summary: QI Residential - FY25-26 - 15 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Alachua Academy
Wayne Halfway House
(Contract Provider)
3430 NE 39th Avenue
Gainesville, Florida 32609
Review Date(s): September 9-12, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Lori Bright, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, North Central Education Coordinator (Standard 2)
Barbara Broomfield, Rite of Passage, Program Director (Standard 2)
Jamie Franz, Office of Postsecondary and Workforce Education, Deputy Director (Standard 2 )
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Forrest Hallam, Office of Accountability and Program Support, Regional Monitor (Interviews)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 1
and 2)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Alachua Academy MQI Program Code: 9394
Provider Name: Wayne Halfway House Contract Number: 10189
Location: Alachua County / Circuit 8 Number of Beds: 28
Review Date(s): September 9-12, 2025 Lead Reviewer Code: 230
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 69 (Revised August 2025)
T h is
O v e ra ll R a tin g S u m m a ry
p ro g ra m h a s re c e iv e d a n o v e ra ll p ro g ra m c o m p lia n c e ra tin g o f F a ile d , a fo llo w -u p re v ie w o f th e p ro g ra m s h a ll b e c o n d u c te d w ith in s ix (6 ) m o n th s o
th e p ro g ra m re p o rt.
T h e fo llo w in g lim ite d a n d /o r fa ile d in d ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n .
Lim ited R atings Failed R atings
1.14 A dvisory B oard 3.05 M ental H ealth and S ubstance A buse A ssessm ent/E valuation
2.07 R esidential A ssessm ent for Y outh (R A Y ) A ssessm ents and R eassessm ents 3.06 M ental H ealth and S ubstance A buse Treatm ent *
2.08 Y outh N eeds A ssessm ent S um m ary (Y N A S ) 3.18 S afety P lanning P rocess for Y outh
2.09 P erform ance P lan D evelopm ent, G oals, and Transm ittal *
2.11 P erform ance S um m aries and Transm ittals
2.19 C ontract S pecific C areer and Technical E ducation S ervices (R esidential C ontract P rovider)
3.04 M ental H ealth and S ubstance A buse A dm ission S creening
3.07 Treatm ent and D ischarge P lanning *
3.08 S pecialized Treatm ent S ervices*
3.10 S uicide P revention S ervices *
3.12 S uicide P recaution O bservation Logs *
5.07 K ey C ontrol *
5.17 D isaster and C ontinuity of O perations P lanning (C O O P )
f p u b lic a tio n o f
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 69 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 69 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
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p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Limited
3.05 Mental Health and Substance Abuse Assessment/Evaluation Failed
3.06 Mental Health and Substance Abuse Treatment * Failed
3.07 Treatment and Discharge Planning * Limited
3.08 Specialized Treatment Services* Limited
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Limited
3.11 Secure Observation * Non-Applicable
3.12 Suicide Precaution Observation Logs * Limited
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Failed
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Overall Rating Summary for Standard 3
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be
conducted within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 69 (Revised August 2025)
Standard 4: Health Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 69 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * 4 .0 1
L ic e n s e d M e d ic a l S ta ff * 4 .0 2
F a c ility O p e ra tin g P ro c e d u re s 4 .0 3
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t 4 .0 4
P a re n ta l N o tific a tio n /C o n s e n t 4 .0 5
H e a lth c a re A d m is s io n & R e s c re e n in g F o rm 4 .0 6
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n 4 .0 7
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e A d m is s io n N o tific a tio n 4 .0 8
H e a lth -R e la te d H is to ry 4 .0 9
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g 4 .1 0
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g 4 .1 1
S ic k C a ll P ro c e s s 4 .1 2
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re 4 .1 3
O ff-S ite C a re /R e fe rra ls 4 .1 4
C h ro n ic Illn e s s /P e rio d ic E v a lu a tio n s 4 .1 5
M e d ic a tio n M a n a g e m e n t 4 .1 6
P s y c h ia tric S e rv ic e s * 4 .1 7
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s 4 .1 8
In fe c tio n C o n tro l/E x p o s u re C o n tro l 4 .1 9
P re n a ta l C a re /E d u c a tio n 4 .2 0
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
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Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control * Limited
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Limited
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 69 (Revised August 2025)
Program Overview
Alachua Academy is a twenty-eight-bed program, for twelve- to eighteen-year-old females,
located in Gainesville, Florida. The program is operated by Wayne Halfway House, through a
contract with the Department. The program provides Substance Abuse Treatment Overlay
Services (SAOS). In addition, the program fosters each youth by providing Impact of Crime,
Living in Balance, Female Health Relationship Bundle, Skill Streaming, Seeking Safety, and
Cannabis Youth Treatment. Additional treatment services provided includes family, individual,
group, and recreational therapy. Program administration is comprised of a facility administrator,
assistant facility administrator, four shift supervisors, human resources, and facility maintenance
manager. Case management services are provided by two case managers, transition service
manager, and a recreation therapist. Mental health staff at the program includes a clinical
director, who is a licensed mental health counselor and serves as the designated mental health
clinician authority, two master’s level, non-licensed therapists, and a contracted psychiatrist.
Medical services are offered from 8:00 a.m. to 6:00 p.m. and are provided by a health services
administrator, a registered nurse, and a designated health authority. Educational services are
provided by the Florida Scholars Academy. The layout of the program includes the main
building comprised of the main gathering area, dormitory, therapist offices, kitchen and dining
area, a multi-purpose room, and the case managers office. Three separate buildings are used
for education and training classes. There is also a utilities and storage building. The program
has fifty-six total cameras, and all were operational. At the time of the annual compliance
review, the program had three vacant positions: two youth care workers and one shift
supervisor.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 69 (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 facility operating procedures (FOPs) for initial background screening. An
Annual Affidavit of Compliance with Level 2 Screening Standards was completed on December
19, 2024, and sent to the Background Screening Unit (BSU) before January 31, 2025. The
FOPs include volunteers, mentors, and interns who work with youth less than ten hours a month
to have sight and sound supervision. The program had twenty-two staff to review for
background screening, and all were completed prior to contact with youth and youth’s records.
The reviewed staff did not have a criminal history. Three of the records had a break in service
and had a new background screening completed. All twenty-two staff received a pre-
employment assessment tool administered with a passing score located in their record. Each
staff was added to the program’s Clearinghouse roster. Twenty-two reviewed contraband
attestation forms were all signed and dated by the staff.
1.02 Five-Year Rescreening Non-applicable
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.)
There have not been any staff applicable for five-year rescreening’s during the annual
compliance review period; therefore, this indicator is rated as non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 69 (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 facility operating procedures for an abuse free environment and
management’s response to allegations. Seven incidents were reviewed. Four incidents were
called into the Department’s Central Communications Center (CCC), three physical and one
psychological. The other three incidents were called into the abuse hotline and all three were
considered physical. None of the seven incidents had any potential human trafficking victims,
child sexual exploitation, or labor trafficking. Five staff records were reviewed for a signed code
of conduct, and all were signed. The Florida Abuse Hotline and the CCC numbers are posted
throughout the program. The program’s steps to report abuse are to call the Florida Abuse
Hotline immediately upon suspecting or upon an allegation of child abuse and then make a call
to the CCC hotline within two hours of the incident or knowledge of the incident. If the youth is
eighteen years of age or older, staff report directly to the CCC. Youth have unimpeded access
to self-report abuse. All staff are considered mandatory reporters. The program completed a
Trauma Responsive and Caring Environment (TRACE) self-assessment on May 16, 2025.
There were nine incidents related to physical and psychological abuse since the last compliance
review and four of the incidents were substantiated. Documentation confirmed the program took
immediate action to address allegations and the applicable corrective action taken by
management for follow-up on substantiated incidents was completed. The facility administrator’s
interview was reviewed and indicated the safety, proper and improper supervision of youth, and
ethics are included in the program’s code of conduct. Actions taken on staff for substantiated
physical abuse, threats, or profanity may include law enforcement involvement which could
include arrest, program suspension, or termination. Anyone who feels a youth has been abused,
shall immediately report to the abuse hotline and complete an abuse report. Staff have training
on abuse and review youth’s ability to call the abuse hotline during the youth orientation
process. The signed forms are kept in the youth’s records.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 69 (Revised August 2025)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has facility operating procedures for incident reporting. The program had sixty-six
Department Central Communications Center (CCC) calls during the annual compliance review
period, which sixteen more incidents than the previous year. Seven reported CCCs were
reviewed, and each were called in to the CCC within two hours. All seven incidents were
documented in the logbook/shift report and there were no additional internal
incidents/grievances which should have been reported to the CCC and were not. The program
reported an increase in Baker Acts and a population of youth with more complex mental health
acuity as a possible lead to the increase in CCC incidents.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has facility operating procedures for Right Interactions (RI) which is the
Department’s Protective Action Response (PAR) curriculum. During the annual compliance
review period, ninety-six RI incidents were reported. Monthly summaries maintained by the
program of RI incidents were submitted to the Department’s regional office by the fifteenth of
each month. The program’s RI plan was last updated on September 25, 2024. The program’s
PAR rate during the annual compliance review period was 9.66, which is above the statewide
Residential PAR rate of 2.41. Nine incidents were reviewed, and all reports were completed by
the end of the staff’s workday. The incidents include statements from all staff involved. The
program does not use mechanical restraints and of the nine cases, one had a result of youth or
staff injury, which was called into the Department’s Central Communications Center (CCC)
within two hours. None of the nine youth claimed any type of abuse; therefore, the Florida
Abuse Hotline was not called. The RI reports were reviewed by a supervisor and by an RI
instructor. In all nine incidents, a RI medical review was completed within thirty minutes after the
incident and an administrator reviewed the report within seventy-two hours of the incident being
reported. The interviewed facility administrator (FA) stated they ensure reports are called in
within the two-hour window and all incident reports are kept on-site to ensure they are tracked.
Five staff were interviewed, and all were direct care. One staff stated a RI report must be
completed including a for each youth involved, and any staff involved must write what they
observed. One staff stated the RI report must be reviewed by the supervisor and to make sure
the youth see medical staff. One mentioned the FA must be notified, and the report must be
completed by the end of shift. Two of the staff mentioned it is important to try to de-escalate the
situation.
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1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has facility operating procedures (FOPs) relating to pre-service and certification
requirements. The maintenance worker may occasionally supervise youth. All instructors were
qualified to deliver training including Right Interaction (RI), first-aid, and cardiopulmonary
resuscitation (CPR). The program submitted a pre-service training plan which was approved
and signed by the facility administrator (FA), the northeast regional manager, and the director of
Talent, Leadership, and Culture. Five staff were reviewed for pre-service training and all five
had more than 120 hours of training within 180 days. Each staff completed child abuse
recognition, reporting and intervention, CPR, first-aid, automated external defibrillator (AED),
emergency procedures, FOPs, Prison Rape Elimination Act, and suicide awareness and
prevention. All five staff’s training records and the Department’s Learning Management System
(SkillPro) indicated the completion of active shooter awareness, adolescent development and
behavior, balanced approach to rehabilitative justice, Department’s Central Communications
Center Incident reporting, civil rights, communication, Confidentiality/Health Insurance
Portability and Accountability (HIPAA), Department of Juvenile Justice legacy/history, and Equal
Employment Opportunity training. Four of the staff completed gang awareness and one did not.
The five staff completed human trafficking intervention, infection control/bloodborne pathogens,
information security awareness, Juvenile Justice Information Systems, and Mental Health and
Substance Abuse training. Motivational Interviewing was marked non-applicable. Four staff
completed quality report writing, and one staff did not. All five staff’s training records reviewed
showed safety, security, and supervision of youth, sexual harassment, effective and respectful
treatment of youth, and trauma response. Each reviewed record indicated grievance procedure,
Infection Control, Exposure Control Plan, Behavior Management System, and intended and the
safe use of tools. The two applicable staff completed the required Substance Abuse Treatment
Services training. The remaining specialized service training courses were non-applicable for all
staff. All five reviewed staff completed prenatal and neonatal staff education and monitoring,
observation, and emergency room care of pregnant females and their infants. The FA
completed an additional sixteen hours of training in leadership and personal accountability. The
shift supervisor completed an additional sixteen hours in coaching and leadership. Three youth
care workers (YCWs) still within 180 days of hire completed all required training prior to staff
being in the presence of any youth.
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 facility operating procedures for in-service training. Five staff were reviewed
for training and each completed active shooter preparedness, cardiopulmonary resuscitation
(CPR), first-aid/automated external defibrillator (AED), human trafficking intervention, and
information security awareness. Four staff completed Mental Health and Substance Abuse
training, and one did not. All five records indicated Prison Rape Elimination Act (PREA) and
Right Interaction (RI) training were completed. All five staff are PREA certified. All staff
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completed emergency response and emergency drills quarterly. Three staff completed infection
control and bloodborne pathogens and two staff did not; however, all five completed the
exposure control plan. The program does not participate in any water activities; therefore,
lifeguard certification was not applicable. Mental Health Overlay and Substance Abuse Overlay
services were non-applicable for reviewed staff, along with comprehensive service for major
disorders, developmental disabilities treatment services, and intensive mental health treatment
services. All staff completed prenatal and neonatal staff education and monitoring, observation,
and emergency room care of pregnant females and their infants. One staff was a shift
supervisor, who completed eight hours of supervisory training to include leadership training. All
instructors were qualified to deliver the training provided. The program submitted an in-service
training plan/calendar prior to implementation. The plan was signed by the facility administrator,
a designee of the assistant secretary for residential services and the director of Talent,
Leadership, and Culture.
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’s facility operating procedures included the training requirements for the grievance
process. The grievance process includes the informal phase, a formal phase, and an appeal
phase. In the informal stage the youth try to resolve the issue without formal intervention. In the
formal phase, there are grievance forms available to the youth in the great room. The youth can
ask for help and will receive help from staff when needed. The grievance officer or designee
reviews the grievance forms and follows up with the youth once a decision is made. If the youth
does not agree with the outcome of the formal stage, the youth can continue to the appeal
phase where the facility administrator (FA) makes the determination. The program’s practice
does correlate with their process, and the program maintains grievances for the last twelve
months. Five youth were interviewed and four youth stated grievance forms are placed
throughout the program and one youth stated there are timeframes for each phase. Youth also
stated they could fill out a grievance form, and the FA will review and speak to youth about the
grievance. All five youth stated they could get help from staff if needed. Five staff were
interviewed, and all stated the grievance forms are placed throughout the program and one staff
stated the youth can ask for help. Two staff indicated the FA reviews the form with the youth.
The FA and/or the assistant facility administrator review forms and come to a decision if the
grievance procedure ends up in the appeal phase. The FA was interviewed and stated youth
have access to and can complete a grievance at any point. The FA was able to explain the
three phases of the grievance process. Five grievances were reviewed for responding within the
specified timeframes. Four were solved within the informal phase and one was solved in the
appeal process. Three were solved on the same day and the other two were solved within two
days, all within the required timeframes.
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1.09 Interventions and Facilitator Training Satisfactory Compliance
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 has facility operating procedures for interventions and facilitator training. A case
manager completes “50 Gang Stories” group weekly with the youth. The case manager has
been trained on completing these groups with the youth and the program considered the staff’s
education and work experience before implementing the intervention. The program provides the
group once every week when applicable youth are admitted, and groups consist of five to ten
youth for duration of an hour. All non-primary and non-clinical groups are provided as outlined in
the contract. Youth are active at least sixty percent of their waking hours. Six staff have
facilitated groups in the past year according to the facility administrator.
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.
Life skills are taught daily and youth work on how to carry themselves and conversational
techniques. Hygiene and cleaning one's room is completed every day. The youth are taught
how to control their anger and practice non-violent conflict resolution. Documentation reviewed
of consisted of sign-in sheets, pictures, and worksheets. Additional life skills activities address
education, financial acuity, and independent living. The youth interviews indicated life skill
activities included substance abuse groups, attitude, communication, goals, how to say no,
gang violence, cardiopulmonary resuscitation (CPR), recreation, crafts, bible studies, book club,
emotions, coping, gardening, and working in the kitchen.
1.11 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Alachua Academy. For details related specific to IOC service delivery, please
refer to the annual SPEP report.
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1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has facility operating procedures for maintaining the internal alert system making it
easy for staff to see which youth have safety risks, health-related concerns, allergies, and/or
special diets. The program has established a continually updated internal alert system which is
easily accessible to program staff, which keeps them alerted to youth who pose a risk to
security or safety, including escape, suicide, other mental health, medical, sexual offender, and
assaultive or violent behavior risks. All alerts are documented on an internal alert form with
accompanying supportive documentation, including the youth’s alert in the Department’s
Juvenile Justice Information System (JJIS), if applicable, internal incident documentation,
Assessment of Suicide Risk or Crisis Assessment, and/or youth’s classification or re-
classification form. Open internal alerts are posted on the alert board in a prominent location
available to staff, identifying which youth are on specific alerts. Additionally, alerts are updated
on a daily report and distributed electronically to administration, shift supervisors, case
management, mental health, and medical staff. This daily report is utilized to inform direct care
staff at shift briefings, conducted by the shift supervisor before each shift. Youth alerts regarding
diet and food allergies were found posted in the kitchen and shielded from view of other youth.
The program had youth on the alert system specified in the program’s written procedure. The
facility administrator’s (FAs) interview confirmed all youth receive a preliminary screening which
includes medical history to assess medical needs. The on-duty medical staff review the youth’s
previous medical records, conduct a thorough assessment of youth, and complete a Facility
Entry Physical Health Screening form (FEPHS). If a youth’s physical custody changes, a new
health screening form is completed upon return of the youth to the program. The FA stated
alerts are updated as appropriate by medical and mental health staff based on results of the
assessment and nature of the alert. The registered nurses stated they are responsible for the
internal alert system and for verifying the system stays correct. Five staff were interviewed and
confirmed they are informed of youth alerts in several ways, to include a review of the logbook,
posted in the kitchen and in medical, through review of face sheets, master control, and
supervisor’s daily briefings. Five youth records were reviewed for alerts and found eleven alerts
were applicable. Documentation for all eleven alerts were included in the logbooks maintained
in the youth’s living area and matched JJIS and the internal alert system. All alerts were entered
in the required timeframe.
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1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program has facility operating procedures for youth records. The program had youth
records divided into two separate records: the individual health care record and the individual
management record. Each individual management record had the youth’s name, Department
identification number (DJJID), date of birth, county of residence, and committing offense. The
individual management record was divided into five sections to include legal information,
demographics and chronological information, correspondence, case management and
treatment team activities, and miscellaneous. The records were marked confidential, and all
records were locked in a room not accessible to youth or visitors. The program identifies the
filing cabinets holding the records as confidential.
1.14 Advisory Board Limited Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has facility operating procedures for an advisory meeting with stakeholders. The
program had an advisory board meeting on April 16, 2025, and the next scheduled meeting was
in September, making the program out of compliance of having a meeting every ninety to 120
days. No other meeting was completed during the annual compliance review period. A meeting
was not rescheduled within the quarter due to the program focusing on getting Protection Active
Responses and the Department’s Central Community Center’s numbers lower. The advisory
board stakeholders include law enforcement, judiciary, community partners, business
community, Florida Scholar’s Academy, and the faith community. There is a victim advocate
who attends the meetings, and the program is still looking for a parent/guardian whose child
was previously involved in the juvenile justice system. The program has had virtual meetings in
the past. There were agendas and minutes from previous meetings. The interviewed FA
confirmed the community advisory board is held quarterly, but there had not been one since
April of this year. The Sheriff of Alachua County was interviewed concerning the advisory board
and indicated they are not always able to participate; however, they will send a representative if
they cannot be there. It was also stated agendas and minutes are emailed to all who participate
on the advisory board.
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 facility operating procedure for evaluating staff based on performance
standards, quarterly and annually. Three staff’s position descriptions were reviewed, and the
performance standards were clearly identified. Three staff’s annual performance evaluations
were reviewed and were completed timely. The performance standards matched the job
descriptions. Six position descriptions were reviewed, and each had a job function for knowing
the Behavioral Management System (BMS). The contract was reviewed to ensure all specific
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contractually required positions were maintained and performed. The program contract requires
a recreational therapist which they had on staff and had the correct credentials. Reviewed
schedule and services confirmed all requirements were being met. The facility administrator
confirmed they minimize staff turnover and keep staff morale up by having staff raffles, annual
evaluation bonuses, and staff appreciation. The program has had to replace a clinical director
twice during this evaluation period and have replaced several youth care workers and
supervisors. Two therapists have been replaced, and all medical staff were replaced along with
a new human resource representative. Weekly human resources and facility meetings along
with monthly meetings are conducted to oversee staffing issues. Five staff were interviewed and
asked how often they have performance evaluations. Two staff stated they have evaluations
annually. One staff stated they were unsure, and one staff stated every two months. The final
staff stated they have not had an evaluation in a long time.
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 has special contract conditions which were negotiated in the contract. The
program provides all youth with substance abuse issues to participate in Alcoholics Anonymous
or Narcotics Anonymous. The program provides guest speakers for education topics for all
youth. The program has provided the youth with a diverse media center. The program provides
regular faith-based opportunities to all youth. Youth can earn points to participate in community
service projects, which can go towards their community service hours upon returning home. The
program will arrange for the youth’s transportation home upon release or will meet the juvenile
probation officer halfway if a parent cannot pick the youth up when the youth has been released.
The program knows they can reach out to faith networks for assistance as well but has not
needed to. The facility administrator confirmed all contract negotiated items are offered at the
program and provided consistently, including mental health treatment, substance abuse
treatment, educational services, vocational services, and career and technical education
services.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program’s practice for data trend analysis involves a quarterly quality improvement process
across all provider programs. The quality improvement committee reviews key program
functions to include youth case management records, incident reporting by category, use of
physical restraints, satisfactions surveys from youth, staff and professional staff, ongoing
maintenance projects program strengths, and areas of positive practice across all programs.
The process is utilized to identify trends, reallocate resources, and ready programs for the
Department of Juvenile Justice, Bureau of Quality Improvement annual compliance reviews.
The information is shared quarterly with stakeholders and staff across all programs. Program
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and corporate leadership meetings include monthly quality assurance review processes which
incorporate reviews of facility data, surveys, and findings of formal monitoring and verification
activities. Within each meeting, progress to date, program strengths, improvement needs, and
corrective actions are discussed. Recommendations are made by the team with on-going
review, follow-up, and technical assistance provided as required. Meeting invites and agendas
for quarterly meetings were reviewed as well as program-level meeting minutes to support the
ongoing process.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
Five youth case management records were reviewed for initial contacts with the parent/guardian
and court notification. Four of the case management records indicated parent/guardians were
notified by telephone within twenty-four hours during the youth’s admission and one record did not
document a contact with parent/guardian. In all five case management records reviewed the
parents/guardians were notified by writing within forty-eight hours of admission, as required. Four
of the five case management records indicated the committing court, assigned juvenile probation
officer (JPO), and post-residential case manager, if applicable, were notified by writing within five
working days of admission, and one record did not document notification in writing of all required
parties.
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 utilizes an orientation checklist to explain and discuss program rules, expectations,
goals of the program, and services applicable to the youth. Each of the five records had
documentation the youth received an orientation, and the orientation checklist was signed by
each youth on the day of admission. Orientation included all required elements as outlined in
Administrative Rule. A youth orientation was unable to be observed, as there were no youth
admitted to the program during the annual compliance review. Five youth were interviewed, and
each reported receiving an orientation to the program within twenty-four hours, including all the
required elements.
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.
Five youth case management records were reviewed for written consent of youth eighteen
years or older. None of the five records reviewed were applicable for being eighteen years of
age or older. The program had two other youth who were eighteen years of age or older during
the annual compliance review period; therefore, the program provided the two additional records
for review. The two applicable records contained documentation written consent was obtained
by the youth prior to discussing any information related to each youth’s physical or mental
health screenings, assessments, or treatments with the parent/guardian.
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2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has facility operating procedures for a classification system promoting safety and
security when assigning youth to a living unit, sleeping room, and youth group or staff advisor on
the day of admission, as well as reassessments for activities. The program reviews classification
factors to include physical characteristics of the youth, the youth’s 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, and any
history of potential or verified human trafficking, level of risk to include suicide, medical, escape,
and security, and any other suspected risk factors. These factors are documented on a
classification form, and a copy is placed in the youth’s case management record. Five youth
case management records were reviewed. Each of the five reviewed youth records contained
documentation indicating the youth were initially classified on the date of admission based on
the classification criteria and factors identified on the classification forms. Each of the five
records contained documentation indicating each youth was classified for the purposes of
assignment to a living area, sleeping room, youth group, staff advisor, and medical, mental
health, substance abuse, security risk factors, and/or special needs. All five youth had any
medical, mental health, security risk factors, and/or special needs alerts entered into the
program’s internal alert system and Department’s Juvenile Justice Information System (JJIS).
Reclassifications were completed for participation in work projects in four applicable case
management records. None of the reviewed youth were applicable for a reassessment based on
an increase in the youth’s privileges or freedom of movement or participation in off-campus
activities. The program’s policy dictates reclassification occurs on a continual basis and easily
accessible by all staff keeping them alert of all youth safety and security risks. An interview with
the facility administrator (FA) confirmed the case manager is responsible for assigning a youth’s
room although this may be done by an administrator at times. A pre-admission staffing is held,
the case manager reviews the youth’s records at the time of entry and each youth is screened
for vulnerability. Important factors are considered such as physical characteristics, age and
maturity, identification of special needs, gang affiliation, current offenses, criminal behavior,
history of violence, medical and mental health issues, co-offenders, suicidal ideations, sexual
aggression, education, predator behavior, separation, delinquent history, escape and risk to
public, deoxyribonucleic acid (DNA) testing, and history or potential human trafficking. The
process is documented on the program’s classification form.
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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 facility operating procedure regarding youth identified as being affiliated with
gangs to include adding an alert to the internal alert system as well as the Department’s
Juvenile Justice Information System (JJIS), documenting the affiliation on the classification
worksheet, and sharing the gang information with law enforcement and the youth’s juvenile
probation officer (JPO). Five youth case management records were reviewed, and none were
applicable for gang identification and notification requirements. At the time of the annual
compliance review the program did not have any youth applicable within the scope of the
review; therefore, the program was unable to provide additional records for review.
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.
Five youth case management records were reviewed for gang identification, prevention and
intervention strategies. Identification of youth to participate in gang prevention or intervention
activities is based on information obtained through the program’s screening, assessment, and
classification processes, as well as gang-associated behaviors exhibited or the youth’s
expressed interest or intent while in the program. Five youth case management records were
reviewed and found none were applicable for gang identification and notification requirements.
At the time of the annual compliance review the program did not have any youth applicable
within the scope of the review; therefore, the program was unable to provide additional records
for review. Gang intervention strategies are implemented when youth are identified as being a
criminal street gang member, are affiliated with any criminal street gang, or are at high risk of
gang involvement. Services are determined by each youth's individualized treatment team and
input from the gang coordinator. Gang prevention/awareness efforts provided to youth at the
program include the Impact of Crime (IOC) curriculum and an ARISE curriculum entitled Gangs:
50+ Stories of Fractured Lives Workbook. The program’s facility operating procedures (FOPs)
also address providing youth an opportunity, if they desire, to develop a plan to disaffiliate with a
criminal street gang. An interview with facility administrator confirmed program FOPs ensure
youth have an opportunity to develop a plan to disaffiliate with a criminal street gang. Each
youth’s performance plan includes relevant goals relating to gang intervention strategies. All
staff are required to have at least one yearly training on gang awareness. This training includes
identification, signs, and symbols, trends, and possible gang activity in the program.
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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 facility operating procedure to assess each youth using the Residential
Assessment for Youth (RAY) within thirty days of admission and reassessment every ninety
days thereafter. Five youth case management records were reviewed. Three of five records had
documentation which showed the youth was assessed within thirty days of arrival to the
program. Two records contained documentation the RAY was completed one and five days late.
In all five records, documentation of the process was maintained in the Department’s Juvenile
Justice Information System (JJIS). Three of the five youth case management records indicated
a RAY reassessment was completed at least every ninety-days after completion of the initial
RAY. Two records contained documentation reassessments were completed one and three
days late. All five youth were applicable for updates or reassessments, when deemed
necessary by the intervention and treatment team, to effectively manage the youth’s case, and
reassessments were completed, as necessary and maintained in the youth’s official record and
JJIS.
2.08 Youth Needs Assessment Summary (YNAS) Limited 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 facility operating procedure to complete a Youth Needs Assessment
Summary (YNAS) for each youth within thirty days of admission. Five youth case management
records were reviewed. Two youth case management records indicated each youth was
assessed within thirty days of admission to the program. Three records contained
documentation the YNAS was completed eight, twenty-one, and twenty-seven days late. All five
of the records had documentation of the process maintained in the Department’s Juvenile
Justice Information System (JJIS). All five records indicated the youth’s top three criminogenic
needs were identified and documentation was maintained in each youth’s case management
record.
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2.09 Performance Plan Development, Goals, and Transmittal
Limited 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.
Five youth case management records were reviewed for performance plan development, goals,
and transmittal. Two of five case management records indicated the Individualized Performance
Plans (IPPs) were developed within thirty days of the youth’s admission. The remaining three
records showed the IPPs were developed ten, twenty, and twenty-nine days late. Four of five
case management records showed the IPPs were developed after the initial Residential
Assessment for Youth (RAY) and Youth Needs Assessment Summary (YNAS) and one which
was not. Three of five performance plans were developed with the intervention and treatment
leader, youth, administration representative, living unit representative, treatment staff, and
education staff. ‘One of five records contained all required party signatures except the living unit
representative. The remaining four records did not have any of the required parties involved.
None of the five records reviewed had Department of Children and Families (DCF) involvement.
In four of five records reviewed, documentation indicated the signature sheets were mailed to
the parent/guardian, and one was not. One of the five records showed performance plans
included goals individualized for each youth based upon the prioritized needs reflecting the risk
and protective factors identified during the initial assessment process and the youth’s top three
criminogenic needs. Four plans did not include the required elements. All five youth records
contained delinquency interventions, targeted court-ordered sanctions which could be
reasonably initiated/completed while in the program, transition activities targeted for the last
sixty days of the youth’s anticipated stay, youth responsibilities to accomplish goals, program
staff responsibilities to enable youth to complete the goals, and target dates for goal completion.
In three of the five records it was unable to be confirmed if a transmittal letter was sent to the
commitment court or juvenile probation office, while two records documentation indicated the
program sent a transmittal letter to both in two records. Only one record indicated the program
sent a transmittal letter and copy of the plan to the youth’s parent/guardian within ten working
days of completion and could not locate transmittal letters to parents in four reviewed records.
Five youth were interviewed, and all five reported participating in the development of their
performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
Five youth case management records were reviewed for performance plan revision and
incorporation of other plans. All five records reviewed had revisions to the performance plan
completed with documentation the youth was demonstrating progress toward completing a goal
or the youth was demonstrating lack of progress toward completing a goal. All five youth had
additional plans, including academic or treatment plans, incorporated into their performance
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plan. None of the youth were applicable for having a current behavior support plan or case plan
through the Department of Children and Families (DCF) and/or the Agency for Persons with
Disabilities (APD).
2.11 Performance Summaries and Transmittals Limited 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.
Five of the five youth records reviewed, and each were applicable for a performance summary.
One of the five youth records included documentation a performance summary was completed
ninety days following the signing of the performance plan. Four summaries were completed
fourteen, twenty, sixty, , and seventy-eight days late. None of the reviewed records were
applicable for a performance summary prior to the youth’s release, discharge, or transfer from the
program. Each reviewed performance summary included the youth’s status on each performance
plan goal, youth’s overall treatment progress, youth’s academic status, youth’s behavior,
interaction with peers and staff, overall behavior adjustment to the program, and significant
positive and negative events. All performance summaries documented the youth’s level of
motivation/ readiness to change. Each record included documentation on the youth performance
summaries indicating the youth were allowed to read and add comments prior to signing. Each
record had the original summary filed in all but one of the records; however, no documentation
was found to confirm each youth were provided a copy of the summary. Four of the five reviewed
performance summaries were signed by the treatment team leader, program director or designee,
and the youth, with one summary not being signed by the youth or treatment team leader. None
of the records included documentation the performance summaries were sent to the youth’s
committing court or juvenile probation officer within ten business days, as required. All five
records documented the summaries were sent to the parent/guardian within the required
timeframe. Three closed records were reviewed for release summaries. All three records included
documentation the performance summaries were sent along with the justifications for release and
Pre-Release Notifications (PRN) to the juvenile probation officers. Two of the three reviewed
closed records were youth who were to be a direct release therefore a discharge summary was
sent. Each record included documentation the release or discharge summary and PRN were sent
within, at least, forty-five days prior to planned release. Each of the closed records included a
signed copy of the youth’s Performance Summary. None of the three records included
documentation the program provided written notification to the youth’s parent/guardian regarding
the planned release. All three records included a completed exit Residential Assessment for
Youth. Only one record was applicable for victim notifications, however there was no
documentation found of the notification being completed.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a facility operating procedure to encourage and facilitate involvement of the
youth’s parent/guardian in the case management process. The program invites the youth’s
parent/guardian to participate in the assessment process, development of the youth’s
performance plan, progress reviews, advanced notice of formal treatment team meeting dates
and times, and transition planning. If unable to attend, the program gives the parent/guardian
the opportunity to participate by telephone/video conference or provide written input prior to the
meeting. There were no treatment team meetings held during the week of the annual
compliance review; therefore, observations could not be completed. An interview conducted
with the facility administrator (FA) indicated parents are included in the development of the
treatment plan with youth and offered family therapy sessions. They are also included in weekly
updates and during formal treatment team meetings which helps keep the parent involvement
high. Parents are a part of emergency treatment teams to discuss problem behavior and
solutions to work best for the youth. Five youth were interviewed, and all five youth reported
their parents/guardians are involved in their treatment by participating in treatment teams, family
therapy, talking with their case managers, and by providing input for their treatment plans.
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 facility operating procedure identifying treatment team members which
include, at a minimum, the youth, representatives from the program’s administration, residential
living unit, education, and others responsible for providing or overseeing the provision of
intervention and treatment services. The program ensures the intervention and treatment team
meet formally, on a bi-weekly basis, to review each youth’s performance, to include Residential
Assessment for Youth (RAY) Reassessment results, progress on Individualized Performance
Plan (IPP) goals, and positive and negative behaviors, including behaviors resulting in physical
interventions. The gang prevention specialist, transition services manager, Department of
Children and Families (DCF), and trafficking-specific service provider are included when
applicable. Five youth case management records were reviewed. In each of the five records,
treatment teams were composed of a treatment team leader, youth, administrative
representative, living unit representative, treatment staff, educational staff, juvenile probation
officer (JPO), parent/guardian, medical staff, and recreational therapist. In two of the five
records, documentation indicated the monthly formal reviews were five and forty-two days late.
In the remaining three records, documentation indicated the intervention and treatment team
met formally on a monthly basis. Two of five reviewed records indicated informal treatment team
meetings were nine and ten days late. The remaining three records indicated informal treatment
team meetings occurred on the required bi-weekly basis. All five records indicated both formal
and informal treatment team meetings documented the youth’s name, date of review, meeting
attendees, comments from treatment team members or others, synopsis of the youth’s progress
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in the program, and performance plan revisions. In all records, the treatment team reviewed
each youth’s performance to include RAY Reassessment results, progress on IPP goals, and
positive and negative behaviors, including behaviors resulting in physical interventions, if
applicable. There were no treatment team meetings during the week of annual review;
therefore, observations could not be completed. Five youth were interviewed. All five youth
indicated the staff talk about their performance to include progress with performance plan goals,
positive and negative behavior, and treatment progress. The youth indicated they can
demonstrate skills they have learned by presenting to the team what they have been working
on, talk about their progress, talk about how they have shown improvement, talk about what
level they are on, and speak about what goals they have accomplished as well.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Three closed youth case management records were reviewed. All three records included
documentation a Transition Conference was held at least sixty days prior to the youth’s targeted
release date. All three records included documentation of the following intervention and
treatment team members attended the Transition Conference: youth, treatment team leader,
program director or designee, and other team members. All three records included
documentation the youth’s juvenile probation officer (JPO), parent/guardian, education staff, and
other pertinent parties were invited and encouraged to participate in the transition planning
conference. One record reviewed required a human trafficking specific service provider,
however, they were not in attendance of the Transition Conference. All three case management
records included documentation reflecting the transition activities on the youth’s performance
plan were reviewed. None of the records required a revised performance plan and/or additional
transition activities to be identified. All three records had transition target completion dates
identified persons responsible for completion were assigned, and the treatment team leader
obtained attendees’ dated signatures representing their acknowledgement of the transition
goals and accountability for completion were discussed during the Transition Conferences. All
three records included documentation a copy of the transition plan was sent with a request for
return with signature to anyone not in attendance who had a responsibility for completion of
transition goals. All three records included documentation a Community Re-entry Team (CRT)
meeting was conducted prior to the youth’s release and there was evidence of an invitation to
participate in the CRT meeting. All three records included documentation the youth and case
manager participated in the CRT meeting.
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2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed youth case management records were reviewed for the Exit Portfolios. All three
records included documentation the Exit Portfolio was discussed and initiated during the
Transition Conference. All three records included the youth’s transition plan, times, and
locations of upcoming community appointments, educational and/or vocational certificates
earned in the program, all educational records/documents, school transcripts, résumés, and a
completed sample of employment applications. Two of the three closed records included a
calendar with all dates, times, and locations of upcoming community appointments. Three
closed records included documentation of request of a Social Security Card and birth certificate.
Two of the three closed records included documentation indicating the parents/guardians did
not provide these documents to the program. In all three closed records, documentation
indicated the youth’s Exit Portfolio was verified during the Exit Conference. All three closed
records included documentation the Exit Portfolio was completed, was provided to the youth
upon release, and was forwarded to the juvenile probation officer.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth case management records were reviewed for the Exit Conference. All three
closed records included documentation the Exit Conference was conducted after the program
notified the youth’s juvenile probation officer of the youth’s release. Two of the three closed
records included documentation the Exit Conference was conducted at least fourteen days prior
to release. One youth’s Exit Conference was completed two days prior to release due to the judge
releasing the youth earlier than the stated release date on the Pre-Release Notifications. Each
closed record included documentation of the date of the conference, signatures, and a summary
with pending transition goals. All three closed records included documentation of the youth’s date
of admission and date of termination, which correlated with the Department’s Juvenile Justice
Information System. All three closed records included documentation the transition activities
established at the Transition Conference and plans were finalized and reviewed for the youth’s
release, including the exit portfolio. Each record documented the youth’s parent/guardian and
juvenile probation officer (JPO) are aware of the youth’s vocational plan. All three closed records
included documentation the following participated in the Exit Conference: intervention and
treatment team leader, parent/guardian, education representative, JPO, youth, and other pertinent
parties. All three closed records included documentation the Exit Conference was held 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 formal process to promote or solicit constructive input from the youth
through multiple avenues of communication which will allow youth to give input and feedback on
a daily, weekly, and monthly basis. These processes include the grievance requests, requests
to speak, and great hall meetings, which include all of the youth. Youth are able to give input in
a constructive way to make good changes. Reviewed documentation included youth
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chronological notes, letters, e-mails, treatment team meetings, and grievance procedures, all
confirming the program’s process. Five youth were interviewed. All five youth confirmed the
program has processes in place to solicit input from the youth. This is accomplished through
community talks, student council, surveys, talking to the facility administrator (FA), and request
to speak forms. An interview with the FA indicated the program uses a Trauma Responsive and
Caring Environment (TRACE) self-assessment, student council, and request to speak forms to
ensure youth can provide input at the program.
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 facility operating procedure to provide educational access. The
program provides education services through Florida Virtual School (FLVS) and the 250-day
calendar, which is distributed over twelve months, including twenty days used for teacher
training and planning was reviewed. A review of eight random dates in the logbook showed the
daily class schedule was being followed, with the exception of day logbook entry not notating
the start time and therefore could not confirm. Further review of logbook entries and video
footage for three days verified the youth were attending school as scheduled. Five interviewed
youth stated they are participating in education classes, however, there are some interferences
with learning due to youth acting out, but staff intervene and resolve the issues quickly.
2.19 Contract Specific Career and Technical Education
Limited Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has facility operating procedures to implement career and technical education
(CTE) services. The provider agreed to serve as collaborative partners who provide CTE
services which lead to career pathways with student outcomes which must include Industry
Certifications earned from the Master Credentials List and may include articulation agreements
which provide enrollment opportunities into in-demand CTE programs at a local technical
college. Should the program contracted provider be unsuccessful in obtaining an agreement
with the education provider and/or the technical college, the provider shall seek guidance from
the Department’s Office of Workforce and Postsecondary Education; however, remain
accountable for the provision of CTE services. None of the five reviewed youth records
contained documentation of any career and technical education services, Occupational Safety
and Health Administration 10, or Ready to Work Soft Skills. All five youth received certificates
for cardiopulmonary resuscitation and First-Aid.
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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 maintains a facility operating procedure ensuring a State of Florida licensed
clinician will serve as the designated mental health clinician authority (DMHCA) and will be
responsible for providing the coordination and implementation of mental health and substance
abuse service delivery. The program has a licensed mental health counselor (LMHC), who
serves as the program’s DMHCA and clinical director. The DMHCA has a clear and active
license which expires on March 31, 2027. Documentation showed the current DMHCA is a full-
time staff and was on-site during the annual compliance review period for forty hours each week
and on call twenty-four hours a day or as needed as contractually required. The program
provided the license and position description for review. The program has a back-up DMHCA
who has a clear and active license with an expiration date of March 31, 2027. The program had
three previous DMHCA’s who were used during the annual compliance review period. The
DMHCA was interviewed and reported they provide clinical oversight and supervision of the
mental health professionals at the facility. The DMHCA indicates they conduct individual and
group counseling sessions and assessments on youth. They are on-call for any mental health
issues which may arise day or night and maintain constant contact with clinical staff at the
program.
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 facility operating procedure to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The designated mental health
clinician authority (DMHCA) and the back-up DMHCA are the only licensed mental health
providers at the program.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a facility operating procedure to ensure mental health and substance abuse
services are provided by individuals with appropriate qualifications. The program has two non-
licensed mental health and substance abuse clinical staff. Each of the two non-licensed clinical
staff hold a master’s level degree in the field of counseling, psychology, social work, or a related
human services field. The designated mental health clinician authority (DMHCA) assures the
non-licensed clinical staff are performing services they are qualified to provide based on
education, training, and experience. A review of weekly clinical supervision found each non-
licensed clinical staff did not receive one hour a week of on-site, face-to-face direct supervision
by the licensed mental health professional during the annual compliance review period. One
non-licensed staff was missing three weeks out of thirty applicable weeks of direct supervision.
The other non-licensed staff was missing three weeks out of eleven applicable weeks of direct
supervision. Each clinical supervision was documented on the Department’s Licensed Mental
Health Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision
Log form. The program currently utilizes a Chapter 397 license, which is posted in the front
lobby, and expires January 30, 2026. The non-licensed clinical staff are on-site forty hours,
seven days a week. There were no vacancies during the annual compliance review period.
Each of the two non-licensed clinical staff completed twenty hours of Assessment of Suicide
Risk training and supervised experience in assessing suicide risk, mental health crisis
intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission Screening Limited Compliance
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 facility operating procedure (FOP) to ensure mental health and substance
abuse needs of youth are identified through a comprehensive screening process ensuring
referrals are made when youth have identified mental health and/or substance abuse needs or
are identified as a possible suicide risk. The program’s FOP includes staff training in mental
health and substance abuse issues and administration of all screening tools. The program
screens all youth utilizing the Massachusetts Youth Screening Instrument-Second Version
(MAYSI-2). Five youth mental health and substance abuse records were reviewed, and two of
the five records reflected a MAYSI-2 was completed in full and entered into the Department’s
Juvenile Justice Information System (JJIS) on the day of admission. Two of the records had a
MAYSI-2 completed in full but entered in JJIS forty-three days late and one day late
respectively. One record did not have a MAYSI-2 completed. Of the four applicable records,
each MAYSI-2 was completed by a staff member qualified to complete the screening.
Documentation confirmed staff reviewed all available information for each youth to include
commitment packet, and reports and/or records for existing documentation of mental health or
substance abuse problems or history of human trafficking. All five reviewed youth MAYSI-2s
indicated further assessment was needed, however, only two of five records had the reason for
the referral documented. Each MAYSI-2 noted the facility administrator’s (FA) signature
verifying they were consulted. Three of the five records were missing the mental
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health/substance abuse referral summary and therefore, consultation with the designated
mental health clinician authority or licensed mental health professional did not happen. Per
procedures, all five youth were referred for Assessment of Suicide Risk (ASR) and a
Comprehensive Evaluation, which were conducted on the date of admission. One of the five
youth was placed on precautionary observation. The FA developed procedures for the
implementation of a standardized admission/intake mental health and substance abuse
screening process which included review of commitment packet information, reports and
records, administration of the MAYSI-2 or Clinical Mental Health Screening by a qualified mental
health professional, referral of youth identified as in need of further evaluation, staff training in
mental health and substance abuse issues and administration of the MAYSI-2, and referral of
youth who are in crisis and need immediate attention via a Baker Act or Marchman Act. An
interview with the FA confirmed the policy of the program is to administer mental health
screening, including suicide risk screening during a youth’s admission to the program. The FA
indicated referrals are made for further evaluation, assessment, and clinical services when
necessary and the initial intake and screening process ensures treatment, gives priority to
urgent needs and emergency situations, and facilitates the identification of youth who have co-
occurring conditions.
3.05 Mental Health and Substance Abuse
Failed Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a facility operating procedure to address the provision of mental health
and substance abuse assessments/evaluations. Five youth mental health and substance abuse
records were reviewed for mental health and substance abuse assessments and evaluations
and two included documentation the program completed a new combined mental health and
substance abuse evaluation which were completed within thirty calendar days of admission.
Three records did not have a new or updated combined mental health and substance abuse
evaluation completed. The week of the annual compliance review was the same week the new
clinical director was hired. The program was unable to say why the evaluations were not
completed but did say this oversight should not happen again going forward. All five-youth
mental health and substance abuse records included a consent form obtained for substance
abuse services. In the two applicable records, the evaluations included demographics, reason
for assessment, relevant background information, behavioral observations, mental status
examinations, an interview or procedures administered, discussion of findings, methods of
assessment, patterns, impact of alcohol and drug abuse, risk factors of continued alcohol and
other drug abuse, clinical impression, original referral reason, and recommendations. An
interview with the designated mental health clinician authority (DMHCA) confirmed assessments
are completed at intake to gather additional information.
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3.06 Mental Health and Substance Abuse Treatment (Critical) Failed Compliance
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 facility operating procedure in place outlining the program’s mental health
and substance abuse services. Five youth records were reviewed for Initial Mental Health or
Substance Abuse Treatment Plans. Three records reflect an initial treatment plan was
developed within seven days of the initiation of treatment. One record had the initial treatment
plan completed twenty-three days late, completed by a non-licensed mental health clinical staff,
and was not signed by the licensed clinical supervisor as required. One initial plan had the
youth’s name written on the form along with the mental health clinical staff’s signature, however,
there were no dates or signatures by any other members, and the form was completely blank.
This same plan was also completed by a non-licensed mental health staff and was not signed
by the licensed clinical supervisor as required. Three records contained all required signatures
on the initial plan. Two records were missing the youth’s signature, documentation of reaching
out to the parent/guardian, and the treatment team leader’s signature. All plans were
documented on the Initial Mental Health/Substance Abuse Treatment Plan form. Five records
were reviewed for treatment plan reviews. Only three individualized treatment plans were
created. Two treatment plans were never created nor were there any treatment reviews
completed. Only one required psychiatric services to be included on the plan and there was
documentation supporting this as well as the frequency of monitoring by the psychiatrist. Of the
fourteen completed reviews for the three applicable records, six were either one, two, seven,
fifteen, or sixteen days late, ten were missing documentation of reaching out to the parent and
missing treatment team member signatures, and three were completed by non-licensed staff
with two of those three missing the licensed clinical staff’s signature. All five individual treatment
plans included the type of intervention (individual, group, and/or family therapy), methods, and
frequency of services. In the four completed plans, all had goals and objectives individualized
for each youth. In an interview, the designated mental health clinician authority (DMHCA)
explained the program utilizes a clinical tracker to ensure all contracted services are provided.
Additionally, the DMHCA and therapists meet with the facility administrator daily to discuss
updates.
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3.07 Treatment and Discharge Planning (Critical) Limited Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a facility operating procedure addressing mental health and substance abuse
treatment and discharge planning. Five youth mental health and substance abuse records were
reviewed, and each youth was assigned to a multidisciplinary treatment team upon admission to
the program. Reviewed documentation revealed each treatment team was comprised of the
youth, program administration, education, medical staff, mental health staff, substance abuse
staff, and the parent/guardian. All five youth who received mental health treatment had a
properly executed Authority for Evaluation and Treatment (AET) form. Each of the five youth
were receiving substance abuse treatment, and all five provided consent through a signed
Department’s Youth Consent for Substance Abuse Treatment. Mental health treatment notes
and substance abuse treatment notes in all five youth records were documented on the
Department’s Counseling/Therapy Progress Notes form. All mental health and substance abuse
therapy included individual psychotherapy or counseling and psychosocial skills training. Due to
the program having an open Outcome Based Corrective Action Plan (OBCAP), progress notes
to determine if youth are receiving services as stipulated on their treatment plans are not being
reviewed. The designated mental health clinician authority (DMHCA) stated the therapists
gather information from the youth and parent to develop youth treatment plans. Three closed
files were reviewed for discharge planning. In each of the three records, the discharge plan was
documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. All three discharge summaries documented the future services needed,
evidence the discharge plan was discussed with the youth, parent/guardian, and juvenile
probation officer (JPO) during the exit conference, and a record each was provided a copy.
3.08 Specialized Treatment Services (Critical) Limited Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
A major deficiency was assigned to the program July 23, 2025, for services not being provided
in accordance with Department policy and failure to meet contractual requirements. Contractual
treatment services to include individual therapy bi-weekly, group therapy four days a week, and
family therapy at least once a month. Dailey services were not being documented in a timely
manner. The Office of Health Services will complete the verification monitoring.
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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 facility operating procedure to address suicide prevention planning which
includes identification and assessment of youth at risk of suicide, staff training to include six
hours annually, suicide precautions, levels of supervision (one-to-one, constant, close),
referrals, communication, notification, documentation, immediate staff response, and a review
process. The review process includes circumstances surrounding the event, program
procedures relevant to the incident, all relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations. The plan was reviewed and signed by the regional director of clinical
services on September 8, 2025.
3.10 Suicide Prevention Services (Critical) Limited 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 facility operating procedure for suicide prevention services. The program’s
process is to complete an Assessment of Suicide Risk (ASR) for each youth during the
admission process. Three records were reviewed for suicide prevention services. Two youth
were determined to be at risk during admission and one youth was a self-report of suicide risk.
The precautionary observation placement start date and ASR referral date were the same date
for all three youth. All three records contained an ASR completed on the Department’s
Assessment of Suicide Risk form. Each of the three youth records documented the youth was
placed on constant supervision. Each ASR documented the parent/guardian and juvenile
probation officer (JPO) for each youth was notified. The mental health staff provided supportive
services for all three youth. Two of the three ASRs were completed by the licensed mental
health counselor (LMHC), and one was completed by a non-licensed mental health staff under
the supervision of the LMHC which was documented on each ASR, including the date and time.
The completion of the suicide risk assessments resulted in two youth being placed on close
supervision and one youth to continue precautionary observation. All three assessments were
completed within twenty-four hours of screening/concerns. All three youth had a follow-up
assessment of suicide risk (FASR) completed prior to the removal of youth from precautionary
observation and the follow-up was documented on the Department’s Follow-Up Assessment of
Suicide Risk, form. All three youth were maintained on suicide precautions and either one-to-
one or constant supervision until the FASR indicated suicide precautions could be discontinued.
In two records, the FASR indicated suicide precautions could be discontinued, and the youth
were stepped down to close supervision prior to transition to normal routine and standard
supervision. Close supervision was maintained in both applicable records until it was
determined no longer necessary by the designated mental health clinician authority (DMHCA) or
licensed mental health professional. One record reflected the youth being transitioned to
standard supervision without being stepped down to close supervision. In all three records,
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there was documentation of a conference held by the facility administrator and licensed mental
health professional to reduce the level of supervision. The discontinuation of close supervision
was documented in accordance with the program’s suicide prevention plan in all three
instances. In two of the three records, a suicide alert in the Department’s Juvenile Justice
Information System (JJIS) was not initiated when the youth were placed on suicide precautions
and all three records did not have the alert accurately closed following the recommendations of
the ASR or FASR. While on precautionary observation, each youth was allowed to participate in
select activities with other youth in designated safe housing/observation areas of the facility.
The designated mental health clinician authority (DMHCA) was interviewed and confirmed the
program’s suicide prevention services procedures. All youth are screened for suicide risk upon
admission. At any time following admission, youth can self-refer, and staff can refer a youth for
an ASR. Mental health professionals are notified of the referral by e-mail, telephone, or face-to-
face twenty-four hours a day. The program’s mental health professionals initiate precautionary
observation, safety planning with the treatment team, and specialized clothing for youth who are
acutely suicidal. Staff are verbally notified by mental health professionals when a youth has
been placed on precautionary observation and are provided with a precautionary observation
log. The alert board is updated, as well as the logbook, to communicate a youth's change in
status. Prior to revising a youth's supervision level, a meeting is conducted with the facility
administrator/designee, which is documented on ASR.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
This program does not utilize secure observations; therefore, this indicator is rated non-
applicable.
3.12 Suicide Precaution Observation Logs (Critical) Limited Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
A major deficiency was assigned July 23, 2025, as a result of missing Precautionary
Observation Logs and missing Close Supervision Logs from youth’s records. The deficiency
was assigned by the Office of Health Services staff. At the time of the annual compliance review
week the deficiency remains open.
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 facility operating procedure addressing suicide prevention training plans
stating all staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions. A review
of eight pre-service training records and five in-service training records documented staff did
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receive the internal mental health and substance abuse training as documented on the staff
individual training plans. The program has ten suicide response kits, which included the knife-
for-life, wire cutters, and needle nose pliers. Three are located in classrooms, one is in the
multipurpose room, one in the kitchen, one in master control, one in the transportation van, one
on the dorm, one in the laundry room, and one in the nurse’s office. The suicide response kits
are co-located with first-aid kits.
The program conducted drills quarterly on each shift. The training included mock suicide drills
for all staff who encounter youth, including the kitchen and maintenance staff. Each of the mock
mental health drills is simulated, in response to a suicide attempt and/or incident of serious self-
injury, and no youth were used in the drill. ten drills were reviewed and found four indicated the
automated external defibrator (AED) was utilized. Video review of the drills indicated they were
simulated. The program provided semi-annual training on emergency response procedures and
provided staff who were not present during a monthly drill the opportunity to review each drill
scenario and procedures. Five staff were interviewed about what to do if a youth expresses
suicidal thoughts. All five said they would notify mental health and put the youth on constant
sight and sound. Three of the five also said they would document supervision and notify their
supervisor. Four staff said the suicide response kits are in master control, one said they are in
the medical office, and all five said there are kits located in the back hall laundry room. All five
staff said medical emergency and suicide drills are conducted monthly on their shifts.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written crisis intervention plan which includes a notification and alert system,
means of referral including youth self-referral, communication, supervision, documentation, and
review.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a facility operating procedure addressing crisis assessments and utilizes the
Department’s form. None of the five reviewed records were applicable for a crisis assessment.
Three additional applicable records were obtained for review. All crisis assessments were
conducted immediately based on the needs of the youth. The crisis assessment documented
the reason for the assessment, a mental status examination and interview, the determination of
danger to self and/or others (including imminence of behavior, intent of behavior, clarity of
danger, lethality of behavior), initial clinical impressions, supervision and treatment
recommendations, recommendations for follow-up or further evaluation, and notification to the
youth’s parent or guardian of follow-up treatment. The crisis assessments were conducted by a
licensed mental health professional, and none of the three were required to be entered into the
Department’s Juvenile Justice Information System (JJIS) as none of them were placed on
precautions after the completion of the crisis assessment. One of the three youth was a victim in
a Prison Rape Elimination Act (PREA) incident and was offered on-going mental health
treatment services.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a facility operating procedure addressing the emergency mental health and
substance abuse plan which includes immediate staff response, notifications, communication,
supervision, authorization to transport for emergency mental health or substance abuse
services, transport for emergency mental health evaluation and treatment under Baker Act,
transport for emergency substance abuse assessment and treatment under Marchman Act,
documentation, training, and review.
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3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program has a facility operating procedure addressing 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. One of the five
reviewed records was applicable for emergency mental health services. Two additional records
were received for review. The three youth in crisis were all under a Baker Act, two had an
assessment of suicide risk (ASR) completed prior to the Baker Act, and one was directly Baker
Acted. All three notifications were made to the licensed mental health counselor (LMHC). Mental
health staff were involved in all three records and all three youth were transported off-site. Law
enforcement transported each youth, and the LMHC authorized all transports out of the
program. Upon return to the program, all three youth were placed on constant supervision and
had a Mental Status Examination (MSE) completed. All three youth had an ASR completed by a
licensed clinical staff and all three youth’s supervision level was maintained until an appropriate
assessment was conducted.
3.18 Safety Planning Process for Youth Failed 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 facility operating procedure to address the safety planning process for
each youth. The safety plan shall be designed to identify stimuli which has both positive and
negative effects on youth. Five youth mental health and substance abuse records were
reviewed for the safety planning process for each youth. Two records did not have the initial
safety plan completed. Three records had the initial safety plan completed within fourteen days
of admission. Two of the three applicable records found the plan was jointly prepared by the
youth, parent(s)/guardian(s), and the program’s clinical staff. One record did not have
documentation of parent involvement. In all three applicable records, the initial safety plans
incorporated recommendations from previous and current clinical assessments and screening
instruments, and incorporated trauma responsive practices. In all three applicable records, the
plan was not reviewed and updated as necessary at least every thirty days. In the three
applicable records, twenty-five reviews should have been completed. Twelve reviews were not
completed. Of the thirteen completed, five were sixty-six, forty-two, forty, twelve, and ten days
late. All three applicable safety plans documented warning signs, youth’s baseline behaviors
and crisis recognition, jointly developed coping strategies, intervention strategies, and a
debriefing process. The plans are reviewed and signed by all staff involved in the development
of the plan and each youth. The safety plans were maintained in each youth’s mental health and
substance abuse binder and within a safety plan binder located in master control. All five
interviewed youth stated they participated in the development of their safety plan. The facility
administrator stated in an interview safety plans are updated monthly.
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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 board-certified physician who is a licensed physician (MD), who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida to serve as the designated health authority (DHA), with a license expiration date of
January 31, 2026. The DHA did not have any disciplinary cases/public complaints on record.
The DHA has designated an advanced practice registered nurse (APRN) for clinical duties, and
the APRN holds an unrestricted, clear and active license to practice in Florida with the license
expiring January 31, 2027. The APRN’s academic specialty is in Family Health and the APRN
has a Collaborative Practice Protocol (CPP) in place. The CPP is maintained on-site at the
program. A review of sign-in/out logs during the annual compliance review period confirmed the
DHA was on-site at least once a week, with a week defined as the seven-day period beginning
on Sunday and ending on Saturday, with no more than nine days passing between each visit. If
the DHA is on vacation or scheduled absences, a back-up DHA is utilized. The back-up DHA
has a number of equal licensure with a license expiration of January 31, 2026. If the DHA
designates another medical doctor (MD) or advanced practical registered nurse (APRN) to
provide the clinical services on-site, the actual DHA performs the administrative duties. The
program does not utilize telemedicine or telehealth services.
An interview with the DHA confirmed the DHA performs Comprehensive Physical Assessments
(CPAs), conducts period evaluations of youth, and develops facility operating procedures for
medical care. The DHA is on-site once per week and communicates with program staff
regarding youth medical needs through the program’s nursing staff. The DHA confirmed they
are available by phone when not on-site. The DHA confirmed they provide on-site clinical
services, and ensures off-site care findings, instructions, and information is reviewed by
reviewing the binder the nurses add all the off-site care documentation. The DHA and nursing
staff review important medical issues pertaining to the youth at the program weekly when DHA
is on-site.
Satisfactory Compliance
4.02 Licensed Medical Staff (Critical)
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.
Daily clinical care is performed by registered nurses (RNs) according to developed and
authorized protocols. The program does not utilize licensed practical nurses (LPNs). A review of
nurse licensure credentials for all nurses who provided services during the annual compliance
review period confirmed the licenses were clear and active for each nurse according to Florida
Department of Health Medical Quality Assurance web site. All nursing staff have current
cardiopulmonary resuscitation (CPR) certifications, as required. According to the program’s
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contract, the required on-site hours for the nursing staff are eighty hours per week and the
nursing staff is following the contracted requirements.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) and facility administrator (FA) signed and dated all
respective treatment facility operating procedures (FOPs). The DHA signed on January 8, the
psychiatrist signed on January 7, and the FA signed January 1, 2025. Nursing staff reviewed,
signed, and dated the cover page on which all FOPs, healthcare protocols, and other
procedures were listed, as required. New FOPs or changes in FOPs made during the year
reviewed were signed and dated by each nurse on the individual changes which occurred
between annual compliance reviews or as signature page added with the specific FOP listed,
date of revision, and signatures, as required. The annual review of medical FOP and protocols
was conducted and signed on January 1, and January 7, 2025. All newly employed healthcare
personnel receive a comprehensive clinical orientation to the Department’s healthcare policies
and procedures, given by a registered nurse or designated, licensed health care professional,
as required. The approval of treatment protocols or standing procedures was written and
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.
Five youth individual health care records (IHCR) were reviewed for The Department’s Authority
for Evaluation and Treatment (AET) forms. For all five youth records, the original AET form or
legible copy was filed in the youth’s IHCR and was signed by the youth’s parent/guardian and
Department representative. None of the parent/guardians refused to sign the AET forms, and no
youth required a court ordered AET. All five youth AETs were valid. None of the youth reviewed
were eighteen years of age or older or in the care of the Department of Children and Families
(DCF).
An interview with the nurse confirmed the youth’s dates of birth are in the medical tracking file
and nurses review the tracker monthly; any youth turning eighteen will sign a Release of
Information form. The original AET remains in the youth’s chart. If the program needs to obtain a
new AET, it is pulled from the Department’s Juvenile Justice Information System (JJIS). If the
AET in JJIS is over one year old, the program notifies the youth’s juvenile probation officer
(JPO) and requests a new AET. The nurse confirmed the AET is valid for as long as the youth is
under any type of supervision by the Department. If the youth is in DCF custody, then the AET
must be signed by the court/judge.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has facility operating procedures regarding parental notification/consent. Five
youth individual health care records were reviewed for documentation of parental notification for
over-the-counter (OTC) medications beyond those covered by the Authority for Evaluation and
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Treatment (AET). Two youth were applicable for receiving OTC medication. For both youth,
consent was provided by the youths’ parent/guardians. Two youth were applicable for new
medications and when new medication was ordered, there was documentation of attempted
contact to the parent/guardian in the progress notes for both youth. For all five reviewed youth,
written notifications were sent utilizing the Department’s Parental Notification of Health-Related
Care form. Two youth were taking psychotropic medication at admission. A staff witnessed all
telephone call attempts and conversations for psychotropic medications for both youth. Three
youth were applicable for new psychotropic medication prescribed or discontinued, or the drug
dosage was significantly changed. For all three records, the parent/guardian’s verbal consent
for psychotropic medication was documented on page three of the Department’s Clinical
Psychotropic Progress Note (CPPN). None of the youth were in the care of the Department of
Children and Families (DCF). Vaccinations were verified within thirty days of the youth’s
admission in all five records reviewed. None of the youth reviewed were applicable for requiring
the administration of vaccinations. None of the records were applicable to refusal of consent for
immunizations.
An interview with the nurse confirmed notifications are required when there are changes in the
youth’s health condition, when there is new medication or changes in the medication or
treatment prescribed, and when there is a recommended treatment by a medical provider, or
dental treatments recommended. Parental notifications are conducted telephonically as a
priority/immediately when events occur; then written notifications are sent out and a copy placed
in the youth’s chart. When a youth’s illness or injury requires emergency medical services or is
life threatening verbal notification must be made to the parent/guardian, followed by written
notification. The Department’s Central Communication Center (CCC) must be notified within two
hours. The designated health authority (DHA), facility administrator, and state nursing director
are notified immediately. Parental notifications are also made upon a youth’s return to the
facility. For new, discontinued, or changes in medication, telephonic contact is made by the
psychiatrist to the parent/guardian to explain the purpose and possible side effects of the
medication, or changes in psychotropic medications including new orders, discontinued
medication or increase or decrease in dosage require a parental or guardian consent which is
witnessed by the nurse who is conducting psychiatric clinic. The nurse also confirmed
vaccinations are provided on-site for youth who need them. Immunization records are obtained
through the Department’s Juvenile Justice Information System (JJIS), printed, and placed in the
immunization section of the youth's chart. If not found, vaccinations can be accessed through
the FLSHOTS website. Records are reviewed twenty-four hours prior to arrival, after the
placement notification occurs, and the records are printed for the youth’s admission chart.
Parental exemption is accepted when the parent will not consent for vaccinations, but the
parent/guardian will have to complete the Religious Exemption Immunization form, sign, and
submit the form to the program.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a facility operating procedure for youth screened upon admission for
healthcare concerns which may require a referral for further assessment by healthcare staff.
Five youth individual health care records (IHCR) were reviewed for Facility Entry Physical
Health Screening Forms (FEPHS). For all five records, the FEPHS was completed on the date
of admission by a registered nurse (RN). None of the youth were applicable to a change in
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physical custody greater than twenty-four hours. An interview with the program nurse confirmed
all newly admitted youth are seen by a registered nurse immediately upon arrival to the
program. After the program receives a notification for a placement from the commitment
manager, the nurse is notified of the arrival of youth by the facility administered and the
admission screening is completed by the RN on duty. An RN always completes the youth’s
admission screening on-site. If there is a change in the physical custody of a youth after
admission, a new FEPHS form will be completed by the RN. A body observation checklist is
completed by two staff and documented in the youth’s record. A pregnancy test and urine drug
screen are also completed and documented on appropriate forms.
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 facility operating procedure to ensure all youth are oriented to the general
process of healthcare delivery services at the program. All youth receive a general care
admission orientation which includes access to medical care, sick call, what constitutes and
emergency and when to notify staff, the medication process to include side effects monitoring,
right to refuse care and how it is documented, what to do in the case of a sexual assault or
attempted sexual assault, non-disciplinary role of healthcare providers, and Standard Universal
Precautions. The program provides monthly health education, as required by contract. Health
education includes, but is not limited to, seatbelt usage, alcohol and rug related problems,
sexually transmitted diseases/infections, tobacco products and smoking cessation, dental
hygiene and care, immunizations, infection control, prevention of sexual and physical violence,
nutrition, breast self-examinations, parenting skills, prenatal, postpartum and parenting
education, as applicable, and chronic conditions/medications, as applicable. Five reviewed
individual healthcare records verified the youth received the required healthcare orientation
documented by a signed orientation sheet. The program also utilizes an education/orientation
binder to ensure all required orientation topics are reviewed.
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 facility operating procedure for the designated health authority (DHA) or
designee to be notified when youth admitted require emergency care or routine notification. Five
youth individual health care records (IHCR) were reviewed for chronic conditions. One of five
youth was applicable for having a chronic condition, as such, the program provided two
additional records for review. For all three youth with known or suspected chronic conditions,
there was evidence of a referral to the physician. None of the youth were identified as in-need of
emergency care upon admission. The DHA is notified upon admission for each youth regardless
of chronic condition; all three-youth had DHA notification in their IHCR within twelve hours of
admission. Two youth were taking psychotropic medication upon admission and the psychiatrist
was notified in both records. An interview with the nurse confirmed when a youth is admitted
with serious or chronic conditions, the registered nurse (RN) on duty notifies the DHA
immediately after the assessment. Referrals to the DHA are noted on the youth’s intake note, a
nursing progress note, on the DHA appointment calendar, and on the sick call log if the referral
is a result of a sick call.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a facility operating procedure to use the Department’s Health-Related History
(HRH) form for all youth admitted into the physical custody of a department facility. Five youth
individual health care records (IHCR) were reviewed for completion of the HRH. All five youth
had HRH forms completed within seven calendar days of admission prior to the completion of
the Comprehensive Physical Assessment (CPA), as evidenced by the signature and date on the
forms. The physician reviewed the HRH form in all five records reviewed. An interview with the
nurse confirmed the HRH is completed immediately upon arrival, by the registered nurse on
duty, with the youth during the admission process.
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 facility operating procedure for the use of the standardized Comprehensive
Physical Assessment (CPA) form for all youth admitted into the physical custody of a
department program. Five youth individual health care records were reviewed and all five
showed the youth’s physical assessment was completed on the Department’s CPA form. All five
youth received a new CPA, and each was completed within seven calendar days of admission
by the program’s designated health authority (DHA), and each youth’s Medical Grade was
documented on the CPA. All sections of the CPA were marked with an “O” or “X,” as required.
None of the CPA’s were applicable to refusal of the gynecological portion of the exam because it
is not clinically mandated to complete a gynecological exam of a youth. The Department’s
Problem List was updated in all five records, as required. All five youth received a Tuberculosis
Skin Test (TST) within seven days of admission, and the results were documented on the CPA
and Infections and Communicable Disease (ICD) forms, which matched. An interview with the
nurse confirmed the CPA is completed within seven days of admission by the DHA, and
annually if the Medical Grade is greater than level two. The most recent TST is noted in the
youth’s chart, medical tracker, and on the front of the medical chart. Tuberculosis (TB) screening
forms are completed annually from the date of the first TB test. Gynecological exams are not
routinely completed as they are not clinically mandated.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has facility operating procedures to ensure all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs) and Human Immunodeficiency Virus (HIV).
Five individual health care records (IHCR) were reviewed, and each youth was clinically
screened and evaluated for STIs on the day of admission. Four youth required further
evaluation, and eachwas referred to the designated health authority (DHA). The referral was
documented on the Department’s STI screening tool for all four applicable records. All five youth
refused STI testing. None of the youth were out of the Department’s physical custody. All five
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youth were offered counseling, testing and a treatment/referral for HIV. One youth requested
and received HIV testing. Consent was obtained for the applicable youth. The HIV results were
filed confidentially in a sealed envelope marked “Confidential,” with proof of review of a
practitioner documented on the sealed envelope. Documentation of pre/post-test counseling
was documented on the IHCR and/or in the progress notes for the applicable youth. The youth’s
confidentiality was protected by not including the youth’s HIV status and any other STI diagnosis
on the program’s internal alert system.
The program has a facility operating procedures reflecting HIV test results are only disclosed to
the youth and the youth’s legally authorized representative, health care 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 health care facility personnel or agents for the
healthcare provider who have a need to know in the course of patient care activities or
administrative operations. The DHA provides HIV pre-testing, post-testing and counseling
services.
Five youth were interviewed, and each youth confirmed they can request an HIV test. An
interview with the nurse confirmed all youth are screened using the STI screening form upon
admission. The DHA decides if testing is needed during the initial Comprehensive Physical
Assessment. If screening indicates a need for further evaluation, the youth will be referred to the
DHA. All previous STI reports are in the Department’s Juvenile Justice Information System
(JJIS) and are documented in the youth’s IHCR. If STI test results are not found, the DHA is
notified, and testing is ordered and normally completed within two weeks. STI results are filed in
the “lab” section of the youth’s IHCR. Testing documentation is noted on the Department’s
Infectious and Communicable Disease Form/STI screening form. If a youth has been out of the
program's/Department's physical custody for more than thirty days and/or symptoms present,
the Sexually Transmitted Disease form is completed. Youth must answer all questions,
document, and sign the form. The youth is retested if symptoms are present. Pre- and post-HIV
counseling is documented under education in the youth’s chart. HIV results are located under
labs, are kept in the youth’s IHCR in a sealed envelope and labeled “Confidential.” To access
HIV counseling and testing services, youth have to consent to HIV testing with sign the form. A
laboratory fingerstick is completed by the nurse at the program Pre-counseling is completed
before testing, and post-counseling is completed after results are received from the laboratory.
Pre- and post-counseling is performed by the DHA and documented under “education” in the
youth’s IHCR, with the date the youth was tested logged in the medical tracker.
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 facility operating procedure for all youth to submit sick call requests and
have complaints treated appropriately through the sick call system. Five youth individual health
care records (IHCRs) were reviewed for sick call process. None of the five records were
applicable for the youth presenting with similar sick call complaints three or more times within a
two-week period. All five youth completed a Sick Call Request form, and the nurse completed
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the appropriate section of the Sick Call Request Form. The program does not use licensed
practical nurses (LPNs); only registered nurses (RNs) conduct sick call. The Sick Call Request
forms were filed in the youth’s IHCR in reverse chronological order in all five records. None of
the youth were applicable to restricted housing of any kind. Sick call forms or progress notes
were documented in accordance with Health Services Rule 63M-2 in all five records. The
youth’s sick call was documented on the Sick Call Index and the program’s Sick Call Referral
Log in all five IHCRs. The dates listed on the Sick Call Index corresponded to the completed
Sick Call forms located in the IHCR in all five records.
A review of the daily schedule, posted schedule, and nurse interview confirmed sick call is
conducted twice daily. The sick call hours and sick call request forms are posted and available
in the program’s main hallway, next to the great room. Only licensed nurses conduct sick call.
When there is not a licensed nurse on-site, the program has procedures whereby the shift
supervisor reviews all sick call requests as soon as possible and within four hours after the
request is submitted. An exam table and equipment are used to perform sick call.
Five youth were interviewed regarding how quickly they can see a nurse once they make a sick
call request; all five stated they can see the nurse within one day of making the request. An
interview with the nurse confirmed the process for youth requesting to see a nurse and/or
physician for health complaints is for the youth to complete a sick call form and place it in the
locked sick call box. The sick call boxes are in the common area on the wall and checked twice
daily. Sick call clinics are conducted from 10:30 a.m.to 11:30 a.m. and 2:45 p.m. to 3:45 p.m.
Youth are seen same day a request is made. The program’s RN on duty conducts the sick call.
The designated health authority (DHA) will conduct sick call if sick call is scheduled when on-
site. Sick call is conducted in the medical clinic, behind closed doors. If a youth presents with
the same complaint three or more times within a two-week period, the youth must be referred to
the DHA. If more urgent concerns arise, the RN calls the DHA for advisement and directs care
as appropriate per the DHA. The program has DHA approved treatment protocols. When a
youth is in restricted housing/confinement, non-healthcare staff conduct five-minute checks
when youths are confined to their rooms, or are on precautionary observation, which is
documented on a tracking form outside of the youth's room/wall. During the annual compliance
review a sick call was observed. The youth was escorted to the medical clinic by direct care
staff. The medical provider identified themselves and stated why the youth was there. The youth
was seen in a private area with no other youth present to hear or see the examination. The
youth was examined by an RN on the exam table. The direct care staff was present during the
exam, but medical staff was able to maintain privacy.
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 facility operating procedure (FOP) which includes a comprehensive process
for the provision of episodic care and first-aid care. Five youth individual health care records
were reviewed and all five showed the youth required on-site episodic or first-aid care. The on-
site care was provided by licensed healthcare staff and documented either in problem-oriented
or standard narrative charting in all five records. None of the youth were applicable to requiring
follow-up care. The program has a total of ten first-aid kits, with one in each classroom, one in
the multipurpose room, one in master control for use in both vans, one in the dormitory, one in
the nurse’s office, and one in the laundry room. The program completed weekly first-aid kit
checks to ensure contents are maintained and stored in accordance with guidelines to prevent
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expiration or deterioration and are replenished, as needed. A review of documentation
confirmed the kits were monitored, as required. An inspection of first-aid kits confirmed the first-
aid kits were fully stocked with designated health authority (DHA) approved contents.
The program has an automated external defibrillator (AED) located in master control. The
procedures for the AED are co-located with the AED in the AED box. On-site nursing staff check
to ensure the AED batteries and pads are operable. Staff conducted a self-test of the AED in
front of regional monitor during the annual compliance review, and the color of the AED battery
indicator light was green. The AED batteries expire on June 1, 2030, and were last changed on
August 27, 2025. The AED pads expire January 10, 2028, and were last changed August 15,
2025. A list of emergency numbers, including the Poison Information Control Center, was posted
and accessible for non-licensed and licensed staff, but are inaccessible to youth. The numbers
are posted in the administration hallway, where youth are not permitted and are covered.
Authorized direct care staff are appropriately trained in the administration of the epinephrine
auto-injector. Five in-service staff training records were reviewed, and training requirements
were met regarding episodic, first-aid, and emergency care.
Direct care staff participated in at least one drill which included the use of cardio-pulmonary
resuscitation (CPR) annually, as required. Video review confirmed the drills were simulated. The
drills simulated an episodic care event which calls for immediate first-aid and/or administration
of CPR techniques and the initiation of the emergency procedures to follow when a life-
threatening emergency occurs. The program maintains documentation for emergency drills.
Announced or unannounced emergency medical drills were conducted at least quarterly, on
each shift. The program did not have any episodic care events during the annual compliance
review, as such, no observations were made. The program has a facility operating procedures
on Narcan. The policy states Narcan nasal spray is to be given right away and does not take the
place of emergency care. Nursing staff check monthly for expirations. The Narcan is stored in
the medical office in the emergency bin, but accessible to all staff. Each staff with access to
Narcan has been trained on when and how to use it. The Narcan is in the emergency bin and is
inventoried daily by nursing staff. Narcan is also counted daily on the daily over-the-counter
(OTC) count for the medical cart.
Five staff were interviewed and asked if they were personally allowed to call 9-1-1 if a youth has
a medical emergency. Three staff stated “yes,” and one staff stated they had to obtain
permission first, and one stated they would have to contact the supervisor to make the call. Five
youth were interviewed and confirmed they can see a dentist and/or doctor if needed. An
interview with the nurse determined the program has ten first aid kits which are in each
classroom, the multipurpose room, kitchen, master control room, van, dormitory, laundry room,
and medical clinic. Episodic care is provided by the registered nurse (RN). A Subjective,
Objective, Assessment and Plan (SOAP) note is completed and placed in the chart and twenty-
four hour follow-up is conducted by the registered nurse (RN). If episodic care is conducted by
non-healthcare staff, the Department’s Report of On-Site Health Care by Non-Health Care Staff
form is completed, and a follow-up is conducted by the RN within twenty-four hours. The
Episodic Log and Daily Emergency Room/Hospital Central Communications Center (CCC)
forms are used to track youth sent off-site for emergency care. The nurse confirmed the
program has one AED located in master control. The AED procedures are in the AED box and
nursing staff check it daily to ensure the battery and pads are operational. Emergency medical
drills are completed monthly according to the FOP’s. CPR/AED refreshers are also included in
the drill at least quarterly. Emergency medical drills are conducted monthly. The health services
administrator (HSA) sends medical drill forms to all shift supervisors and facility administrator at
the beginning of each month. Supervisors are expected to include the HSA at each drill to
ensure proper medical response. The HSA logs the times the drill starts, when emergency
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medical services (EMS) 9-1-1 is activated and arrives, times when first-aid/CPR/AED is initiated,
and when EMS departs. The HSA documents all the events of the process and procedures,
critiques the events, and conducts a debriefing and education after the medical drill to discuss
deficiencies in the drill and maintains documentation of these 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 health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a facility operating procedure to provide for timely referrals and coordination of
medical services to an off-site health care provider. Five youth individual health care records
(IHCRs) were reviewed for off-site care referrals. All five-youth required off-site care. For all five
youth the Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR.
None of the youth required off-site emergency care. Parental notification efforts were
documented for all five youth and discharge and other applicable documents were filed the
youth’s IHCR, as required. The DHA or designee reviewed and signed/initialed all off-site care
findings, instructions, and information for all five records. Three of the five youth required follow-
up appointments and there was evidence indicating the referrals were tracked and youth
received the appropriate, timely, follow-up care, as needed. An interview with the nurse
confirmed the Episodic Log and Daily Emergency Room/Hospital Central Communications
Center (CCC) forms are used to track youth sent off-site for emergency care. When hospital
orders are received, the registered nurse (RN) calls the DHA for a telephone order to continue
the orders. The orders are then faxed to the pharmacy and transcribed to the Department’s
Medication Administration Record (MAR), placed in the medical chart, the medication pass list is
updated, and the parent is notified telephonically, and notification is also mailed. Once the off-
site information is received, the RN notifies the DHA of any orders or instructions. Off-site
summaries with all attachments are placed in the DHA’s book to review and sign during the next
visit to the facility. Nursing staff track follow-up testing, referrals, and appointments through the
appointment tracker, appointment book and episodic log.
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 facility operating procedure which ensures youth who have chronic
conditions receive regularly scheduled evaluations and necessary follow-up. Five youth
individual health care records (IHCRs) were reviewed for chronic conditions. One youth record
was applicable. As such, the program provided two additional records for review. The youth
identified on the Facility Entry Physical Health Screening (FEPHS) form with a current chronic
condition in all three records. None of the youth had a communicable disease. All three of the
youth were taking medications on an ongoing basis. One youth was undergoing treatment for a
physical health condition. The youth were classified with a medical grade four or five, as two of
three youth were also taking psychotropic medications. Two of the youth were identified as
being pregnant and both youth were placed on the chronic illness list. Both pregnant youth
received periodic evaluations at least every ninety days. None of the youth were taking anti-
tuberculosis meds. For both pregnant youth, evaluations were conducted every two to four
weeks for the first eight months, then every two weeks during the eighth month and weekly
thereafter, as required. None of the youth were applicable to renewing prescription medication
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which had expired. For two applicable youth, when an evaluation was conducted off-site, the
evaluation was documented on the Summary of Off-Site Care Form and filed in the IHCR
Chronological Progress Notes. The DHA followed-up with the youth after receiving off-site care
and signed off on the documents for both youth. There were no indications of lapses in care or
missed periodic evaluations for either youth. The Department’s Problem List was updated for all
three youth, as required.
The facility administrator (FA) was interviewed regarding what formalized procedures are in
place with the healthcare staff to review the important youth medical issues and how often the
FA meets with healthcare staff. The FA stated the health services administrator (HAS) ensures
all admitted youth receive a preliminary screening including a review of their medical history to
assess medical needs. The assessment is conducted within initial intake processes upon
program placement. Upon admission, the on-duty health care staff review the youth’s previous
medical records, conduct a thorough assessment of the youth and complete the FEPHS) form.
A health care admission rescreening will be completed each time the physical custody of the
youth changes and they are subsequently returned or readmitted to the facility. If the screening
is completed by a direct care staff, it will be reviewed within twenty-four hours by the nurse. An
interview with the DHA confirmed periodic evaluations for youth with chronic conditions are
completed and tracked every ninety days, as required, which is ensured by consistently
reviewing the Chronic Log. An interview with the nurse confirmed all youth with chronic
conditions are seen by the DHA every three months. Youth chronic conditions are identified in
the Chronic Log by disease process with a coded number, which is monitored by all nurses on
the medical tracker, and in the chronic clinic book.
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 facility operating procedure (FOP) for medication to be received, stored,
inventoried, and provided in a safe and effective manner. Five youth individual health care
records (IHCRs) were reviewed for medication management. Two of five youth records had the
Facility Entry Physical Health Screening (FEPHS) form and progress notes indicating the youth
was admitted with medication. For both youth taking medication at admission, the medication
was verified prior to being admitted into the program and the prescription verification was
included in the Chronological Progress Note, in the IHCR/Electronic Medical Record (EMR)
and/or by utilizing the Prescription Medication Verification Checklist. For both records, the
designated health authority (DHA)/designee, and when applicable, the psychiatrist was
contacted to obtain the order to resume the specified medications prescribed prior to admission.
When current medications were continued, discontinued, changed, or new ones were ordered,
the DHA placed an order on the Practitioner Order Form in both records reviewed. Neither of the
youth were applicable to restricted housing.
For the two of five youth records applicable for over-the-counter (OTC) medications not listed on
Department’s Authority for Evaluation and Treatment (AET) form were administered according
to approved protocols or Practitioner’s Order unless the parent/guardian prohibited the
administration of OTC medications. Four youth were applicable to taking medications of any
kind. The standard Department Medication Administration Record (MAR) was used to document
all medication and treatment, and the MAR clearly indicated medication start and stop dates for
all four youth. Only licensed healthcare staff delivered medications, and the staff initialed each
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medication entry in each record, as required. There were no undocumented explanations for a
lapses or errors in medication administration in any of the records reviewed. The nursing staff
documented weekly side-effect monitoring on the MAR for all four records reviewed. Two
records were applicable for refusing medication and in both records, the youth signed the
Refusal of Treatment form indicating the refusal, and the refusals were clearly documented on
the MAR. All five youth records contained a MARS which included all the required elements
including name, Department of Juvenile Justice identification number (DJJID), date of birth,
allergies, precautions, Medical Grade, medical alerts, and a current picture of the youth
attached to the MAR. All four applicable youth receiving medication while at the program
initialed each provided medication entry, as required. The remaining youth record contained a
MAR, but the youth had not received any medication while at the program. None of the youth
required parenteral medication.
There were no standing orders for psychotropic medications, emergency treatment orders for
psychotropic medication, or pro-re nata orders for psychotropic medications. Medication delivery
is the sole responsibility of the nurse/staff person during the time of administration. Medication
administration was observed during the annual compliance review. Direct care staff escorted
youth to the medical office. The youth approached the nurse administering medication
individually. The medical provider identified themselves and stated why the youth was there,
prepared and administered the medication, verified each youth’s allergy and alert status, and
initialed the youth’s MAR along with the youth. Only the registered nurse provided medications.
Staff observed the youth to make sure the medication was swallowed. No OTC medications we
administered. Prescription medications were not pre-poured from original packaging and placed
in another container for subsequent administration. The Six Rights of Medication
Delivery/Administration were verified: right youth, right medication, right dosage, right time, right
route, and right documentation.
Five youth were interviewed regarding the medication process. All five youth stated the nurse
gives youth their medication and all five were able to explain the proper medical pass
procedures. An interview with the nurse confirmed each youth’s medication is verified upon
admission using the prescription medication sheet. The medication is verified prior to arrival and
recorded on the transfer form. The form and the medication are checked by the receiving nurse
when youth arrives at the program. All medications must have a pharmacy label intact with the
youth’s name on it. Non-health care staff would use the form as well and could have access to
the nurse or DHA if they require assistance. The program uses a pre-printed pharmacy MAR
from 1st Choice Pharmacy. The nurse confirmed non-healthcare staff can provide medication
after medical hours for OTCs to the youth. Staff are trained by the health services administrator
(HAS) for FOPs. Trained staff, including the trained facility administrator and assistance facility
administrator, can also give prescription or OTC meds. The approved staff medical pass list is
posted on the medical cart closet door and in the alert log in master control. The nurse
confirmed the program does not provide gynecological exams regularly and does not have a
modified Class II permit. Medications are sent into the pharmacy via fax transmittal to 1st
Choice Pharmacy. Most of the youths’ medications are procured through our contracted
pharmacy. Community pharmacies are used in case of urgent medication requests. The
licensed psychiatrist is on-site twice a month to provide psychiatric/substance abuse evaluations
and medication management.
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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 facility operating procedure for psychiatric services including psychiatric
evaluation, psychiatric consultation, medication management, and medical supportive
counseling provided to youth with a diagnosed mental disorder and each youth receiving
psychotropic medication in the program. Psychiatric services are provided by a psychiatrist with
a clear and active license, or a psychiatric advanced practice registered nurse (APRN), and
meeting requirements in Florida Administrative Code. The psychiatrist has a clear and active
license in the state of Florida with a license expiring January 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist or psychiatric APRN providing psychiatric services briefs a representative of the
treatment team regarding the psychiatric status of each youth receiving psychiatric services who
is scheduled for treatment team review. The psychiatrist or psychiatric APRN’s evaluation and
recommendations for the youth are incorporated into the mental health clinical staff’s
evaluations of the youth and the youth’s individualized mental health or substance abuse
treatment plan. The psychiatric APRN position is a designee for clinical responsibilities only. The
psychiatric APRN has a clear and active license in the state of Florida with a license expiring
July 31, 2026. The psychiatric APRN’s education, experience, and certification/licensure is in
psychiatry/mental health, as stated on the Department of Health website. The psychiatric APRN
has a Collaborative Practice Protocol in place. A review of the Collaborative Practice Protocol
with the APRN verified a copy is maintained on-site and specifies to be with the psychiatrist on-
site. A review of sign-in/out logs confirmed visits during the annual compliance review period
were conducted as required by the contract or agreement. The psychiatrist actively participates
in, manages, and supervises psychotropic medication services in the program. When duties
were delegated to the psychiatric APRN, reviewed documentation indicated the psychiatrist
provided biweekly on-site supervision of the APRN’s medication management services and was
available to evaluate and monitor youth as needed. When duties were delegated to the
psychiatric APRN, the psychiatrist was available to the APRN by telephone or by another
communication device when not physically available on the premises. The program had a back-
up psychiatrist of equal education to the psychiatrist, with a clear and active license in the state
of Florida with a license expiring January 31, 2027. The program does not provide
telepsychiatry.
An interview with the psychiatrist confirmed his role at the program is to coordinate treatment,
including evaluation and medication management which is completed twice per month. The
psychiatrist confirms they meet with the designated mental health clinician authority (DMHCA)
and the facility administrator to discuss youth receiving psychiatric services every two weeks.
He also meets with the nursing staff and counselors every two weeks to review the important
medical issues pertaining to the youth at the program receiving psychiatric services. All
communication while on-site is face-to-face with the nurses and when off-site, communication to
nurses, therapists and the clinical director is completed telephonically. An interview with the
DMHCA confirmed he meets with the psychiatrist bi-weekly.
Five youth records were reviewed for psychiatric services. Two of the youth were applicable for
entering the program on psychotropic medications. The program had no other youth applicable
to entering the program on psychotropic medications. All five youth were referred for a
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psychiatric interview. For both youth admitted on psychotropic medications, each youth received
a diagnostic interview within fourteen days of admission, as required. One other youth was
placed on psychotropic medications after admission to the program after an initial diagnostic
interview was completed. For all three applicable youth reviewed, the Initial Diagnostic
Psychiatric Interview included all the required elements. The interview was completed on the
Department’s Clinical Psychotropic Progress (CPPN) form for all three records and was clearly
identified as the “Initial Diagnostic Psychiatric Interview.” For two youth, the initial psychiatric
diagnostic interview resulted in the prescription of psychotropic medications or changes to the
youth’s existing psychotropic medication regimen, and page three of the CPPN was completed
for both records, as required. For one youth, the psychiatric evaluation resulted in the
prescription of psychotropic medication and page three of the CPPN was completed. The
reviewed documentation supported the youth were seen for a medication review by the
psychiatrist or psychiatric advanced practice registered nurse (APRN), at a minimum, every
thirty days in all three records reviewed. For all three youth, documentation on page three of the
CPPN was completed when psychotropic medication was prescribed/dispensed/administered
by the psychiatrist or psychiatric APRN, which included all required elements. The program
does not use telepsychiatry.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a facility operating procedure regarding 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 medical equipment classified as sharps (e.g., syringes,
needles, scissors, and suture removal kits) was secured and inventoried utilizing a routine
perpetual inventory descending count as each sharp was utilized and disposed, as required. All
medications were identified and secured in the locked area designated for storage of
medications, and different medications such as injectable, topicals, drops, liquids were
separated. The program does not have narcotics or controlled substances currently on-site, but
does have a separate, secured area, behind two locks, which is inaccessible to youth in the
event the program ever needs to keep controlled substances in the program. Medications which
require refrigeration are stored in a secured refrigerator, which is used for medication only. A
Drug Buster disposal kit is used for the destruction and disposal of expired or discontinued
medications. Discontinued PolarisRX medications which are not expired are returned to the
pharmacy for credit. Perpetual and weekly inventories of all sharps and stock over-the-counter
(OTC) medications were completed as required. Pursuant to Board of Pharmacy regulatory
requirements, there are shift-to-shift inventory counts of all controlled substances documented
on the youth’s Individualized Controlled Medication Inventory Record when applicable. Seven
supervisory-level, non-healthcare staff are trained in the delivery and oversight of medication
self-administration, which was delivered by the program’s registered nurse (RN). Counts were
conducted of three over-the counter (OTC) medications and three sharps and all counts match
the ending inventory numbers. The program does not keep controlled substances, as such, no
count could be conducted. The reporting criteria and procedures regarding inventory
discrepancies includes completing a recount, reporting the discrepancy to the supervisor and
program director, and calling the Department’s Central Communications Center (CCC) to report
the discrepancy.
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An interview with the nurse confirmed Alachua County Health Department dental services are
utilized twice a month for youth to attend dental cleanings, x-rays and obtain teeth sealants to
prevent cavities, and receive fillings, extractions and address other dental health related
concerns. Medications are secured behind two locked doors in the medical clinic. Medications
are counted daily and re-ordered as prescribed and as needed. Stock orders are assessed and
ordered as needed.
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 had a facility operating procedure (FOP) to include implemented Infection Control
procedures including prevention, containment, treatment, and reporting requirements related to
infectious diseases, as according to Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
FOPs were signed by the program’s designated health authority (DHA) on January 7, 2025, and
facility administrator (FA) on January 1, 2025. The infection control procedures include all the
required elements. Hepatitis B immunizations are available for all staff and staff have access to
protective equipment. There were no instances in which the local county health department,
CDC, and/or Department’s Central Communication Center (CCC) should have been notified of
an infectious disease. The program director/designee has established a separate file used for
containing all documents for youth and staff who have experienced a facility/occupational
exposure.
The exposure control plan was written in accordance with OSHA standards and is available to
all staff. The plan was reviewed and signed annually by the administration of the program and/or
designees and was signed January 1, 2025. The program’s process for needle stick post-
exposure evaluation includes the FA arranging for a confidential medical evaluation, follow-up
post-exposure analysis and counseling as required by the OSHA Standard. The FA established
a separate file maintained for youth and staff who have experienced a facility/occupational
exposure. There were not three or more cases of any reportable infectious diseases which
needed to be reported to the local county health department and/or CDC during the review
period.
An interview with the nurse confirmed a copy of the Exposure Control Plan is available to
medical staff in the medical closet. Infection control training for staff is conducted by the register
nurse (RN) or health services administrator (HSA). The RN conducts a monthly discussion on
washing hands, hygiene, and infection prevention with youth which is either discussed
individually or in a group environment. The RNs and HSA are responsible for providing training
to staff on the program’s Exposure Control Plan. An interview with the FA confirmed the
Exposure Control Plan is in a binder in the medical clinic. Also, the HAS conducts infection
control training for staff. In addition, infection control training is provided to youth upon
admission by an RN on intake.
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4.20 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has a facility operating procedure (FOP) to provide access to prenatal care for all
pregnant youth and health education to both youth and staff. Five youth records were reviewed
for prenatal care and education. None of the five records were applicable, as such, the program
provided three additional records for review. For all three records, prenatal care began
immediately upon determination the youth was pregnant and continued until discharge/transfer
and through postpartum. The designated health authority (DHA)/designee, physician’s assistant
(PA), or advanced practice registered nurse (APRN) provided routine, focused medical
evaluations of the youth’s pregnancy every thirty days, or sooner if ordered, for all three records.
The youth was placed on the internal alert system for vital nutrition and health awareness for
staff and an alert entered into the program’s internal alert system regarding the youth’s sleeping
arrangements in all three records. All three youth signed a waiver to decline Human
Immunodeficiency Virus (HIV) testing, which was filed in each youth’s individual health care
record (IHCR). When the youth has complained of issues related to pregnancy, the DHA was
immediately notified in all three records. There was a documented plan for post-birth
psychological and physical care for all three youth. All three-youth received prenatal and/or
postnatal care at recommended intervals. The youth receive nutritious food in quantities
appropriate for pregnant youth as ordered by the practitioner and the licensed healthcare
professional staff provided routine monitoring of the pregnant female’s nutritional and weight
status during the course of the pregnancy for all three youth, as required. Education was
provided to all three youth regarding alcohol and drug use, smoking, nutrition, sexually
transmitted infections, contraception, prenatal care, birthing process, postpartum care, basic
baby care, child/infant development, and parenting skills. All education was documented in each
IHCR on the Health Education Record. All non-healthcare staff involved in the supervision or
treatment of pregnant youth received in-service education on girl’s healthcare annually. A
licensed nurse provided in-service education on youth prenatal healthcare annually to all non-
healthcare staff involved in the supervision or treatment of youth. In-service training included
observation and monitoring of emergency care needs/symptoms of possible miscarriage. The
program has nursing protocols and treatment plans for pregnant youth.
An interview with the nurse confirmed the program provides monthly visits with the DHA,
appointment scheduling and management, obstetric appointments, special laboratory visits as
needed, and in-house laboratory work as needed. Pregnant youth also receive daily to weekly
visits with the nurses, as needed. Nurses weigh the youth weekly, take vital signs to evaluate
blood pressure problems, check for edema, check for youth reports of baby movements, and
provide education. Youth are routinely tested for pregnancy upon admission, according to the
program’s policy. Pregnant youth are given extra vegetables and fruits and healthy snacks. The
registered nurses provide education to non-healthcare staff regarding healthy signs and
complications of pregnancy. Youth are educated on pregnancy stages, what to look for and
report to nurses, and are given pregnancy and delivery handouts and books to read.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains facility operating procedures (FOPs) stating they will always maintain
active supervision of youth. According to FOPs, staff-to-youth ratios are as follows: 1:8 during
day-time activities and 1:12 during sleep hours. Observations of staff during the annual
compliance review week included in the classroom, while youth were giving a tour to the review
team, pat down searches, during sleep hours, movement, response to a disturbance, and
breakfast. During each observation, staff-to-youth ratio was appropriate and in accordance with
procedures. Positive interactions between staff and youth were observed. An informal interview
with three staff indicated they knew immediately the number of youth they were supervising.
The policy and procedures include interacting positively with the youth, engaging youth in a full
schedule of constructive activities, closely observing behavior of youth and changes in behavior,
and consistently applying the program’s behavior management system. The daily schedule is
posted and available to youth in the living unit and in the dining hall. Observations of youth
rooms confirmed windows were not covered by any means which would affect the direct line of
sight of youth. There were no escapes during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
A review of the program’s behavior management system (BMS) was conducted to ensure the
appropriate parties were involved in the development, implementation, and on-going
maintenance of the BMS. The program’s facility operating procedures include a protocol where
staff are provided with feedback regarding the implementation of the BMS. There is an
agreement between the program and the school related to the BMS. The education staff are
trained in the BMS and there are rules and guidelines for BMS in each classroom. Five youth
case management records were reviewed and confirmed the orientation provided to each youth
included a review of the program’s BMS. Four position descriptions were reviewed and all four
included the implementation of the program’s BMS. Five staff training records were reviewed,
and all were trained in the program’s BMS. Postings of the BMS were observed in classrooms
and the common area. The phase sheets and how to earn the next level in the program were
observed in the common area. The grievance forms and box were in a central location for the
youth. The BMS was in the student handbook the youth receive at orientation and was
confirmed during review. The BMS has not been changed and was not in the process of being
changed during the annual compliance review period. The BMS included all the required
elements including youth recognition of accomplishment and positive behaviors using a four-
positives-to-one negative ratio. Staff and youth positive interactions were observed throughout
the week of the annual compliance review. There were no negative interactions observed during
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the week of the review. The program provides a variety of incentives for the youth: recognition
of good behavior from the time they arrive at the program by being awarded a varsity jacket,
Mega-Monday for youth who have no negative incidents over the weekend, extra snacks, off-
campus outings, and participation in dance or choir.
Five staff were interviewed and all five were familiar with the BMS used in the program. Each
understood the level expectations, timeframes, and point system. The five staff reported youth
rewards include movie night, extra snacks, special dinners, point store, off-campus outings, and
game day. All five staff confirmed basic rights cannot be taken away from youth consequently.
All five interviewed staff explained the youth are informed of the consequences of their behavior
and are provided an opportunity to explain their behaviors during emergency treatment team,
behavior meetings, and are notified at the time of the behavior occurrence. Five youth were
interviewed and asked about rewards and consequences in the program. Three youth described
receiving red-level for negative behavior, three youth indicated an emergency treatment team
takes place, and one youth also indicated a level may drop also. All five youth indicated the
program provides rewards for positive to include an activity in school on Friday, weekly special
meals, outings, the point store, movie night, extra snacks, and a special jacket. All five
interviewed youth were familiar with the level/point system used at the program. Each youth was
able to explain, in detail, each level’s expectations and how to progress in the BMS. All five
stated youth are never allowed to punish other youth. Four youth indicated all staff administer
the BMS fairly and consistently. One youth indicated staff pick and choose. The facility
administrator (FA) was interviewed and reported the BMS utilized at the program ensures the
youth are held accountable for their behavior either positive or negative. The rules governing
conduct and positive and negative consequences are posted in the student handbook in which
the youth can access daily. The FA ensured the BMS is based upon the youth’s status
progression, daily progress notes, and code of conduct. All staff have received training on the
BMS during the first phase of employment. Youth are rewarded for positive behavior. When a
youth consistently displays positive behavior, they can earn incentives including off-site trips,
restaurant outings, personal items, and other rewards. The FA went on to report, consequences
are monitored through the program’s code of conduct and the BMS. Program staff and
education staff are trained in the implementation of the program’s BMS. The shift supervisors
and youth care workers provide feedback regarding the implementation of the BMS during staff
briefings, shift meetings, and random conversation throughout the day. The youth are informed
of their consequences and are allowed an opportunity to explain their behavior. The staff
implementation of the BMS is monitored through daily documentation and cross referenced with
write-ups and disciplinary action provided to the youth as well.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s facility operating procedures or contract states the program does not use
restricted housing, to include confinement, seclusion, room restriction, or secure observation;
therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a facility operating procedure to 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. The program has fifty-six cameras, all of which
were operational at the time of the annual compliance review. The video recordings are stored
for thirty days. The program’s practice is to conduct checks of youth in their rooms every eight to
ten minutes. Eleven months of ten-minute check sheets were reviewed, finding no more than
ten minutes passed without the staff actively observing each youth. Video review of nine
samples of ten-minute checks in thirty-minute increments on both dorms was conducted. Forty-
one total ten-minute checks were reviewed. All ten-minute checks were conducted within the
required frequency except for three checks, which were one minute, two minutes, and eight
minutes late. When questioned about the discrepancy in video versus the check sheet, the
program reported the staff use their personal watches; therefore, the time was off and as a
result the program is installing two digital clocks for each end of the living unit hallway. Five staff
were interviewed, and all confirmed room checks are conducted every eight minutes when a
youth is placed in their room for sleeping or non-punishment reasons. The facility administrator
was interviewed and confirmed the program has fifty-six operational security cameras.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains facility operating procedures (FOPs) which address population census,
counts, and tracking of youth. The program’s FOP indicates program staff shall be able to
account for the whereabouts of youth under their supervision at all times. The program’s system
for accounting of youth requires the physical counting of youth at various times throughout the
day. Staff shall conduct and document counts minimally at the beginning of each shift, after
each outdoor activity, and during emergency situations such as escapes or riots. The program
shall maintain a chronological record of events as they occur within the logbook maintained in
master control. Daily census information at a minimum shall include the total daily census count,
new admissions, releases or direct discharges, transfers, and youth temporarily away from the
program. An observation of counts occurred in master control during the annual compliance
review week with the census count of twenty-five youth being cleared. Eleven months of
logbooks were reviewed. Counts are conducted at the beginning of each shift, after each
outdoor activity, and during emergency situations. The logbook also tracks daily census counts,
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head counts, youth movements, transfers, and youth temporarily away from the program. Five
staff were interviewed. All staff confirmed youth counts are conducted every hour. The staff
relayed emergency counts are conducted after a code is called, during drills, and when the
formal count cannot be reconciled.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains facility operating procedures (FOPs) addressing logbook entries. The
program maintains a chronological record of events, incidents, and activities in a logbook as
required by the FOP. Eleven months of logbooks were reviewed with each being bound with
numbered pages, and entries were made in ink with no white-outs or logbook entries being
destroyed or removed. In two applicable logbooks, all errors were struck through with a single
line and initialed by the staff correcting the error. In all logbooks, entries included the dates and
times of the events, with the names of staff and youth involved, brief descriptions of the events,
and the names and signatures of the staff making the entries. FOP requires logbooks to include
any internal incidents reported to the Florida Abuse Hotline or the Department’s Central
Communications Center; however, none of the samples contained applicable information. The
activity schedule and logbooks documented minimal interference of educational instruction with
entries indicating education classes were conducted as scheduled, and the youth arrived and
departed school on time. Logbook entries also confirmed recreation time for the youth was
conducted as scheduled. Logbook entries included emergency situations, incidents, special
instructions for supervision and monitoring of youth, population counts at the beginning and end
of each shift, and any other population counts conducted during a shift, perimeter security
checks and other security checks conducted by direct care staff, transports away from the
facility, including the names of the staff, youth involved, and the destination, requests by law
enforcement to access any youth, removal of any youth from the mainstream population, and
admission and releases, including the name, date, and time of anticipated arrival or departure
and mode of transportation. The program did not have any escapes during the annual
compliance review period requiring documentation in the logbook. On-coming staff members
participate in a shift briefing and sign the logbook acknowledging they are aware of all
information from the last shift and any alert changes. Each reviewed logbook entry was legible
and included the time and date of the entry, and printed name and the signature of the staff
member making the entry.
5.07 Key Control (CRITCAL) Limited 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.
Facility operating procedures addressed key assignment and usage including restrictions on
usage, inventory and tracking of keys, secure storage of keys not in use, missing or lost keys,
and reporting and replacement of damaged keys. A review of the inventory matched the key
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rings in use. Observations during the annual compliance review week found the staff personal
keys are kept in a secure lock box within master control which is not accessible to youth. Each
set of keys has an assigned key hook. Keys are assigned to staff according to their department.
A tamper proof box was observed in master control where restricted keys are stored. The
program’s process for reporting and replacement of damaged keys states damaged keys are
reported to the shift supervisor who will complete a maintenance request form. There were no
incidents reported to the Department’s Central Communications Center (CCC) or Program
Monitoring and Management (PMM) deficiencies related to key control concerns during the
annual compliance review period. An informal interview with the facility administrator about the
process for restricting usage of keys such as medical and youth and staff records keys
confirmed keys are kept in a locked key box in master control. Medical keys are only given to
medical staff. Case management staff are given access to youth records and human resource
staff and administration are given access to staff records. A sampling of five key rings was
observed and compared to the inventory and key log and found one count was correct. One set
of keys was not listed on the inventory and the key tag number did not match the actual number
of keys on the key ring. The remaining three incorrect sets of keys did not have the correct
number of keys listed on the inventory. An informal interview was conducted with three staff.
Each staff knew the number of keys on their key ring and the function of each key. Five staff
were interviewed. All staff confirmed they give their personal keys to master control upon entry
and their personal keys are securely stored. One staff confirmed visitor keys are given to master
control upon entry and one staff stated the visitors are given a chit to receive their personal keys
upon leaving. Four staff confirmed program keys are assigned to the staff the beginning of their
shift and an inventory of the keys is kept. Three staff relayed there is a daily key log kept in
master control. One staff mentioned if they lose their keys, master control must be notified and
then an emergency count is conducted.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system in place to prevent contraband entering the facility which includes
the program defining items/materials considered contraband, as well as exemptions, providing
youth with a list of contraband and informing them of consequences if found with contraband,
and searching the physical plant, facility grounds, the youth, incoming mail, and outgoing mail.
The program’s visitor log contains a contraband attestation statement. There were twenty-four
new staff hired since the last annual compliance review and all twenty-four staff completed the
attestation forms. The facility operating procedures also state any staff who is found in
possession of contraband in the program will be subject to disciplinary action up to, and
including, dismissal, as well as procedures regarding notification of law enforcement for items
considered illegal as defined in Florida Statutes. The program clearly delineates those items
considered contraband to include, but not limited to, sharps, escape paraphernalia, tobacco
products, lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food
or clothing, any intoxicating beverage, any controlled substance, any prescription or non-
prescription drug, any firearm or weapon of any kind or any explosive substance, non-facility
issued electronic equipment or devices to include smartwatches, metals, personal cell phones,
unauthorized currency or coin(s), and non-facility issued keys. The program maintains room
search forms which document any contraband findings and documents these findings in the
program logbook; however, there were no instances of contraband being found during the
annual review period. The facility administrator (FA) was interviewed and reported contraband
items designated as contraband are prohibited on campus by staff, volunteers, contractors,
visitors, or students. During orientation, all youth were given a youth handbook which lists all
items considered contraband, and there are postings of a list of contraband items throughout
the program. The program conducts contraband searches of the physical plant, facility grounds,
each youth, and incoming and outgoing mail. Program policy addresses any staff who is found
in possession of contraband in the program and law enforcement is to be contacted if any item
is considered illegal as defined in Florida Statutes or if there is evidence of any type of unlawful
activity. All contraband discovered is confiscated and harmful contraband is turned into the FA
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who will contact the appropriate authorities if needed. Five staff were interviewed. All staff
indicated youth room searches are done daily.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a facility operating procedure addressing searches and full body visual
searches. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the facility. During the annual compliance review week,
youth searches were observed during movement to and from class and following access or
ability to obtain tools. Youth were observed using a broom, dustpan, mop, and mop bucket.
Youth were being observed at a ratio of one to three. Youth were supervised closely during the
entire time they were using tools. Youth were searched after completion of using tools by a staff
member of the same gender. Youth were treated with dignity and respect during the search to
reduce stress and embarrassment. Searches were also conducted as required by the right
interactions (RI) training manual. Youth searches during admission, before and after visitation,
and upon return from off-campus activities were unable to be completed as these activities were
not completed during the annual compliance review week. Video review of five staff and visitor
searches was completed. Two days of visitor searches were observed showing the visitors were
scanned with the handheld metal detector, patted down, and their shoes were removed and
searched. Three days of staff searches were observed showing staff being scanned with the
handheld metal detector, being patted down, removing their shoes and having them searched,
and having their bags searched. Five staff were interviewed. All five staff confirmed the youth
are checked every movement. The staff check shoes and conduct a pat down. Five youth were
interviewed, and all stated they receive visual and full body searches. They stated the searches
occur when returning from off-campus activities, after outdoor activities, when items are
missing, after visitation, and after meals.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a facility operating procedure addressing vehicles and maintenance.
The program has two vans to transport youth. The program is currently in the process of
obtaining two new vans; however, the program has not received the new vans as of the time of
the review. During the annual compliance review week, eight vehicles including (six staff
vehicles and two program vehicles were checked one day to ensure the vehicles were locked
while not in use. Observations found all checked vehicles were locked. Of the two program
vans, one had documentation of a current annual safety inspection completed with the previous
inspection being done on both vans June 4, 2024. Maintenance records for both vehicles were
documented, both were always secured, and both contained a fire extinguisher, approved first-
aid kit, seatbelt cutter, window punch, appropriate number of seat belts, and child safety locks.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a facility operating procedure (FOP) addressing transportation of youth,
outlining staff to youth ratio during transports as one-to-five; however, if there are five or less
youth, a minimum of two staff are needed to perform all transports, and one must be the same
gender as the youth. The program’s FOPs meet all requirements outlined by the Department’s
policy. FOPs, observations, and interviews verified staff will utilize a facility cellular telephone
during transports During the annual compliance review week, an observation of a transport was
unable to be observed. The human resource manager at the program ensures all staff operating
a program vehicle has a current driver’s license by completing a driver’s license check during
the hiring process and annually thereafter along with monthly updating of the approved driver’s
list. Five staff were interviewed. All five confirmed if youth are coming or going, they utilize a
seatbelt and doors remain locked. One staff drives and the other staff will ride in the back with
the youth. All staff taking youth on transports have a two-way radio and a cell phone they check
out from master control. Staff confirmed safety equipment utilized includes flashlight, first-aid kit,
suicide response kit, emergency hazard kit, and youth information binder. All five staff stated
youth are never transported in personal vehicles and the transport vehicles are checked for
contraband prior and after each use. The staff indicated when emergency occurs while on
transport the staff would either call 9-1-1 or master control depending on what the emergency is.
Five youth were interviewed and each confirmed they were never handcuffed to any part of the
vehicle. All five youth confirmed they had never seen anyone place contraband in a transport
vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a facility operating procedure (FOP) which designates the facility administrator
(FA), assistant facility administrator (AFA), or a designee as being responsible for conducting
the weekly security audits and safety inspections. A corrective action plan will be developed for
all deficiencies noted on the Safety & Security Audit Tool. The corrective action plan will be
documented on the Safety & Security Audit Tool document. The FA will follow up on a weekly
basis to ensure the corrective action plan is followed thoroughly to correct the deficiency. A
review of the weekly safety and security audits binder ensured all weekly safety and security
checks were completed as required during the annual compliance review period except for two
weeks in November and three weeks in December. Reportedly the reports were completed and
received by the Department; however, were in the e-mail of an employee no longer reachable.
There were no program monitoring and management deficiencies documented in the
Department’s Juvenile Justice Information System (JJIS) during the annual compliance review
period. The program’s Preventative Maintenance Checklist was reviewed and meets the
requirements outlined in Florida Administrative Code. The interview with the FA confirmed the
programs FOPs include completion of a weekly Safety and Security Audit, the development and
implementation of corrective actions warranted as a result of safety and security deficiencies
found during any internal or external review audit, and inspection. If deficiencies are found, work
orders are put in place and all supervisors are notified along with administrators.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a facility operating procedure (FOP) to address tool inventory and
management of tools. The FOP addresses the issuance, inventory, and control of equipment
and tools. All tools are inventoried prior to being issued for work and following work activities. All
tools are inventoried daily such as sharp-edged and pointed tools except for days those tools
are not used. Machetes, bowie knives, and other long blade knives are not allowed. There were
no missing or lost tools during the annual compliance review. The physical plant manager does
have a practice in place in the event this happens. The facility is locked down with youth placed
into their rooms as well as a search, investigation, and video review completed. There were also
no broken tools which had to be disposed of and replaced during the annual compliance review,
however, there is a process in place should this event occur. The maintenance manager is
responsible for replacing and disposing of dysfunctional tools. A review of the inventory and
verification of ten tools found the tools to be secure, to have marking for easy identification, and
the inventory to be accurate except one rubber mallet not being listed; however, the
maintenance manager added the tool and began completing inventory of it while the review
team was on-site.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a facility operating procedure addressing youth tool handling and
supervision and includes supervision requirements when youth use tools, issuing tools to youth
and staff, including an assessment to determine a youth’s risk to self and others, and
established ratios, tool distribution and collection, and search criteria during work projects.
During activities involving tool use, the program maintains a ratio of one staff to five youth.
Based on observations during the annual compliance review week, the staff to youth ratio while
youth were using tools was one to three. During search procedures, the staff to youth ratio was
within the one to eight requirement. Five youth case management records were reviewed, and
all records indicated youth have been trained on the proper usage of class B tools during their
orientation process. Youth signed an acknowledgement of tool training form during the
orientation process. All reviewed case management records contained a risk assessment which
was completed prior to the use of tools. Five staff were interviewed and confirmed youth are
allowed to use mops and brooms under supervision. All five-youth confirmed they could use a
mop or a broom in front of staff when cleaning. Two youth indicated they are also allowed to use
a scrub brush.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which include
information regarding tool control and restrictions.
The program maintains a facility operating procedure which addresses outside contractors. The
program shall closely monitor the use of tools when brought into the facility or onto facility
grounds. When a repair person or other worker comes on-site from the outside community with
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the tools of their trade, program staff should alert them to the potential danger of tools used on
grounds and request them to limit the tools used to only those necessary to complete the job,
check tools when they arrive and leaves, keep close track of tools while working on-site. and
immediately notify program staff if any tool is missing. The outside worker or repairman will sign
an acknowledgment form indicating all tools must be inventoried upon entry into the program
and exit from the program. This acknowledgment shall be recorded on the Contractor Tool
Procedures Form and Inventory. When outside workers are on-site with tools, program staff
should restrict youths’ access to the work area to the extent possible, closely monitor the
situation, and vigilantly always supervise youth. When the work is completed, staff shall check
the work area to ensure the repair person takes all tools (and toxic substances, if applicable)
when they leave. If any tool brought on-site under these types of circumstances is found to be
missing, staff shall take immediate action per the program’s facility operating procedure. Sign-in
sheets for the contractors were reviewed. Each sheet includes the contractor's name, purpose
of visit, arrival time, whether or not tools are required, statement where staff checked the
contractors tools upon arrival, a list of tools to be utilized during the visit, whether or not tools
were missing after completion of project and if so, was there immediate reporting of the missing
tool(s) and follow-up which occurred; arrival and departure times; and signatures of the
contractor staff and program staff. The program inventoried the tools or other equipment when
the vendor arrived; however, several instances documented tools were not documented upon
contractor exit. Three program invoices were reviewed to ensure outside contractor agreements
were signed on the date of service. All invoices and contractor agreements matched and there
were no discrepancies found.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a facility operating procedure to provide for the safety and security of
both staff and youth in the event of an emergency or disaster. All drills for the annual
compliance review period were reviewed. The documentation showed drills were consistent with
the Continuity of Operations Plan (COOP). All drills contained the type of drill, date, time,
participants, and a brief scenario, including findings and recommendations. Drills were
conducted monthly on each staffing shift on a rotating basis. The types of drills completed were
fire, mental health, escape, medical, COOP (Bomb Threat), COOP (Riot/Disturbance), COOP
(Hurricane Drill), and Right Interactions (RI). Evacuation and egress routes were posted
throughout the facility, and all five fire extinguishers were inspected annually. Five staff were
interviewed and asked what drills they had participated in within the last twelve months. The
drills confirmed were fire drills, active shooter drills, suicide drills, medical drills, and missing
youth drills. Five youth were interviewed and confirmed they participate in fire-drills regularly.
One youth stated they occur once a month. The remaining four youth indicated they occur at
least twice monthly. Per the facility administrator, drills occur monthly to include fire, mental
health, medical, COOP, and RI.
Florida Department of Juvenile Justice Residential Annual Compliance Report
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5.17 Disaster and Continuity of Operations Planning Limited Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a facility operating procedure (FOP) addressing the Continuity of
Operations Plan (COOP). The program maintains a combined COOP and Emergency Disaster
Preparedness Plan. The FOP states the COOP is in the administrative hallway and master
control and observations during the annual compliance review week confirmed this practice as
well as confirming it is readily available to staff. The COOP was submitted to the Department for
approval on March 11, 2025, and last reviewed and updated on March 13, 2025.The plan
addresses alternative housing plans approved by the applicable Department regional
director/designee. The program has food and necessary supplies readily available in case of
emergency evacuation, which are maintained on-site in the kitchen storeroom and in master
control. Emergency equipment maintained at the program includes first-aid kits, gloves, soap,
window break, medications, and hygiene items. The program maintains an administrative hard
copy file on all youth in case of an emergency. This information is also required to be contained
in the COOP Binder/Transport Binders, which should contain all required information on all
youth. The program maintains two COOP binders, one for each van. Five youth emergency files
were reviewed and determined the binders were not kept as required by the COOP plan. One
youth’s information was not in one of the binders and was missing the photograph, committing
court, and overall health information in the other binder. Two youth were missing their
photograph, committing court information, and overall health status information in both binders.
One youth had no information in one binder and was missing their overall health status
information in the other. Program staff corrected the issues while the review team was on-site.
The facility administrator’s (FA) interview confirmed the COOP is in the FA’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains facility operating procedures (FOPs) addressing storage and inventory
of flammable, poisonous, and toxic items and materials. The program’s FOPs also address
chemical spills and clean-up of chemical spills. The maintenance manager will maintain
inventories of all flammables, poisonous, and toxic fluids used at the facility. Items identified as
flammable, poisonous, or toxic fluid may only be drawn by an authorized person. This includes
the maintenance manager, assistant facility administrator (AFA), safety, shift supervisors, cook,
and the facility administrator (FA). Youth are not allowed to handle these items, and do not have
access to where these items are being used and stored. As they are considered potentially
hazardous or dangerous, youth will not be permitted to clean, handle, or dispose of any other
person’s bio-hazardous material, bodily fluids, or human waste. All flammable, poisonous, and
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Office of Accountability and Program Support Page 65 of 69 (Revised August 2025)
toxic fluids must remain secured when not in use. All flammable materials such as paints, fluids,
and gasoline, are stored in a metal fireproof safety secured locker. All hazardous chemicals no
longer used or outdated will be disposed of by returning them back to the venders or hazardous
waste center and in accordance with the safety data sheet (SDS). The program’s flammable,
poinsonous, and toxic items are located in a flame-resistant cabinet located outside the physical
plant manager’s office, in a locked storage area within the kitchen, and in the locked laundry
room within a locked cabinet inaccessble to youth. The program maintains a perpetual inventory
of these items. The physical plant manager, FA, AFA, direct-care staff, and kitchen staff are the
individuals authorized to handle flammable, poisonous, and toxic items. The program’s physical
plant manager was interviewed on the proper procedures of disposing chemicals and confirmed
adherence to progam FOP. The physical plant manager further stated the program has not
needed to dispose of any chemicals during the annual compliance review period. Liquid waster
(dirty mop water, unused beverages) from work details was disposed of in the plumbing drains.
Kitchen staff dispose of kitchen waste by use of the plumbing drains. Kitchen grease is disposed
of monthly by a contracted grease disposal company. A review of ten flammable, toxic, caustic,
and poisonous items being maintained on-site were confirmed by the inventory with no items
missing, except for one item stating there were none on hand when there was actually one and
a SDS included for each except for three of the ten samples. The physical plant manager added
the required SDS to the SDS binder while the review team was on-site. An interview with the FA
indicated program FOPs include completion of a weekly Safety and Security Audit, the
development and implementation of corrective actions warranted as a result of safety and
security deficiencies found during any internal or external review audit, or inspection. If
deficiencies are found the issue will be discussed during the daily department head meetings
and during all staff meetings when staff from both shifts are present.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a facility operating procedure (FOP) addressing youth handling and
supervision of flammable, poisonous, and toxic materials. The program’s FOP states program
youth are not allowed to handle these items and they will not have access to where these items
are being used and stored. The program maintains strict control of flammable, poisonous, and
toxic items and materials. Youth do not use, handle, or clean up dangerous or hazardous
chemicals. There is restricted youth access to areas where these items are used or stored.
Video observation during the annual compliace review week reflected youth using a mop, broom
and dust pan, as well as cleaning rags. Staff were seen supervising youth during the entire time
youth were in possession of cleaning tools. Five youth were interviewed and all confirmed they
had never used any chemicals or cleaning products.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 69 (Revised August 2025)
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in 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 maintains a facility operating (FOP) procedure to allow visitation and
communication for youth while in the program. The program’s FOP states immediate family
members are allowed to visit during specified times. The program case manager and the
juvenile probation officer (JPO) shall review for verification and approval of visitor(s) placed on
the visitation roster. All visitors are placed on the roster and identified as appropriate and
inappropriate for visitation. This roster is kept in the youth’s individual management record.
Referring agents, attorneys, Department of Children and Families (DCF), Family Service
Workers, clergy, government officials, legislators, and medical representatives shall be
approved for visitation on an unlimited basis but must be pre-approved by the case manager or
designee to ensure the visit is planned and communicated to the appropriate staff on shift.
These visits will not count against the youth's normal visiting schedule. A special area shall be
set aside for official interviews. The program recognizes each youth's need for and right to
maintain contact with persons outside the program and. Written FOP governing youth
correspondence is made available to all staff and youth and is reviewed annually and updated
as needed. Copies of the regulations are mailed to a youth’s family within twenty-four hours of
the youth’s admission. Youth are provided access to publications, counsel, confidential contact
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Office of Accountability and Program Support Page 67 of 69 (Revised August 2025)
with attorneys, their authorized representatives, the courts, and legal material. Contact includes,
but is not limited to, telephone communications, uncensored correspondence, and visits. The
visitation schedule is posted throughout the program on the daily activity schedule. An informal
interview with facility administrator (FA) indicated visitation is scheduled every other Saturday. A
review of the visitation log confirmed visitation is being offered on Saturdays during the
scheduled times. A review of the telephone log and schedule determined telephone calls are
offered weekly on Thursday. Mail can be sent out any day; however, a review of the mail log
could not be conducted as the program had not been keeping one. A log was developed and
began being used while the review team was on-site. The program was able to show
documentation of copies of youth mail to confirm mail is sent and received. Alternative visitation
arrangements with parent/guardian(s) were available if needed. Documentation could not be
located where case management verified for youth with a history of human trafficking, they
request clarification from the juvenile probation officer (JPO) to verify the youth’s
parent/guardian and other family members are not under current or past investigation for human
trafficking-related charges; however, case management does review alert information during
orientation regarding any youth with a history of human trafficking. The program also has an
agreement with a third-party language service. whichoffers translation services by telephone
utilizing the telephone touch pad. Five youth were interviewed, and each youth stated they can
call their parent/guardian once a week and/or can send a letter. An interview with the FA
confirms the program offers interpreter services for youth whom English is not their primary
language. This service is provided in all areas of treatment, including individual and family
therapy and formal and informal treatment team meetings. Educational services have been
provided in Spanish, and as well to General Education Development (GED) youth.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a facility operating procedure (FOP) stating recreation and leisure
activities shall be provided. The FOP states the program will provide one hour of large muscle
activity daily, both indoors and outdoors, as well as provide youth access to other means of
mental and physical exertion throughout the day as appropriate. A review of the program’s
activity schedules confirms a range of supervised and structured indoor and outdoor recreation
and leisure activities are provided for the youth for at least one hour daily with large muscle
activity also being provided. Activities which promote social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness are also being
provided. A review of the logbook indicated recreation was conducted as scheduled. All
recreational activities were observed and monitored to ensure the program takes precautionary
measures to prevent overexertion, heat stress, dehydration, frostbite, hypothermia, and
exacerbation of existing illness or physical injury. A review of the program’s contract finds a
recreation therapist is required to be on staff. A review of the staffing roster revealed the
program has one recreation therapist with the appropriate credentials. A review of five youth
records revealed recreational therapy was included in each youth’s individualized performance
or treatment plan. Five youth were interviewed and all youth stated physical activities last at
least one hour. Some of the activities included kickball, running, basketball, volleyball,
cheerleading, step team, soccer, and other forms of exercising. Five staff were interviewed
regarding indoor and outdoor activities. All staff confirmed activities are at least one hour.
Outdoor activities Zumba, yoga, kickball, basketball, volleyball, church, painting, and running.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 69 (Revised August 2025)
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Appliable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 69 (Revised August 2025)

report_type: QI Residential

program_name_raw: Alachua Academy

rule: Indicator 1.14

excerpt: Advisory Board

rating: Limited Compliance

excerpt: Youth Needs Assessment Summary (YNAS)

rule: Indicator 2.09

rule: Indicator 2.11

excerpt: Performance Summaries and Transmittals

rule: Indicator 2.19

rule: Indicator 3.04

rule: Indicator 3.05

excerpt: Mental Health and Substance Abuse

rule: Indicator 3.06

rule: Indicator 3.07

rule: Indicator 3.08

rule: Indicator 3.10

excerpt: Suicide Prevention Services (Critical)

rule: Indicator 3.12

rule: Indicator 3.18

excerpt: Safety Planning Process for Youth

rule: Indicator 5.07

excerpt: Key Control (CRITCAL)

rule: Indicator 5.17