by the registered nurse (RN). The RN
administered the medication as required and did not pre-pour any of the medications. The nurse
reported all medication is verified and the DHA is notified for continued use of medication. The
nurse was knowledgeable regarding the process of administering medication and completing
the MAR. Five interviewed youth reported the nurse gives them their medication and were able
to explain the process.
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4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a written policy and procedures for the provision of psychiatric services within
the program. The program maintains a contract with a psychiatrist who is responsible for
providing psychiatric services. The psychiatrist had a clear and active license in the State of
Florida, expiring on March 31, 2026. The psychiatrist is available for emergency consultation
twenty-four hours a day, seven days a week. The psychiatrist provided psychiatric services
briefly as a representative of treatment team and psychiatric recommendations for youth are
incorporated into evaluations and planning at the program. The program utilized two back-up
psychiatrists during the annual compliance review period. Both psychiatrists held a clear and
active license in the State of Florida, expiring on January 31, 2026. The program has a
psychiatric advanced practice registered nurse (APRN), who holds a clear and active license in
the State of Florida, expiring on April 30, 2026. Reviewed documentation confirmed a
Collaborative Practice Protocol was in place with the APRN starting June 25, 2025. When duties
were delegated to the psychiatric APRN the psychiatrist was available by telephone or by
another communication device when not physically available on the premises. A review of the
psychiatric sign-in logs verified the psychiatrist was on-site biweekly, as required. Reviewed
documentation indicated the psychiatrist actively participated in, managed, and supervised
psychotropic medication services in the program. Tele-psychiatry services were provided when
needed. A review of five youth Individual Healthcare Records (IHCRs) indicated one youth was
applicable for psychiatric services. The program only had one additional youth record for review.
One applicable youth entered the program with prescribed psychotropic medications. Each
youth was referred for a psychiatric interview, and each youth received a diagnostic interview
within fourteen days of admission. Each Initial Diagnostic Psychiatric Interview was documented
on the Department’s Clinical Psychotropic Progress Note (CPPN). Psychotropic medication or
changes to the youth’s existing psychotropic medication regimen, were documented on page
three of the CPPN. Each of the youth’s reviewed Initial Diagnostic Psychiatric Interviews
included all required elements. Reviewed documentation confirmed each youth was applicable
for a psychiatric medication review and each youth was seen by a psychiatrist at least every
thirty days. None of the reviewed records were applicable for a psychiatric evaluation update.
Each instance where page three of the CPPN was used, the psychiatrist documented the
identifying data, diagnosis, target symptoms of each medication, effects of the medication,
medication dosage, dosage range, frequency, route of administration, side effects, adherence to
the medication regime, height, weight, laboratory findings, and whether there was telephone
contact with the youth’s parent/guardian. Reviewed documentation confirmed each CPPN was
signed and dated by the psychiatrist. None of the youth were applicable for monitoring of
Tardive Dyskinesia. Each youth received tele-psychiatry during the annual compliance review
period. An interview with the psychiatrist and designated mental health clinician authority
verified the psychiatric treatment processes at the program.
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4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures regarding tracking inventory of all medication
and medical equipment. The program’s policy requires all medical equipment to be classified
and perpetually inventoried. Observations of the medical office confirmed controlled medication
was locked in a secure medical cart inside of another lock box. The medication cart was
observed clean and organized with stock items separated from youth medication. The medical
equipment classified as sharps included syringes, needles, scissors, and suture removal kits,
and each was secured and inventoried utilizing a routine perpetual inventory. During the week
of the annual compliance review, an observation of counts was conducted for three over-the-
counter (OTC) medications, three controlled medications, and three sharps, and the inventory
counts were accurate. The medications were stored in a separate secured area not accessible
to the youth. The medication, sharps, and OTC medications were all stored in a designated
locked area clearly labeled. A review of five staff training records confirmed the registered nurse
(RN) conducted training for delivery and oversight of medication self-administration. An informal
interview with the clinical manager confirmed in the instance of a discrepancy with the inventory,
the nurse who found the discrepancy reports the inventory discrepancies to the medical clinical
manager. The clinical manager will notify the medical supervisor, facility administrator (FA) or
designee on-site. An internal investigation will be initiated, and the Department's Central
Communications Center (CCC) will be contacted. An interview with the program’s nurse
confirmed the program’s disposal process consists of two RNs, or the pharmacist signing the
medication disposal form and disposing of the medication using a chemical disposal agent.
Additionally, the nurse reported medication is returned to the pharmacy. The program maintains
a copy of the local pharmacist license in the medical office. The pharmacist conducts monthly
on-site checks of all the medications. The nurse stated controlled substances such as narcotics
are delivered by the pharmacy and stored behind a double locked cabinet. Two nurses are
required to count the controlled medications shift-to-shift.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a written policy and procedures for infection and exposure control. The
program’s policy requires infection control procedures for prevention, containment and
treatment. The program’s infection control policy and procedures were signed by the designated
health authority (DHA) on September 24, 2025. The facility administrator (FA) signed and
reviewed the policy on September 24, 2025. The nursing staff reviewed the policy on
September 24, 2025. The procedures included common, infectious diseases of childhood, self-
limiting, episodic contagious illnesses, viral or bacterial infection diseases, tuberculosis,
Hepatitis A, B, and C, human immunodeficiency virus (HIV), Methicillin-Resistant
Staphylococcus Aureus (MRSA), bio-terrorist agents, chemical exposures, outbreaks of lice,
and epidemics. Reviewed documentation confirmed staff have access to protective equipment
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and Hepatitis B immunizations. A review of the facility/occupational exposure book confirmed
there were no incidents where the local health department or Department's Central
Communications Center (CCC) should have been contacted during the annual compliance
review period. The Exposure Control Plan, which is located in master control, was written in
accordance with Occupational Safety and Health Administration (OSHA) standards. The
program maintains separate records for youth and staff who have experienced a
facility/occupational exposure. An informal interview with the clinical manager confirmed the
program’s process for needle sticks post-exposure evaluation. The clinical manager reported
staff will immediately wash the exposed area, dispose of the needle into the sharps container,
notify the supervisor, or facility administrator (FA), contact the CCC, and transport the exposed
person to urgent care for additional treatment. An interview with the FA confirmed the Exposure
Control Plan was in master control and the medical office. The FA reported the plan is reviewed
yearly with direct care staff. An interview with the nurse confirmed training is provided by the
health services administrator (HSA) or director of nursing yearly for the staff and new hires. The
training is provided to the youth at the time of admission. The nurse indicated immunizations are
provided by the local health department. Additionally, the nurse was aware of where to locate
the plan.
4.20 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a written policy and procedures requiring all program staff to promote safety
and security by maintaining active supervision of youth to include interacting positively with
youth, engaging youth in a full schedule of constructive activities, closely observing behavior of
youth, and consistently applying the program’s behavior management system (BMS). The
program’s contract requires staff-to-youth ratios of one staff to eight youth during awake hours
and one staff to ten youth during sleeping hours. The ratio for off-site activities, transportation,
and visitation is one staff to five youth. A program tour verified the daily youth activity schedule
was posted throughout the program and is designed to keep youth engaged in a full schedule of
activities. The program staff are required to account for the whereabouts of youth under their
supervision and ensure staff-to-youth ratios are in compliance with contract requirements.
Observations of staff supervision for four days during the annual compliance review week
included classroom activities, line movement, school/education, meals, youth head counts,
mental health groups, vocational activities, youth searches, and outdoor/indoor recreation
activities. In addition, the youth were observed to be working in the kitchen and using Class B
tools while participating in cleaning duties. The observations ensured staff-to-youth ratios were
maintained, as required. A tour of the program verified the program and living units were clean,
well maintained, and graffiti free. A perimeter check was conducted, and fencing appeared to be
in good repair. Staff and youth were appropriately attired. During outdoor activities and/or
movement, observations verified staff were strategically positioned to ensure proper supervision
of youth and to ensure there were no physical obstructions in their view of the youth.
Observations of interactions between program staff and youth reflected the interactions were
positive and consistent with the program’s BMS. Three informally interviewed staff knew how
many youth they were supervising. The program’s policy states active supervision ensures
appropriate supervision of the youth is maintained at all times. Staff are to provide effective
positioning for optimal sight and sound supervision of youth. Staff shall communicate with youth
and co-workers effectively to ensure expectations are clearly defined. Video observations of
youth were conducted during sleep hours. The observations verified the staff-to-youth ratios
were in compliance and staff were awake and alert.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a written policy and procedures addressing the implementation and training of
the program’s behavior management system (BMS) which has not changed since the last
annual compliance review. The BMS is posted and outlined within the youth handbook allowing
easy access for youth and includes rules governing conduct and positive and negative
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consequences for behavior including while in the classroom. A review of the youth handbook
indicated the BMS is designed to promote safety, respect, and fairness. The BMS shall
complement the performance and treatment planning process, including the coordination of
individualized behavior plans, as applicable. The program utilizes the iChoose BMS, which is a
coordinated system of promoting, monitoring, recognizing, and rewarding a youth’s progress. It
is a program of incentives and consequences which promotes individualized skill building,
appropriate behavior, and accountability. Staff use point cards to monitor how well the youth are
progressing in the program. Youth earn points daily for complying with the program rules. The
youth receive rewards based on the number of points earned. At admission, youth enter the
program on an orientation level, prior to starting the BMS and progress their way up the four
levels. The four levels of the BMS include beginner, intermediate, veteran, and expert levels.
Youth learn about the BMS during the orientation process. The BMS promotes and protects
youth rights and has opportunities for positive reinforcement. The BMS includes positive and
negative consequences and uses constructive disciplinary actions. The BMS promotes socially
acceptable means for youth to meet their needs, includes a process for explaining to youth the
reasons sanctions are being imposed, youth have the opportunity to explain their behavior,
there are opportunities for staff and youth to discuss the impact of behavior to others, includes
reasonable reparations for harm caused by others, there are discussions of alternative
behaviors, promotes positive dialogue, and minimizes separation of the youth from the
population. A review of the BMS confirmed it is not used solely to increase a youth’s length of
stay, deny basic rights or services, promote the use of group punishment, allow youth to punish
other youth, or include disciplinary confinement. Youth have access to the youth handbook
which clearly outlines the BMS, program rules, and the progressive disciplinary system for the
youth. In addition, the parent/guardian handbook includes a description of the BMS. The facility
administrator (FA) ensures all staff having direct contact with youth are trained on the BMS.
Observations confirmed, the BMS was posted throughout the program. A review of five staff in-
service and five pre-service training records indicated staff were trained on the BMS by the staff
development coordinator. A review of five position descriptions confirmed the job functions
included implementation of the BMS. A review of five youth case management records indicated
each youth participated in an orientation upon arrival to the program and received a copy of the
youth handbook. Observations of staff and youth interactions verified staff were adhering to the
BMS by utilizing a ratio of four-to-one positive rewards to negative consequences when
redirecting the youth as indicated in the program’s policy. The program provides the youth with
incentives which include using points to purchase items from the canteen, or to participate in the
activities such as “Mega Monday” and/or “Phat Friday”. Other activities included the use of
board games, card games, and/or receiving extra snacks. Five staff were interviewed, and each
reported the BMS consists of a point and level system which consists of incentives and
consequences. Each of the interviewed staff verified youth receive incentives which include the
purchase of canteen items, receiving extra snacks, earning extra telephone calls, and youth can
participate in Mega Mondays and Phat Fridays. Five staff were interviewed, and four stated the
youth’s basic rights cannot be taken away from a youth as a consequence, and one staff
indicated the youth’s late bedtime incentive can be taken as a consequence. Each interviewed
staff stated youth are informed of the consequences and they are able to explain their behavior
during the review of the Behavior Reports (BRs) and during treatment team meetings. Five
youth were interviewed, and each stated the consequences for negative behaviors included not
earning daily points, level freezes, controlled observation, privilege restriction, and early
bedtime. Each youth stated they receive incentives such as special meals, snacks, canteen,
tournaments, and participate in family days, Mega Mondays and Phat Fridays. Five interviewed
youth indicated staff are consistent with the utilization of rewards and consequences for all
youth. All five youth were able to explain the difference between each level and how they move
from level to level. All five-youth verified youth are never allowed to punish other youth. An
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interview with the FA confirmed the program utilizes the iChoose BMS. The FA indicated, the
BMS is responsive and designed to maintain order and security, while fostering compliance with
the program’s rules, while teaching youth alternative prosocial methods of dealing with problems
using both rewards and a system of progressive discipline. The BMS 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 four-to-one positive to negative
consequences, promotes socially acceptable means for youth to meet their needs, and includes
processes which address the needs of, and cognitive capacity of youth. The FA stated rewards
include incentive calendars, nightly incentives, Phat Friday, Mega Monday, random reinforcers
to include additional telephone calls, food incentives, music, and free time. The program
ensures consistency by reviewing the BMS during behavior review team meetings, annual
performance evaluations, all-staff training, and monthly coaching.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, or room restriction; therefore, this indicator is rated
non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a written policy and procedures to conduct and document ten-minute checks
during sleep hours or at other times, such as during an illness, or room restriction. The program
has a total of 113 video cameras capable of recording thirty-days of video footage. During the
annual compliance review week, all cameras were operational. Prior to conducting checks, staff
are situated where they are able to see any movement within the living unit. Staff are required to
conduct room checks every ten-minutes when youth are in their rooms and document the time
of the check on the Ten-Minute Check Log. The informally interviewed facility administrator (FA)
reported the program had two shifts from 7:00 a.m. to 7:00 p.m., and 7:00 p.m. to 7:00 a.m.
during the annual compliance review period. A review of nine separate video samples of ten-
minute checks from each program living unit and log sheets reflected there were no
discrepancies. Documentation confirmed staff who complete the checks initial or sign the check
sheet. In addition, the Ten-Minute Check Logs since the last annual compliance review were
reviewed. A sample of various days, times, and shifts indicated the ten-minute checks were
completed within the required frequencies. Five interviewed staff verified room checks were
conducted every nine or every ten minutes when a youth is placed in their room for sleeping or
non-punishment reasons. An interview with the FA confirmed the program has 113 cameras, in
which the program has video recording capabilities for thirty days.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a written policy and procedures to ensure the continuity of custody and care of
youth and protection of the public. The program’s policy requires staff to conduct formal head
counts each hour and after outdoor activities. In addition, the policy indicates counts are
conducted during power outages, escapes, program disturbances, or any other disruptions
which may occur. Head counts are conducted before and after each movement, and during
emergencies and drills. A review of the Continuity of Operations Plan (COOP) verified program
staff must always account for the whereabouts of the youth in the care and custody of the
program. This includes the need for continual head counts to be conducted minimally at the
beginning of each shift, during any emergency situation, and at regular intervals. Twelve
randomly selected dates and times in the program’s logbook were reviewed for census counts
during the annual compliance review period. Documentation validated head counts and
movements were conducted at the beginning of each shift, after outdoor activities, during
emergency situations such as program disturbances, and during actual and/or simulated drills.
The logbooks included youth who were temporarily away from the program, transferred,
admitted, and released. Additionally, observations confirmed the program staff conducted a
physical head count during school, and before and after each movement. Five interviewed staff
verified formal counts are conducted every hour, during emergencies, and during every
movement. Each staff stated if a count cannot be reconciled, the program is locked down, all
movement is stopped, and an emergency count is conducted until the count is reconciled. Each
staff stated emergency counts are conducted anytime a code is called, during power outages, if
there is a discrepancy in the count, if a youth is missing, and during drills.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a written policy and procedures to ensure the maintenance of a chronological
record of events, incidents, and activities in a central logbook. The logbook documents head
counts, shift changes, and group movement. At a minimum, each logbook entry shall be legible
and include the date and time of the event, the names of staff and youth involved, a brief
description of the event, the name and signature of the person making the entry, and the date
and time of entry. No logbook entries shall be obliterated or removed. All errors shall be struck
through with a single line and initialed by the staff correcting the error. All direct care staff and
supervisors shall be briefed when coming on duty. A review of the logbooks and observations
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verified since the last annual compliance review, all errors were struck through and initialed by
staff, the logbooks were bound with numbered pages, and there were no loose, or missing
pages found. Logbook entries included shift briefing, youth movement, head counts, emergency
drills and situations, program checks, perimeter checks, and law enforcement data. Internal
incidents reported to the Florida Abuse Hotline and/or the Department’s Central
Communications Center (CCC) were documented. Reviewed logbooks showed recreation was
conducted. All entries included the dates and times of events, when education was scheduled,
documented when a youth arrived or departed, and logbook entries contained the names of the
staff and youth involved. The program ensures direct care staff, including each supervisor, are
briefed when coming on duty. Each staff signs the shift briefing sign-in sheet to acknowledge
receiving the information. A review of shift reports since the last annual compliance review
verified each report was completed on a daily basis. A copy of the shift report was made
available to staff for at least forty-eight hours. Reviewed documentation and a review of the
CCC reports indicated there were no instances of escapes or attempted escapes during the
annual compliance review period.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures to ensure program safety and security, safety
of staff, youth, and the public by implementing and maintaining a system of program key control.
All staff shall be provided with guidelines and training on the key control policy and required
procedures on the physical control and use of program keys, while ensuring the provision of
community protection through safe and secure programming for youth. The assistant facility
administrator (AFA) is assigned as the key control manager who is responsible for the security
and accountability of keys and key control systems as well as damaged keys. Observations
confirmed the program has a key log sheet for staff assigned permanent keys which they are
required to sign, indicating the number of keys issued and the key identification number.
Permanent keys are kept to a minimum and must be authorized in writing by the facility
administrator (FA). A review of the signed acknowledgment forms indicated each staff signed for
the use of permanent keys. Program keys are maintained in master control on a board with the
corresponding tracking number. The program has a daily key log to track keys. Keys are bound
on a tamper resistant ring which includes a brass-colored tag with the number of keys and a
tracking number. The log indicates the name of staff and what type of key they are to be
assigned according to their position. The program maintains a master inventory list of program
keys. A random check of five different sets of program keys compared to the inventory list
indicated the keys were accounted for and the master control staff knew which area each key
was assigned to. Active keys are assigned to direct care staff while restricted keys are
designated for medical staff, kitchen staff, case managers, and therapists. Medical staff, kitchen
staff, case managers, and therapists receive their respective restricted keys from master control
after their personal keys are collected. An informal interview with the master control staff
indicated the program’s practice is when direct care staff arrive to the program, personal keys
are collected by master control and placed on a board in master control. Both the master control
operator and the staff receiving a program key initial the key log before keys are issued and
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again at the end of the shift when the keys are returned. An informal interview with the AFA and
maintenance manager confirmed the program’s method of daily tracking and reconciliation of
keys. A review of the key logs and logbooks since the last annual compliance review verified
this practice. An informal interview with three staff confirmed each staff knew the number of
keys and each key’s function. A review of the Department’s Central Communications Center
(CCC) reports since the last annual compliance review indicated there were no incidents related
to key control. Five staff were interviewed and were able to explain the program’s key control
process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures addressing safety and security and to control the
introduction of materials considered contraband into the program. Search practices shall be
initiated to assist in prevention, detection, and removal of all items considered contraband or
unauthorized within the program. The program’s youth handbook and policy include a list of
contraband items and informs youth of the consequences if found with contraband. All staff shall
be trained to properly identify contraband items and the steps required for removal of
contraband. Search practices and observations shall be conducted throughout the program and
shall include searches of youth, staff, visitors, property, program grounds, and the program’s
physical plant. Each youth is provided with a written copy of the youth handbook upon
admission into the program and are oriented to the program rules including the list of items
considered to be contraband. The program’s policy and youth handbook included all items
considered contraband as outlined in Florida Administrative Code. The list of contraband items
included sharps, escape paraphernalia, tobacco products, lighters or matches, electronic or
vaporless cigarettes, unauthorized food or clothing, any intoxicating beverages, any controlled
substance, any prescription or non-prescription drug, any firearm or weapon, any explosive
substance, non-program issued keys, unauthorized currency, non-program issued cellular
telephones and/or equipment or electronic devices capable of taking pictures or video
recordings, and smart watches. In addition, the program’s policy and youth handbook include
consequences if found with contraband, search procedures of the physical plant, searching the
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program grounds, youth searches, and searches of incoming and outgoing mail. The program’s
policy specifies the manner in which any unauthorized or contraband item is to be disposed of,
to include return to the sender, mailed to the youth’s home, returned to the youth upon release,
or, in the case of illegal contraband, turned over to law enforcement. Unannounced room
searches are conducted at least weekly at irregular and unpredictable times and common area
searches are conducted daily. During the program tour, several randomly selected rooms were
checked, and no contraband was observed. A review of shift reports, the master control
logbook, visitation forms, and common area search forms validated the program’s practice of
monitoring areas of the program, grounds, and youth rooms for contraband. The program’s
policy requires case managers to inspect all outgoing and incoming correspondence in the
presence of the youth for unauthorized items, contraband, or information which may breach the
security of the program. A review of the visitor’s sign-in log verified it included an attestation
statement regarding contraband. There was a total of thirty-one new staff hired during the
annual compliance review period. A review of thirty-one staff records found each included a
signed contraband attestation form. The program documents the confiscation and disposal of
contraband. Reviewed documentation included the procedures for searching incoming and
outgoing mail. The policy indicates all illegal contraband will be surrendered to law enforcement,
and unlawful activity will be reported to law enforcement. A review of the Department’s Central
Communications Center (CCC) reports since the last annual compliance review indicated there
were no instances of contraband found at the program applicable to be turned over to law
enforcement. The interviewed facility administrator (FA) reported the program adheres to the
Florida Statute and policy and procedures of the program, which addresses contraband and
how illegal contraband is handled and disposed of. Search practices shall be initiated according
to the Department’s Right Interactions (RI) training curriculum to assist in prevention, detection,
and removal of all items considered contraband or unauthorized within the program. Program
staff, including school staff, subcontracted staff, visitors, and volunteers are prohibited from
introducing any item into the secure area without authorization from the FA or designee. The
introduction, removal, or possession of certain unlawful articles and the associated penalties are
outlined in Florida Statutes. Five staff were interviewed, and each stated room searches are
conducted at a minimum of at least once a week, during youth shower time.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures to ensure searches and full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-campus activities, and visitation. Parent(s)/guardian(s) are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched before entering and prior to leaving the classroom, after outdoor
recreation activities, after work detail, and upon all movement. Youth who are a new admission,
re-admission, returning from visitation, returning from off-campus activities and/or appointments,
suspected of contraband, or are a security risk are full body searched. Observations made
throughout the annual compliance review week validated youth are provided instructions
regarding the search, youth searches were conducted by staff of the same gender as the youth,
were conducted in a manner so as not to degrade the youth and were based on the Right
Interactions (RI) training manuals. Observations during the annual compliance review week
verified youth were searched after every movement, after using Class B tools or after
participating in any other activities or projects. During the annual compliance review week an
observation of a youth transport was conducted, and observations confirmed the vehicle, and
the youth were thoroughly searched, and the youth was secured for transportation. The program
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did not have any new admissions, visitations, and there were no youth returning from off-
campus activities; therefore, searches for those activities were not able to observed. In-person
observations and a video footage review of five staff and/or visitors confirmed searches were
conducted as required. Logbook documentation and video review verified youth were being
thoroughly searched before and after each movement. Five staff were interviewed, and each
stated youth are searched randomly and after every movement. Five youth were interviewed,
and all indicated searches occur after outdoor activities, when items are missing, after meals,
and after visitation.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a written policy and procedures to ensure all program vehicles used for the
transportation of youth are properly maintained and documentation of use and vehicle services
are maintained. Transporting staff shall have a cellular telephone for use in the case of an
emergency during the transport. Mechanical restraints shall be used in the secure transportation
of youth, and all mechanical restraint equipment will be double locked. Youth shall never be
restrained to stationary objects. Each vehicle being used for transportation of youth shall pass
an annual safety inspection. The program has a total of three vehicles. Two are used to
transport youth and one is for program use. Each of the three vehicles used at the program, had
an annual safety inspection conducted by a certified automobile mechanic. Observations of
each of the vehicles confirmed each vehicle was locked when not in use. An observation of the
two vehicles used to transport youth, showed they had the appropriate number of seatbelts, a
seatbelt cutter, a window punch, an up-to-date fire extinguisher, and a first-aid kit with items
approved by the designated health authority (DHA). Documentation indicated weekly visual
vehicle inspection checks were conducted on all vehicles as required and documented on the
preventative maintenance check sheets. Each of the observed vehicles used to transport youth
had passenger doors which could not be opened from the inside and had a safety screen
separating the front seat from the rear passenger’s compartment. A random check of seven
staff personal vehicles and the three program vehicles was conducted during the annual
compliance review week, which found all of the vehicles were locked and secured when not in
use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures to ensure an appropriate minimum staff-to-
youth ratio is maintained while youth are transported off program grounds ensuring the safety
and security of youth, staff, and the public. All transporting staff shall have a valid Florida
Driver’s License and an acceptable driving record. Any staff whose driving record is deemed
unacceptable shall not be permitted to operate a program vehicle for the purpose of transporting
youth. Human resource staff shall obtain monthly driving record information from the
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Department of Motor Highway Safety and Motor Vehicles (DMHSMV) for all staff. The program’s
policy states youth are not permitted to drive program or staff vehicles. The program uses a
minimum staffing ratio of one staff for every five youth; however, at least two staff shall
accompany youth on all transports with one staff present of the same gender as the youth. The
program provides transportation for secure maximum-risk youth determined to be at greater
risk. During the annual compliance review week an observation for a transport was conducted,
and observations confirmed the program’s practice. Five staff were interviewed, and each stated
prior to conducting a transport the youth and vehicles are searched for contraband and youth
are secured in the vehicle with hand and leg cuffs, and by wearing a seatbelt. All five
interviewed staff stated they use the program’s cellular telephone during transports. Each of the
five interviewed staff confirmed the safety equipment in the transport vehicles included a first-aid
kit, suicide response kit, seatbelt cutter, and fire extinguisher. All five staff confirmed they are
not allowed to use personal vehicles to transport youth. All five interviewed staff stated the
transport vehicles are searched for contraband prior to and after each use. All five interviewed
staff indicated in case of an emergency, they would call 9-1-1, and/or contact the program. Each
interviewed staff knew the staff to youth ratio during transport. Each staff confirmed there are
safety screens in the vehicles used to transport youth. Five youth were interviewed, and each
stated they were not secured to any part of the vehicle during transportation. Five interviewed
youth stated they never witnessed anyone placing contraband in a transport vehicle. An
interview with the facility administrator (FA) confirmed all vehicles used for transporting youth
have a safety screen.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a written policy and procedures to ensure safety and security is maintained.
The policy addressed who is responsible for conducting the audits, procedures to implement
corrective actions for deficiencies, and an internal system to verify deficiencies are corrected.
Weekly safety and security audits are conducted by the facility administrator (FA) or designee
and documented on the Weekly Safety and Security Audit Inspection form. Any deficiencies are
addressed on the form, and a work order is submitted to the appropriate staff for corrections. In
addition, deficiencies are discussed during the morning management meetings. A review of the
Weekly Safety and Security Audit Inspection forms since the last annual compliance review
indicated inspections were completed as required. Supervisors conduct perimeter checks on
each shift and checks are documented in the program’s logbook. A review of the program’s
logbooks verified this practice. A review of deficiencies entered in the Juvenile Justice
Information System (JJIS) verified there were no deficiencies assigned regarding the safety and
security audits during the annual compliance review period. The program's Preventative
Maintenance Checklist was reviewed, and maintenance schedules and repairs were conducted
as needed. An interview with the FA indicated Weekly Safety and Security Audit Inspection
forms are submitted to the Department each week and they identify any security issues or
deficiencies.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a written policy and procedures for a tool management system which ensures
youth do not use tools or equipment as weapons or for security breaches. The policy addresses
the issuance, inventory, and control of equipment and tools. The policy states prohibited tools at
the program include machetes, bowie knives, and other long bladed knives. A review of
inventory logs and observations verified tools are securely stored when not in use, easily
marked for identification, inventoried prior to, and following work activities. All sharp edged and
pointed tools are inventoried daily when in use. The maintenance staff are responsible for
conducting the inventories and securely maintaining all Class A tools and equipment. The
maintenance staff complete a tool inventory list which documents each tool in inventory. All
maintenance tools were inaccessible to youth and were observed to be secured in the
maintenance building. Observations of the tool storage area found it was organized and secure.
Class B tools including mops, brooms, and buckets are maintained in a locked closet in the
hallway between the east and west wings which are inaccessible to the youth. The items are
used by staff and youth when performing daily cleanup activities. Staff are required to complete
a sign-out and sign-in log when items are taken and are returned to the designated storage
room. Kitchen staff are responsible for securing, maintaining an inventory log and sign-out/sign-
in log for kitchen utensils and sharps. A random review of ten unique kitchen utensils, sharps,
and unique tools in the maintenance building verified the tool inventory and the logs were
accurate, with the exception of the tape measure which had the same identification number as a
drop light. Maintenance staff corrected the identification number of the tape measure and
updated the inventory log during the annual compliance review week. Reviewed documentation
and the Department’s Central Communications Center (CCC) reports verified there were no
instances of missing or lost tools since the last annual compliance review. If a tool is broken or
inoperable, the physical plant manager is responsible for replacing the broken tool. If a tool is
missing staff will notify administration, fill out an incident report, document the incident in the
logbook, call the CCC, and the program will be searched until the tool is found. The program
has a vocational woodshop program on-site which is operated by the Home Builder’s Institute
(HBI) in which Class A tools are utilized by the youth. Observation of tools in the vocational
building indicated tools are maintained under lock and key with access only to HBI staff.
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 written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures include
supervision requirements when youth are using tools, the issuing of tools to youth and staff, a
youth assessment to determine the youth’s risk, and established ratios which include one staff
to five youth during work detail or vocational training. A review of the program’s procedures
verified staff are required to complete a sign-out and sign-in log when Class B tools are taken
and are returned to the designated storage room. A Youth Risk Assessment is completed by the
case manager for youth to use Class A and Class B tools. In addition, the Home Builder’s
Institute (HBI) program completes a risk assessment prior to youth participating in the program.
Five youth case management records were reviewed, and each youth had a Youth Risk
Assessment completed by the case manager prior to youth using tools. Five youth case
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management records included documentation each youth was trained on the intended and safe
use of Class B tools. An observation of four youth working kitchen details and two youth
conducting cleanup duties verified the youth were properly supervised and followed safety
protocols. Five youth were interviewed, and each stated they use mops, brooms, and scrub
brushes. In addition, four youth participating in the HBI program stated they use saws,
hammers, and screwdrivers. Five staff were interviewed, and each indicated youth are allowed
to use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
sign the Outside Contractor On-Site Work Project Log which lists unauthorized items. The
program’s policy states personal cellular telephones, electronic devices capable of taking
pictures and/or audio/video recording, including smart watches are prohibited in the secure
area. The physical plant manager or designee inspects all tools upon the arrival of outside
contractors and is responsible for providing approval if such tools are required. The program’s
guidelines for external workers include checking of tools upon arrival and departure, searching
of all vendors prior to entering the program, tool restriction while in the program, missing tool
follow-up, and restriction of youth from the work area. The outside contractor completes the
program’s Outside Contractor form upon entrance to the program, where they document which
tools are needed to complete the work order. Maintenance staff will review the form and sign
once the tools are inventoried and approved. Upon exiting the program, the Outside Contractor
form is reviewed, all tools are verified, then the form is signed. Any tools required to be used
within the program are inventoried and recorded on the contractor’s agreement form before and
after the repair is completed. Reviewed documentation for three project invoices showed the
vendors signed contractor agreements. Documentation for the Outside Contractor forms verified
the forms were completed and all requirements were met. A review of the work project logs
since the last annual compliance review verified the contractors signed the log confirming
notification of what items are considered unauthorized. If any unauthorized items are needed by
the contractor while in the program, approval is obtained by the facility administrator (FA) or
designee. An observation of outside contractors installing a new water heater system was
conducted during the annual compliance review week. There were no youth in the work area,
and a program staff was with the contractors during the work project.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes and the frequency of conducting drills at random times, and under varied
conditions. The informally interviewed facility administrator (FA) stated the program had two
shifts from 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. during the annual compliance
review period. Reviewed documentation validated fire, escape, and COOP drills were
conducted for all shifts each month, as required. Reviewed drill documentation included the type
of drill, date and time, participants, a brief scenario description, deficiencies identified during the
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drill, and applicable corrective actions. Observations and an informal interview with the FA
verified there were thirty annually inspected fire extinguishers and egress plans were posted
throughout the program. Five interviewed staff all reported they had participated in COOP drills,
fire drills, mental health, and medical drills. Five youth were interviewed, and each indicated
drills are conducted at least monthly and they have been instructed on what to do in the case of
an emergency. An interview with the FA indicated the program facilitates emergency/COOP,
medical, mental health, fire, and Right Interactions (RI) drills. Drills are conducted according to
the program’s drill calendar.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a Department approved Continuity of Operations Plan (COOP) available for all
staff to review. The COOP was reviewed and submitted to the Department on January 22, 2025.
The Department approved the COOP on February 3, 2025. The COOP provides for basic care
and custody of youth in the event of an emergency or disaster. The COOP addresses phases of
a disaster plan as well as emergency management including preparedness, response, and
recovery. The COOP addresses emergencies including fire prevention, severe weather, riots,
bomb threats, hostage situations, chemical spills, flooding, and terrorist threats. In addition, the
COOP includes staff roles and responsibilities, equipment and supplies needed, youth
information, provisions for continuity of care and custody of youth, and provisions for public
protection. The COOP is readily available to all staff and is located in the administration
conference room, the facility administrator’s (FA) office, and in master control. A review of the
plan indicated alternative housing has been identified should the program require evacuation
due to an emergency or disaster. The program has provisions of equipment and supplies
maintained in the kitchen and master control to ensure a continuous operation of services
during emergency or disaster situations. In addition, the program has a generator to provide
continuous power. The program maintains identifying information on each youth in the program
in the event the program has to evacuate, and the youth record accompanies the youth to the
temporary location. A review of five youth case management records indicated each had the
youth’s name, Department identification number, admission date, gender, race, contact
information, emergency contact, assigned juvenile probation officer (JPO), committing judge,
victim information, physical description, health status, and a photograph. The interviewed FA
reported staff have full access to the COOP. The COOP is located in the administrative
conference room and in the program’s administrator's office.
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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 for the storage and inventory of flammable,
poisonous, and toxic materials. Toxic items are stored outside the program in locked cabinets
within a locked chain link fence. A list of staff which includes the facility administrator (FA),
assistant facility administrators (AFA), unit managers, medical staff, shift supervisors, and food
service staff are authorized to use chemicals maintained in the storage cabinet. All caustic
materials are stored according to type and use. A Safety Data Sheet (SDS) binder is located
inside the storage area with a picture of each material and a number corresponding to the SDS
for each chemical. A perpetual chemical inventory list is maintained, and the chemicals are
checked daily. A review of the inventory list verified this practice. The program has a Chemical
Daily Usage Log used to track all toxic items when in use by authorized staff. Observation of the
storage area indicated it was clearly marked for hazardous chemicals and securely locked.
Items were stored on metal shelving and numbered according to the SDS. Flammable items are
stored in a metal cabinet clearly marked as flammable items. Some of the metal chemical
storage lockers were heavily rusted. Chemicals used to clean the program are stored in locked
closets located in the main hallway of the program and in a secured closet in the kitchen. An
inventory sheet is maintained and documents the daily use. A review of the storage closet
verified the number and type of chemicals were maintained on the inventory list. A random
sample of ten chemicals verified the actual count matched the inventory logs, with one
exception. The inventory log stated there were four bottles of bleach in the kitchen storage area;
however, the actual count was five bottles of bleach. The inventory was corrected during the
annual compliance review week. All of the chemicals were secured, and the SDSs were present
for the items reviewed. In addition, the program maintains a written policy and procedures to
ensure all flammable, toxic, caustic, and poisonous items are disposed appropriately. The FA or
designee and maintenance staff are responsible for the control and accountability of all caustic,
toxic, poisonous, flammable, hazardous fluids, substances, or chemicals used in the program.
All unused hazardous materials are kept in the secured storage area located outside the
program and are disposed of according to the SDSs. In an informal interview the physical plant
manager stated the program makes every effort to use up all chemicals. Any unused chemicals
are taken to a local bio-hazardous waste contractor. The physical plant manager stated there
were no chemicals disposed of during the annual compliance review period. Used kitchen
grease and waste is stored in a large container outside the kitchen area and is disposed of by a
local vendor. All liquid waste from work details is disposed of by pouring the liquid down
plumbing drains. The program’s policy states all chemical spills are reported to master control
and the shift supervisor immediately. An evacuation of the affected area is conducted and
determination by the FA is made as to whether to contact outside assistance to contain the spill.
Staff and youth are not allowed to return to the affected area until it has been deemed safe by a
qualified professional. The interviewed FA stated hazardous items and toxic substances, or
chemicals are disposed of in accordance with Occupational Safety and Health Administration
standards.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items, or materials. Youth are not to clean, handle, or dispose of any
toxic, bio-hazardous materials, bodily fluids, or human waste. Youth are strictly prohibited from
the maintenance area where toxic items and chemicals are stored. An observation of two youth
conducting cleanup detail and four youth in the kitchen detail cooking and washing pots and
pans was conducted during the annual compliance review. None of the observed youth were
handling chemicals or cleaning products. Observations of completed projects at the Home
Builder’s Institute (HBI) verified youth used paint after receiving a risk assessment. Five youth
were interviewed, and each youth stated they have used bleach, four stated they have used
toilet cleaner, four stated they have used paint, and three stated they have used floor wax.
Youth stated when using cleaning chemicals staff spray the cleaning agent and are supervised
by staff. Youth participating in HBI have an assessment completed prior to handling chemicals.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 67 (Revised August 2025)
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to allow youth to have visitation and communication
with family members while in the program. The program assists youth and families in
maintaining connections in a visitation environment which provides monitoring, control of
movement, and security practices to ensure visitor, youth, staff, and program safety. The
program’s policy provides each youth opportunities to promote communication and engagement
which fosters family reunification and community connections. The program maintains a list of
approved visitors; however, attorneys, representatives of the court, juvenile probation officers
(JPO), other agency representatives, and clergy are authorized to visit at any time. Searches of
visitors will be conducted upon entry and all youth are to be searched following visitation
sessions. The program’s visitation policy indicated considerations for requests of alternative
visitation arrangements with parents/guardians were made, if needed. Youth are informed about
visitation upon their admission to the program during the orientation process. The visitation and
communication procedures are covered in the youth handbook, parent/guardian handbook, and
addressed on the orientation checklist. Visitation is held in the administration area on Saturdays
from 10:00 a.m. to 12:00 p.m. and 1:00 p.m. to 2:00 p.m., and on Sundays from 1:00 p.m. to
3:00 p.m. Youth are given opportunities to communicate with their family in person, by
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 67 (Revised August 2025)
telephone, and by mail. Each youth is provided an opportunity to correspond on a regular basis
with identified individuals specified on their Approved Correspondence List and legal
representatives. Youth are permitted weekly telephone calls. The youth’s use of telephone calls
is documented in each youth’s case management chronological documentation. A review of the
telephone chronological notes verified youth have consistent telephone communication with
family members. Youth can write to the parents/guardians at least once each week and are
encouraged to correspond with their assigned JPO and committing judge. All outgoing and
incoming mail is searched by the case manager. A review of the logbooks, visitation sign-in
logs, and outgoing and incoming mail logs verified the program allows visitation and mail only
for approved immediate family members to include parents, stepparents, legal guardians,
siblings, grandparents, and spouses. The JPO must approve the immediate family members. It
is the program’s practice for the assigned case manager to follow-up with the JPO regarding
human trafficking victims to determine whether the parent/guardian should be permitted to
communicate with the youth; however, there were no youth applicable for a history of human
trafficking during the annual compliance review period. Five youth were interviewed, and each
confirmed they can call and/or send letters to their parent(s)/guardian(s). The interviewed facility
administrator (FA) stated for youth whom English is not their primary language the program
uses interpreter services and a language assistance program.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the program’s contract verified there were two
recreation therapist positions slated for the program. A review of the staff roster confirmed the
program has one recreation therapist, who met all requirements for the position. Reviewed
documentation of five youth records verified recreational therapy is part of the youth’s
Individualized Performance Plan. The program’s recreation calendar designates an activity for
the youth to participate in outdoor recreation each day, as well as a calendar of alternative
activities if recreation is indoors. The program’s activity schedule is posted throughout the living
units and common areas of the program. All activities promote social and cognitive skill
development, creativity, teamwork, healthy competition, mental stimulation, and physical fitness.
Youth are provided with at least one hour of large muscle activity daily. Reviewed
documentation of the logbook and daily activity schedule confirmed the program has a range of
supervised and structured indoor and outdoor recreation and leisure activities for the youth, for
at least one hour daily. Observations made throughout the annual compliance review week
validated youth are provided with at least one hour of indoor or outdoor recreation and leisure
time. Five staff were interviewed regarding the type of recreation activities the program provided
and how long the activities lasted. Staff indicated the program provides youth with at least one
hour each day. Each staff indicated the outdoor activities consist of basketball, and football. The
indoor activities consist of board games, card games, watching television, and playing video
games. Five youth were interviewed, and each youth stated they are provided at least one hour
of physical activity which includes playing basketball, football, board games, and dodge ball.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 67 (Revised August 2025)
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 to ensure staff search and inspect controlled
observation rooms prior to placing a youth in controlled observation. Youth shall never be left
alone in a controlled observation room until an inspection of the room is conducted, it is deemed
safe and secure, and in compliance with the room specifications. The program has a designated
area to house youth who have been placed in controlled observation. Observations of the rooms
indicated the program met the measurements and construction required by Florida
Administrative Code. The Controlled Observation Report was reviewed, and the program did not
have any controlled observation placements since the last annual compliance review. In an
informal interview, the facility administrator (FA) confirmed the program did not have any
controlled observation placements since the last 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 regarding controlled observation, which may
be used as an immediate short-term crisis management strategy when a youth’s aggressive,
violent, or potentially dangerous behavior substantially threatens the physical safety of others,
compromises program security, and when non-physical interventions would not be effective.
Youth demonstrating acute psychological distress shall not be placed in controlled observation.
The facility administrator (FA) shall ensure all use of controlled observation is implemented only
as authorized and in accordance with policy. The program’s policy, procedures, and practice
confirm the program utilizes controlled observation. The program did not have any controlled
observation placements since the last annual compliance review; therefore, there were no
instances of controlled observations available for 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 to ensure safety checks and release
procedures, for youth in controlled observation are conducted. The policy states safety checks
of youth will be completed every fifteen minutes to ensure the youth’s safety and observations of
the youth’s behavior shall be documented, including the time, code, explanation of behavior,
and staff initials on the Controlled Observation Safety Checks form. Continuous sight and sound
supervision of youth will be maintained as a provision of continuous, uninterrupted visual and
sound monitoring of the youth when demonstrating physical behaviors, posing a high risk of
self-injury, and documentation of all safety checks will be documented on the Controlled
Observation Safety Checks form. Medical staff will be notified of any illness or reported injury.
Youth shall not be denied meals or dietary needs when in controlled observation. Once the
youth is determined to be appropriate for release from controlled observation, the facility
administrator (FA) or designated supervisor gives approval for the youth’s release. The release
is documented on the Controlled Observation Report. The program’s policy, procedures, and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 67 (Revised August 2025)
practice confirm the program utilizes controlled observation safety checks and release
procedures. The program did not have any controlled observation placements since the last
annual compliance review; therefore, there were no instances of controlled observations
available for review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 67 (Revised August 2025)

source: DJJ

program_name_raw: Everglades Youth Academy - SOP