state: FL

facility_name: Tampa Residential Facility

summary: QI Residential - FY25-26 - 22 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Tampa Bay Girls Academy High-Max
Wayne Halfway House, Inc.
(Contract Provider)
9504 East Columbus Drive
Tampa, Florida 33619
Review Date(s): November 4-7, 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:
Amanda Nelson, Office of Accountability and Program Support, Lead Reviewer (Standard 1 and
3)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 4 and
5)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 4)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 2
and 4)
Meloney Rhynie, Florida Youth College, Regional Workforce Education Coordinator (Standard
2)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Interviews and
Standard 1)
George Simon, Rite of Passage, Regional Director of Clinical Services (Standard 3)
Program Name: Tampa Bay Girls Academy High/Max MQI Program Code: N/A
Provider Name: Wayne Halfway House, Inc. Contract Number: 10889
Location: Hillsborough County / Circuit 13 Number of Beds: 44
Review Date(s): November 4-7, 2025 Lead Reviewer Code: 177
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 p ro
O v e ra ll R a tin g S u m m a ry
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 f p u b lic a tio
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
1.04 Incident R eporting (C C C ) * 2.04 C lassification Factors, P rocedures, and R eassessm ent for A ctivities
1.06 P re-S ervice/C ertification R equirem ents * 2.10 P erform ance P lan R evisions and Incorporation of O ther P lans
1.12 Internal A lerts S ystem and A lerts (JJIS ) * 2.13 Treatm ent Team M em bers and M eetings (Form al and Inform al R eview s)
1.16 S pecial C ontract C onditions 2.15 E xit P ortfolio
2.01 Initial C ontacts to P arent/G uardian and C ourt N otification 2.16 E xit C onference
2.07 R esidential A ssessm ent for Y outh (R A Y ) A ssessm ents and R eassessm ents 2.19 C ontract S pecific C areer and Technical E ducation S ervices (R esidential C ontract P rovider)
2.09 P erform ance P lan D evelopm ent, G oals, and Transm ittal * 3.07 Treatm ent and D ischarge P lanning *
2.11 P erform ance S um m aries and Transm ittals 3.11 S ecure O bservation *
2.14 Transitions P lanning, C onference, and C om m unity R e-entry Team M eeting (C R T) 3.18 S afety P lanning P rocess for Y outh
2.18 E ducation A ccess (R esidential P rovider) *
3.08 S pecialized Treatm ent S ervices*
5.04 Ten M inute C hecks *
5.06 Logbook E ntries and S hift R eport R eview
5.16 Fire, S afety, and E vacuation D rills
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)
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
* 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
re s id e n tia l, p ro b a tio n ).
S a tis fa c to
N o n -A p p lic a
S a tis fa c to
L im ite d
S a tis fa c to
L im ite d
S a tis fa c to
S a tis fa c to
N o n -A p p lic a
S a tis fa c to
N o n -A p p lic a
L im ite d
S a tis fa c to
S a tis fa c to
S a tis fa c to
L im ite d
S a tis fa c to
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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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)
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 L im ite d
Y o u th O rie n ta tio n 2 .0 2 S a tis fa c to
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 S a tis fa c to
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 F a ile d
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 S a tis fa c to
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 S a tis fa c to
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 L im ite d
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 S a tis fa c to
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 L im ite d
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 F a ile d
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 L im ite d
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 S a tis fa c to
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 F a ile d
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 L im ite d
E x it P o rtfo lio 2 .1 5 F a ile d
E x it C o n fe re n c e 2 .1 6 F a ile d
Y o u th In p u t 2 .1 7 S a tis fa c to
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 L im ite d
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 r) 2 .1 9 F a ile d
* 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 e d ia te a tte n tio n if a
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 tin g in e a c h o f th e s e
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 a re a (d e te n tio n ,
re s id e n tia l, p ro b a tio n ).
O v e r a ll R a t in g S u m m a r y f o r S t a n d a r d 2
T h is s ta n d a r d h a s r e c e iv e d a s ta n d a r d -le v e l r a tin g o f F a ile d , a fo llo w -u p r e v ie w o f th e p r o g r a 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 f p u b lic a tio n o f th e p r o g r a m r e p o r t.
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 69 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* 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
re s id e n tia l, p ro b a tio n ).
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
F a ile d
L im ite d
S a tis fa c to
S a tis fa c to
F a ile d
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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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)
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
re s id e n tia l, p ro b a tio n ).
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
N o n -A p p lic a
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Limited
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Limited
5.07 Key Control * Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Limited
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 69 (Revised August 2025)
Program Overview
The Tampa Bay Girls Academy High/Max is a forty-four bed program, for twelve to twenty-one
year old females, located in Tampa, Florida. The program is operated by Wayne Halfway
House, Inc., through a contract with the Department. The program provides the following
services: Intensive Mental Health Services, Borderline Intellectual Functioning/Borderline
Developmental Disability Services, Developmental Disability Services, Mental Health Overlay
Services, Substance Abuse Treatment Overlay Services and Medically Complex Services for
high and maximum-risk females. In addition, the program fosters each youth by providing
Impact of Crime, Dialectical Behavior Therapy Skills Manual for the Adolescent, Living in
Balance, Moral Reconation Therapy, and Skillstreaming for the Adolescent. Additional provided
treatment services include family and individual therapy, therapy groups, and recreational
therapy. Program administration is comprised of a facility administrator, two assistance facility
administrators, clinical director, director of case management, and a health services
administrator. Case management services are provided by a director of case management,
three case managers, and a transitional services manager. Mental health staff at the program
include one licensed clinical director, two licensed assistant clinical directors, and three
unlicensed therapists. Medical services are offered from 7:00 a.m. to 7:00 p.m. daily and are
provided by a health services administrator who is a registered nurse (RN), five additional full-
time RNs, one pro re nata RN, one contracted medical doctor, and one contracted psychiatrist.
Educational services are provided by the Florida Scholars Academy and Florida Youth College.
The layout of the program includes: one large building which houses administration,
classrooms, case management, a medical clinic, dormitory rooms, and a cafeteria. The program
has ninety-two operating video security cameras providing coverage and all cameras were
operational at the time of the annual compliance review. At the time of the annual compliance
review, the program had two vacant positions: one recreational therapist and one non-licensed
therapist.
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 a policy and procedures addressing pre-employment background screening
for all staff, contracted staff, and volunteers/mentors/interns who provide services more than ten
hours a month and prior to contact with youth or with youth confidential records. An Annual
Affidavit of Compliance with Level 2 Screening Standards was completed and submitted to the
Department’s Background Screening Unit (BSU) on December 19, 2024, meeting the annual
requirement. A review of the program’s staff, volunteers, and contractor rosters found seventy
staff were applicable for an initial background screening during the annual compliance review
period. Each of the seventy applicable staff had a completed and eligible background screening,
as required, prior to contact with youth and confidential youth records. Reviewed documentation
validated a criminal history report was reviewed for each staff. None of the reviewed staff were
applicable for needing an exemption prior to working with youth. A pre-employment assessment
tool was administered for each direct care staff and a pre-employment assessment passing
score was documented in each reviewed direct care staff record. Sixty-nine of the seventy staff
were added to the program’s roster in the Agency for Healthcare Administration’s Clearinghouse
system, as required. The program stated the remaining staff member will be added to the
program’s roster. None of the reviewed staff had a break in service as indicated in the
Department’s Staff Verification System (SVS) requiring a new background screening to be
completed. Each staff member signed a contraband attestation form.
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 a policy and procedures to ensure program-related incidents, which place at
risk or have the potential to place at-risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. The program has a zero-tolerance policy
regarding any abuse. All staff shall immediately report any knowledge or suspicion regarding an
incident of abuse which occurred in the program by calling the Florida Child Abuse Hotline, and
additionally notification is made to the Department’s Central Communications Center (CCC) and
the program’s facility administrator or supervisor on duty as soon as possible. The program had
eleven incident reports of a claim against staff for physical, psychological, or emotional abuse
during the annual compliance review period. A random sample of five incidents was reviewed.
Four of five reviewed incidents were called into the Florida Abuse Hotline for allegations of
physical or sexual abuse. The remaining incident was not reported by the program; however,
the Department’s Central Communications Center (CCC) received the report from the Florida
Abuse Hotline for allegations of sexual abuse. Documentation confirmed four of five incidents
had an immediate management response to allegations. An interview with the program’s
statewide compliance manager reflected the program’s assistant facility administrator (AFA)
thought they had called the CCC with the allegations as law enforcement was called; however,
this did not happen. The AFA received corrective action for failure to report. Four of the five
reviewed incidents reflected the program removed staff from contact with youth and conducted
an internal investigation. The remaining incident the program could not find the documentation
of program conducting an internal investigation. Two of the five incidents resulted in the
termination of the staff member’s employment. None of program’s eleven incidents during the
annual compliance review period were substantiated. The program conducted the Trauma
Response and Caring Environment (TRACE) on July 2, 2025. Staff adhere to a code of conduct,
as acknowledged by the review of personnel records. A review of seven staff personnel records
confirmed this practice. A facility tour conducted during the annual compliance review week
confirmed telephone numbers for the CCC and Florida Abuse Hotline are posted throughout the
facility to include the dormitories and cafeteria. An interview with the facility administrator
confirmed the program’s practice. Seven youth were interviewed, and each youth stated they
feel safe in the program and have never been stopped from reporting abuse to the Florida
Abuse Hotline or CCC. Each youth stated the number for the Florida Abuse Hotline is posted
throughout the program. Six of seven interviewed youth stated staff are respectful when talking
to youth. The remaining youth stated staff are respectful most of the time; however, they can
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yell sometimes when other youth are irritating the staff. Each youth denied staff ever using
profanity when speaking to youth and no interviewed youth have ever exchanged telephone
numbers, emails, or social media information with staff. Seven staff were interviewed, and each
could articulate the process of reporting allegations of abuse. None of the interviewed staff have
ever witnessed another staff member preventing a youth from calling the Florida Abuse Hotline
or CCC. Six of seven interviewed staff stated they have never witnessed staff using profanity
when speaking with a youth. The remaining staff member stated they had observed one
instance of a staff member using profanity when speaking with a youth.
1.04 Incident Reporting (CCC) (Critical) Limited Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures to ensure notification of all reportable incidents to the
Department’s Central Communications Center (CCC) within two hours of incident or program
becoming aware of incident. The program had 160 CCC reports during the annual compliance
review period. A random sample of ten percent of all incidents were reviewed for a total of
sixteen incidents. Five of sixteen reviewed incidents were not reported within the required two
hour time frame. The five late reported incidents were sixty-seven hours and fifty-minutes late,
four hours and fifteen minutes late, two hours and fifty-six minutes late, fourteen minutes late,
and thirteen minutes late. The remaining eleven incidents were reported within two hours as
required. Fifteen of sixteen CCC incidents were applicable for requiring documentation in the
program’s logbook. Eleven of fifteen CCC incidents were not documented in the logbook. The
remaining four CCC incidents were recorded in the logbook. During the annual compliance
review week, the review team determined the program had failed to report an abuse allegation
to the CCC. Once the program was notified of this by the review team, the program gave
corrective action to the assistant facility administrator who failed to report. This incident did not
need to be called into the CCC during the annual compliance review week due to the CCC
already receiving the report from the Florida Abuse Hotline. The program did not have an
annual compliance review last year; therefore, the program was not applicable for experiencing
an increase of reportable incidents to the CCC since the last annual compliance review. Seven
staff were interviewed, and each could articulate the process for reporting incidents to the
Florida Abuse Hotline and/or CCC.
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 a policy and procedures addressing the use of the Right Interactions (RI)
curricula as the program’s Protective Action Response (PAR). The program had ninety-six RI
incidents during the annual compliance review period. A random sample of ten percent, ten
incidents, were reviewed. Eight of the ten RI incidents confirmed the RI report was completed by
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the end of the staff’s workday and included statements from all staff involved. One incident was
missing statements from two staff who were involved in the incident and the report was
completed a day late. The remaining incident included statements from all staff who were
involved in the incident; however, one staff narrative was completed two days after the incident,
and one staff narrative did not include the date the statement was written. None of the reviewed
incidents required the use of mechanical restraints, resulted in injury to the youth or staff
requiring notification to the Department’s Central Communications Center, nor did any of the
youth allege abuse. Each report was reviewed by a supervisor, a RI instructor, and the facility
administrator within seventy-two hours of the incident, except for one report which did not
contain the date/time of the supervisor review and one report which did not contain the
date/time of the post-RI review. None of the reviewed incidents’ post-RI interviews indicated the
need for a RI medical review. Monthly summaries of all RI incidents were submitted to the
Department’s regional office by the fifteenth of each month and are maintained by the program
during the annual compliance review period. The program’s RI rate during the annual
compliance review period was 23.49, which is above the statewide Residential RI rate of 2.57.
The program last updated their RI plan on July 24, 2025, and the Department approved the plan
on July 24, 2025. An interview with the facility administrator confirmed the program’s practice.
Seven staff were interviewed, and six were able to articulate the process of what staff should do
if RI is used. The remaining staff member was not direct care staff.
1.06 Pre-Service/Certification Requirements (Critical) Limited Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures to ensure all staff complete all required pre-service
training requirements within 180 days of hire. Policy states only youth care workers and shift
supervisors are considered direct care staff and/or counted in staff-to-youth ratio.
Documentation confirmed all training instructors were qualified to deliver training for the
program and the program submitted a pre-service training plan prior to implementation of pre-
service training which was signed on October 25, 2024, by all required parties except the facility
administrator. Seven staff training records were reviewed for completion of pre-service training
within 180 days of hire. None of the seven reviewed staff completed their required pre-service
training or 120 training hours within 180 days of hire. Four of seven staff completed their
required pre-service training after the program received the seven-day notification of their
annual compliance review. Two of the three remaining staff were missing one training course
each and the last remaining staff had supervisory training hours to complete. Three of seven
reviewed staff were applicable for supervisory training. None of the three applicable staff
completed sixteen hours of supervisory training in coaching, leadership, and personal
accountability within 180 days of hire. Two of three applicable supervisors completed the
required supervisory training during the annual compliance review week. The remaining
supervisor completed ten of sixteen hours during the annual compliance review week. There
were no staff applicable for returning to employment within two years of separation. Three
additional staff training records were reviewed for staff within 180 days of hire to ensure they
have completed the eight essential training courses prior to contact with youth. Each staff
member completed all eight required trainings and are on target to complete all required training
within 180 days; however, cardiopulmonary resuscitation/first-aid and automated external
defibrillator training was not entered into the Department’s Learning Management System.
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1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures outlining the in-service training requirements for staff.
There were no staff applicable for in-service training due to all staff being new hires during the
annual compliance review period. The program maintains an annual in-service training calendar
which is updated as changes occur and was submitted on October 25, 2024. The training plan
was approved by all required parties except for the facility administrator. Documentation
confirmed all program training instructors are qualified to provide training to staff.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures which includes training requirements for the
grievance process, as well as the informal, formal, and appeal phase. Youth are encouraged to
resolve issues and complaints through informal communication with program staff utilizing a
Request to Talk form called “What’s Tea”. This form is placed in the grievance box and
reviewed by the facility administrator who checks the grievance box daily. The program
maintained a grievance binder which contained all grievances for each month of the annual
compliance review period. The program had two grievances submitted during the annual
compliance review period and each was addressed within twenty-four hours by supervisor or
facility administrator/designee during the informal phase. Seven youth were interviewed, and all
indicated they knew where to find a grievance form and each knew what to do with the form
upon completion. All seven stated they could not ask staff for assistance in completing a
grievance form. The annual compliance review team did not inform program of this response
during the annual compliance review week. Seven staff were interviewed, and all were able to
accurately describe the grievance review process, indicated grievance forms are placed
throughout the program, and the process had three phases. All seven indicated the facility
administrator or supervisor reviews the grievances. Six of seven staff stated youth can request
assistance in completing the grievance forms, the remaining staff member did not mention staff
assisting youth in completion of grievance form as part of the grievance process. An interview
with the facility administrator confirmed the program’s grievance practice.
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1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures to ensure youth develop life and social skill
competencies while in the program. The program’s clinical staff, medical staff, and case
managers meet with youth to provide education on health, employment, parenting/family,
interpersonal relationships, money management, emotional regulation, stress, and other topics.
The program completed a training on October 11, 2025, with speakers from the local domestic
violence shelter to discuss teen dating/partner violence. Seven youth records were reviewed.
Documentation in each youth’s case management, mental health and substance abuse, and
individualized health care records confirmed the program’s practice. Seven youth were
interviewed, and each stated they are participating in either dialectal behavior therapy (DBT),
Moral Reconation Therapy (MRT), or Living in Balance groups for life skills and are provided
opportunities to role play or discuss the skills learned. An interview with the facility administrator
confirmed the program’s practice. An interview with the designated mental health clinician
authority confirmed youth are provided DBT, MRT, and Living in Balance groups and are
provided opportunities daily through the program’s behavior management system to
demonstrate the skills learned.
1.11 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Tampa Bay Girls Academy. For details related specific to IOC service
delivery, please refer to the annual SPEP report.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Limited Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
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Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to determine how new alerts are identified,
documented, updated, and communicated to staff. Any staff can identify and place a youth on
alert status; however, only medical, mental health, and facility administrator/designee can
update or close medical, mental health, and safety and security alerts. All alerts will be entered
and updated in the Department’s Juvenile Justice Information System (JJIS). Suicide alerts will
be updated or closed by the mental health clinical staff or a licensed mental health professional.
Medical alerts will be updated or closed by medical staff. Safety and security alerts are updated
or closed by the facility administrator or designee. The program maintains an internal alert board
in the staff break room as well as in master control and alerts are reviewed daily during shift
briefing. Food alerts are also maintained in the program’s kitchen. Seven youth case
management records were reviewed, and six were applicable for requiring entering or updating
alerts in the Department’s Juvenile Justice Information System (JJIS) for a total of thirty-five
alerts. Three of thirty-five alerts did not indicate who closed/updated the alert, one additional
mental health alert was closed by the facility administrator, not mental health staff as required,
and three alerts were not reviewed by any program staff. The remaining twenty-eight alerts were
reviewed by the appropriate program staff member as required. Eight of thirty-five alerts were
medical alerts which were open prior to youth’s admission to the program and were not
reviewed in JJIS by medical staff until one to four months after the youth’s admission. Nineteen
of thirty-five alerts were applicable for documentation in the program’s logbook. Nine of nineteen
applicable alerts were not documented in the logbook. The remaining ten alerts were
documented in the logbook. Nineteen of thirty-five alerts were applicable for requiring the alert
to be updated/closed. Five of nineteen applicable alerts were entered or updated late. Four
alerts were one day late, and one alert was ten days late. Twelve of thirty-five alerts were
applicable for being documented in the program’s internal alert system and in JJIS. All twelve
applicable alerts matched in JJIS and the program’s internal alert system. An interview with the
facility administrator confirmed the program’s practice. An interview with the program’s health
services administrator confirmed nursing staff will verify youth’s alert upon admission and will
make updates to alerts as needed. Seven staff were interviewed, and each staff stated they are
informed of youth alerts in shift briefing and/or the internal alert board in the breakroom.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains an official case record for each youth, which consists of three separate
records for each program area to include, case management, healthcare, and mental health and
substance abuse services. All reviewed individual management records contained the youth’s
name, Department of Juvenile Justice identification number, date of birth, county of residence,
and committing offense. Each individual youth case management record contained the required
sections to include legal information, demographics and chronological information,
correspondence, case management and treatment team activities, and a miscellaneous section.
All youth records were labeled “Confidential” and secured in a locked room or file cabinet also
labeled “Confidential” and inaccessible to youth.
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1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures to maintain a community advisory board which will
meet every ninety to 120 days. A review of advisory board sign-in sheets confirmed the program
held advisory board meetings on May 12, 2025, July 7, 2025, and October 13, 2025, which met
the ninety to 120 day requirement. A review of meeting invitations and attendance sheets
confirmed facility administrator solicited involvement from all required community partners. The
program did not reschedule any meetings during the annual compliance review period. The
program held meetings virtually. An interview with the facility administrator confirmed the
program’s practice. The annual compliance review team were unable to interview an advisory
board member during the annual compliance review week due to the board member not
responding to requests to speak with an annual compliance review team member.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to ensure staff are evaluated on established
performance standards once a year. A review of seven position descriptions confirmed
performance standards were clearly identified. Five staff were applicable for an annual
performance evaluation, and each staff had a performance evaluation completed annually as
outlined in program’s policy and performance standards matched staff position descriptions.
Three staff positions were applicable for job functions which include implementation of the
program’s behavior management system (BMS) and each position description included
expectations for implementation of the BMS. The program has had a vacancy for a recreation
therapist since August 23, 2025. The program previously had two recreation therapists who did
not have a bachelor’s degree in recreational therapy; however, the program received a waiver
from the Department to hire these staff. An interview with the facility administrator (FA) stated
continuous training and mentoring by supervisory staff has shown promising future staff
retention. The FA confirmed staff received performance evaluations based on established
performance standards. Seven staff were interviewed, four staff stated they receive
performance evaluations annually and three staff stated they receive performance evaluations
bi-annually.
1.16 Special Contract Conditions Limited 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 several additional services or items which were negotiated and outlined in the
provider’s contract with the Department. These special contract conditions are: providing three
snacks to the youth daily; transition specialist manager shall seek court orders for youth to go
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on outings to establish bank accounts, get identification cards, and other activities as allowed;
therapist are to create a relapse prevention plan with all youth; visitation should be taking place
every Saturday and Sunday; the program shall provide inspirational murals, individualized
comforters, sensory room, game room, and reflection area, faith-based services shall be
provided quarterly and quarterly documented attempts to provide religious services and
education encompasses all religions. Documentation was provided for snacks and indicated
youth are only receiving two snacks each day, instead of the required three. The program also
stated youth are not stable enough to leave the program to attend outings to obtain identification
cards and create bank accounts and other community activities. The program was only able to
provide an example of two relapse prevention plans completed for substance abuse treatment
overlay service youth; however, the special contract condition states each youth shall work with
their therapist to create a relapse prevention plan as a safeguard against relapse. The program
is currently conducting visitations every other Saturday; however, the special contract condition
states visitation should be conducted every Saturday and Sunday. The program youth have
individualized comforters, a sensory room, a game room, and a reflection area in the program.
The program currently does not have inspirational murals/posters due to the youth taking them
off the walls. The program currently holds faith-based programming every Saturday. A review of
the facility administrator (FA) interview indicated the program provides youth with training in
cardiopulmonary resuscitation/first-aid as part of the program’s contracted services; however,
the FA could not specify any of the additionally negotiated services/items in the program’s
contract.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures to review and analyze data in decision-making
practices. The program tracks various operation and safety and security data to include Right
Interactions (RI), incident reports, grievances, youth placed on precautionary observation, ten-
minute checks, and census. This information is shared daily during administration meetings, and
monthly with all staff and the program’s corporate office during the all-staff meeting. The
program shares data with the Department monthly and shares data with the community advisory
board. The program also sends out a quarterly newsletter with data trends and youth survey
results which is provided to the program’s Board of Directors and accreditation organization.
Documentation of administration and all-staff meeting minutes and emails to the Department
confirmed this practice. The program has utilized data to determine areas to retrain their staff to
improve their interactions with youth to include reducing youth on suicide precautionary
observations and Right Interaction responses, missed ten-minute checks, and training and
meeting sign-in sheets confirmed these re-trainings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Limited Compliance
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures establishing guidelines for initial contacts with the
parent/guardian, committing court, juvenile probation officer (JPO), and the post-residential
service provider, if applicable, for each youth. A review of seven youth case management
records was conducted, and each record contained documentation the parent/guardian was
contacted by telephone within twenty-four hours of each youth’s arrival to the program. Three of
the seven reviewed records also contained documentation the program provided written
notification to the parent/guardian with forty-eight hours of admission; two records contained
documentation of late notification, one by four days and one by six days; and the remaining two
records did not have documentation of the required written notification. Each record shall
contain documentation of notification to the committing court, JPO, and the post-residential
service provider, if applicable, within five working days of admission. Three of the seven
reviewed records had the required JPO notification; one was two days late; and the remaining
three records did not have the required JPO notification. Two of the seven reviewed records had
the required notification to the committing court; the remaining five did not. Four of the seven
reviewed records were applicable for post-residential services; two records are post-
commitment probation youth; and the remaining record was a direct release youth. One of the
four applicable records had the post-residential service provider notification; and the remaining
three records did not. The notification forms observed were not filled out in their entirety,
including blank signature lines for the case manager and facility administrator.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to ensure each youth receives an orientation upon
admission. The policy requires each youth’s orientation include the following topics: available
services, daily schedule, youth expectations and responsibilities, written behavior management
system, availability of medical and mental health and substance abuse services, information
about the Florida Abuse Hotline and the Department’s Central Communications Center, the
zero-tolerance policy regarding sexual misconduct, youth rights, contraband items, performance
planning process, dress code and hyenine, visitation and mail guidelines, release expectations,
community access, grievance procedure, emergency numbers, room assignment, and a facility
tour. Not included in the program’s policy was the special accommodations available to ensure
all written information about sexual misconduct policies conveyed to youth, with reading skill
limitations or have a visual or hearing impairment; however, the program was able to confirm
the intervention utilized for these circumstances. A review of seven youth case management
records was conducted, and each record contained documentation of a youth orientation which
began on the date of admission. A youth orientation was observed during the annual
compliance review week, and each required element was observed.
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Seven youth interviews were conducted, and each interviewed youth confirmed they received
an orientation which began within twenty-four hours of arrival. Each youth confirmed the
orientation contained 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.
The program has a policy and procedures to ensure each youth eighteen years old or older has
provided written consent before providing any medical or mental health information to the
parent/guardian. A review of seven youth case management records was conducted; only two
records were applicable. A third applicable record was selected to meet the minimum sample
size. All three applicable records contained the required written consent.
2.04 Classification Factors, Procedures, and Reassessment for
Failed Compliance
Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures to ensure each youth is properly assessed for
treatment services, room assignments, and activities while in the program. The program’s
classification process includes youth’s physical characteristics, age and maturity level, special
needs, history of violence, gang affiliation, criminal behavior, sexual behaviors and victimization,
vulnerability, human trafficking factors, and risk alerts (medical, suicide, escape, and security). A
review of seven youth case management records was conducted and two contained
classification documentation completed on the day of admission; the remaining five were not
completed at all Neither applicable record had suicide or escape risk factors; both had medical
risk factors; one had a security factor and the other had an additional risk factor. Both applicable
records had documentation of a review of the Department’s Juvenile Justice Information System
(JJIS) Alert List, confirmation each youth was classified for the purposes of room assignment,
and each record had the identified risk factors entered into JJIS. One of the two reviewed forms
did not have the room and dorm assignments noted on the form; the remaining form did have
this information. Four of the seven reviewed records were applicable for reclassification; the
remaining three did not have any reclassification needs. One of the four applicable
reclassification records had documentation of the reason for the reclassification; the remaining
three did not. None of the four reclassifications resulted in an increase in youth privileges or
activities. The program’s policy and procedures clearly outline the classification process and the
required factors which must be accounted for as specified in the Florida Administrative Code.
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The program reclassifies a youth when new information is obtained or if there is a significant
change is circumstance or risk level.
The facility administrator (FA) was interviewed about the factors considered when classification
and reclassification of a youth takes place. The FA confirmed each youth is initially classified at
admission utilizing the youth’s JJIS records and the program’s orientation interview of the youth.
The information utilized confirms the program’s reviewed policy and procedures.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures to ensure law enforcement is notified about any gang
related information collected about the youth. A review of seven youth case management
records was conducted, and none were applicable for gang notification. The program’s only two
applicable youth records during the annual compliance review period were reviewed. Both
applicable youth records contained the required documentation for gang notification to law
enforcement in each youth’s home county and in the county where the program is located.
These notifications were made prior to the Department’s Bureau of Monitoring and Quality
Improvement’s seven-day notification of the annual compliance review. Each record had the
required gang alerts in the program’s internal alert system and in the Department’s Juvenile
Justice Information System within twenty-four hours of admission. The program’s educational
provider is provided with the program’s internal alert system, and notification is completed with
this system. The program had documentation of notification to the juvenile probation officer in
each record; however, no documentation was located for the post-residential counselor in either
reviewed record.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to ensure all youth identified with gang association or
risk factors receive gang education and intervention while at the program. A review of seven
youth case management records was conducted, and none of these youth were applicable for
gang notification. The program’s only two applicable youth records during the annual
compliance review period were reviewed. Both applicable youth records contained
documentation of gang education and intervention. Each youth’s individual performance plan
(IPP) had gang related goals identified. The program utilizes Impact of Crime, according to
policy, to address gang prevention, and the assigned case manager utilizes a specific gang
curriculum during individual sessions. A review of the program’s gang individual session sign-in
logs was conducted and confirmed these interventions are being held as identified in each
youth’s IPP. The gang identified youth can develop a plan to disaffiliate with the criminal street
gang.
The facility administrator (FA) was interviewed and confirmed the program’s gang policy and
procedures.
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2.07 Residential Assessment for Youth (RAY) Assessments and
Limited Compliance
Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure each youth receives an assessment within
thirty days of admission to utilize when structuring the performance plan goals while in the
program. A review of seven youth case management records was conducted. Each record
contained documentation the initial Residential Assessment for Youth (RAY) assessment was
completed within thirty days of admission as confirmed in the Department’s Juvenile Justice
Information System (JJIS). Five of the seven reviewed records were applicable for re-
assessment(s), which are required every ninety days; the remaining two records were not. One
of the five applicable records required two re-assessments; and the remaining four records only
required one reassessment each. One of the six required re-assessments was completed within
the required ninety-days; one re-assessment was missed/not completed; and the remaining four
were completed late: one was sixteen days late, two were twenty-one days late, and one was
thirty-four days late.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to ensure each youth receive a needs assessment
within thirty days of admission. A review of seven youth case management records was
conducted, and each record had documentation a Youth Needs Assessment Summary (YNAS)
was completed as confirmed in the Department’s Juvenile Justice Information System (JJIS).
Six of the seven records had the YNAS completed within thirty days of admission as required;
the remaining YNAS was one day late. Each YNAS identified the youth’s top three criminogenic
needs.
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.
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The program has a policy and procedures to ensure each youth is assigned a treatment team
containing a treatment team leader, the youth, parent/guardian, administrative representative,
living unit representative, treatment staff, education staff, and if applicable medical staff and
Department of Children and Families (DCF) case manager; and has an individualized
performance plan, which is required to be shared with the parent/guardian, committing court,
juvenile probation officer (JPO), and the Department of Children and Families case manager, if
applicable. A review of seven youth case management records was conducted, and each
contained an initial performance plan completed after the Youth Needs Assessment Summary.
Four of the seven completed initial performance plans were completed within thirty days of
admission as required; and the remaining three were late: one was two days late, one was
seven days late, and one was ninety-eight days late. Five of the seven reviewed initial
performance plans had all required treatment team members’ signatures; one was missing the
youth’s signature; and the remaining was missing all required signatures with the exception of
the treatment team leader. All seven reviewed plans had individualized treatment goals based
on needs, risks, and protective factors, to include each youth’s top three criminogenic needs
and delinquency interventions, transition activities, and court-ordered sanctions, if applicable.
Each goal had specified youth and staff responsibilities to complete, and a target date of
completion. Six of the seven reviewed records contained documentation of required written
notification to the committing court, JPO, and parent/guardian within ten working days of the
plan creation; the remaining record did not. None of the records were applicable for notification
to DCF.
Seven youth were interviewed, and each confirmed they participated in the development of their
performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Failed Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures to ensure performance plan reviews are conducted
and revisions occur as needed, and to ensure all youth plans are incorporated in the
performance plan. A review of seven youth case management records was conducted, and
there was a total of fourteen revisions. Each revision was due to youth progress on goals;
however, there was no documentation within the seven reviewed records to determine if any
revisions were based on or warranted from Residential Assessment for Youth (RAY) re-
assessment results, newly acquired or revealed information, or lack of progress on goals. Two
of the fourteen revised plans had the required treatment teams signatures; the remaining twelve
did not have any signatures. One of the seven reviewed records had revisions based on the
need to facilitate transition activities in the youth’s last sixty days; the remaining six were not
applicable. All reviewed plans incorporated each youth’s additional plans, and none of the youth
were applicable for behavior support plans through the Department of Children and Families.
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
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release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures to ensure performance summaries are completed
every ninety days. A review of seven youth case management records was conducted. Five of
the seven reviewed records required the initial ninety-day Performance Summary; the remaining
two were not applicable. One of the five completed performance plans was completed as
required; one was not completed as of the annual compliance review week; and the remaining
three were completed late: one was four days late, one was twelve days late, and one was
eighty-two days late. None of the four completed summaries were completed due to the youth’s
release or discharge. All four completed summaries included the status of each youth goal, the
youth’s overall treatment progress, behavior status and adjustment, level of
motivation/readiness for change, interaction with staff and peers, and significant positive and
negative events. Three of the four also included the youth’s academic status, grades, and
credits earned; the remaining summary did not. None of the four original summaries were
maintained in the youth’s case management records as required; each contained a copy. All
four performance summaries had the required signatures, to include the treatment team leader,
youth, administrative representative, and the staff who prepared the summary. All four records
contained documentation of written notification, including a copy of the summary, to the
committing court, juvenile probation officer (JPO), and the parent/guardian. None of the records
were applicable for notification to the Department of Children and Families.
A review of three closed youth case management records was conducted. None of the three
records were applicable for a direct discharge summary. Two of the three closed records had
documentation of the signed release summary sent with the Pre-Release Notification (PRN) to
the JPO; the remaining record did not have documentation of a release summary. All three
records had documentation of a PRN. Two of the three records had documentation sent at least
forty-five days prior to the youth’s release; the remaining was fourteen days late. None of the
records had documentation of written notification to the parent/guardian of the planned release.
All three records had a completed Residential Assessment for Youth exit assessment. None of
the youth were applicable for sexual offender or sexually violent predator program requirements,
nor victim notification of release requirements.
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 policy and procedures to facilitate and encourage parent/guardian
involvement in case management activities. A review of seven youth case management records
was conducted. There was documentation to support the program encourages parent/guardian
involvement with the assessment process, development of the youth’ performance plans, formal
treatment team meetings, and transition planning. When the parent/guardian is unable to attend
in person, the program ensures they can participate through telephone/video conferencing or
provide written/verbal input prior to the meeting. A formal treatment team meeting was observed
during the week of the annual compliance review. The program attempted to call the parent;
however, there was no answer. The program utilizes telephone calls to maintain contact with
each youth’s parent/guardian.
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The facility administrator was interviewed and confirmed the program’s policy and procedures to
ensure parent/guardian involvement.
Seven youth were interviewed, and each youth confirmed at least one parent/guardian has been
involved in their case management activities.
2.13 Treatment Team Members and Meetings (Formal and
Failed 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 policy and procedures to ensure each youth has a treatment team with all
required members and informal and formal treatment team meetings are held as required to
review the youth’s progress. A review of seven youth case management records was
conducted, and a total of forty-one formal meetings and thirty-one informal meetings were
required. Thirty-eight of the required forty-one formal treatment team meetings were conducted
every thirty days; one was five days late; and the remaining two were not conducted/missed.
Fifteen of the thirty-one required informal treatment team meetings were conducted bi-weekly
alternating with formal meetings; the remaining sixteen were not conducted/missed. A review of
the documentation for each conducted treatment team meeting was completed. The
documentation had the youth’s name, date of the review, submitted information/comments from
team members, summary of youth’s progress in the program and on goals, positive and
negative behaviors, and treatment progress; and not included in the documentation were
behaviors resulting in physical interventions, Residential Assessment for Youth results, nor
attendance and signature of required treatment team members. Each youth has a portion of the
meeting to present information and practice newly acquired skills. The program case manager
invites and encourages participation of the parent/guardian, juvenile probation officer (JPO), and
other pertinent parties. In the review of the meeting documentation, it was observed to be
incomplete with missing information, incomplete forms, and absence of required parties. An
informal interview with a case manager found only the youth, case manager, parent/guardian,
and JPO regularly attend formal meetings. A formal treatment team meeting was observed
during the annual compliance review week. All required treatment team members were present,
except for the parent/guardian who did not answer the telephone call attempts at the start of the
meeting.
Seven youth were interviewed, and each confirmed staff talk to them about their performance
on goals, behaviors, and treatment progress. Each youth stated they are able to demonstrate
learned skills and were able to provide at least one example of a skill.
2.14 Transition Planning, Conference, and Community Re-Entry
Limited Compliance
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
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transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures to ensure the treatment team plans for successful
transition to the community upon release. Three closed youth case management records were
reviewed for transition planning, activities, and required meetings. One of the three reviewed
records had a transition conference held at least sixty days prior to release; the remaining two
were held late: one was three days late and one was twelve days late. Two of the three records
had documentation of the attendance of the youth, treatment team leader, administration
representative, juvenile probation officer (JPO), parent/guardian, education staff, and medical
staff; the remaining record was missing documentation of the youth, treatment team leader,
administrative representative, and the parent/guardian. None of the records were applicable for
human trafficking requirements. Documentation in two of the three records confirmed the
transition conference included a review of transition activities, revision of the performance plan,
target completion dates and responsible parties, and signatures of attendees; the remaining
record did not have any of the required documentation. No additional transition activities were
identified. None of the three reviewed records contained documentation of the plans being sent
to parties not in physical attendance for signature, nor the electronic transmission to the JPO.
Two of the three reviewed records contained documentation to confirm a Community Re-entry
Team (CRT) meeting was held prior to release; the remaining record did not. The youth and
case manager participated in each of the two held CRT meetings, and there was evidence to
confirm an invitation to the CRT meeting was sent.
2.15 Exit Portfolio Failed Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to ensure each youth is released with an exit portfolio
to assist them with their re-entry into the community. Three closed youth case management
records were reviewed. None of the three reviewed records contained an exit portfolio or
evidence of one. An exit portfolio is required to include state-issued identification, copy of
transition plan, calendar with all dates, times, and locations of upcoming community
appointments, social security card, birth certificate, educational and/or vocational certificate(s)
earned, resume, and sample employment applications. The program’s contract specifies
additional elements will be included in the exit portfolio: all applicable healthcare screenings,
health education material, and links to a local Planned Parenthood or health department;
Healthcare Determination of Medicaid eligibility and application; contact information for Care
Review Teams; a copy of the current insurance information, date of expiration; address mental
health, social/behavioral concerns, and problems; making appointments with clinicians and
building bridges with community psychiatrists; age-appropriate support groups which continue
the twelve-step message learned in Alcoholics Anonymous/Narcotics Anonymous group;
services to promote positive use of leisure time, prevent gang involvement, and discourage
association with antisocial peers engaged in delinquent activities; and healthy coping skills
learned.
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2.16 Exit Conference Failed Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure an exit conference is held to finalize
release plans. Three closed youth case management records were reviewed. Two of the three
reviewed records had documentation of an exit conference being held; however, neither were
held at least fourteen days prior to release: one was one day late, and the other was eleven
days late. The remaining record did not have any exit conference documentation.
Documentation for both youth who had an exit conference confirmed all required parties were
invited by emaiil. Both records were missing the signature of attendees of the exit conference,
verification of release date, status of transition activities, education or employment status, a
review of the exit portfolio, and parent/guardian and juvenile probation officer awareness of
youth’s vocationa plan.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to ensure youth have a formal process to provide
input into the program’s processes and activities. The program has the grievance process and
the What’s Tea forms for youth to provide input. These forms are available throughout the
facility. Thirteen What’s Tea forms were reviewed, and all sections were completed to include
the staff signature and a solution to the issue. The program’s youth advisory board binder was
reviewed, and meetings were held in February, April, June, July, August, September, and
October of 2025. Meeting minutes/agendas, sign-in sheets, and an action log were also
reviewed. The policy outlines the program has a youth advisory board and surveys; however,
the time intervals to hold or conduct these activities was not specified. An informal interview with
the regional compliance manager confirmed youth advisory boards are conducted at least
quarterly and a Trauma Response and Caring Environment (TRACE) survey is conducted
annually; the last TRACE was conducted on July 2, 2025.
Seven youth were interviewed and six confirmed the youth advisory boards are held; and the
remaining youth stated the youth have to act out to get input.
The program administrator was interviewed and confirmed the methods of input available to the
youth at the program.
2.18 Educational Access (Residential Contract Provide) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to ensure youth receive educational services. The
program’s daily activity schedule includes the education schedule and times. The reviewed
schedule does coincide with the Educational Contract Provider’s scheduled times. A video
review of three educational days was conducted and confirmed the youth are receiving
educational services as outlined on the schedule. Logbooks were reviewed, one educational
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day each month of the annual compliance review period, for a total of eight months. One of the
eight reviewed days had the start time of school listed accurately to reflect the schedule; one
day started thirty minutes late; and the remaining six months did not have any documentation of
the start of school. None of the eight months had documentation of the commencement of the
school day reflected in the logbook as required.
Seven youth were interviewed and all seven youth confirmed they are receiving educational
services. Six of the seven interviewed youth stated there are no interruptions during the school
day; the remaining youth stated sometimes other youth talk loudly, causing staff to redirect them
which is disruptive.
2.19 Contract Specific Career and Technical Education Services
Failed Compliance
(Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has a policy and procedures which requires the implementation of career and
technical education (CTE) services, which are negotiated in the contract. A review of the
program’s approved contract reflects the required CTE services are SPARK, Choices, Business
Education, ServSafe, Florida Ready to Work Soft Skills, Occupational Safety and Health
Administration (OSHA-10), and cardiopulmonary resuscitation (CPR)/first-aid.
A review of CTE documentation confirmed fourteen youth completed CPR/first-aid certification.
Eight youth were enrolled in Florida Ready to Work Soft Skills after the program received the
seven-day notification of the annual compliance review; however, none of the youth enrolled
had begun services at the time of the annual compliance review. One youth is participating in
OSHA-10 training. One youth has completed the National Center for Construction Education &
Research (NCCER) Basic Construction Skill Training Course which is not on the Master
Credentials List; however, it builds the foundation for the Level One NCCER certification which
is on the Master Credentials List. No youth have participated in the following required CTE
services: SPARK, Choices, Business Education, and ServSafe.
Seven youth case management records were reviewed. According to the program's schedule,
contract and CTE requirements courses are required to begin immediately upon a youth
receiving a general equivalency diploma or high school diploma or for high risk youth six months
prior to release and for max risk youth twelve months prior to release; these course include
Florida Ready to Work Soft Skills, OSHA-10, and CPR/first-aid. Five of seven reviewed youth
were required to begin courses in Florida Ready to Work Soft Skills, OSHA-10, and CPR/first-
aid. The remaining two youth are not within six or twelve months of release. Three of five youth
completed CPR/first-aid certification, the remaining two youth have not received their CPR/first-
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aid certification. None of the five applicable youth had earned certifications or begun coursework
in OSHA -10 or Florida Ready to Work Soft Skills. All seven reviewed youth were applicable for
requiring participation in a course on the Master Credentials List. None of the seven reviewed
youth were participating or had completed any courses on the Master Credentials List which is
required to begin within three months of admission to the program.
A review of the program’s daily activity schedule did not reflect any CTE services; however,
contract stipulates CTE services are to be provided from 9:00 a.m. to 11:00 a.m. every Saturday
and Sunday.
A review of the staff roster and position descriptions revealed there is no assigned staff position
specifically responsible for CTE coordination. The contract designates the transition services
managers (TSMs) are responsible for CTE delivery; however, the TSM qualifications do not
align with the credentialing requirements for CTE.
No CTE activities were available to be observed during the annual compliance review week.
Seven youth were interviewed and three stated they are being provided CTE services. The
remaining four youth stated they were not being provided any CTE services. Two youth stated
they were certified in CPR and one youth stated they were trained in OSHA.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a policy and procedures which provides for a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program. The program employs a licensed mental health counselor (LMHC) who
serves as the designated mental health clinician authority (DMHCA). The DMHCA is employed
full-time by the program and is on-site at least forty hours a week as required by contract to
ensure appropriate coordination and implementation of mental health and substance abuse
services. In the event of a mental health or substance abuse emergency, the DMHCA is
available on-call twenty-four hours a day, seven days a week. A review of the DMHCA position
description confirmed the required hours for the DMHCA. A review of the DMHCA’s license
found it to be clear and active, with an expiration date of March 31, 2027. The program had two
previous DMHCA’s employed during the annual compliance review period and each had a clear
and active license with an expiration date of March 31, 2027. The previous DMHCAs were a
licensed clinical social worker and a LMHC, respectively. An interview with the DMHCA
indicated they are responsible for day-to-day operation of the clinical department to ensure the
treatment programming complies with all requirements outlined in the program’s contract.
Additionally, the DMHCA is responsible for ensuring accurate and timely completion of intake
documentation, provision of required assessments, administration of evaluations, and
development of treatment plans completed by all licensed and non-licensed clinicians under the
direct supervision of the DMHCA. The program employs two assistant directors of clinical
services who serve as the back-up DMHCA to provide coverage in the absence of the DMHCA.
Each assistant director of clinical services maintains licensure as a LMHC, and both licenses
were found to be clear and active with an expiration date of March 31, 2027.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The program provides licensed
mental health and substance abuse clinical staffing in accordance with the current contract and
Florida Administrative Code. The program employs a licensed mental health counselor (LMHC)
who serves as the designated mental health clinician authority (DMHCA)/clinical supervisor. A
review of the DMHCA’s license found it to be clear and active with an expiration date of March
31, 2027. The program employs two licensed mental health counselors who maintain the title of
assistant director of clinical services. The assistant director of clinical services will provide
coverage in the absence of the DMHCA. The DMHCA ensures the two licensed clinical mental
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health staff working under their supervision are performing services they are qualified to provide
based on education, training, contract outlined requirements, and experience. A review of the
position description and an informal interview with the DMHCA confirmed this practice. A review
of their licenses found they are clear and active, and do not expire until March 31, 2027. The
program does not maintain a license through the Department of Children and Families in
accordance with Florida Statute, Chapter 397, to provide substance abuse services for
outpatient treatment; therefore, all substance abuse services are provided by licensed mental
health staff.
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 policy and procedures to ensure mental health and substance abuse staff
have the appropriate qualifications. An informal interview with the designated mental health
clinician authority (DMHCA) indicated it is a duty of the DMHCA to ensure the non-licensed
clinical staff working under the supervision of the DMHCA are performing services they are
qualified to provide based on education, training, and experience. A review of the position
description also confirmed this practice. Each of the three non-licensed clinicians hold a
master’s degree in a relevant field of study. At the time of the annual compliance review, there
was one clinical vacancy for a non-licensed mental health and substance abuse staff, effective
November 1, 2025. The DMHCA interview indicates schedules are staggered to ensure the
program has clinical staff present seven days a week. A review of the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Supervision Log for the annual compliance review period confirmed non-licensed mental health
clinical staff were provided with at least one hour on-site face-to-face direct supervision by the
DMHCA, or their back-up, each week they worked, with the exception of a five-week period from
April 2025 to mid-May 2025 where there was a transition of the DMHCA position. The program
provided documentation of twenty hours of on-the-job-training in assessing suicide risk, mental
health crisis intervention, and emergency mental health services for each of the non-licensed
clinical staff. The reviewed documentation confirmed each staff completed the training, which
allows them to conduct Assessments of Suicide Risk (ASR) and prepare them for approval by
licensed clinical staff. The program does not maintain a license through the Department of
Children and Families in accordance with Florida Statute, Chapter 397, to provide substance
abuse services for outpatient treatment. A review of substance abuse group sign-in sheets
confirmed substance abuse groups were only facilitated by licensed clinical staff.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures which explains the comprehensive screening process
conducted on each youth at admission. The program does not utilize a clinical mental health
and substance abuse screening. A review of documentation confirmed the program follows the
procedures outlined in the policy for utilizing the Massachusetts Youth Screening Instrument –
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Second Version (MAYSI-2) and includes all required elements for the admission mental health
and substance abuse screening process. A clinician or trained case manager completes a
MAYSI-2 on each youth as part of the admission process. Seven youth mental health and
substance abuse records were reviewed. Five of the records reflected the screener reviewed
available information to include the electronic commitment packet, and reports and/or records
for existing documentation of mental health or substance abuse problems or history of human
trafficking, the remaining two records did not reflect a review of pre-existing documentation. The
reviewed documentation in five records, cross referenced with the Department’s Juvenile
Justice Information System (JJIS), confirmed assessments were completed on the day of
admission, by a trained licensed mental health counselor, master’s-level therapist, or trained
case manager in a confidential manner, and were entered into JJIS. The two remaining youth
mental health and substance abuse records did not contain documentation for the completion of
the MAYSI-2 assessment. The program’s practice is for each youth to be screened using an
Assessment of Suicide Risk (ASR) and for each youth to be referred for a new comprehensive
mental health and substance abuse evaluation regardless of their scores on the MAYSI-2. All
five reviewed MAYSI-2 instruments indicated a need for further assessment, and each youth
was referred for a new comprehensive mental health and substance abuse evaluation. At the
time of the annual compliance review, the program currently had an open deficiency for the
completion of MAYSIs. The remaining two youth were also referred for a new comprehensive
mental health and substance abuse evaluation.
Each of the seven reviewed youth was referred for an ASR and had an ASR completed the day
of admission as part of the program’s assessment process. One of the seven youth was
applicable for requiring a referral for immediate assessment due to youth being in crisis. The
program was unable to provide documentation verifying the facility administrator was informed
of this youth’s immediate need for crisis intervention as the referral form was not signed by the
facility administrator (FA); however, documentation did reflect the youth was placed on
precautionary observation pending an ASR and it was indicated the FA conferred with clinical
staff. An interview with the FA confirmed the program’s practice.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a policy and procedures defining the process for completion of a new
Comprehensive Mental Health and Substance Abuse Evaluation within thirty calendar days of
youth’s admission. Seven youth mental health and substance abuse records were reviewed.
Four youth had a new Comprehensive Mental Health and Substance Abuse Evaluation
completed by a licensed clinician or master-level therapist within thirty calendar days of
admission; one youth record indicated the evaluation was completed one day late; one youth
record indicated the evaluation was completed two days late; and the remaining youth record
indicated the evaluation was completed eighty-three days late. A licensed clinical staff member
completed the substance abuse portion of the evaluation for all seven youth, and each record
contained a consent for substance services signed by each youth. The mental health portion
was completed by licensed clinical or master’s-level therapist. Each evaluation, where the
mental health portion was completed by a master’s-level clinician, was reviewed and signed by
a licensed clinician on the same day, except for one evaluation which was not signed by clinical
staff. Each reviewed assessment included the reason for assessment, identifying information,
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relevant background information, family history, history of abuse/neglect/trauma, behavioral
observations, methods of assessment, patterns and impact of alcohol and other drug abuse,
mental health, mental status examinations, substance abuse history and treatment, diagnostic
impression/formulation, summary of clinical impressions, treatment recommendations, and
addressed the youth’s original referral reason. An interview with the designated mental health
clinician authority (DMHCA) confirmed the program’s practice.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures regarding mental health and substance abuse
treatment. Seven youth mental health and substance abuse records were reviewed and each
youth had an Initial Mental Health/Substance Abuse Treatment Plan developed within seven
days of initiation of treatment, on the date of admission. The Initial Mental Health and Substance
Abuse Treatment Plan for each youth was documented on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Six of seven youth Initial Mental
Health/Substance Abuse Treatment Plans were signed by the mental health clinical staff
completing the form, the remaining youth’s Initial Mental Health/Substance Abuse Treatment
Plan was not signed by the mental health clinical staff completing the form. Three of the Initial
Mental Health and Substance Abuse Treatment Plans were completed by non-licensed mental
health clinical staff, and each was signed by licensed clinical staff within ten days, as required;
three plans were completed by licensed clinical staff; and the remaining plan was signed by the
youth only, so it was unable to be determined who completed the form. All plans were signed on
the same date they were developed. Six of seven plans were signed by all treatment team
members who participated in the development of the plan; the remaining plan was only signed
by the youth. One of the seven reviewed youth was prescribed psychotropic medications upon
intake as determined through review of youth clinical psychotropic progress note completed by
the program contracted psychiatrist; this information was not contained in the youth’s Initial
Mental and Health/Substance Abuse Treatment Plan.
Two of seven youth were applicable for psychiatric services during the initial development of the
Individualized Mental Health/Substance Abuse Treatment Plan and included each youth’s
psychiatric needs, including medication, and frequency of monitoring by the psychiatrist. All
seven youth Individualized Mental Health/Substance Abuse Treatment Plans were developed
on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. All
seven Individualized Treatment Plans were developed and signed by the licensed mental health
professional or if signed by the non-licensed mental health clinical staff completing the plan,
were signed by the licensed mental health professional on the same date. Each plan was
signed by all treatment team members who participated in the development of the plan.
Reviewed documentation indicated each youth’s plan was mailed to their parents/guardians for
signature. All seven youth had their Individualized Mental Health/Substance Abuse Treatment
Plan developed within thirty days of admission. Services were individualized for each youth and
included goals and objectives. Services included individual sessions, groups, family sessions,
and psychiatric services. Six of seven youth’s Individual Mental Health/Substance Abuse
Treatment Plans included family counseling at least once a month; one youth opted out, in
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writing, of family therapy services. Individualized Treatment Plan reviews were completed on the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form for
each youth and reviews were completed at least every thirty days following the development of
the Individualized Mental Health/Substance Abuse Treatment Plan.
3.07 Treatment and Discharge Planning (Critical) Failed 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 policy and procedures addressing treatment and discharge planning. Seven
youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. Six of seven reviewed youth records reflected youth were assigned
to a treatment team upon arrival to the program, the remaining youth record did not contain
documentation to determine when the youth was assigned to a treatment team. The
multidisciplinary treatment teams were comprised of the youth, program administration, staff
from the residential living unit, and other staff responsible for delinquency intervention and
treatment services for the youth. Six of seven reviewed youth records contained treatment team
documentation, which validates the treatment team was comprised of all required members.
The remaining youth did not have treatment team documentation reflecting participation of all
required treatment team members except for youth. All seven youth were applicable for mental
health and/or substance abuse treatment services. Treatment services consisted of individual,
group, and/or family counseling for each youth, which were provided by licensed clinical staff
when applicable for substance abuse services. Five of seven youth were applicable for being
aged eighteen and under and each applicable youth record r contained a properly executed
Authority for Treatment and Evaluation (AET). The remaining two youth were aged eighteen or
older and did not required an AET. Each youth record had a signed copy of Youth Consent for
Substance Abuse Treatment. Mental health treatment and substance abuse treatment notes
were documented on the Department’s Counseling/Therapy Progress Notes form. All seven
youth records contained documentation youth were involved in individual psychotherapy or
counseling, psychosocial skills training, designed to address specific skill deficits or maladaptive
behaviors, which promote skill development and improved functioning of youth with mental
disorders, as stipulated in each youth’s treatment plans.
Three closed youth mental health and substance abuse records were reviewed for treatment
and discharge planning. The program was unable to provide documentation of treatment and
discharge planning for any of the three youth. Discharge plans are documented on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary forms, which
documents the services needed for daily maintenance of positive improvement in behavioral,
emotional, and social skills made by the youth during treatment. Through review of the
Department’s Juvenile Justice Information System (JJIS), it was determined none of the three
youth were released while on suicide risk alert/suicide precautions. None of the three youth
records contained documentation to reflect the discharge plan was discussed with the youth,
parents/guardians (when allowed), and juvenile probation officer (JPO) during the exit
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conference or if copies of the Mental Health/Substance Abuse Treatment Discharge Summary
forms were provided to the youth, JPO, and to the parent/guardian.
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.”
The program has a policy and procedures which require specialized intensive mental health
treatment services to be provided to youth. A review of the program’s contract and clinical
program description indicated the program has five components of treatment to include
intensive mental health (IMH), borderline intellectual functioning/borderline developmentally
delayed (BIF/BDD), developmentally delayed (DD), mental health overlay services (MHOS), and
substance abuse treatment overlay services (SAOS). Seven youth mental health and substance
abuse records were reviewed. Two youth were applicable for MHOS, one was applicable for BIF
services, and the remaining four youth were designated for IMH services. During the annual
compliance review week, the population of the program had zero youth designated as DD and
two youth designated as requiring SAOS; DD services were not reviewed due to the program
not having any active youth participating in DD services. All specialized treatment services are
provided by licensed therapists or non-licensed therapists working under their direct
supervision. The program is not licensed under Chapter 397; therefore, all substance abuse
services are provided by licensed clinical staff.
Group services include Dialectical Behavioral Therapy Skills Manual for Adolescents (primary
service for IMH and BIF/BDD, non-primary for MHOS/SAOS), Skillstreaming the Adolescent
(IMH and BIF/BDD youth only), Moral Reconation Therapy (primary service for MHOS/SAOS
youth only), and Living in Balance (MHOS/SAOS youth only).
Mental health and substance abuse evaluations, mental health and substance abuse treatment
planning, and individual and family therapy are provided to each youth in the program with a
frequency determined by youth designation, contract requirement, and through the department’s
Bureau of Procurement and Contract Administration (BPCA) which contains outlined
attachments for the requirements of service delivery and duration for each identified population.
Youth additionally receive group services four to five times a week based on youth designation,
daily mental health support services including skills training, support groups, psychoeducation,
mental health crisis intervention, and psychiatric and pharmacological services.
A review of clinical staff caseloads verified each therapist had an average of five to six youth on
their caseload which is compliant with the program’s contract and all specialized treatment
services. A review of sign-in sheets, youth progress notes, and the program’s schedule verified
groups were provided. The licensed psychiatrist provides psychiatric evaluations, medication
management, and participates in treatment planning. An interview with the designated mental
health clinician authority (DMHCA) verified the program provides IMH individual sessions on a
weekly basis, family sessions two times a month; and BIF, MHOS, and SAOS individual
sessions bi-weekly with monthly family sessions. The program has not had any DD youth during
the annual compliance review period. Seven interviewed youth reported participating in family
and/or individual counseling at the program. Seven interviewed staff reported the program’s
mental health staff facilitate all clinical groups at the program. An interview with the facility
administrator confirmed program’s specialized treatment services.
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Review of sign-in sheets and daily progress notes confirmed therapy groups contained ten or
fewer youth for all specialized treatment services. Each of the seven reviewed youth treatment
plans addressed frequency of prescribed services for each youth to include individual, group,
and family therapy sessions. A review of documented progress notes indicated youth were not
consistently receiving individual therapy, family therapy, and group services as stipulated on
their treatment plans. The program was assigned an Outcome Based Corrective Action Plan
(OBCAP) during the annual compliance review period for previous noted deficiencies in this
area of specialized services and treatment planning. Each of the seven youth records which
were reviewed contained deficiencies captured in the OBCAP.
All mental health and substance abuse services are provided by or under the direct supervision
of the DMHCA, who is responsible for the oversite and delivery of all treatment related services
at the program.
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 maintains a suicide prevention plan detailing the program’s suicide prevention
procedures. The plan contains all the required elements outlined in Florida Administrative Code
and outlines how the program will safely assess and protect youth with elevated risk of suicide
in the least restrictive means possible. An annual review of the plan was completed by the
designated mental health clinician authority, facility administrator, and psychiatrist on October
31, 2025. The plan includes identification and assessment of youth at-risk of suicide, staff
training including a minimum of six hours annually, suicide precautions, level of supervision
(one-to-one, constant, and close supervision), referrals, communication, notification,
documentation, immediate staff response, and a review process including suicide attempts and
mortality review processes which contains all required elements.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a policy and procedures which governs suicide prevention services. Seven
youth mental health and substance records were reviewed for suicide prevention services.
Three of seven youth were applicable for suicide prevention services. Two youth were identified
as being at-risk for suicide from staff observations and the remaining youth self-reported suicide
ideation. The Assessment of Suicide Risk (ASR) referral was generated for each of the youth.
The ASR was completed using the Department’s Assessment of Suicide Risk form and was
completed within the twenty-four hour time frame. Two youth participated in an assessment and
remained on constant supervision; one youth was evaluated and remained on one-to-one
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supervision. Each ASR was completed by a licensed mental health professional (LMHP). A
review of each ASR reflected notification was made to the youth’s parent/guardian and their
assigned juvenile probation officer. Each youth received daily supportive services from mental
health staff while on suicide precautions. Each youth who remained on supervision was seen for
a Follow-Up ASR (FASR) within twenty-four hours each day they were on precautionary
observation, until the decision was made to transition each youth to close supervision and was
documented on the Department’s FASR form. Each youth was maintained on one-to-one or
constant supervision until an FASR indicated suicide precautions could be discontinued. Each
youth was stepped down from close supervision through the completion of a FASR and was
maintained on close supervision until licensed clinical staff determined it was no longer
necessary. The documentation also reflected a conference was held with licensed clinical staff
and the facility administrator/designee prior to reducing the level of supervision for each youth
and in accordance with the program’s suicide prevention plan. Documentation reflecting the
placement status of each youth was found in the master control logbook and in the
Department’s Juvenile Justice Information System (JJIS) alerts. Each youth’s suicide risk alert
was closed in JJIS following recommendation of the FASR. Each youth was allowed to
participate in select activities with other youth in designated safe housing while on suicide
precautions. One of the three youth’s ASR was not signed by the facility administrator/designee
and there was no time on the signature for the LMHP, and did not indicate the mental health
professional conferred with the facility administrator/designee on youth’s status throughout the
time youth was on suicide precautions; however, facility administrator and licensed mental
health staff did sign the subsequent FASRs for youth.
A review of video camera recordings of three youth placed on precautionary observation was
reviewed and confirmed youth were maintained on precautionary observation for the entire time
they were on suicide precautions
3.11 Secure Observation (Critical) Limited Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program has a policy and procedures to address youth on suicide precautions being placed
on secure observations. Seven youth mental health and substance abuse records were
reviewed. None were applicable for being placed in secure observation. An additional three
youth mental health and substance abuse records were requested for a minimum sample of
three. Two of three youth did not have authorization by the facility administrator (FA)/designee
and designated mental health clinician authority (DMHCA) authorizing the youth’s placement in
secure observation. The remaining record contained authorization from the FA and DMHCA
prior to the youth’s placement in secure observation. Each record contained documentation of
secure housing designation in writing. Two of three records contained a health status checklist
completed prior to placement in secure observation, the remaining record did not contain a
completed health status checklist. Two of three records reflected a visual check of each youth
was completed to determine if each youth had any observable injuries which would make
secure observation inappropriate; however, documentation did not confirm if the visual check
was completed by a same gender staff for either of the two youth. The remaining record did not
contain documentation a visual check was completed of youth. Two of three records confirmed
the secure observation room was inspected immediately prior to the youth’s placement to
ensure the room was safe and secure. The remaining record did not reflect a room search prior
to placement. Two of three records did not reflect the reason each youth was placed in secure
observation. The remaining record indicated the youth was placed in secure observation due to
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“at-risk” or “suicide risk” behavior. Two of three youth had Suicide Precautions Observation
Logs which were not completed in their entirety. One log was missing the mental health staff’s
signature, and the other log was missing four hours of required staff checks. The remaining log
was completed in its entirety. Each record reflected a new Assessment of Suicide Risk (ASR)
was completed within eight hours of placement and each youth was removed from secure
observation within twenty-four hours. None of the youth were applicable for requiring supportive
counseling from mental health staff due to not being in secure observation over eight hours.
Two of three youth did not have a conference with the FA and DMHCA prior to level reduction.
The remaining youth had documentation the FA and DMHCA held a conference prior to level
reduction. Two of three youth did not have an ASR review by licensed clinical staff prior to
youth’s removal from secure observation. The remaining youth had an ASR completed by a
licensed clinical staff member prior to removal from secure observation. Two of three youth
records did not contain documentation reflecting the licensed clinical staff member concurred
with the removal of secure observation nor did it contain the FA’s written authorization was
obtained for the removal of either youth from secure observation. The remaining record
contained the required documentation prior to removal from secure observation. None of the
three reviewed records contained documentation of the discontinuation of secure observation or
step-down to close supervision by the FA in the logbook and mental health and substance
abuse record by clinical staff. A review of video camera footage and documentation confirmed
proper staff supervision of one-to-one or constant was maintained throughout the period youth
were on suicide precautions.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision for youth placed on suicide precautions. A review of seven youth mental health and
substance abuse records found three out of seven youth were placed on suicide precautions. All
Suicide Precautionary Observation Logs were maintained for the duration for two of the three
youth on suicide precaution, and the staff documented the youth’s behavior in real time at
intervals which did not exceed thirty minutes on the required Department forms. The remaining
youth’s Suicide Precaution Observation Log reflected staff did not maintain documentation of
youth’s entire duration on suicide precautions and did not document checks of youth’s behavior
every thirty minutes as required. Each youth’s Suicide Precautionary Observation Log reflected
warning signs were not documented after notification was made to the designated mental health
clinician authority and the facility administrator/designee. Two of three youth had all required
reviews by supervisory staff; the remaining youth did not have consistent supervisory reviews.
Each youth’s log was reviewed and signed by licensed clinicians. None of the reviewed youth
records reflected identification of designated safe housing areas for the youth. The program
prints the Suicide Precaution Observation Logs on orange or red paper making them more
noticeable for staff. The program was on an Outcome Based Corrective Action Plan during the
week of the annual compliance review.
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3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures to ensure staff are trained in suicide prevention and
implementation of suicide precautions. A review of ten pre-service staff training records
confirmed each staff member received six hours of training in suicide prevention. The program
has three suicide response kits located in master control, sub control, and the program’s
medical office. All suicide response kits contained the required equipment and were co-located
with first-aid kits. A review of mock suicide drill documentation confirmed drills were conducted
at least quarterly on each shift during the annual compliance review period, except for one
quarter on second shift. All drills were simulated and were in response to a suicide attempt or
serious self-injury. No drills utilized youth in the drill simulations. Documentation confirmed the
program provides semi-annual training on emergency response procedures which includes
cardiopulmonary resuscitation in response to a “mock” suicide or serious self-injurious attempt.
Documentation confirmed staff who are not present during the quarterly drill have an opportunity
during the monthly all-staff meeting to review each drill scenario and procedures in an effort to
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or incident of serious self-inflicted injury at the program. An interview with the facility
administrator confirmed the program’s practice. Seven staff were interviewed, and each staff
member could articulate suicide precaution procedures. Six of seven staff stated suicide
response kits are kept in master control and in the medical office. The remaining staff member
did not know where the suicide response kits were kept. All seven interviewed staff stated
medical emergency and suicide drills are conducted monthly on each shift, except for one staff
member who stated drills were conducted every two weeks. A video camera review of two mock
suicide drills reflected each drill was simulated, did not involve any youth, and staff brought the
suicide response kit and first-aid kit to the drill.
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 maintains a comprehensive mental health crisis intervention plan. The plan
outlines how the program responds 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 program.
The plan contains all the required elements outlined in Florida Administrative Code including a
notification and alert system, means of referral including youth self-referral, communication,
supervision (one-to-one, constant, close, and standard supervision), and documentation and
review of the crisis.
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
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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 policy and procedures which requires a response 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 program. The program maintains a crisis intervention plan which
includes provisions for crisis intervention, suicide prevention, and emergency services. The plan
states crisis intervention for youth who require immediate processing relating to a specific
incident will be provided as needed in a one-to-one setting. The program’s crisis intervention
services address anger control issues, depression and anxiety symptoms, maladaptive coping
mechanisms, impaired impulse control, and non-suicidal mental health events.
In the event a youth exhibits out of control behaviors, the program’s direct-care staff places the
youth on mental health alert and refers the youth to a qualified mental health professional for a
crisis assessment. Seven youth mental health and substance abuse records were reviewed,
none were applicable for crisis assessments; therefore, the program provided three applicable
records for review. A review of three youth mental health and substance abuse records found a
crisis assessment was completed immediately, within two hours, or within twenty-four hours
based on the needs of the individual youth. Each youth was offered ongoing mental health
treatment services. All three crisis assessments included the reason for the assessment; a
mental health status examination and interview; determination of danger to self or others
including imminence of behavior, intent of behavior, clarity of danger, and lethality of behavior;
initial clinical impressions, supervision recommendations, treatment recommendations,
recommendations for follow-up evaluation, and notification to parent/guardian for follow-up
treatment when applicable. Each assessment was conducted by a licensed mental health
professional or a non-licensed mental health clinical staff working under the direct supervision of
a licensed mental health professional. Each youth received a crisis assessment due to being an
alleged victim of the Prison Rape Elimination Act, and a Mental Health/Substance Abuse
Referral Summary was submitted immediately for a crisis assessment. All three youth declined
any additional mental health treatment services. Each youth was assessed and determined to
not be in crisis; therefore, an alert was not required to be entered into the Department’s Juvenile
Justice Information System, and each youth was maintained on standard supervision after
completion of the assessment. Each youth’s parent/guardian, as well as juvenile probation
officer, were notified by telephone of the results of the crisis assessment. The program had no
youth applicable for an off-site Crisis Assessment during the annual compliance review period.
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 policy and procedures for the maintenance of an emergency mental health
and substance abuse services plan which delineates each of the required elements outlined in
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Florida Administrative Code. The plan includes immediate staff response requirements,
notifications, communication expectations, supervision requirements, authorization for transport
for emergency mental health or substance abuse services, transport for emergency mental
health or substance abuse assessment and treatment, documentation, staff training, and a
review process for each incident.
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 policy and procedures for youth who require emergency mental health or
substance abuse services. Seven youth mental health and substance abuse records were
reviewed. One of seven youth was applicable for being Baker Acted. Two additional records
were requested for a minimal sample of three. Documentation reflected how and when each
youth was determined to be in need of emergency care, the staff response for each youth, and
confirmed mental health staff made the notification. Documentation confirmed each youth was
placed on one-on-one supervision at the time of discovery of risk. Each youth was assessed by
mental health staff and a Baker Act was authorized by the designated mental health clinician
authority (DMHCA) and facility administrator. Each youth was then transported to a local
receiving facility by law enforcement. Upon return to the program, each youth was placed on
constant supervision. None of the youth records contained documentation a referral was
completed indicating a Mental Status Examination (MSE) was to be conducted; however, each
youth did receive a MSE upon return to the program as the program’s practice is for each youth
to receive a MSE upon return to the program. Two of three youth had an ASR completed by a
licensed mental health staff member, the remaining youth’s ASR was completed by a non-
licensed therapist which was reviewed by licensed clinical staff on the day of completion.
Supervision was maintained for each youth until mental health staff could complete an
appropriate assessment.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures in place regarding on-going safety planning
processes for each youth. The program utilizes a safety plan designed to identify stimuli which
has both positive and negative effects on the youth. Seven youth mental health and substance
abuse records were reviewed. Each record reflected the initial safety plan was completed within
fourteen days of admission with warning signs indicating a youth is escalating in their behavior;
baseline behaviors gathered from collateral contacts, parent/guardian input, youth’s history, and
current evaluations when applicable; crisis recognition from the youth and staff perception of
verbal and non-verbal stimuli impacting the youth (positive or negative impacts), jointly
developed coping strategies to include people and healthy environments as defined by the
youth; intervention strategies preferred by the youth; and a debriefing process youth identified
as safe. Six of seven reviewed records indicated the initial safety plan was jointly prepared by
the youth, parent/guardian or family member, and the program’s clinical staff. The remaining
youth was nineteen years old and did not require parent/guardian input. Each youth’s safety
plan incorporated recommendations from previous or current clinical assessments or screening
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instruments and incorporated trauma responsive practices. In five of seven records, each safety
plan was updated every thirty days. One youth was missing two months of safety plan reviews,
and the remaining youth was missing one month of a safety plan review. The program maintains
a copy of each youth’s safety plan in their mental health and substance abuse record and in
master control which is assessable to staff. Seven youth were interviewed, and each confirmed
they were involved in the development of their safety plan. An interview with the facility
administrator confirmed safety plans are updated every thirty days or following any significant
behavior or mental health event. Five staff were informally interviewed, and each staff could
provide the location where the youth safety plans are kept. Each staff reported they have
reviewed the youth safety plans during shift debriefing meetings daily, changes were noted on
the alert board, and they have access to the safety plans at any time.
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Office of Accountability and Program Support Page 42 of 69 (Revised August 2025)
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 policy and procedures indicating the designated health authority (DHA) shall
be clinically responsible for the medical care of all youth at the program. The program’s DHA is
a licensed physician (MD) who holds a clear and active license with an expiration date of
January 31, 2027. The physician’s specialty training is in internal medicine. The DHA does not
have any disciplinary cases or public complaints on record. The program does not utilize a
physician’s assistant or advanced practice registered nurse. Reviewed sign-in/out logs for the
annual compliance review period confirmed the DHA was on-site at least once a week, as
required by contract. The program has a back-up physician in the event of the DHA’s absence,
who holds a clear and active license with an expiration date of January 31, 2027; however, the
DHA has not been absent during the annual compliance review period. A review of the
program’s contract found the program does not utilize telemedicine or telehealth for medical
services. The DHA was interviewed and stated they are on-site once a week to conduct initial
intake exams, periodic evaluations, sick calls, and make referrals to specialists as needed. The
DHA indicated they communicate with program staff regarding youth medical needs through
written orders, telephone calls, and through in-person contact when on-site, and stated they are
available to staff by telephone or an answering service when not on-site. All off-site care
findings, instructions, and information are placed in the DHA’s chart for their review. The DHA
stated they are informed of all youth medical changes, and they meet with healthcare staff
quarterly to review important medical issues pertaining to youth at the program. The DHA stated
they have a back-up for scheduled absences and do not have any concerns with healthcare at
the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures stating 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, according to developed and authorized
protocols. The program’s contract indicates they will have a full-time health services
administrator (HSA), and five full-time registered nurses (RN) to provide coverage seven days a
week for a total of 240 hours. At the time of the annual compliance review, the program had one
full-time RN, who serves as the HSA, five full-time RNs, and one pro re nata (PRN) RN. A
review of nursing licensure credentials confirmed each RN’s license was clear and active. Each
nurse has a current cardiopulmonary resuscitation certification card.
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Office of Accountability and Program Support Page 43 of 69 (Revised August 2025)
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The medical FOPs were signed by the designated health
authority (DHA) October 10, 2025, the facility administrator (FA) on October 8, 2025, and the
psychiatrist on October 14, 2025. The nursing protocols were signed by the DHA on January 10,
2025. A cover page indicating all FOPs and nursing protocols were reviewed, was signed by the
program’s health services administrator (HSA) and each registered nurse (RN). The program’s
medical FOPs were revised in October 2025. The HSA and each full-time RN signed and dated
a cover page indicating they were reviewed. The one pro re nata (PRN) RN had not been on-
site since the FOPs were revised. Each newly employed healthcare staff received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures
which were given by a RN. Approval of treatment protocols and standing procedures were
written and authorized by the DHA and were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET), authorizing specific treatment for youth in the custody of the
Department. Seven youth Individual Healthcare Records (IHCRs) were reviewed and five
contained a valid, legible AET form. Each AET was signed by a parent/guardian and a
Department representative. The remaining two youth were eighteen years of age or older, and
both had a documented release of information in their IHCR. During an interview with nursing
staff, it was stated they obtain each youth’s AET from the Department’s Juvenile Justice
Information System. The nurse indicated if an AET is over a year old, or invalid for any reason,
they will work with the youth’s juvenile probation officer to obtain a new one. When a youth turns
eighteen years old, a release of information is signed.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure parents/guardians are informed of
significant changes in youth’s conditions and to obtain consent when new medications and
treatments are prescribed. Seven youth Individual Healthcare Records (IHCRs) were reviewed.
Six were applicable for parent/guardian notification, as the remaining youth was eighteen years
of age at the time of admission. Four youth IHCRs were applicable for parent/guardian
notifications for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). All four IHCRs contained documentation of parent/guardian
notification and consent for each OTC medication. The remaining two youth did not receive any
OTC medications beyond those covered by the AET. New medication was ordered for five
reviewed youth. Documentation of notification to the parent/guardian for each new medication
was in each youth’s IHCR. All written notifications were sent utilizing the correct forms. One
youth was taking psychotropic medications at the time of admission, and two additional youth
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Office of Accountability and Program Support Page 44 of 69 (Revised August 2025)
were prescribed psychotropic medications while at the facility. Documentation in all three IHCRs
found parent/guardian verbal consent was documented on page three of the Clinical
Psychotropic Progress Note (CPPN) when a new psychotropic medication was prescribed or
discontinued, or the drug dosage was significantly changed. A signature indicating a staff
witnessed telephone conversations for psychotropic medications was located on page three of
the CPPN for all three youth. Five of the seven reviewed youth had their vaccinations verified
within thirty days of admission. One youth’s vaccinations were reviewed twenty-three days late
and the remaining youth’s vaccinations were reviewed fourteen days late. One reviewed IHCR
contained a Religious Exemption from Immunization form. None of the reviewed youth received
a vaccination at the program. An interview with nursing staff found parent/guardian notifications
are required when a new medication is ordered, or when significant changes in medication or
treatment is prescribed. Nursing staff indicated parent/guardian notifications are made when
new treatments are recommended and when a youth has returned from an off-site appointment.
Nursing staff stated telephone calls are made and documented when a new order is provided.
At least three attempts are made to contact a parent/guardian verbally and written notifications
are sent. If emergency medical services are needed, parents/guardians are contacted verbally,
with a written notification to follow. A notification is also made when a youth returns to the
facility. For psychotropic medications, the psychiatrist makes verbal contact with each youth’s
parent/guardian to explain risks and benefits of the medication. Each telephone call is witnessed
by a registered nurse, who signs page three of the CPPN if consent is given. A written
notification is then sent to the parent/guardian. Nursing staff indicated vaccinations are not
provided on-site; however, will be ordered by the designated health authority if deemed
medically necessary. Immunization records are obtained through the Florida Shots database
upon each youth’s admission to the program. Parent/guardian exemption from immunizations
are documented on the Religious Exemption from Immunization form, which is completed by a
parent/guardian and submitted 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 policy and procedures which ensure youth are screened upon admission for
healthcare concerns which may require a referral for further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of the
Department’s Facility Entry Physical Health Screening (FEPHS) form. Each youth’s IHCR
contained a FEPHS form completed by a registered nurse (RN) on the day of admission. Four
reviewed youth were applicable for a change in physical custody for greater than twenty-four
hours. The program completed a new FEPHS form as required for each. An interview with
nursing staff found they are notified of new admissions through written communication. Nursing
staff meet with each youth immediately upon admission and the RN on shift completes an
admission screening. If there is a change in custody, a new FEPHS form is completed upon the
youth’s return to the program. If a youth returns to the program while nursing staff is not on-site,
a non-healthcare staff will complete the screening, and a RN will see the youth and review the
screening the next time they are on-site.
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Office of Accountability and Program Support Page 45 of 69 (Revised August 2025)
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 maintains a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. Seven youth Individual Healthcare
Records (IHCRs) were reviewed for healthcare orientation. Each youth received a general care
orientation on the day of admission. The program’s healthcare orientation included all required
topics. Each youth’s IHCR included a signed Youth Health Education Summary form indicating
they received an orientation. A Health Education Record was also located in each youth’s IHCR.
The program’s contract indicates they must provide health education monthly. Documentation in
each youth’s IHCR indicated they receive monthly education on the required topics.
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 maintains a policy and procedures to ensure the designated health authority
(DHA) is notified when an admitted youth requires emergency care or routine notification in
accordance with the Department’s requirements. The program’s practice is to notify the DHA of
each admission. Seven youth Individual Healthcare Records (IHCRs) were reviewed. Three
reviewed youth had a known or suspected chronic condition upon admission. None of the
reviewed youth were identified as in-need of emergency care upon admission. Each youth’s
IHCR contained documentation of notification being made to the DHA within twelve hours of
admission. One youth was taking psychotropic medication when admitted to the program. The
youth’s IHCR included documentation of the psychiatrist being notified. During an interview,
nursing staff stated a nurse notifies the DHA of all admissions by telephone on the day of
admission. Each notification is documented on an Admission Chronological Progress Note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a policy and procedures to ensure the standard Department’s Health
Related History (HRH) form is used for all youth admitted into their physical custody. Seven
youth Individual Healthcare Records (IHCRs) were reviewed for completion of an HRH form. A
new HRH form was completed on the day of admission for each youth. Each reviewed HRH
form was completed prior to the Comprehensive Physical Assessment and reviewed by the
designated health authority. Nursing staff stated a registered nurse completes an HRH
immediately when a youth is admitted.
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Office of Accountability and Program Support Page 46 of 69 (Revised August 2025)
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 policy and procedures ensuring the standardized Comprehensive Physical
Assessment (CPA) form is used for all youth admitted into the program. A review of seven youth
Individual Healthcare Records (IHCRs) found a new CPA form was completed by the
designated health authority (DHA), on the Department’s CPA form, within seven days of
admission for each youth. Each youth’s Medical Grade was documented on their CPA. Two
youth were identified as Medical Grade one, one youth was identified as Medical Grade two,
three youth were identified as Medical Grade three, and one youth was identified as Medical
Grade five. All sections of each CPA were marked with an “O” or an “X.” Those sections marked
with an “X” had comments by the DHA in the comments section of the form for each youth. One
youth refused a portion of the exam. The youth’s IHCR included a signed refusal form reflecting
the refused portion and was dated the same date of the exam. The Department’s Problem List
was updated, as required, for each youth. All seven youth had at least one verified Tuberculosis
Skin Test (TST) completed and documented within the last year. Each youth’s results were
documented on their CPA and Infectious Communicable Disease form, and each youth’s test
results matched on both forms. An interview with nursing staff found CPAs are conducted by the
DHA upon admission, and then annually for youth who are Medical Grade two or higher.
Nursing staff stated they note each youth’s most recent TST in their medical tracker and in their
IHCR. Screenings are conducted annually. Nursing staff stated gynecological exams are not
routinely completed on each youth.
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 maintains a policy and procedures ensuring all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). Seven youth Individual Healthcare
Records (IHCRs) were reviewed. Each youth’s IHCR contained documentation showing they
were screened and evaluated for STIs on the day of admission. Further evaluation was required
for one youth, the youth was referred to the designated health authority (DHA), the referral was
documented on the screening tool, and testing was ordered. Testing was performed and the
results were documented on the youth’s Infectious and Communicable Diseases (ICD) form.
One youth was out of the Department’s physical custody and/or had symptoms present,
requiring a rescreen. A rescreen was completed. Consent forms in all seven reviewed IHCRs
reflected each youth was offered counseling, testing, and if indicated, treatment/referral for
human immunodeficiency virus (HIV). Four youth refused HIV testing and a refusal was
documented for each. The remaining three received HIV testing, and documented consent was
obtained for each. Each youth’s results were reviewed by the DHA and filed confidentially.
There was documentation of pre/post-test counseling documented in each youth’s IHCR. Each
youth’s confidentiality was protected by not including their HIV status or any other STI diagnosis
on the program’s internal alert system. The program’s policy and procedures indicate youth HIV
test results are only disclosed to entities as outlined in Florida Administrative Code. The DHA
provides pre and post-test counseling services to youth at the program. Seven youth were
interviewed, and each stated they can ask for an HIV test. Nursing staff confirmed youth are
screened for STIs upon admission, and indicated the DHA decides if testing is needed during
the initial Comprehensive Physical Assessment. Nursing staff indicated STI test results are filed
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in the laboratory section of each youth’s IHCR in reverse chronological order. Documentation of
testing and treatment is located on each youth’s ICD form. If a youth has been out of the
physical custody of the Department for more than thirty days and/or symptoms are present, a
rescreen is completed. Nursing staff confirmed HIV test results are placed in an envelope in the
laboratory section of each youth’s IHCR. Once a youth is screened, they meet with the DHA to
complete pre-test counseling, provide consent, receive testing, and receive post-test
counseling. Pre and post-test counseling is documented on a health education log.
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 maintains a policy and procedures to ensure all youth can submit sick call
requests and have their complaints treated appropriately through the program’s sick call system.
Seven Individual Healthcare Records (IHCRs) were reviewed for sick calls. One youth
presented with a similar sick call complaint three or more times within a two-week period. A
referral was made to the designated health authority (DHA) as required. There was a total of
eighty sick calls documented for the seven youth. Each Sick Call Request form was completed
by the youth requesting a sick call and the nurse conducting the sick call. Reviewed
documentation found each sick call was completed by a registered nurse (RN). Each youth’s
Sick Call Request forms were filed in their IHCR in reverse chronological order. Each Sick Call
Request form was documented in accordance with Florida Administrative Code. Each youth’s
sick calls were documented on their Sick Call Index in their IHCR. Each sick call was
documented on the program’s Sick Call Referral Log. All dates listed on the Sick Call Indexes
corresponded to the completed Sick Call Request forms located in the IHCRs. One youth was in
restricted housing and was questioned daily regarding health complaints. A review of the daily
schedule, posted schedule, and nurse interview found sick call is held from 10:30 a.m. to 11:30
a.m. and from 2:00 p.m. to 3:00 p.m. daily, which meets the contract requirement of providing
sick call twice a day seven days a week. Sick call hours are posted on both doors to the medical
clinic. An exam table is located in the medical clinic to utilize during sick calls and only RNs
conduct sick call. Sick Call Request forms are available to youth on each dormitory. If there are
no nursing staff on-site, the program’s policy indicates Sick Call Request forms should be
submitted to a supervisor for review within two hours. Seven youth were interviewed and four
indicated they see a nurse immediately when requesting a sick call, and the remaining three
indicated they see a nurse within one day. An interview with nursing staff confirmed sick call is
conducted by a RN within twenty-four hours of a youth submitting a request. Nursing staff
indicated the DHA will conduct sick call if on-site. Sick calls are conducted in the medical clinic
behind a curtain. Nursing staff stated youth must be referred to the DHA if they have the same
complaint three or more times in two weeks, and the program has DHA approved treatment
protocols. One sick call was observed during the annual compliance review week. The youth
was escorted to the medical clinic by direct care staff, who remained outside the clinic door
while the youth was being examined. No other youth were present during the examination. The
RN identified themselves, indicated why the youth was there, and conducted an examination.
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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 maintains a policy and procedures showing they have a comprehensive process
for the provision of episodic care and first-aid care. Seven youth Individual Healthcare Records
(IHCRs) were reviewed and six were applicable for episodic care. A total of thirty-seven episodic
care or first-aid care events were reviewed for the six youth. On-site care was provided by
licensed healthcare staff for thirty-five of the thirty-seven events. All thirty-five events were
documented in the required subjective, objective, assessment, and plan (SOAP) format. The
remaining two events were conducted by non-healthcare staff and both events were
documented on the Department’s Report of On-Site Healthcare by Non-Healthcare Staff form.
The youth received a follow-up evaluation from a registered nurse (RN) the next time they were
on-site for both events. An episodic care event was not observed, as one did not take place
during the annual compliance review week. During an interview, nursing staff stated if episodic
care is provided by a RN, it is documented on a SOAP note. If episodic care is provided by non-
healthcare staff, it is documented on the required Department form, and the youth is seen by a
RN within twenty-four hours. Nursing staff indicated youth who are sent off-site for emergency
care are documented on an Episodic Care Log.
The program maintains ten first-aid kits. The kits are kept in master control, master control two,
each of the three classrooms, the medical clinic, administration, the kitchen, and two for the
vans. Nursing staff check each first-aid kit weekly and restock if needed. Three first-aid kits
were checked. Each first-aid kit was fully stocked with designated health authority (DHA)
approved items. A review of documentation for the annual compliance review period found first-
aid kits were inspected weekly by nursing staff. Nursing staff was interviewed and indicated
there are first-aid kits located in each dormitory, in the kitchen, in master control, in the medical
clinic, and one utilized for transports.
The program has two automated external defibrillators (AEDs), which are located in master
control and the medical clinic. Instructions are located with both AEDs. On-site nursing staff
check to ensure the AED batteries and pads are operable. A review of documentation for the
annual compliance review period found checks were conducted monthly. The green light was
flashing on both AEDs during the annual compliance review week. The batteries for both AEDs
are the original batteries and expire on July 31, 2030. The pads for both AEDs are the original
pads and expire on February 2, 2027. Nursing staff confirmed in an interview there are two
AEDs in the facility and instructions are kept with both AEDs. Nursing staff also confirmed they
check to ensure the AEDs are operable and confirmed the expiration dates for the batteries and
pads.
A review of emergency drill documentation for the annual compliance review period found the
program has conducted drills, which simulate an episodic care event which calls for immediate
first-aid and/or administration of cardiopulmonary resuscitation (CPR) techniques and the
initiation of the emergency procedures to follow when a life-threatening emergency occurs, at
least quarterly on each shift. A review of drill documentation found all direct care staff
participated in a drill including the use of CPR during the past year. A video review of
emergency drills confirmed drills were simulated as required. An interview with nursing staff
found emergency medical drills are conducted monthly, and CPR is included in a drill at least
quarterly.
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Office of Accountability and Program Support Page 49 of 69 (Revised August 2025)
The program has a list of emergency numbers, inaccessible to youth, located a binder in the
medical clinic. A review of training logs found all authorized direct care staff who were trained to
assist in the administration of medication, were trained by a RN on the administration of the
epinephrine auto-injector. A review of seven pre-service staff training records found each staff
was trained in episodic, first-aid, and emergency care. Nursing staff stated emergency numbers
are inaccessible to youth and located in master control and the medical clinic.
The program has a policy on the use, access, and inventory of Narcan. The policy indicates the
program will maintain Narcan in the medical clinic, in the medication cart, emergency response
kit, and with the back inventory. Program staff are trained to administer Narcan, and a
supervisor will administer, if needed. The program stores Narcan in the medication cart,
emergency response kit, and in a locked cabinet in medical. Nursing staff and supervisory staff
have access to the Narcan. A review of training logs found all staff who have access to Narcan
have been trained on the administration. A review of inventories found Narcan is inventoried
shift-to-shift. Seven staff were interviewed, and each indicated they are able to call 9-1-1 for a
medical emergency. Seven interviewed youth stated they can see a doctor or dentist, if needed.
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 policy and procedures ensuring the program provides for timely referrals
and coordination of medical services to off-site healthcare providers. Five of seven reviewed
youth Individual Healthcare Records (IHCRs) were applicable for off-site care. A total of
eighteen off-site care events were reviewed for the five youth. The Department’s Summary of
Off-Site Care Consultation Report form was utilized for seventeen of eighteen off-site care
events. The form was not utilized for the remaining event. Four of the off-site care events were
for emergency care, and documentation was located on the Episodic Care Log for two. The
remaining two events were not located on the Episodic Care Log. Three of the five applicable
youth were applicable for parental notification efforts, as the remaining two youth were eighteen
years of age or older at the time they received off-site care. Documentation of parent/guardian
notification was located for all three applicable youth. The designated health authority (DHA)
reviewed all off-site care findings, instructions, and information and signed acknowledging their
review. Three youth required follow-up care. Evidence indicating each youth received
appropriate follow-up care was provided. During an interview, nursing staff indicated youth who
are sent off-site for first-aid or emergency purposes are tracked utilizing the Episodic Care Log.
All hospital orders are provided to the DHA or psychiatrist by telephone upon a youth’s return to
continue orders. The DHA or psychiatrist makes the determination for all orders. Any youth who
receives off-site medical care will be seen by the DHA the next time they are on-site. Nursing
staff indicated all off-site care findings are provided to the DHA for review. All follow-up care is
tracked on a medical tracker.
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 maintains a policy and procedures to ensure youth who have chronic conditions
receive regularly scheduled evaluations and necessary follow-up. Seven youth Individual
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Healthcare Records (IHCRs) were reviewed. Six of the youth were applicable for chronic
conditions. Two youth were identified on the Department’s Facility Entry Physical Health
Screening form as having a chronic condition and the remaining four were identified during their
Comprehensive Psychical Assessment. None of the reviewed youth had a communicable
disease. Three youth were taking prescribed medication on an ongoing basis. All six youth were
undergoing treatment for a physical health condition and were classified with a Medical Grade
two through four, or a Medical Grade five for youth also taking psychotropic medications. None
of the youth were identified as pregnant. Five youth were placed on the program’s chronic
illness list, and one was not. A review of progress notes found five youth received periodic
evaluations at least every ninety-days. The remaining youth did not receive a periodic
evaluation every ninety-days; however, their chronic condition was resolved prior to the ninetieth
day. There were no youth at the program who were taking anti-tuberculosis medication. All
periodic evaluations were conducted on-site, and periodic evaluations were completed prior to
renewing any prescription medications which expired for the three youth taking prescribed
medications for their chronic condition. There were no instances of lapses in care or missed
periodic evaluations for five youth. The remaining youth did not receive a periodic evaluation;
however, their chronic condition was resolved prior to the ninetieth day. The Department’s
Problem List was updated, as required, for each youth. The facility administrator was
interviewed and indicated they meet with the health services administrator daily to discuss any
medical concerns pertaining to youth. An interview with the designated health authority (DHA)
confirmed there is a tracking system in place and periodic evaluations are conducted every
three months. Nursing staff confirmed youth with chronic conditions are seen by the DHA every
three months and this is monitored with a medical tracker and chronic condition calendar.
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 maintains a policy and procedures indicating they shall receive, store, inventory,
and provide medication in a safe and effective manner which shall be demonstrated by
observation, as well as review of documentation of procedures and processes. Seven youth
Individual Healthcare Records (IHCRs) were reviewed. Three youth were identified on the
Department’s Facility Entry Physical Health Screening form and in the progress notes as
admitted to the program with medication. Documentation in each youth’s IHCR found each
youth’s medications were verified, utilizing the required Department form, prior to being admitted
into the program. The designated health authority (DHA) and/or psychiatrist was contacted to
obtain an order to resume the medication prescribed prior to admission for all three youth. Three
additional reviewed youth were prescribed medication after their admission. All medications for
all six youth were observed to have a current, valid order, and were given pursuant to a current
prescription. Each time a medication was continued, discontinued, changed, or a new one was
ordered, the DHA placed an order on a Practitioner Order form. One youth was in restricted
housing and received all prescribed medications as ordered. Six youth were applicable for over-
the-counter (OTC) medications not listed on the Authority for Evaluation and Treatment form. All
OTC medications for each youth were administered in accordance with approved protocols or
practitioner’s order. The program utilizes a pre-printed pharmacy Medication Administration
Record (MAR), which includes all required elements and indicates all medication start and stop
dates. A review of MARs found staff initialed each administered medication and side-effect
monitoring was documented at least weekly for each youth. There were no undocumented
explanations for lapses or errors in medication administration. Trained non-healthcare staff did
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not assist in the administration of medication for any reviewed youth. Five youth refused
medication. Four youth signed a Refusal of Treatment form for each refusal, and each refusal
was clearly documented on their MAR. No Refusal of Treatment form was located for the
remaining youth for one refusal. None of the reviewed youth required parenteral medication.
There were no standing orders, emergency treatment orders, or pro re nata orders for
psychotropic medications. Medication pass was observed for two youth during the annual
compliance review week. Medication delivery was the sole responsibility of the nurse during the
time of administration. Both youth were escorted to medication pass by direct care staff and
approached the nurse administering medication individually. The nurse identified themself and
stated both youth were there for medication pass. The same staff prepared and administered
the medication. The nurse verified each youth’s allergy and alert status, and the staff initialed
the MAR. Staff observed both youth take their medication to ensure it was swallowed, and the
nurse had both youth cough and had direct care staff check to ensure the medication was
swallowed. The medication was not pre-poured from its original packaging and placed in
another container for subsequent administration. The six rights of medication
delivery/administration were verified by nursing staff. Seven youth were interviewed. Six youth
indicated they receive their medication from a nurse. The remaining youth indicated they do not
take medication. All six youth were able to explain the process for receiving medication. Nursing
staff was interviewed and started all prescribed medication is verified utilizing the Department
form. Medication is inventoried and the forms are placed in each youth’s IHCR. Nursing staff
confirmed the program utilizes a pre-printed pharmacy MAR and non-healthcare staff are
trained by the health services administrator in the administration of medication. There is a list of
approved staff posted in the medical clinic. Nursing staff indicated medication pass is held at
8:00 a.m., 12:00 p.m., and 5:00 p.m. daily. Nursing staff indicated they have a modified Class II
permit, and most patient specific medications are procured from their vendor. Rarely, a youth
will be discharged from a hospital and return to the facility with medication from the hospital
pharmacy.
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 policy and procedures outlining psychiatric services at the program.
Psychiatric services at the program are provided by a psychiatrist who holds a clear and active
license with an expiration date of January 31, 2026. The program’s psychiatrist is available for
emergency consultation twenty-four hours a day, seven days a week. A review of treatment
team documentation during the annual compliance review period found the psychiatrist briefed a
representative of the treatment team regarding the psychiatric status of each youth receiving
psychiatric services who was scheduled for a treatment team review. The psychiatrist’s
evaluation and recommendations for each youth are incorporated into mental health clinical
staff’s evaluations of each youth and each youth’s individualized mental health or substance
abuse treatment plan. A review of sign-in/out logs found the psychiatrist was on-site weekly
during the annual compliance review period, as required. A review of documentation found the
psychiatrist actively participates in, manages, and supervises psychotropic medication in the
program. The program maintains a back-up psychiatrist who holds a clear and active license
with an expiration date of January 31, 2026; however, the back-up was not utilized during the
annual compliance review period. The program’s contract was reviewed for tele-psychiatry
inclusion; however, no youth received tele-psychiatry services during the annual compliance
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review period. An interview with the psychiatrist found they are on-site weekly to evaluate new
youth, diagnose and treat psychiatric disorders, and implement treatment recommendations.
The psychiatrist stated they see youth who are not receiving psychiatric care promptly. The
psychiatrist indicated they meet with the designated mental health clinician authority (DMHCA)
and nursing staff weekly to discuss youth receiving psychiatric services. The psychiatrist
indicated they are notified of three medication refusals in a row by nursing staff. The DMHCA
was interviewed and indicated they meet with the psychiatrist two to four times a month and as
needed.
Seven youth Individual Healthcare Records (IHCR) were reviewed for psychiatric services. All
seven youth were referred for a psychiatric interview and received an interview within fourteen
days of admission. Each youth’s psychiatric interview was documented on the Department’s
Clinical Psychotropic Progress Note (CPPN) form, was labeled as an initial interview, and
included all required elements. One youth came into the program on psychotropic medications,
and the medications were continued as a result of the interview. Page three of the CPPN was
completed. None of the remaining six youth were placed on psychotropic medications as a
result of the interview; however, three youth were later ordered psychotropic medications. A
review of documentation for all four applicable youth during the annual compliance review
period found each youth was seen by the psychiatrist for a medication review at a minimum of
every thirty days. Each time a psychiatric evaluation resulted in the prescription of psychotropic
medication or changes to a youth’s existing psychotropic medication, page three of the CPPN
was completed and included all required elements for each youth. None of the reviewed youth
received tele-psychiatry during the annual compliance review period.
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 maintains a policy and procedures stating 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’s sharps are secured in a locked area in the medical
clinic. A review of sharps inventories during the annual compliance review period found sharps
were inventoried utilizing a routine perpetual inventory descending count as each sharp was
utilized and disposed. All medications were identified and secured in a locked area designated
for storage of medications in the medical clinic. Medications are kept in the locked medication
cart, with all overflow medications stored in a locked cabinet in the medical clinic. The
medication cart was found to be organized with stock items separate from youth specific
medications and all injectable, topical, drops, and liquids separated. Controlled medications are
stored behind a double lock in the medication cart. All controlled substances have a perpetual
inventory, and a shift-to-shift count which is signed off on by two staff. The program has a
dedicated refrigerator for only medication requiring refrigeration. The program has a process for
the destruction and disposal or return of expired or discontinued medication. Expired or
discontinued medications are destroyed and disposed of utilizing a drug buster. Medications
which are not expired are returned to the pharmacy for a credit. A review of over-the-counter
(OTC) inventories during the annual compliance review period found a perpetual inventory is
done whenever an OTC medication is utilized, and weekly inventories are conducted by
healthcare staff. Five staff training records were reviewed for non-healthcare staff who may
assist in delivery and oversight of medication self-administration. Each staff received training,
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delivered by a registered nurse, on medication administration. A nurse was observed counting
three controlled medications, three OTC medications, and three sharps. All counts matched the
ending inventory numbers. Nursing staff indicated if there were an inventory discrepancy they
would notify the facility administrator and contact the Department’s Central Communications
Center if it was not located within two hours. An interview with nursing staff confirmed individual
doses of medication are disposed of by two staff utilizing a drug buster. Larger amounts of
medication are returned to the pharmacy. Controlled medications are disposed of with the
pharmacy consultant and two additional staff monthly. Nursing staff confirmed controlled
medications are kept in the medication cart with a double lock. OTC medications are stored in
the medication cart and in a locked cabinet and are inventoried weekly, and as used. Nursing
staff stated a pharmacy consultant is on-site monthly to monitor the medication cart, Medication
Administration Records, medication management and disposal, and storage.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has implemented infection control procedures which include prevention,
containment, treatment, and reporting requirements related to infectious diseases, in
accordance with the Occupational Safety and Health Administration (OSHA) federal regulations
and the Center for Disease Control and Prevention (CDC) guidelines. The program’s Infection
Control Plan and Exposure Control Plan were reviewed and signed by the designated health
authority on October 10, 2025, and by the facility administrator (FA) on October 1, 2025. The
program’s Infection Control Plan includes all required topics. Hepatitis B immunizations are
available for all staff and staff have access to protective equipment, as needed. There were no
instances in which the local county health department, CDC, and/or the Department’s Central
Communications Center should have been notified of an infectious disease or any facility or
occupational exposure in the last year. The program’s Exposure Control Plan was found to be
written in accordance with OSHA standards and is available to all staff in the medical clinic and
master control. The program has a comprehensive process for needle stick post-exposure
evaluation to determine how the exposure occurred, ensure individuals are tested and provided
results, and provide the healthcare professional with the OSHA standard. The FA was
interviewed and indicated the exposure control plan is located in the medical clinic and is
reviewed with staff monthly. Nursing staff indicated the exposure control plan is available in the
medical clinic. Nursing staff indicated initial infection control and exposure control plan training
is provided to staff by the training team and a registered nurse (RN) provides ongoing refresher
trainings. Nursing staff stated a RN provides youth with education on infection control upon
admission and during monthly health education sessions.
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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 maintains a policy and procedures ensuring pregnant youth have access to
prenatal care. The program did not have any pregnant youth during the annual compliance
review period. A review of training sign-in sheets confirmed the program provides all non-
healthcare staff education on girl’s healthcare and prenatal healthcare by a registered nurse
(RN) annually. A review of the training curriculum found training includes observation and
monitoring of emergency care needs/symptoms of possible miscarriage. The program has
approved nursing protocols in place for pregnant youth. An interview with nursing staff found a
RN provides each youth with education about pregnant youth. Pregnant youth are provided
education on pregnancy health, labor and delivery preparation, postpartum, and lactation care.
Nursing staff stated youth are routinely tested for pregnancy upon admission, and if the program
had a pregnant youth, they would provide appropriate prenatal care, including a special diet.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures to maintain active supervision of youth while
engaging in constructive activities, interacting positively with youth, closely observing behavior
and behavior changes in youth, and consistently applying the program’s behavior management
system (BMS). The policy states all program staff shall provide appropriate levels of physical
sight and sound supervision. An informal interview with three staff members found all three
knew the correct count of youth in their supervision. The program’s staff-to-youth contract
required ratio is one-to-five during both daytime and nighttime activities. The program’s ratio
was observed throughout the annual compliance review week and found to be in compliance
with the contract’s requirements. The program has a daily schedule to be followed, which is
posted and available to youth in each living unit/dormitory. Observations throughout the annual
compliance review week confirmed all youth were engaged in a full schedule of activities. Policy
and procedure define active supervision as a strategy which focuses on intentional observation
of youth at all times. Staff were observed during school, recreation, line movements, and group
therapy actively supervising youth with positive interactions. A video review of the overnight shift
confirmed the staff observe youth in their rooms during sleep hours every ten minutes as
required. Observations of youth rooms found no window coverings which would affect the direct
line of sight of the youth. The program had 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.
The program has a detailed description of the behavior management system (BMS). A facility
tour was conducted and found the BMS to be posted in the youth living units. It is also explained
in the youth handbook which is easily accessible to youth. The written description includes rules
governing conduct and positive and negative consequences for behavior including while in the
classroom. The appropriate parties were involved, including an agreement with education, in the
development, implementation, and on-going maintenance of the BMS, and providing staff
feedback regarding the implementation of the BMS. The BMS did not change within the annual
compliance review period. The program director provided training to education related to the
BMS. Observations of staff and youth interactions found the staff adhering to the BMS as
required. Seven reviewed youth case management records confirmed each youth’s orientation
included a review of the program’s BMS. A review of the BMS verified it included promoting
safety, respect, fairness, promoting and protecting youth rights, positive and negative
consequences, constructive disciplinary/non-punitive actions, opportunities for positive
reinforcement, recognition of accomplishments and positive behaviors at a four to one ratio,
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promoting socially acceptable means for youth to meet their needs, a process for explaining to
youth the reasons for any sanctions imposed, youth having the opportunity to explain to explain
their behavior, opportunities for staff and youth to discuss the impact of behaviors on others,
reasonable reparations for harm caused to others, discussion of alternate behaviors, promoting
positive dialogue and peaceful conflict solutions, and separation of youth from population is
minimized. The BMS does not include increased length of stay, denial of rights, promotion of
group punishment, punishment of youth by other youth, or disciplinary confinement. Incentives
at the program include fun days, MP3 players, point store/Bodega and extra food. Seven
reviewed staff position descriptions confirmed each included the BMS in the job functions.
Seven reviewed pre-service staff training records included documentation staff were trained in
the program’s BMS. Seven interviewed staff were asked to explain the behavior management
system (BMS), and all were familiar and able to explain the BMS used at the program. Each
understood the level expectations, time frames, and point system. The seven staff reported
youth rewards include fun Fridays, mega Mondays, Bodega and personal music players. All
seven staff confirmed basic rights cannot be taken away from youth as a consequence. The
seven interviewed staff explained youth are informed of the consequences when a disciplinary
board form is completed and youth are able to explain their behavior in emergency treatment
team, which conducted by the youth's regular treatment team. Seven interviewed youth were
asked what consequences the program has for bad behaviors, six reported youth can lose
incentives, four youth reported they will be placed on red level, receive a write-up and could lose
their current level. One of seven youth reported youth could lose a phase. Seven interviewed
youth were asked to describe the rewards they can earn at the program, six reported they earn
mega Mondays and can get a personal music player, four reported they can earn extra food or
snacks, three stated they can earn fun Fridays and two stated they can earn Bodega. All seven
youth reported staff are consistent with giving rewards and consequences. All interviewed youth
knew the program’s BMS consisted of orientation and five levels, which they need to earn. Each
youth stated youth cannot punish other youth. The interviewed facility administrator stated the
BMS consists of a level system to give clear information to youth, staff, parents, and others
about specific behavioral and treatment expectations which youth must complete before the
Inter-Disciplinary Treatment Team can authorize a successful completion of the residential
treatment program. The system is designed to give youth guidelines for their behavior as they
progress through the program. The length of time a youth remain on a certain level will be
determined solely by their performance. Youth learn a sense of pride and accomplishment as
they progress through the levels and additional privileges and responsibilities are awarded.
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 has a policy and procedures in place which meets the indicator requirements of
not using room restriction as a major infraction, if used documentation must include a
description of the behavior resulting in room restriction, date in and date out of room restriction,
youth was not out-of-control or suicidal, name of staff who recommended room restriction, door
must remain open, staff and youth had a discussion every thirty-minutes, date out and time out
of room restriction, youth were not denied basic rights or services, description of
behavior/attitude of youth upon removal, any follow-up actions and the use of room restriction
must be documented in the logbook, and showing room restriction did not exceed four hours.
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The program policy which states room restriction can be used as a means to gain control of the
program youth if needed. There has been no use of room restriction in the program during the
annual compliance review period. Seven interviewed youth stated they had never been sent to
their room for getting in trouble. Seven interviewed staff and the facility administrator stated no
youth has been placed on room restriction.
5.04 Ten-Minute Checks (Critical) Limited 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 policy and procedures in place to conduct ten-minute checks while the youth
are in their sleeping rooms. The program had a major deficiency closed on October 17, 2025;
therefore, this indicator will be rated a limited. The program’s policy states staff shall observe
youth at least every ten minutes while the youth are in their sleeping rooms. the observations in
a manner to ensure the safety and security of each youth and each observation shall be
documented in real time. The program has a total of ninety-two operating cameras which store
recordings for thirty-days. Staff are required to conduct room checks every ten minutes and
document the time of the check on the ten-minute check log when youth are sleeping. A review
of nine samples of video footage of the two dormitories confirmed staff conducted checks as
required. A review of the ten-minute check logs revealed checks are conducted every eight
minutes. Nine days were reviewed and confirmed checks were conducted in real time, and staff
observed youth for safety. All reviews were on second-shift due to this being the only shift which
conducts ten-minute checks. Seven interviewed staff reported checks are completed every eight
minutes when youth are in their rooms for sleeping. The interviewed facility administrator stated
the program has a total of ninety-two cameras which are all operational and record for thirty-
days
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures for ensuring youth are always accounted for through
a system of physically counting youth at various times throughout the day and documenting
each count as well as a chronological order of events. The policy states youth counts should be
conducted during emergency situations such as escapes, riots, or in an event which disrupts the
safety and security of the program. The policy maintains a track record of the daily census
information which includes total daily census count, new admissions, releases or direct
discharges, transfers, and youth temporarily away from program. If staff are unable to account
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for the whereabouts of youth, the program’s policy states the program will reconcile it
immediately. A review of one day each month since the start-up monitoring occurred in April
2025, confirmed youth head counts were performed at the beginning of each shift, after each
outdoor activity, and during emergency situations when they occurred. The logbook also
documented total daily census counts, head counts, except for April 12, 2025, and May 11,
2025, youth movements, new admissions, releases or direct discharges, transfers, transports
with the name of the youth and staff, and youth temporarily away from the program. During the
annual compliance review week, counts were observed during movements from the common
area, to and from the classroom, and to outdoor activities. Seven interviewed staff were asked
when youth counts are conducted. One stated master control calls for a head count and staff
physically count the youth in their group, one staff stated every hour, one staff stated before
every shift, every hour, and end of shift, and random headcounts, one staff stated every hour,
before shift, end of shift, and after emergencies, another staff stated before shift, after
movement, and end of shift. Two of seven staff stated beginning of every shift, every hour and
random throughout the shift. All seven interviewed staff stated they stop all program movement
when the count is off and recount until correct, and emergency counts are conducted after an
emergency.
5.06 Logbook Entries and Shift Report Review Limited Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures to ensure the program maintains a chronological
record of events, incidents, and activities in a logbook located in master control. The program
ensures the logbooks are bound with numbered pages. Some pages in the reviewed logbooks
displayed pages stapled together and some ripped slightly. Pages were numbered consistently
with no missing pages. A couple mistakes were scratched out and uninitialed, the remaining
were crossed out with a single line and initialed by the staff making the entry. There were no
erasures or white out areas. All entries included the dates and times of the events, with the
names of the staff and youth involved, brief description of the events, and the names and
signatures of staff making the entries. Eight incident reports to the Department’s Central
Communication Center (CCC) were not documented in the logbook. The logbook indicated
activities are held as scheduled. A review of the logbooks found the program documented
incidents which included the use of mechanical restraints, special instructions for monitoring
youth, population counts at the beginning, during, and end of shift, perimeter security checks,
transports away from facility including the names of staff, youth, and destination, and admission
and releases, including the name, date, time of anticipated arrival or departure, and mode of
transportation. Youth placement of suicide precautions was inconsistently entered shift by shift
for the duration of the youth’s placement. Information from the logbook is reviewed during the
beginning of each shift. Shift supervisors and staff were inconsistent with signing the logbooks.
Shift assignments were inconsistently documented.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
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• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures in place to maintain key control and security which
consists of key assignment, inventory, tracking, and storage of keys. The policy includes the
protocol for addressing missing or lost keys, and reporting and replacing damaged keys.
Observations conducted during the annual compliance review week verified staff and visitors
submitted their personal keys to the control station which is located in the lobby upon entering
the program. The keys are then stored in a locked wooden cabinet in the control station, and not
easily accessible. Program keys are stored in master control, which is located in the program.
Upon entry into the program, staff receive program keys based on their job function. Staff sign
the key logbook, enter the date, key ring number, and time the keys were taken. Upon exiting
the program, staff will enter the time and sign the key logbook indicating the keys were returned.
Observations of floor staff distribution of keys could not be observed due to the time of shift
change. Observations of nursing, mental health and case management staff key distribution
was observed and was conducted as required. A review of the key logbook for the annual
compliance review period verified this procedure was followed. There were no staff assigned
permanent keys authorized by the facility administrator during the annual review period. Policy
states permanent keys are issued following the staff approval process and signed
acknowledgement form indicating a key identification number and the number of keys on the
key ring. Damaged or lost keys are to be reported to the shift supervisor and a maintenance
request is completed. The damaged keys are given to the maintenance manager and staff are
given new keys. There were no incidents of lost keys reported to the Department’s Central
Communications Center (CCC). The Program did have a major deficiency related to key control
concerns which was closed on October 3, 2025. An informal interview with the master control
operator was conducted and determined the process for restricting usage of keys such as
medical, youth and staff records, and youth property locker keys consists of each department
issuing separate keys in order to gain access to certain storage areas. Five sets of keys were
observed and compared to the inventory and key log, with each matching. Three staff were
informally interviewed and confirmed the number of keys on their key ring and the function of
each key. Their responses were compared to keys observed in the key inventory with no
discrepancies. Seven interviewed staff were asked to explain the key control process and each
stated personal keys are turned in upon entry and securely stored, a key log is used for daily
tracking, program keys are assigned to staff, youth do not have access to keys, they would
notify master control of missing keys, the facility and youth are searched if keys are missing,
and keys are replaced if damaged. Six of seven interviewed staff stated there is an inventory of
keys. Five of seven interviewed staff stated visitor keys are turned into the control station and
three of seven stated a chit is provided to visitors when their keys are turned in.
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
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materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures to establish a system to prevent the introduction of
contraband which include all required items and outline the consequences for possessing
contraband as required by Florida Administrative Code. Youth are provided a list of items
considered to be contraband and the consequences of possessing contraband upon admission
in the youth handbook. Upon arrival to the program all visitors are required to sign a sign-in log
which includes a contraband attestation statement. Staff are required to sign attestation forms,
upon hire, acknowledging the contraband policy and the consequences up to and including
dismissal. Seventy staff were hired during the annual compliance review period and each staff
signed a form, as required. A review of logbooks and search reports for the annual compliance
review period confirmed searches were conducted as required by policy; and five incidents of
contraband items were found during the annual compliance review period. There were five
reported incidents to the Department’s Central Communications Center (CCC); during the
annual compliance review week. One staff had a secure digital (SD) card, one had a vape pen
and charger, one had a plastic knife, one had pills and one had a vape pen. Three items of
illegal contraband were turned over to law enforcement; the two vape pens and pills. All other
contraband was disposed of according to policy. The facility administrator was interviewed and
confirmed there are contraband notices posted throughout the facility, staff conduct searches of
youth and youth rooms, and staff are notified of the contraband policy upon hire. If contraband is
found, disposal is conducted in accordance with the program policy and all illegal contraband
turned over to law enforcement, a report is made to the Department’s Central Communications
Center (CCC) and residential regional director. Seven interviewed staff confirmed staff search
youth rooms daily on every shift.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to perform searches to prevent contraband from
entering the program. Searches are conducted according to Florida Administrative Code at the
time of admission, before and after off-campus activities, before all movements, visitation, and
randomly. All parents/guardians are notified of searches during visitation by way of the
parent/guardian intake letter, which is sent at the time of each youth’s admission. All youth are
searched before all movements, during a new admission, returning from visitation, returning
from off campus activities or appointments, when there is suspicion of contraband, or when a
youth is identified as a security risk. During the annual compliance review week, youth searches
were performed by staff of the same gender in a respectful manner, thoroughly, and in
accordance with the Right Interactions (RI) manual. There were no transports, visitation, or off-
campus activities during the annual compliance review week to observe. During observation of
video, five staff and visitors were observed being searched by same gendered staff, upon
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entering the program. Seven interviewed staff were asked when youth searches are conducted
and four of seven answered as if they were describing room searches, three stated before and
after every movement. Seven interviewed youth were asked when searches occur and each
answered when returning from off campus, after outdoor activities, when items are missing,
after visitation, after meals, and one stated after work details. A follow-up with the program and
a review of policy states the program does not do work details.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures in place to ensure any vehicles used by the program
to transport youth are properly maintained and inspected for safety. The program has one van
to transport youth. The van received an annual safety inspection which was documented and
maintained in the vehicle binder, as were maintenance records. The van was observed during
the annual compliance review week and found to be secured and include a fire extinguisher,
approved first-aid kit, seatbelt cutter, window punch, and appropriate number of seatbelts. The
van doors accessible to the youth passenger area were unable to be opened from the inside.
Six personal vehicles including the program van were checked during the annual compliance
week and confirmed all vehicles were secure when not in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to ensure the staff-to-youth ratio is maintained while
youth are outside of the program to provide safety and security of youth, staff, and the public. A
ratio of one-to-five, not including the driver, is used during all transports. Policy states youth are
not permitted to operate any program vehicles. During the annual compliance review week, no
transports were conducted. An informal interview with the human resources staff advised all
staff are to possess a valid driver's license, which is confirmed through monthly checks. The
interviewed facility administrator stated the program vehicle does not have a safety screen;
therefore, a staff must ride in the back with the youth. Seven interviewed staff were asked how
youth are secured within the vehicle during transports and six of seven staff stated youth are
shackled and placed in the back with one staff. One of seven staff stated for every one youth
there should be a least two staff. When asked what type of communication devises are supplied
to staff during transports, all seven interviewed staff reported three-way radios, six of seven
interviewed staff also reported they receive the supervisor mobile telephone, and one reported
they receive the transport telephone. When asked what safety equipment is in the transport
vehicle, all seven interviewed staff stated the vehicle is equipped with a first-aid kit, seatbelt
cutter and a flashlight, one added a wheel lock, and another staff added a glass breaker. Seven
interviewed staff stated they are not allowed to use their personal vehicles to transport youth,
transport vehicles are searched for contraband prior to being used, the ratio for staff to youth
during transports is two staff to one youth, and the vehicle has a safety screen. Seven
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interviewed staff were asked to explain the emergency response process during vehicle
transports. Six of seven staff reported they would notify the facility, four of seven staff also
stated they would notify 9-1-1, one of seven staff stated they would notify the facility
administrator and shift supervisor. Four of seven staff added they would transfer the youth to a
new vehicle, once it arrived. Two of seven staff stated they would make sure the youth is
unharmed, and one stated they would pull the vehicle over. Five of the seven interviewed youth
participated in a transport, and the five stated they have never been handcuffed to a transport
vehicle, and none of the seven youth have witnessed anyone placing 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 policy and procedures which outline the audit/inspection process to include
who is responsible for conducting the weekly security audits and safety inspections, 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, and an
internal system to verify the deficiencies are corrected and existing systems are improved or
new systems are initiated. The facility administrator (FA), and assistant facility administrator
(AFA), or designated staff are responsible for conducting the weekly security audits and safety
inspections. A review of the Weekly Safety Audits since April 2025 confirmed they were
completed as required. When applicable, the corrective action plan was documented on the
Weekly Safety Audit form as well as when the corrective action was completed. . A review of the
Weekly Safety Audits since April 2025 confirmed they were completed as required. During an
interview with the FA, the process of identifying and tracking safety and security deficiencies
was explained the weekly safety/security audit includes checking surveillance video,
radios/communication, keys/locks/doors, metal detectors, mechanical restraints, sally port,
transportation, youth rooms/living areas/bathrooms, classroom/education, kitchen/dining room,
grounds, exterior structure, perimeter fencing, chemicals and storage areas, tool and sensitive
item control, and their deficiencies. Any deficiencies will be reviewed with the FA.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures regarding tool management to ensure youth do not
use tools or equipment as weapons or security breaches. The program’s policy and procedures
address the issuance, inventory, and control of equipment and tools. A tour of the facility
revealed all tools are secured when not in use and marked for identification. The tools in the
maintenance office were reviewed during th annual compliance review week. Ten reviewed
tools were secured properly, individually marked for easy identification, and had an accurate
inventory. The tool inventory located in the maintenance office displayed tools being checked in
and out accurately and a monthly inventory of tools is being completed monthly as required. The
program maintains a locked box in the kitchen which contains knives, serving forks, and pizza
cutter. Machetes, bowie knives, or other long blade knives are prohibited. In the event a tool is
broken or non-operational, the maintenance manager is immediately notified and is responsible
for replacing the broken tool. There were no dysfunctional tools reported or on-site at the time of
the annual compliance review. If a tool is missing, administration is immediately notified by staff,
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the program will stop all youth movement, and the program will be searched until the tool is
found. A review of the tool inventory list found the tools were inventoried as required.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures to ensure youth supervision requirements while
handling tools are maintained and address all required elements. The facility administrator
advised youth do not use tools while admitted at the program; therefore, youth are not assessed
for tool usage or trained in the use of tools. Four of the seven interviewed staff reported youth
are allowed to use mops, and brooms, three of seven stated they do not use tools. Seven
interviewed youth reported youth are only allowed to use mops, and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures to maintain guidelines required for outside
contractors regarding tool control and restrictions. The program’s policy states it is the plant
manager and facility administrator’s (FA) responsibility to monitor the use of tools and
equipment in the facility. The plant manager contacts contractors when a repair is needed. The
program has procedures in place when a repair person or other external worker with tools arrive
on-site. The program advises them of the guidelines for worker tools which include tools are to
be checked upon arrival and departure, tool restrictions are initiated while in the facility, youth
are restricted from the work area, and if a tool is missing, there will be a follow-up. Upon arrival,
contractors are also instructed to sign in and out of the facility on a separate contractor visitor
log and sign an agreement form confirming the awareness of items which are unauthorized. The
FA or designee must approve of any unauthorized items needed by the contractor. During the
annual compliance review week, five reviewed invoices were compared to the contractor visitor
log and matched. The contractors’ names, signatures, and tool count were all documented
appropriately.
5.16 Fire, Safety, and Evacuation Drills Limited Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to address fire, safety, and evacuation drills. It was
confirmed through drill documentation, during the annual compliance review period, the program
conducted fire drills monthly on every shift with the exceptions of missing fire drills on second
shift for the months of September, July, June, May and April. First shift was missing a fire drill
for the month of May. The drills included type of drill, date and time, participants, brief scenario,
findings, and recommendations. The fire evacuation routes, and egress plans are posted
throughout the facility. The program has twenty-one fire extinguishers which were inspected
annually. The Continuity of Operations Planning (COOP) drills were conducted on first shift bi-
annually as required by the COOP plan; however, there were no COOP drills completed on
second shift for the annual compliance review period. Seven staff were interviewed, and all
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reported participating in various types of drills during the past year, including fire, hostage,
escape, medical, mental health, and suicide drills. Six of seven interviewed youth stated they
have been instructed on what to do in the event of a fire. One youth stated they were not
instructed on what to do in the event of a fire. The facility administrator (FA) was interviewed
and advised fire drills, medical drills, and mental health drills are conducted monthly on each
shift and COOP drills are conducted simi-annually on each shift.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a Disaster and Continuity of Operations Plan (COOP) approved by the
Department to ensure youth receive basic care and custody in the event an emergency or
disaster occurs. The plan was reviewed and update on October 28, 2025, by the new facility
administrator, and approved by the Department on October 30, 2025. The previous FA reviewed
the COOP March 26, 2025, and the Department approved it on March 28, 2025. The plan
addresses alternative relocation sites approved by the applicable Department regional director
or designee. The plan is posted and readily available in the facility administrator’s (FA) office,
assistant facility administrator’s (AFA) office, master control, administration and master control
room. Emergency equipment and supplies include lock box of records, medications, first-aid
kits, food, water, toiletries, clothing, mattresses, and blankets. The program reported in the
event of an emergency, records are kept in a lock box in the case management office and
brought to the evacuation site. The facility maintained a hard file of critical identifying information
for each youth in a binder located in case management. Seven reviewed youth emergency
records confirmed all required and applicable information was included. The interviewed facility
administrator stated a copy of the COOP is available to staff and a copy is in the FA 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 has a policy and procedures regarding the storage and inventory of flammable,
poisonous, and toxic items. Flammable, poisonous, and toxic items are secured in the
maintenance area outside the facility in a secured flammable chemical cabinet, where youth do
not have access. Inventories are maintained for all flammable, poisonous, and toxic items. The
program maintains a list of positions authorized to handle flammable, poisonous, and toxic items
which include the facility administrator, assistant facility administrators, maintenance staff, shift
supervisors and medical staff. Ten chemicals were randomly selected, all items matched
inventory, were secured, and had Safety Data Sheets (SDS) present, and with no discrepancies
noted. The plant manager was interviewed and indicated the program uses the county landfill
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for disposal. The facility administrator, in consultation with the physical plant manager, has
designated the following staff to dispose of flammable, poisonous, and toxic items and
materials: the facility administrator (FA) assistant facility administrator (AFA), and the plant
manager. All disposal procedures were in accordance with Occupational Safety and Health
Administration (OSHA) standards. Hazardous liquid waste is disposed of in accordance with the
SDS. The program has not disposed of any hazardous waste since April 2025. Kitchen grease
is placed in a separate container for proper disposal. In line with the program’s policy and
procedures, liquid waste is disposed of in the plumbing drains. Chemical spills are cleaned up
as follows: upon discovering a chemical spill, staff are required to notify master control of the
location, the shift supervisor or master control will then direct the shutdown of all air handlers
and ventilation systems, and ensure all windows and doors are closed, as instructed by the on-
scene supervisor or FA. If necessary, assistance from outside the facility is contacted in
accordance with emergency procedures. The reviewed FA interview results indicated the
program utilizes the local waste management site for the disposal of hazardous items.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures to ensure youth shall not be permitted to handle
flammable, poisonous, toxic items and materials and prohibited where these items are being
used and stored. Youth are not permitted to clean, handle, or dispose of any person’s bio-
hazardous material, bodily fluids, or human waste. Youth were not observed during the annual
compliance review completing daily cleaning activities. Seven interviewed youth reported they
do not handle chemicals.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
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• 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 has a policy and procedures addressing visitation and communication, youth
correspondence, and use of the telephone by youth. The visitation schedule is posted in the
lobby and at the entrance of the facility. At the time of the review, visitation was scheduled for
bi-weekly; however, the contract requires weekly. The facility administrator (FA) was unaware of
the weekly requirement. As a result, the provider’s regional compliance manager indicated they
would address with leadership. A review of the visitation log confirmed visitation was held bi-
weekly. The program’s policy and procedures state the program shall make every effort to assist
youth in maintaining and strengthening positive family ties. Each youth is provided an
opportunity on a regular basis to correspond with identified individuals specified on their
approved correspondence list and legal representatives. A review of the correspondence logs
confirmed all incoming and outgoing mail is searched and recorded in the correspondence logs.
The parent/guardian may contact the case manager and request an alternative visitation day if
needed. The program’s visitation hours are Saturdays from 1:00 p.m. to 3:00 p.m. A review of
the visitation logs validated visitations were taking place as scheduled. Telephone calls and
opening of mail are conducted by the youth with their case managers and documented in each
youth’s case management record. Telephone calls are offered weekly according to the
program’s policy and procedures. A review of telephone phone logs confirmed this practice.
Each youth is allowed to make one telephone call a week to approved family members. Each
youth can earn additional telephone calls through the behavior management system. The case
manager is responsible for scheduling these telephone calls. The program provides postage for
each youth within the program and does not limit the number of letters a youth is able to mail
each week. There were no youth whose parent/guardian were under investigation for current or
past human trafficking-related charges. The program does have an agreement with an
interpreter service if needed or requested by the youth, parent/guardian. The FA’s interview
indicated services for youth are offered who have Limited English Proficiency (LEP) by
prohibiting discrimination and addressing it as part of its civil rights monitoring. The FA was
informally interviewed and asked if there is a specific interpreter service available to be used,
they confirmed there is. The seven interviewed youth confirmed they can call their
parent/guardian or write letters to them as a means of communication. There was no visitation
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scheduled during the week of the annual compliance review; therefore, visitation was not
observed.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures which provide a variety of recreation and leisure
activities to the youth. The daily activity schedule documents a range of supervised and
structured indoor and leisure activities for youth at least one hour daily. Indoor and outdoor
activities involve large muscle activities. A review of the logbook confirmed recreation was
conducted as scheduled. The program promotes social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. During the
annual compliance review week, youth were observed doing yoga, jogging, walking, and playing
cards. The program takes steps to ensure during recreation to prevent overexertion, heat stress,
and dehydration. Youth are provided water if the heat index is too high and indoor recreation if
it’s raining or too cold. The recreational therapist position has been vacant since August 23,
2025. The recreation therapist’s, who vacated the position in August, credentials met the
contract requirements. Recreational therapy was included in the seven youth Individualized
Performance Plans and Mental Health Treatment Plans. Seven interviewed youth reported the
youth get at least one hour of recreation time where they play kickball, basketball and football.
Seven interviewed staff were asked what indoor and outdoor activities youth can participate in.
Two of the seven staff work nights and do not participate in daytime recreation; however, they
do offer movie night or game night during their shift. One of seven staff answered listening to
the radio, bingo, activities on recreation yard, flag football, and kickball for at least an hour.
Another staff answered recreation, football, basketball, bingo night, and arts and craft for at
least an hour. Two staff answered recreation and groups for an hour and one staff stated bingo
and recreation for an hour.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a policy and procedures for the search and inspection of the controlled
observation room. The rooms used for controlled observation had a metal door with a shatter-
resistant window, was at least thirty-five unencumbered square feet, properly covered vents and
lighting and no electrical outlets. Electrical switches for lights were located outside the controlled
observation room. Mattresses in the program are fire retardant. Five Controlled Observation
Reports were reviewed and indicted staff documented an inspection of the room and a search of
each youth before the youth was placed in the room, as required. Staff of the same gender
searched each youth before the youth was left alone in the controlled observation room.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a policy and procedures for controlled observation. The program had five
youth with documented controlled observations for the review period and each were reviewed.
None of the reports reflected youth in a mental health crisis or suicide. Each youth met at least
one of the required criteria for controlled observation. All five contained documentation of
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supervisory or higher-level staff authorizing placement. Staff advised each youth of the reason
for placement in controlled observation and explained the expected behavior for removal. A
healthcare professional or staff of the same gender completed the health status checklist for
each youth. There was no youth who complained about injuries. Times of controlled observation
ranged from one to two hours; in one of the five reports the facility administrator or designee
gave approval to go over the two-hour window.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a policy and procedures for controlled observation safety checks and
releases, including staff designations for controlled observation. A sample of five youth records
were reviewed for youth under controlled observations since April 2025. All five reports included
documentation of staff responsible for placement, completion of the first page of the controlled
observation report, submission to the supervisor, documentation of safety checks conducted at
least every ten minutes, as required by the program’s policy and procedures, and observing the
youth’s behavior on the controlled observation safety check form. It was determined an internal
alert was warranted for each reviewed youth. The facility administrator or designee gave written
approval before each youth was released from controlled observation. The Controlled
Observation Report, Health Status Checklist, and Controlled Observation Safety Checks forms
were maintained in both an administrative file and the youth’s individual management record.
Each of the five reports documented approval from the facility administrator or designee for the
youth's release from controlled observation, based on behavior. Additionally, all reports were
reviewed and approved by the facility administrator or designee within fourteen days of the
youth’s release from controlled observation. Staff designations for controlled observation are
included in the program’s policies and procedures.
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source: DJJ

program_name_raw: Tampa Bay Girls Academy- High/Max

rule: Indicator 1.04

excerpt: Incident Reporting (CCC) (Critical)

rating: Limited Compliance

rule: Indicator 1.06

rule: Indicator 1.12

rule: Indicator 1.16

excerpt: Special Contract Conditions

rule: Indicator 2.01

rule: Indicator 2.04

rating: Failed Compliance

rule: Indicator 2.07

rule: Indicator 2.09

rule: Indicator 2.10

rule: Indicator 2.11

excerpt: Performance Summaries and Transmittals

rule: Indicator 2.13

rule: Indicator 2.14

rule: Indicator 2.15

excerpt: Exit Portfolio

rule: Indicator 2.16

excerpt: Exit Conference

rule: Indicator 2.18

rule: Indicator 2.19

rule: Indicator 3.07

rule: Indicator 3.08

rule: Indicator 3.11

excerpt: Secure Observation (Critical)

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.06

excerpt: Logbook Entries and Shift Report Review

rule: Indicator 5.16

excerpt: Fire, Safety, and Evacuation Drills