summary: QI Residential - FY24-25 - 5 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Wimauma Academy
Wayne Halfway House
(Contract Provider)
4337 Saffold Road
Wimauma, Florida ZIP 33598
Review Date(s): April 15-18, 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:
Cheryl Francis, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Central Education Coordinator (Standard 6)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor (Lead
Assist)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 6
and interviews)
Zamara Williams, TrueCore Behavioral Solutions, LLC., Director of Case Management
(Standard 2)
Program Name: Wimauma Academy MQI Program Code: N/A
Provider Name: Wayne Halfway House Contract Number: 10795
Location: Hillsborough County / Circuit 13 Number of Beds: 32
Review Date(s): April 15-18, 2025 Lead Reviewer Code: 219
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
1.07 Pre-Service/Certification Requirements * 5.04 Ten Minute Checks *
1.08 In-Service Training
3.13 Suicide Precaution Observation Logs *
5.09 Searches and Full Body Visual Searches
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 69 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Limited
1.08 In-Service Training Limited
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 69 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 69 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Limited
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 69 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 69 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Failed
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Limited
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 69 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) 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 9 of 69 (Revised September 2022)
Program Overview
The Wimauma Academy is a thirty-two-bed program, for fourteen to eighteen year old males,
located in Wimauma, Florida. The program is operated by Wayne Halfway House, through a
contract with the Department. The program provides the following services including, Mental
Health Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services. In
addition, the program fosters each youth by providing Aggression Replacement Training (ART),
Cannabis Youth Treatment (CYT), Dialectical Behavior Therapy (DBT), Impact of Crime (IOC),
and Living in Balance (LIB). Additional treatment services provided includes family therapy,
individual therapy, groups, and recreational therapy. Program administration is comprised of a
facility administrator, assistant facility administrator, and human resources assistant. Case
management services are provided by two case managers, and a transitional case manager.
Mental health staff at the program include one licensed clinical director, one licensed therapist,
one recreational therapist, and one unlicensed therapist. Also providing mental health services
is a licensed psychiatrist. Medical services are offered 7:00 a.m. through 5:00 p.m. daily and are
provided by a health service administrator, two full-time registered nurses (RN), one part-time
RN, and one contracted medical doctor. Educational services are provided by Florida Virtual
School including, one instructional lead teacher, one teacher, and one paraprofessional teacher.
The layout of the program includes an administration building, a vocational building, two
dormitories, a kitchen and dining hall, an education building, a medical building, a large group
room, one portable classroom, and a maintenance area. The program has fifty-eight operable
security cameras providing coverage. At the time of the annual compliance review, the program
had three vacant positions including three youth care workers.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 69 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures in place regarding initial background screenings,
including volunteers, mentors, and interns who work with youth less than ten hours a month
requiring sight and sound supervision. The program’s policy requires a staff, who is background
screened, to always be in the presence of and within the line of sight of the volunteer who is not
background screened. A review of the program’s staff, volunteers and contractor roster found
twenty-three program staff were applicable for an initial background screening during the annual
compliance review period. There was documentation to support each staff received a completed
and eligible background screening in the Clearinghouse system prior to their date of hire. None
of the staff were applicable for an exemption and reviewed documentation validated a criminal
history report was reviewed for each staff. Each staff was added to the program’s roster in the
Clearinghouse system and a pre-employment assessment tool was administered for each
direct-care staff. It is noted eleven of twenty-three staff members who scored less than the ideal
range of forty on the pre-employment assessment are monitored during training. The program
indicated in addition to staff members being monitored, another company is being considered to
recalibrate assessment tool scores. Six out of the twenty-three staff had a break in service
which was documented in the Department’s Staff Verification System module and a new
background screening was completed for each. A review of the program’s volunteer roster and
sign-in logs verified the program did not have any volunteers, mentors, or employed interns who
required a background screening during the annual compliance review period. An Affidavit of
Compliance with Level 2 Screening Standards was submitted to the Department on December
19, 2024. The Annual Affidavit of Compliance with Level 2 Screening Standards for education
staff was completed and submitted to the Department’s Background Screening Unit, on January
28, 2025, meeting the annual requirement. A signed contraband attestation form was completed
for all twenty-three staff.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 69 (Revised September 2022)
The program has a policy and procedures addressing five-year background rescreening for
staff. There were no staff, volunteers, or contracted providers applicable for a five-year
background rescreening during the annual compliance review period.
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 outlining the provision of an abuse-free environment
for both staff and youth. 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 Abuse Hotline, and additionally the notification is
made to the Department’s Central Communications Center (CCC) and the facility administrator
(FA) or supervisor on duty as soon as possible. The program had five incidents alleging staff
physically, psychologically, or emotionally abused a youth in the program’s care during the
annual compliance review period. All five were called into the CCC and two were accepted by
the Florida Abuse Hotline. Two of the allegations were substantiated, the three remaining
allegations were unsubstantiated, and none of the youth involved were potential victims of
human trafficking, child sexual exploitation, or labor trafficking. A review of seven staff personne
records indicated each staff had signed a document acknowledging a review of the program’s
code of conduct. The program had the Florida Abuse Hotline and the CCC telephone numbers
posted throughout the facility for youth and staff access. The program completed a Trauma
Responsive and Caring Environment (TRACE) self-assessment dated June of 2024. Seven
youth were interviewed and none reported they were ever stopped from calling the Florida
Abuse Hotline or CCC. All seven youth stated they can find the reporting numbers throughout
the facility. Three of the seven youth stated staff are respectful when talking with youth, three
youth stated sometimes or most of the time staff are respectful, and one youth stated no staff
are disrespectful; however, one youth reported he was yelled at by a staff. None of youth
reported having exchanged emails, telephone numbers, or social media contact information with
staff. Seven staff were interviewed and each were able to explain the process of reporting
abuse, which included who to notify. Each staff reported never observing a co-worker telling a
youth they could not call the Florida Abuse Hotline or CCC. Seven staff were asked if they ever
heard another staff using profanity while speaking with youth, five staff indicated they had not,
one staff stated once, and the remaining staff stated staff will use profanity in conversation;
however, not directed at the youth. The FA was interviewed and was able to provide information
regarding the code of conduct and administrative actions taken should staff act in a prohibited
manner. The FA confirmed the program’s response process to allegations of abuse, and how
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 69 (Revised September 2022)
the program ensures staff and youth have access to the Florida Abuse Hotline and the CCC
numbers.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures outlining the process of how management responds
to allegations of physical, psychological, and emotional abuse. A review of internal incidents
found the program had two substantiated incidents of physical abuse against staff and three
unsubstantiated incidents of physical abuse against staff documentation confirmed the program
management took immediate actions to address all five incidents. Program management
reported each applicable incident to the Florida Abuse Hotline and/or the Department’s Central
Communications Center (CCC), as required, and took applicable corrective action. All staff
were removed from working with the youth and the two staff invovled in the substantiated
incidents had their employment subsequently terminated. An interview was conducted with the
facility administrator who stated if management is made aware of any allegations of abuse, an
internal investigation is initiated. Management will contact the Florida Abuse Hotline or CCC to
make the reports, as required. Following the completion of the investigation or when identified
during the investigation, disciplinary action will be issued following the program’s progressive
disciplinary system which can lead up to termination of employment.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures regarding notification to the Department’s Central
Communications Center (CCC) of reportable incidents. The program had a total of thirty-six
reportable incidents in this annual compliance review period. All five reviewed incidents were
reported within the required two hours from the time the reporter became aware. Three of the
five incidents were documented in the logbook as required, the two remaining incidents were
not documented in the logbook and the program indicated it was human error. There were no
additional reportable internal incidents or grievances located. The program had one CCC
incident in the prior annual compliance review period; an increase of thirty-five incidents was
documented this annual compliance review period. The facility administrator (FA) was
interviewed and stated the program experienced multiple administrative leadership changes, in
addition to high staff turnover rate and the lack of youth accountability contributed to the
increase in incidents. The FA interview also suggested trends were identified which included
same youth having multiple incidents throughout the year. There has been a cultural shift within
the last sixty days with stable leadership, staffing, and youth accountability.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 69 (Revised September 2022)
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 requiring Right Interactions (RI) as the Department
approved Protective Action Response (PAR) curriculum. A RI Incident Report will be completed
and filed in agreement with the 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). The program had fifty-one RI incidents
during the annual compliance review period. All five RI Reports were completed by the end of
the staff’s workday and included statements from all staff involved. Mechanical restraints were
not utilized in any of the RI incidents. None of the RI Reports resulted in allegations of abuse. All
five RI Reports were reviewed by a supervisor, a RI instructor, and the facility administrator (FA)
within seventy-two hours of the incident. None of the 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. The program
last updated their RI plan on September 25, 2024, and the Department approved the plan on
October 3, 2024. The program had twenty-five RI incidents during the previous annual
compliance review period. The program’s RI rate during the annual compliance review period
was 6.70, which is above the statewide Residential RI rate of 1.71. The program indicated they
have experienced multiple administrative leadership changes in addition to high staff turnover
rate and lack of youth accountability. Trends were also identified which included the same youth
having multiple incidents throughout the year. There has been a cultural shift within the last sixty
days with stable leadership, staffing, and youth accountability. The fFA was interviewed and
confirmed the program’s RI practice. Seven staff were interviewed and all seven were able to
articulate the program’s RI process.
1.07 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 outlining the pre-service training and certification
requirements for all new staff. The program considers youth care workers, shift supervisors,
recreational therapist, facility administrator (FA), assistant FA, to be direct-care staff and can be
counted in the staff-to-youth ratio. A review of documentation indicated the program’s instructors
were qualified to deliver training in cardio-pulmonary resuscitation (CPR), first-aid, automated
external defibrillator (AED) and Right Interactions (RI). The program submitted a pre-service
training plan on October 25, 2024, prior to implementation. The training plan was approved by
the highest ranking official at the location, the assistant secretary for residential services, and
the director of the Department’s talent, leadership, and culture. A review of seven pre-service
training staff records indicated all seven pre-service staff are missing Effective and Respectful
Treatment of Youth training and not all training was documented in the Department’s Learning
Management System (SkillPro) as required. Four of the seven staff were applicable to have
completed 120 hours of training in the first 180 days. The three remaining staff had not been at
the program for the 180 days yet. The four staff who were past the first 180 days were missing
the following training, which were neither captured in SkillPro or any other training
documentation. The first staff was missing eleven required pre-service trainings. The staff
completed Motivational Interviewing (MI) eleven days late. The second staff was missing five
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 69 (Revised September 2022)
required pre-service trainings and eight hours of leadership training. The third staff was missing
MI training. The fourth staff was missing thirteen required pre-service trainings.
1.08 In-Service Training Limited 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.
The program maintains an annual in-service training calendar and submitted an in-service
training plan on October 25, 2024, prior to implementation. The training plan was approved by
the highest-ranking official at the location, the assistant secretary for residential services, and
the director of the Department’s Talent, Leadership, and Culture. There were only four
applicable in-service staff training records for the annual compliance review period. None of the
four were applicable for supervisory training due to the supervisors still being in pre-service
training phase. Two of the four in-service training staff records were missing Active Shooter
Preparedness, Information Security Awareness, Mental Health and Substance Abuse,
Emergency Response and Emergency Drills quarterly on each shift, Infection Control, Blood-
borne Pathogens, and Exposure Control Plan. Three of the four staff were missing Trauma
Responsive Practices. In addition to these trainings, one staff was missing Professionalism,
Interpersonal Communication, and Ethics training. All instructors were qualified to deliver the
trainings provided. Two of the four trainings records reviewed were missing training in the
Department's Learning Management System (SkillPro).
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures to address the grievance process, as well as the
informal, formal, and appeal phase. The program’s informal phase indicates when a youth feels
they are being treated unfairly or their rights have been violated, the youth should first speak to
the staff or peer he is having a problem with or utilize the 411 form at the time the grieved
situation occurs and try to work out the situation informally. Informal complaints should be
handled within twenty-four hours after receipt. A youth can submit an informal request anytime
as an alternative to filing a formal grievance. A review of documentation indicated the program’s
practice correlates with their process. The program maintained copies of all twenty-eight
grievances for the last twelve months. A review of five grievances indicated all were handled
within twenty-four hours of receipt during the formal phase and were resolved. Seven youth
were interviewed and were able to explain how they would submit a grievance. Six of the seven
youth stated they could ask for assistance in completing a grievance form, the remaining youth
stated they could not ask for assistance in completing a grievance form. The facility
administrator (FA) interview confirmed the program’s grievance process, which included the
three phases.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 69 (Revised September 2022)
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures ensuring the program provides instruction to youth
focusing on developing life and social skill competencies. The interventions include Living in
Balance, Dialectical Behavior Therapy, and Process group. These services are provided
through treatment team planning by clinical staff. Non-clinical staff and direct care staff model
pro-social behaviors through daily youth interactions to help youth function responsibly and
successfully in everyday life situations. The services address communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking skills, including problem-solving and decision making. Seven youth individual
healthcare education records were reviewed and confirmed the program incorporates additional
life skills interventions to include dental hygiene, nutrition basics, personal hygiene, physical
fitness, and health education provided by medical staff. In addition to the life skills intervention
services, the program works with each youth to create a portfolio to include a resume, cover
letter, practice job applications, finances, and budgeting. Seven youth were interviewed, and
each youth was able to provide examples of groups and/or activities they have participated in
while at the program. The facility administrator (FA) interview results indicated the youth
participate in groups four times a week, completing worksheets and have discussions which are
documented by the clinician completing the group. The designated mental health clinician
authority interview results indicate the youth can practice skills learned in group during daily
programing with the behavior management system.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures which address restorative justice awareness to youth
through Impact of Crime (IOC). IOC is designated as a Standardized Program Evaluation
Protocol (SPEP) primary service at the Wimauma Academy program. For details related specific
to IOC delivery, please refer to the annual SPEP report. Restorative justice groups/activities are
provided twice a week, in accordance with the program schedule, and are designed to assist
youth in accepting responsibility for harm caused and impact of their offense, expose the youth
to victims’ perspectives, and provide opportunities to participate in restoration activities. The
program also has youth participate in community service project activities intended to restore
victims and communities. The program’s activity schedule, group sign-in sheets, group notes,
and observations confirmed restorative justice groups were provided and conducted as
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 69 (Revised September 2022)
scheduled. An interview with the facility administrator (FA) confirmed the program’s policy and
procedures for youth participation in restorative justice groups and activities. Seven youth were
interviewed, and all confirmed they participated in IOC groups.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
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. All alerts will be entered and updated in the
Department’s Juvenile Justice Information System (JJIS). Any staff can identify and place a
youth on alert status; however, suicide alerts will be updated or closed by the mental health
clinical staff or a licensed mental health professional. The program maintains an internal alert
board in the conference room and an internal alert binder in master control and alerts are
reviewed daily. Additionally, the program utilizes a shift briefing and logbook to help
communicate alerts to staff. Seven youth records were reviewed to address the program
entering alerts into JJIS, and all seven youth records were applicable for alerts. Documentation
reflected a total of thirty-one alerts were entered into JJIS, updated and/or closed, if required,
written on the alert board, and in the logbook if applicable. One of thirty-one alerts did not match
JJIS or the internal alert board. An interview with the facility administrator (FA) confirmed the
policy and procedures for entering and removing alerts. The nursing staff interview confirmed
the nursing staff are responsible for entering and updating medical alerts upon each youth’s
admission and as needed, thereafter. Seven staff were interviewed, each were able to describe
ways alerts are shared with staff including shift briefings, alert board, and logbook. An interview
with the nursing staff confirmed nurses are the only staff who update or close medical alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program has a policy and procedures on how the program maintains an official case record
for each youth, which consists of three separate files for each program area to include, case
management, healthcare, and mental health and substance abuse services. All reviewed
individual youth records contained the youth’s name, Department of Juvenile Justice
Identification Number (DJJID), date of birth, county of residence and committing offense. Each
individual 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 and inaccessible to youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 69 (Revised September 2022)
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures ensuring the program has a community advisory
board (CAB) meeting at least once every ninety to 120 days. The program had a virtual CAB
meeting on April 14, 2025. The programs CAB is combined with the Tampa Bay Girls Academy
program. Transcribed meeting minutes and agenda confirmed both programs were discussed,
and all required board members were invited or in attendance. A CAB member interview was
conducted with an education liaison. He indicated the CAB is effective and is important to the
youth and the community. He reported he brings an education perspective to the youth and
other board members and believes he brings positive insight to the board. The interview with the
facility administrator (FA) confirmed the policy and procedures for the CAB, how the program
solicits members and the recommendations which are made by the board. A minor deficiency
was assigned on February 11, 2025 due to the program not having an advisory board meeting
in the second quarter or having identified advisory board members. During the annual
compliance review week, the review team was able to confirm through documentation and an
informal interview with a CAB member a meeting was conducted, and all required elements
were in compliance. The review team will recommend the deficiency be closed.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to ensure staff are evaluated, at least annually, on
established performance standards. A review of four position descriptions to include, youth care
worker, shift supervisor, case manager, and therapist found performance standards were clearly
identified and matched the job description for each staff and whose job function included
implementation of the program’s behavior management system. The program has maintained
all contractually required positions including the recreational therapist. A review of
documentation for the recreational therapist indicated all requirements were met. The facility
administrator (FA) was interviewed and indicated the program has experienced a high turnover
rate due to mainly the location of the program and staff transportation issues. The FA indicated
during an interview the program has monthly job fairs and a human resource recruiting team, in
addition to a morale committee. Seven staff were interviewed, six staff stated they have a yearly
performance evaluation or a ninety-day evaluation, and one staff stated they never had an
evaluation.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 69 (Revised September 2022)
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. The program has a Memorandum of Negotiation and has five special contract
conditions.
The first special contract condition reflects an increase in the bed capacity from twenty-four (24)
beds to thirty-two (32) beds. The program must add one assistant facility administrator (AFA)
position; add one additional case manager (CM); add three youth service officer I's (YCW’s I);
add three youth care worker shift supervisors (YCWS); increase the registered nurse (RN) and
the designated mental health clinician authority (DMHCA) salary 00 annually. Documentation
confirms the program has increased the bed capacity to thirty-two. The staff roster indicates one
AFA, three YCWS and three YCW 1’s had been added, in addition to hiring a second CM.
Documentation confirmed the RN salary is $72,000 and the DMHCA is $88,000.
The second special contract condition states the Department's suggested edits to Exhibit 3 and
offer Aggression Replacement Training (ART), Impact of Crime (IOC), and Cannabis Youth
Treatment (CYT) as their primary services. *Note: The stated interventions can be changed
throughout the term of the resulting Contract upon agreement between the respondent and the
Department. The program is providing ART, IOC, and CYT. Reviewed documentation confirms
the programs groups.
The third special contract condition states to hire a compliance officer for their Florida contracts
and commit to one of their corporate positions being onsite at this program every two weeks for
the first three months of the contract. The special condition was not applicable for this annual
compliance review period as the first three months have passed.
The fourth special contract condition states within six months of the contract start date, the
provider agreed to establish a relationship with Erwin Technical College (or other local technical
college) with the expectations youth receiving services from the college will allow youth to obtain
industry specific certificates to assist the youth in obtaining employment once discharged from
the program. The provider reached out to Erwin Technical College during the first six months,
which falls into the last annual compliance review period. Currently, the provider has Florida
Youth College and Florida Virtual Schools as providers for education/vocational.
The fifth special contract condition states one filled bed per diem of $270.00, and an unfilled bed
per diem of $250.00. Documentation supports the program utilizes the allotted per diem amount.
An interview with the facility administrator (FA) confirms the program’s policy and procedures for
services provided to the youth.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program 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, fights and assaults, and turnover rate. This
information is shared weekly during supervisor meetings, monthly staff meetings, and weekly
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 69 (Revised September 2022)
corporate meetings and discusses ways to fix any issues noted. The program also shares data
with the Department on a monthly basis and with the community advisory board. Documentation
of supervisor staff meeting minutes and emails to the Department confirmed this practice. All
staff meeting agenda documentation covers various data topics. The program has utilized data
to determine areas to retrain their staff to improve their interactions with youth after several
grievances were made relating to youth and staff interactions. Additionally, the findings from the
data trend analysis assist with determining hiring strategies, youth supervision practices, and
policy and procedures. The program management team uses data to inform and educate staff,
providers, and stakeholders on a minimum of a quarterly basis.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 69 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures in place to address initial contact to the youth’s
parent/guardian as well as the committing court of the youth’s safe arrival and admission to the
program. Diligent effort shall be made to contact the youth’s parent/guardian by telephone within
twenty-four hours of the youth’s admission to the program and in forty-eight hours of admission,
a letter signed by the case manager and/or designee shall be sent to the parent/guardian. The
case manager and/or designee must notify the committing court in writing within five working
days of any admission. Seven youth case management records were reviewed, and all records
contained documentation the parent/guardian was contacted by telephone on the day of
admission. All records indicated each youth’s parents/guardians were mailed a parent
admission letter on the day of admission which spoke about length of stay, visitation, and the
performance planning process. Along with the admission letter, the parent/guardian also
received supplemental information to include a Parent Intake Survey, and rules for visitation.
Each of the reviewed case management records contained documentation verifying the
program notified each youth’s committing court and juvenile probation officer of youth’s
placement which was mailed on the day of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures in place to address youth orientation. Seven youth
case management records were reviewed and all seven indicated the program provided each
youth with an orientation on the day of admission. The orientation included services available,
daily schedule, expectations and responsibilities of the youth, written information on the
program’s behavior management system, access to medical and mental health services, zero-
tolerance regarding sexual misconduct, access to the Florida Abuse Hotline or the Department’s
Central Communications Center if the youth is over eighteen years of age, and items
considered contraband. Each youth orientation also included information on the performance
plan process, dress code and hygiene requirements, procedures regarding visitation, mail, and
use of the telephone, expectations for release from the program, community access, grievance
procedures, emergency procedures, physical design of the facility with a tour, and assignment
to a living dormitory. The program had one youth admission during the annual compliance
review week; however, the program indicated they were unaware of the admission,
subsequently, the review team was unable to observe a youth orientation. Seven youth were
interviewed and stated their orientation to the program began within twenty-four hours of
admission and included a review of program rules, procedures, and schedules.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 69 (Revised September 2022)
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 in place which require written consent of any youth
eighteen years of age or older, unless the youth is incapacitated and has a court-appointed
guardian, before providing or discussing with the parent/guardian any information related to the
youth’s physical or mental health screening, assessment, or treatment. Seven youth case
management records were reviewed and two were applicable as the remaining four youth were
under the age of eighteen. One additional youth case management record was requested to
meet the minimum sample of three. All three applicable youth records contained consent forms
signed by each youth allowing the program to share, with the parent/guardian, any information
related to each youth's physical or mental health screening, assessment, or treatment.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures in place which addresses the classification process
and promotes safety and security as well as the effective delivery of treatment services based
on the youth’s individual needs and identified risk factors. The program will screen each youth
upon admission and all youth shall be classified to determine the most appropriate group
placement and sleeping arrangements and to increase staff awareness of classification issues.
Seven youth case management records were reviewed and each record contained a
classification form completed on the day of youth admission to the program which addressed all
requirements. In all instances, hard copies of the Victimization and Sexually Aggressive
Behavior (VSAB) were completed by mental health staff on the day of each youth’s admission to
the program and reviewed with the treatment team during the classification process. Four of the
seven youth bed assignments were missing from their admission classification. Five of the
records indicated they were missing risk assessments. During the annual compliance review
period two out of the seven youth had security risk listed under other factors. The program’s
policy and procedures also address reassessing youth prior to considering an increase in
privileges or freedom of movement, participation in work projects or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in off-campus activities. Seven youth case management records were reviewed for
risk assessments. All seven youth case management records included documentation for risk
assessments completed at admission to the program as well as monthly
reassessments/updates completed during their formal treatment team meeting; one youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 69 (Revised September 2022)
participated in an off-campus activity. An interview with the facility administrator confirmed the
program’s practice.
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 in place which outlines notification of law
enforcement regarding youth entering the program with suspected gang affiliation, or
documented gang membership, as well as for youth who are observed engaging in gang
activities during their commitment to the program. The program’s policy and procedures also
include providing a youth the opportunity, if they desire, to develop a plan to disaffiliate with a
criminal street gang. Seven youth case management records were reviewed; however, only one
youth was applicable. Two additional youth case management records were requested to meet
the minimum sample of three. The program was unable to provide additional youth case
management records as there were no additional applicable youth to review. The one applicable
youth case management record confirmed the program notified local law enforcement, the
youth’s home county law enforcement and the youth’s juvenile probation officer. Documentation
confirmed gang information was not shared with the educational staff at the program. The youth
was not applicable for notification of a post-residential services counselor. Reviewed
documentation reflected the youth’s gang alert was maintained in the Department’s Juvenile
Justice System and updated as required.
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 in place which addresses the implementation of gang
prevention and intervention strategies. The program’s policy and procedures also include
providing a youth the opportunity, if they desire, to develop a plan to disaffiliate with a criminal
street gang. The program utilizes the Impact of Crime intervention groups as part of the
program’s gang prevention and intervention services. Gang prevention/awareness efforts may
include education and/or guest speakers, when applicable. Seven youth case management
records were reviewed; however, only one youth was applicable. Two additional youth case
management records were requested to meet the minimum sample of three. The program was
unable to provide additional youth case management records as there were no additional
applicable records for review. The one applicable youth case management record confirmed the
youth had gang goals listed on their Individualized Performance Plan. A review of the program’s
gang binder found the youth participating in monthly gang intervention groups as evidenced by
observed sign-in sheets. An interview with the facility administrator (FA) confirmed the
program’s gang intervention and prevention strategies.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 69 (Revised September 2022)
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures in place to ensure a Residential Assessment for
Youth (RAY) is completed within thirty days of the youth’s admission to the program, and a RAY
reassessment is completed within ninety days after completion of the initial RAY assessment.
Seven youth case management records were reviewed and contained an initial RAY
assessment completed within the required time frame. Three of the seven youth case
management records were not maintained in the Department’s Juvenile Justice System due to
the Department-wide system outage at the time of the annual compliance review period. All
seven youth case management records we applicable for RAY reassessments, three youth’s
RAYs were not completed at least every ninety-days. One RAY was completed three days late,
the second RAY was completed four days late, and the remaining RAY was completed six days
late. Each of the seven RAY reassessments were maintained in each youth’s case
management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures in place to ensure the Youth Needs Assessment
Summary (YNAS) is conducted within thirty days of the youth’s admission to the program.
Seven youth case management records were reviewed and each contained a YNAS and was
completed within the required time frame. Five of the seven YNAS were documented in the
Department’s Juvenile Justice Information System, two YNAS were not documented in JJIS due
to the Department-wide system outage at the time of the annual compliance review period;
however, a paper copy was completed. Reviewed documentation supported all seven youth
records included each youth’s top three criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 24 of 69 (Revised September 2022)
The program has a policy and procedures in place to ensure all members of the treatment team,
youth, juvenile probation officer, and parent/guardian are involved in the development of the
youth’s Individualized Performance Plan (IPP) within thirty days of admission to the program.
Seven youth case management records were reviewed and all contained documentation of the
IPP being developed within the required time frame and developed following each youth’s initial
needs assessment and after the completion of the initial Residential Assessment for Youth
(RAY), as required. Each reviewed IPP was developed and signed by all parties who have
significant responsibility in goal completion, including, the treatment leader, youth, treatment
staff, and/or the Department of Children and Families (DCF) counselor. Each of the case
management records contained individualized goals based on the prioritized needs reflecting
the risk and protective factors identified during the initial assessment. All seven of the
performance plans included delinquency interventions, court-ordered sanctions, community
service hours, transition activities, recreation/wellness needs, and education. Each performance
plan listed the responsibility of staff in completing the goal, responsibility of youth in completing
the goal, start date, and projected completion/end date. There was documentation to support in
all seven youth case management records the performance plans were mailed to each
parent/guardian requesting they review and sign the signature sheet and return it in the self-
addressed stamped envelope provided by the program; however, there was only one signed
parent/guardian signature page returned. All reviewed youth case management records
documented a transmittal letter and copy of the performance plan were sent to the committing
court, juvenile probation officer, parent/guardian, and DCF counselor, as applicable within ten
working days of the plan being completed. Seven youth were interviewed, and each youth
reported they participated in the development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in place which addresses performance plan revisions.
After creation of the Individualized Performance Plan, at thirty-day intervals, the assigned
treatment team meets to formally review the youth’s performance plan goals and determine
whether revisions are necessary. In addition, every ninety days after completion of the initial
Residential Assessment for Youth (RAY), case management staff complete a RAY
reassessment should the results warrant and will revise the youth’s performance plan goals.
Seven youth case management records were reviewed and all were applicable for performance
plan revisions due to newly acquired information, youth’s progress towards completing goals,
and/or lack of progress toward goal completion. Three of the seven records contained a
performance plan with revisions to facilitate transition activities during the last sixty days of each
youth’s stay. All seven youth performance plans included incorporation of additional plans
including academic or treatment. One applicable youth had behavior support plans or case
plans through the Department of Children and Families (DCF) and documentation confirmed the
performance plan coordinated with the DCF related issues.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 25 of 69 (Revised September 2022)
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 in place to ensure performance summaries and
transmittals are completed within required time frames. At each ninety-day interval, beginning
ninety days from the signing of the youth’s performance plan, the treatment team meets to
create a Performance Summary. In addition, prior to the youth’s release, discharge, or transfer
from the program, the treatment team will meet to create the Performance Summary. All
performance summaries include the youth’s status on each performance/treatment plan goal
and the youth’s overall behavior adjustment to the program. Seven youth case management
records were reviewed and were applicable for the completion of the Initial Performance Plan
(IPP). Four of the seven youth records included performance summaries which were completed
within ninety days of the completion of the IPP. One remaining summary was four days late, one
summary was seven days late, and the remaining summary was nonapplicable due to not
meeting the ninety-calendar days following the signing of the performance plan. Each applicable
Performance Summary was signed and dated by the treatment team leader, staff member
preparing the summary, facility administrator (FA), and youth. Each applicable record contained
documentation to support each Performance Summary was sent to each youth’s committing
court, juvenile probation officer (JPO), youth, parent/guardian, and the Department of Children
and Families (DCF), when applicable, within ten days of completion. Three closed youth case
management records were reviewed for release summaries. Each record contained a copy of
the signed original summary sent to the JPO along with the Pre-Release Notification
(PRN)/discharge summary at least forty-five days prior to each youth’s anticipated release date.
Each summary contained a justification for release. The program provided written notification of
approval for release to each youth’s parent/guardian. Documentation supported each record
contained a completed exit Residential Assessment for Youth (RAY). None of the youth were
applicable for the sexually violent predator program (SVPP) or notification to a victim.
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 encourage and facilitate the involvement of the
youth’s parent/guardian in the case management process. The program encourages
parent/guardian involvement in the assessment process, in the participation of the performance
plan, during progress reviews, during treatment team meetings, and during transition planning. If
the parent/guardian is unable to attend any of these meetings in person, they are given the
opportunity to participate by telephone and can provide verbal or written input as well. Seven
youth case management records were reviewed, and each record reflected the case manager
sent an admission letter to the parent/guardian, which included the dates and times for youth’s
treatment team meetings. If a parent/guardian is unable to attend the meetings in person, they
are afforded the opportunity to participate by telephone or conference call or can provide verbal
or written input prior to the meeting. An observation of a treatment team during the annual
compliance review week validated parent/guardian participation by telephone. An interview with
the facility administrator (FA) validated the program’s practice. Seven interviewed youth
reported their parent/guardian was involved with case management activities by telephone.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 69 (Revised September 2022)
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures in place to ensure each youth and his intervention
and treatment team meet on a bi-weekly basis (formally and informally) to review the following:
the youth’s performance, to include Residential Assessment for Youth (RAY) reassessment
results; progress on Individualized Performance Plan (IPP) goals; positive and negative
behavior, including behavior resulting in physical interventions, and treatment plan progress.
Seven youth case management records were reviewed and each record contained evidence of
the parent/guardian, juvenile probation officer, and other pertinent parties actively participating
in these formal treatment team progress review meetings. Formal reviews were conducted at
least every thirty days and were appropriately documented in the case management record for
each youth Each formal review included a review of the performance plan progress report
(status of performance plan goals and objectives, contact with parent/guardian and juvenile
probation officer (JPO), changes in risk level, current level, current level/level status,
performance plan goal focus for the month, and stage of change), physical and medical
progress report (sick calls, new medications, medical goals), education progress report (current
grade, total credits earned, review of each youth’s Individualized Academic Plan/Individualized
Education Plan , review of progress reports, teacher and student comments, and overall
progress), mental health/substance abuse progress report (number of individual, group, and
family sessions, status of current objectives, progress toward completing goals, group
participation, and overall progress), youth and/or parent/guardian progress report (satisfaction
with services, contact with the JPO, issues/concerns with peers or staff, and overall program
satisfaction), and program behavior and performance progress report (number of times before
disciplinary hearing board, current monthly point average, youth’s greatest strength in the
program, and areas of concern in the program). In addition for each reviewed record there were
indications of the youth’s performance plan revisions based on results of the RAY Re-
assessment. In each of the seven reviewed youth case management records, there was
documentation of bi-weekly treatment team meetings taking place (formal and informal). During
the annual compliance review week an observation of a treatment team meeting validated all
required parties were present during the meeting. Seven youth were interviewed, and each
youth confirmed staff review youth’s performance on the performance plan goals, behavior, and
treatment progress. Each youth indicated they can demonstrate the skills learned in the
program.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 69 (Revised September 2022)
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures in place addressing the program’s transitional
planning process, to include participation of the program and the youth in the Community Re-
Entry Team (CRT) meeting. A review of three closed youth case management records found
documentation of the program held a transition conference at least sixty days prior to each
youth’s anticipated release date. The program invited all required members to the transition
meetings through mail correspondence or email for each youth Transition conferences were
attended by each youth, parent/guardian, juvenile probation officer, facility administrator (FA),
treatment team leader, and other treatment team members. None of the reviewed youth records
required a human trafficking specific service provider. During the transition conferences for each
reviewed youth, the team discussed all required topics including transition activities, completion
dates, and parties responsible for completion of goals. All attendees signed each transition
conference form, and the forms were mailed to all parties for their signature with a request to
return signature sheet to anyone not in attendance who had a responsibility for completion of
transition goals. Documentation in each record confirmed a community re-entry (CRT) meeting
invite and the CRT meeting was conducted prior to each youth’s release, and each youth and
case manager participated in the CRT meeting.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures in place addressing the program’s exit process to
include assembling an exit portfolio for each youth in order to assist the youth once they are
released back into their home community. A review of three closed youth case management
records found all records contained an exit portfolio. The exit portfolio for each youth was
discussed and initiated at the transition conference, and then verified during the exit conference.
Reviewed documentation for each exit portfolio included the following items, a transition plan,
and a calendar containing the dates and times of follow-up appointments for each youth to
attend in their home community. One youth case management record contained a copy of the
birth certificate, none contained state issued identification cards, and one record contained a
social security card; however, each youth case management record noted various attempts to
procure these items from the parent/guardian. Each youth record contained the remaining
required elements. For youth who were required to complete community service hours, they
were documented, and included as part of the exit portfolio. The program’s contract does not
include additional requirements for the exit portfolio. Upon release from the program, each
youth’s exit portfolio included signed documentation indicating they were given a copy of the exit
portfolio. In addition, documentation confirmed, case management staff forwarded exit portfolio
information to the juvenile probation officer for each youth.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures in place to ensure an exit conference is conducted to
finalize release plans and prepare each youth for re-entry back to the community. Three closed
youth case management records were reviewed for the completion of an exit conference and all
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 28 of 69 (Revised September 2022)
contained documentation at an exit conference being conducted after the juvenile probation
officer (JPO) was notified of each youth’s release. Each record reflected the exit conference
was conducted at least fourteen days prior to the youth’s release in which the status of goals
developed at the transition conference were reviewed and release plans were finalized to
include education/employment and notification to the parent/guardian and JPO of the vocational
plan for youth, if applicable, and all required representatives participated in the exit conference.
A summary of the conference was found in all three youth case management records and
included the date, signatures, names of participants by telephone, and a summary of pending
transition goals. The date of admission and date of release correlated with the Department’s
Juvenile Justice Information System for each youth. Each exit conference was held separate
from the Transition Conference and Community Re-Entry Team meeting.
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 in place to promote constructive input by youth. The
program will solicit input from youth through multiple avenues of communication which will allow
youth to give input and feedback on a daily, weekly and monthly basis. Some of which include
the grievance process, request to talk “411”, Trauma Responsive and Caring Environment
(TRACE) assessments and regular living unit meetings. This will give the youth experience in
identifying systemic issues impacting their residential community and making recommendations
for resolution to improve conditions and enhance the quality of life for staff and youth in the
program. Staff will ensure grievance and 411 Forms are always available. The program’s youth
advisory board meetings are held weekly, and this allows youth to speak of any issues.
Documentation for youth surveys and the grievance process were reviewed during the annual
compliance review week which validated the programs practice. Seven youth were interviewed,
and six youth confirmed they can fill out forms or have community meetings, the remaining
youth stated they don’t have anything to provide input regarding what happens at the program.
The facility administrator (FA) was interviewed and confirmed the programs practice.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 69 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program maintains a policy and procedures ensuring a State of Florida licensed clinician
will serve as the designated mental health clinician authority (DMHCA), and will be responsible
for providing the coordination, and implementation of mental health, and substance abuse
service delivery. The program has a licensed mental health counselor (LMHC), who serves as
the DMHCA. The DMHCA has a clear and active license which expires on March 31, 2027.
Documentation showed the current DMHCA is a full-time staff and was on-site during the annual
compliance review period for forty hours a week and on call twenty-four hours a day or as
needed as contractually required. The program provided the license and agreement for review.
The program has a back-up DMHCA who has a clear and active license with an expiration date
of March 31, 2027. The DMHCA was interviewed and reported the role of the DMHCA is
oversight of the mental health and substance abuse services, group sessions, and family
sessions.
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 is contractually required to have one designated mental health clinician authority
(DMHCA), two full-time licensed therapists; one acting as the DMHCA, and one non-licensed
therapist. The program currently has three licensed mental health counselors, one licensed
clinical social worker, and one non-licensed therapist. An informal interview with the DMHCA
confirmed the clinical supervisor ensures the licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. All copies of licensed mental health professionals were posted within view at
the program, and all licenses were clear and active.
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
services are provided by individuals with appropriate qualifications. The designated mental
health clinician authority (DMHCA) provides direct supervision for non-licensed staff. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 69 (Revised September 2022)
DMHCA assures the non-licensed clinical staff working under their supervision are performing
services they are qualified to provide based on education, training, and experience. At the time
of the annual compliance review, the program was fully staffed with one non-licensed therapist
working under a full-time DMHCA. Documentation supported the non-licensed therapist
received a minimum of one hour a week of on-site, face-to-face direct supervision by the
DMHCA for the purpose of overseeing and directing the mental health services provided in the
program during the annual compliance review period. Documentation confirmed direct
supervision was recorded on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. The non-
licensed therapist provides substance abuse services in the program. The service provider is
licensed under Chapter 397 and the therapists are working under direct supervision of a
qualified professional. The Chapter 397 license expires May 9, 2025. A review of documentation
confirmed non-licensed mental health and substance abuse clinical staff are in accordance with
current contractual hours. The program has not had any vacancies for licensed mental health
professionals or non-licensed therapists since the last annual compliance review. The non-
licensed therapist holds a master’s level-degree from an accredited university or college in the
field of psychology. The non-licensed therapist completed twenty hours of training for
Assessments of Suicide Risk. The therapists were also trained in assessing suicide risk, mental
health crisis intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The policy and
procedures were reviewed and included a standardized screening process which includes a
review of commitment packet information, reports, records, administration of the Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2) in the Department’s Juvenile Justice
Information System (JJIS), clinical mental health screening by a licensed mental health
professional, Clinical Substance Abuse Screening by a qualified professional, and referral of
juvenile offenders identified by screenings as in need of further evaluation or immediate
attention. The policy and procedures included staff training in mental health and substance
abuse issues, administration of the MAYSI-2, and a standardized process for referrals of youth
identified in need of further mental health or substance abuse evaluation to an appropriate
service provider/professional, or when immediate attention is needed to a hospital, Baker Act, or
Marchman Act receiving facility. Seven youth mental health and substance abuse records were
reviewed for a mental health and substance abuse screening confirming all each of the seven
youth records included the commitment packet, reports, and records for existing documentation
of mental health, substance abuse problems, or history of human trafficking. All seven youth
MAYSI-2 screenings were completed on the date of each youth’s admission to the program in a
confidential manner. All seven youth screenings were completed by trained staff, and a review
of the Department’s Learning Management System (SkillPro) trainings confirmed the
completion. All seven youth MAYSI-2 screenings were completed in full. The designated mental
health clinician authority (DMHCA) reviewed all MAYSI-2 screenings and indicated if each youth
needed further assessments or a referral. All seven youth screenings indicated further
assessment was required. Staff determined all seven youth were assessed to have either a
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 69 (Revised September 2022)
mental health need, substance abuse problem, or was a suicide risk. The DMHCA was notified
for all seven youth when the MAYSI-2 or other admission information indicated the need for an
assessment, crisis intervention, or emergency services. All seven youth received an
Assessment of Suicide Risk (ASR) and were subsequently referred for assessment. All seven
youth ASRs were conducted within twenty-four hours of the referral. The facility administrator
(FA) and DMHCA signed off on all seven youth ASRs. All seven youth mental health and
substance abuse records reviewed had an ASR, comprehensive evaluation, and the reason for
referral was documented. The staff who made the referral documented a consultation with the
DMHCA on the mental health substance abuse referral summary on all seven reviewed youth
mental health and substance abuse records. An informal interview with the DMHCA stated
normal protocol consists of newly admitted youth being referred for a comprehensive bio-
psychosocial evaluation, to be completed within twenty-one days of admission. The FA was
interviewed and reported the youth are screened using the MAYSI-2 and ASR to identify youth
at risk for mental health and substance abuse issues.
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 to address the provision of mental health and
substance abuse assessments/evaluations. Seven youth mental health and substance abuse
records were reviewed for mental health and substance abuse assessments and evaluations
and all included documentation the program completed a new combined mental health and
substance abuse evaluation. All evaluations were completed within thirty calendar days of
admission, and none were late. All seven youth mental health and substance abuse records
included a consent form obtained for substance abuse services. All seven reviewed mental
health and substance abuse records included documentation which included demographics,
reason for assessment, relevant background information, behavioral observations, mental
status examinations, an interview or procedures administered, discussion of findings, methods
of assessment, patterns, impact of alcohol and drug abuse, risk factors of continued alcohol and
other drug abuse, clinical impression, original referral reason, and recommendations. None of
the youth required an updated comprehensive evaluation. The designated mental health
clinician authority interview explained at intake the program will conduct a review of the
comprehensive assessment as well as, have a conversation with the youth and family at the
initial screening. The process for obtaining the comprehensive assessment for behavior is
based on observations, documentation, and monitoring through the behavioral management
system.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures in place outlining the program’s mental health and
substance abuse services. At the time of the annual compliance review there was an open
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 69 (Revised September 2022)
deficiency 53408-27379 for Mental Health and Substance Abuse Treatment Planning and
Treatment Services which was identified on February 20, 2025. The seven reviewed youth
mental health and substance abuse records for mental health and substance abuse treatment
were not applicable. The program provided two additional youth records for review which were
applicable; however, there were no additional applicable youth. Two youth mental health and
substance abuse records included documentation an initial treatment plan (ITP) was developed
within seven days of initiation of treatment. Both youth’s initial mental health treatment plans
were documented on a form which included all elements of the Department’s Mental
Health/Substance Abuse Treatment Plan form. Both youth records reviewed documented
neither youth was taking psychotropic medication. Both youth’s ITPs were signed by the mental
health clinical, or substance abuse clinical staff. One youth’s ITP was signed by the
parent/guardian; however, was missing the youth signature. One youth’s ITP was signed by the
youth, parent/guardian, treatment team leader, and program management. Two youth’s ITP
were developed on forms which contained all elements of the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan form. Neither youth were not applicable for
treatment plan reviews because the review date was still within thirty days. Both youth’s ITP
were completed by the mental health clinical, or substance abuse clinical staff. One youth’s ITP
plan contained the appropriate signatures except, the living unit staff. One youth’s ITP contained
the appropriate signatures except for the juvenile probation officer (JPO), living unit staff and
education staff. Both youth’s ITPs included documentation of the prescribed services, to include
individual, group, family, and psychiatric services. All services were individualized for each
youth. A review of three days of video, sign-in sheets and group sign-in sheets since the last
annual compliance review indicated all groups were conducted for a minimum of fifty minutes
each, during the time as designated on the group schedule, with no more than ten youth
present, and by a qualified facilitator. The designated mental health clinician authority (DMHCA)
interview stated the process for ensuring services is through a tracker and clinical audits. The
ITP is updated with the treatment team, juvenile probation officer, parent/guardian, case
manager, DMHCA, transition service manager, and other agencies involved in the youth’s
treatment.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a policy and procedures addressing mental health and substance abuse
treatment and discharge planning. Seven youth mental health and substance abuse records
were reviewed and each youth was assigned to a multidisciplinary treatment team upon
admission to the program, and none were late. Documentation revealed each treatment team
was comprised of the youth, program administration, residential living unit staff, education,
medical staff, mental health staff, substance abuse staff, and parent/guardian. All seven youth
records included documentation each youth received individual, group, and/or family counseling
provided by a licensed qualified professional, or a non-licensed professional under the direct
supervision of a licensed professional for substance abuse treatment. All seven youth records
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 69 (Revised September 2022)
included documentation an Authority for Evaluation and Treatment form was properly executed.
All seven youth records included documentation of a signed Youth Consent for Substance
Abuse Treatment Records form. For each reviewed youth record all mental health treatment
notes or substance abuse treatment notes were documented on a form which contains the
Department’s Counseling/Therapy Progress Notes information. All seven youth records included
documentation each youth received individual psychotherapy or counseling and psychosocial
skills training. All seven treatment plans included the frequency of prescribed services for each
youth to include individual, group, and family sessions. A review of progress notes revealed
each youth received services as stipulated on the treatment plan. Three closed youth mental
health and substance abuse records were reviewed for treatment and discharge planning and
each records included documentation the discharge plan was completed on the Department’s
Mental Health/Substance Abuse Treatment Discharge Summary form. All three discharge
summaries included future services needed. The reviewed documentation reflected the
discharge plan was discussed with each youth, parent/guardian, and juvenile probation officer
(JPO) during the exit conference. A copy of the discharge summary was also provided to each
youth, JPO, and parent/guardian. The DMHCA interview explained treatment planning is a
collection of youth goals, parent goals, observations, individualized substance abuse treatment
planning, comprehensive assessments, and interviews with youth or parent/guardian.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a policy and procedures to establish a delivery protocol for Substance
Abuse Treatment Overlay Services (SAOS) programming and Mental Health Overlay Services
(MHOS). Substance abuse and mental health treatment are provided on-site through the
provision of SAOS/MHOS. The focus of substance abuse and mental health treatment is to
target and reduce/alleviate the youth’s symptoms of substance related disorder, and/or mental
disorder to improve youth functioning within the program, and ultimately the community. The
program provides SAOS and MHOS services through group therapy, individual therapy, family
therapy, and psychiatric services. Ancillary services shall be provided directly or through referral
in instances where youth require certain services which may not be provided by the program.
The policy indicated therapy models utilized include Cannabis Youth Treatment, Aggression
Replacement Training, Living in Balance, and Dialectical Behavioral Therapy). The program
does not provide urinalysis drug testing. The non-clinical group provided is Impact of Crime
(IOC). Seven interviewed youth reported participating in individual, group, and family therapy
services at the program. Seven interviewed staff reported only mental health clinicians facilitate
mental health and substance abuse groups. Three interviewed staff stated they do not facilitate
groups, two staff stated they were not applicable because they work nights, and one staff stated
they were not applicable because they work evenings. One staff stated they do facilitate groups
because the groups are alternated on different days; however, it was not clear if the staff was
referring to youth supervision rather than facilitating groups. The designated mental health
clinician authority (DMHCA) confirmed services included SAOS, MHOS, individual, group, and
family sessions. The program provides group services five times each week based on the
services prescribed to youth through their treatment plans. Youth with co-occurring disorders
are provided both mental health and substance abuse treatment. The facility administrator (FA)
interview explained the program provides SAOS and MHOS to youth admitted to the program
based on the youth’s needs. The DMHCA is a full-time staff who works forty-hours a week.
Licensed mental health staff are on-site at least five days a week, and one staff is on call on the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 69 (Revised September 2022)
weekends. Caseload sizes were reviewed and reflected the average caseload for each program
therapist was sixteen youth which is the contractual maximum. The non-licensed therapist holds
a master’s-level degree in psychology. The reviewed sign-in sheets verified mental health
groups consisted of ten or fewer participants and substance abuse groups consisted of fifteen or
fewer participants. A review of mental health groups since the last annual compliance review
confirmed four total mental health groups were being held each week for all youth. The program
has a Chapter 397 license through the Department of Children and Families to provide
substance abuse treatment services to adolescents. All mental health clinicians working at the
program were qualified to provide substance abuse treatment and education services. A review
of psychiatric logs since the last annual compliance review confirmed the psychiatrist was
available and provided services according to the contractual requirement. The program has an
agreement with a psychiatrist which requires psychiatric services to be provided at least once
every two weeks, with no more than fourteen days between visits, to provide psychiatric
evaluations, medication management services, and participate in treatment team meetings and
family sessions (when possible). Psychiatric services providers must be available twenty-four
hours a day, seven days a week for emergency consultation services. No youth missed services
due to being on a medical quarantine since the last annual compliance review.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures to address the psychiatric services provided to the
youth. The program provides psychiatric services to the youth who require this service. The
psychiatrist has a clear and active license which expires on January 31, 2026. The psychiatrist
is available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist briefs a representative of the treatment team regarding the status of each youth
receiving psychiatric services. The psychiatrist evaluation and recommendations for the youth
are incorporated into the mental health clinical staff’s evaluations of the youth and the youth’s
individualized mental health or substance abuse treatment plans. The program doesn’t utilize a
psychiatric advanced practiced registered nurse (APRN). A review of the sign-in/out logbooks
since the last annual compliance review confirmed the psychiatrist was on-site, twice a month,
at least every two weeks. The psychiatrist did participate in, manage, and supervise
psychotropic medication services in the program. The back-up psychiatrist has a clear and valid
license, and the license expires on January 31, 2026. The back-up psychiatrist does have equal
education credential to the psychiatrist. The contract was reviewed and confirmed the program
utilizes tele-psychiatry inclusion; however, this was not utilized during the annual compliance
review period. The program had two youth who were applicable for review for psychiatric
services since the last annual compliance review, and the facility administrator (FA) confirmed
the program did not have any youth coming in with psychotropic medication. Two youth mental
health and substance abuse records were reviewed for psychiatric services. Both applicable
youth entered the program on psychotropic medication. Both youth were referred for a
psychiatric interview. Both youth received an Initial Diagnostic Psychiatric Interview within
fourteen days of admission. Both youth were applicable for psychiatric services. The initial
diagnostic interview for both youth included the medical history, mental health history,
substance abuse history, Mental Status Examination, and the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-V) diagnosis, prescribed medications, target symptoms,
treatment goals, side effects, risks and benefits of taking the medication, and frequency. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 69 (Revised September 2022)
initial diagnostic psychiatric interview was documented on a form which contains all required
information based upon the Department’s Clinical Psychotropic Progress Note (CPPN). Page
three of the CPPN was completed on the Department’s CPPN form for both youth if the
psychiatric evaluation resulted in the prescription of psychotropic medication or changes to each
youth’s existing psychotropic medication. Both youth records had the following information
documented on page three of the CPPN chart; identifying data, diagnosis, symptom, evaluation
and description of each medication, prescribed psychotropic medication to include name,
dosage, quantity, normal dosage range, frequency and administration. Furthermore, the CPPN
chart for both youth included side effects, adherence to the medication, height, weight, blood
pressure, contact with the parent/guardian, a signature of the psychiatrist and date of the
signature. The psychiatrist and nursing staff documented monitoring for Tardive Dyskinesia
monthly which was indicated on the CPPN. Neither youth did not utilize tele-psychiatry. The
designated mental health clinician authority (DMHCA) was interviewed and reported they meet
with the psychiatrist bi-weekly for a psychiatric treatment team meeting. The psychiatrist was
interviewed and explained he works with the clinical and nursing staff to coordinate and
implement services. The psychiatrist is on-site at least every two weeks, usually on Thursday.
The psychiatrist provides evaluations of every youth, medication management, and provides
suggestions for therapy. The psychiatrist receives written feedback after each visit, updating him
on every youth seen. The psychiatrist meets with the clinical director or therapist to discuss the
youth. The psychiatrist reviews nursing documents, medication refusals, lab results, and any
other medical issues with the clinical staff when on-site. The psychiatrist confirmed he conducts
face-to-face communication with the treatment team. The psychiatrist does not have any
concerns at the program, and believes the program is doing a good job.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures to address suicide prevention plans which includes
identification and assessment of youth at risk of suicide, staff training to include six hours
annually, suicide precautions, levels of supervision (one-to-one, constant, close), referrals,
communication, notification, documentation, immediate staff response, and a review process.
The review process includes circumstances surrounding the event, program procedures
relevant to the incident, all relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, and recommendations.
The plan was reviewed and signed by the facility administrator (FA) on April 4, 2025, the
designated mental health clinician authority on April 8, 2025, and the psychiatrist on April 10,
2025.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 69 (Revised September 2022)
The program has a policy and procedures for suicide prevention services. The program’s
process is to complete an Assessment of Suicide Risk (ASR) for each youth during the
admission process. At the time of the annual compliance review there was an open deficiency
#53408-27380 for Suicide Prevention which was identified on February 20, 2025. The facility
administrator (FA) confirmed there was only two applicable youth who were placed on
precautionary observations since February 20, 2025. Both applicable youth records
documented each youth was determined to be at risk during the admission screening. The
precautionary observation placement start date and ASR referral date were the same date for
each youth. Both youth records documented each was placed on suicide precautionary
observation and were on standard supervision. Both youth records documented the
parent/guardian of each youth was notified an ASR was completed, and each youth was no
longer at risk. The parent/guardian and juvenile probation officer (JPO) for each youth was
notified and documented on the ASR. The mental health staff provided supportive services for
both youth. The ASR for each youth was completed by the licensed mental health counselor
(LMHC), and the result of the suicide risk assessment was both youth were placed on standard
supervision. The two ASRs were reviewed and signed by a licensed therapist within twenty-four
hours, and the non-licensed clinical staff conferred with both the licensed therapist and the
FA/designee, which was documented on each ASR, including the date and time. The two ASRs
were conducted immediately after each youth was deemed to be having a crisis. Both youth did
not require a follow up ASR. A suicide alert in the Departments Juvenile Justice Information
System (JJIS) was initiated for one youth and the youth was placed on suicide precautions. The
remaining youth was not applicable. The JJIS suicide risk alert was not accurately closed
following the recommendations of the ASR, and t was closed fourteen days late. While on
Precautionary Observation one youth was allowed to participate in select activities with other
youth in the designated safe housing/observation areas of the facility. The program does not
utilize secure observation. The program indicated they did not have any youth placed on
Precautionary Observation for the past thirty days; therefore, video observation was unable to
be completed.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
This program does not utilize secure observations; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Limited Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program has a policy and procedures for youth placed on suicide precaution. At the time of
the annual compliance review there was an open deficiency #53408-27380 for Suicide
Prevention which was identified on February 20, 2025. The facility administrator (FA) confirmed
there was only one applicable youth who was placed on suicide precautions since February 20,
2025. A review of one youth mental health and substance abuse record confirmed the Suicide
Precaution Observation Logs, was maintained for the duration the youth was on suicide
precaution. A review of the form confirmed the appropriate level of supervision and observations
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 69 (Revised September 2022)
of the youth’s behavior documented in real time had exceeded the thirty-minute intervals. The
supervision was documented at 12:57 p.m, and not again until 1:57 p.m. There was no warning
signs observed; therefore, did not require notification to the FA or mental health clinical staff.
The Suicide Precaution Observation Log was reviewed and signed by the supervisor and the
mental health clinical staff. The Suicide Precaution Observation Log documented the safe
housing requirements. Seven interviewed staff stated mental health staff and a supervisor are
notified if a youth expresses suicidal thoughts and also, the youth are never out of sight and
sound. Five staff stated the knife for life is kept in master control, four staff stated the medical
office, and one staff stated administration and in a large group room.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures addressing suicide prevention training plans stating
all staff who work with youth shall be trained to recognize verbal and behavioral cues indicating
suicide risk, suicide prevention, and implementation of suicide precautions. A review of seven
pre-service training records documented staff did receive the internal mental health and
substance abuse training as documented on the staff individual training plans. A review of five
in-service training records documented four of the five staff did receive the internal mental
health and substance abuse training as documented on the staff individual training plans;
however, one staff did not. The program had three suicide response kits, which included the
knife-for-life, wire cutters, and needle nose pliers. One kit was in dormitory one, one kit was in
the medical office, and one kit was in master control. The suicide response kits are co-located
with the first-aid kits. The program conducted nineteen drills; however, was only able to
complete eighteen drills during the annual compliance review period, which exceeds the
quarterly expectation. One of the nineteen drills was unable to be completed due to not enough
staff to safely perform the drill. The program operated on two shifts during the annual
compliance review period. The training included mock suicide drills held no less than quarterly
on both shifts, for all staff who encounter youth including the kitchen and maintenance staff. Of
the nineteen drills conducted, four indicated the automated external defibrator (AED), or suicide
kit, or first-aid kit was not brought to the scene; however, this was listed in the corrective actions
on the drill form and discussed with the drill participants. A video review indicated drills were
simulated, all conducted were in response to a simulated suicide attempt and/or incident of
serious self-injury and none of the youth were utilized during the simulation. The program did
provide semi-annual training on emergency response procedures and provided staff who were
not present during a quarterly drill the opportunity to review each drill scenario and procedures.
The facility administrator (FA) interview reiterated the program’s policy and indicated the
program provides training or mock suicide drills for staff, including emergency response to
suicide attempts or self-inflicted injury are conducted with all staff on each shift. Seven staff
were interviewed and five indicated the program conducts medical emergency and suicide drills
monthly. One staff stated they do them every two to three weeks, and one staff stated one drill
was conducted yesterday and one last week.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 69 (Revised September 2022)
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written crisis intervention plan which includes a notification and alert system,
means of referral including youth self-referral, communication, supervision, documentation, and
review. Reviewed documentation confirmed the plans were signed off by the facility
administrator (FA) on April 4, 2025, designated mental health clinician authority on April 8, 2025,
and psychiatrist on April 10, 2025.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures addressing Crisis Assessment and utilizes the
Department’s form. During the annual compliance review period the program did not have any
Crisis Assessment since the last annual compliance review.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a policy and procedures addressing emergency mental health and substance
abuse plan which includes immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health or substance abuse services, transport
for emergency mental health evaluation and treatment under (Baker Act, transport for
emergency substance abuse assessment and treatment under Marchman Act, documentation,
training, and review. Reviewed documentation confirmed the facility administrator (FA) signed
the policy and procedures on April 4, 2025, the designated mental health clinician authority
(DMHCA) signed on April 8, 2025, and the psychiatrist signed on April 10, 2025. An interview
with the DMHCA confirmed no youth had to be transferred to the crisis stabilization unit since
the last annual compliance review for Baker Act or Marchman Act services.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 69 (Revised September 2022)
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a policy and procedures to address the safety planning process for each
youth. The safety plan shall be designed to identify stimuli which have both positive and
negative effects on youth. A review of seven youth mental health and substance abuse records
was conducted in reference to a safety planning process for each youth. Reviewed
documentation found the program had developed a safety plan form which identifies stimuli to
include positive and negative effects on the youth. The program’s Safety Plan form included an
initial and a review planning process. The initial planning process is initiated by each youth’s
therapist within fourteen days of the youth’s admission to the program. All seven youth records
confirmed a Safety Plan was completed within fourteen days upon admission, and none of the
records reviewed were late. All seven records documented the safety plans are jointly prepared
by youth, parent/guardian or family member, case manager, and clinical staff. All seven youth
safety plans incorporated recommendations of previous or current clinical assessments, or
screening instruments and incorporated trauma responsive practices as required. Each of the
seven youth’s safety plans were reviewed and updated every thirty-days to include dated
signatures of youth and staff. None of the seven reviewed youth safety plans were late. Two of
the seven youth safety plans were reviewed and updated as necessary following any significant
behavioral or mental health event identified by each youth’s intervention and treatment team.
The remaining five safety plans did not have any significant behavioral event identified, and they
were not applicable. The program’s Safety Plan form included each youth’s warning signs,
baseline behaviors gathered from collateral contacts, crisis recognition, jointly developed coping
strategies, intervention strategies, and debriefing preferences. All seven youth reviewed safety
plans documented warning signs, youth’s baseline behaviors and crisis recognition, jointly
developed coping strategies, intervention strategies and a debriefing process. The plans are
reviewed and signed by all staff involved in the development of the plan and each youth. The
safety plans were maintained in each youth’s mental health and substance abuse records and
within a centralized binder inside master control, easily accessible by all staff. All seven
interviewed youth said they contributed to the development of their safety plan. An interview
with the facility administrator (FA) confirmed safety plans must be updated every thirty days or
following any significant behavioral or mental health event identified by the youth’s intervention
and treatment team.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 69 (Revised September 2022)
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 stating the designated health authority (DHA) shall be
clinically responsible for the medical care of all youth at the program. The designated health
authority (DHA) is a licensed physician, who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in Florida. The DHA license expires on
January 31, 2027. The DHA’s specialty training is in Pediatrics. The DHA does have one
disciplinary case or public complaint on record. The resolution was obligations imposed. The
program does not employ a physician assistant (PA) or advanced practice registered nurse
(APRN). Sign-in and sign-out logs for the annual compliance review period were reviewed. The
reviewed documentation indicated the program utilized back up DHA for the dates of December
13,2024 and January 10, 2025.The back up DHA utilized was a doctor of equal licensure whose
license expires on January 31,2027. Sign-in and sign-out logs indicated DHA was on-site at
least once a week for the contract required minimum hours. The program does not utilize an
APRN or PA as a designee. The program has a facility operating procedure for tele-health;
however, the program does not utilize the service. The DHA was interviewed regarding his role
and responsibilities within the program. He reported his duties include reviewing protocols for
various health conditions, conducting medical evaluations for newly admitted youth, and
providing ongoing healthcare to all youth in the program. The DHA is on-site once a week and
communicates directly with program staff during visits. When off-site, he remains available
twenty-four hours a day, seven days a week by telephone or text to address any medical
concerns. Clinical services are provided on-site by the DHA. Off-site care findings and
instructions are reviewed by him; documents are flagged in the youth’s chart for review and
signature during on-site visits. Urgent matters are communicated immediately by the telephone
or text. The DHA also meets weekly with healthcare staff while on-site to review significant
medical issues or by telephone if the matter requires immediate attention.
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 maintains a policy and procedures confirming the Designated Health Authority
(DHA) holds clinical responsibility for all healthcare services provided to youth. The program
currently employs two full-time registered nurses (RNs) and one part-time RN, meeting
contractual staffing requirements. There is no licensed practical nurse (LPN) currently
employed, in accordance with the contract requirements. Medical coverage is maintained
through the combined efforts of two full-time nurses and one part-time nurse, fulfilling the
contracted eighty-hour requirement. Ten of those hours are covered by the part-time RN. A
review of licensure for all three nurses confirmed credentials are clear and active. All nursing
staff have current certification in cardiopulmonary resuscitation (CPR). The contract requires on-
site nursing coverage ten hours a day, seven days a week. The health services administrator
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 69 (Revised September 2022)
provides clinical supervision and medical support services Monday through Friday from 7:00
a.m. to 5:00 p.m., totaling fifty hours weekly. Medical services are delivered by the full-time
nurses and one part-time nurse, on-site daily from 7:00 a.m. to 5:00 p.m.
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 maintains facility operating procedures (FOPs) for all health-related protocols and
practices. Documentation confirmed the DHA approved all treatment protocols and standing
procedures without delegating this responsibility to others. The Designated Health Authority
(DHA) reviewed and signed the treatment procedures on April 11, 2025. The psychiatrist
completed their review and signed on April 10, 2025, and the facility administrator (FA) signed
on April 4, 2025. Nursing staff signed and dated the cover page listing all FOPs, healthcare
protocols, and related procedures. The FOPs state newly hired healthcare staff receive a
comprehensive clinical orientation to the program’s medical services and on-site registered
nurses (RNs) provide the training covering medical procedures and protocols; however, there
were no newly hired healthcare staff during the annual compliance review period.
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 in place to ensure completion of the Authority for
Evaluation and Treatment (AET), authorizing medical care for youth in the custody of the
Department. A review of seven individual healthcare records (IHCRs) confirmed each contained
a valid, legible copy of the AET form. Five youth had forms signed by a parent or guardian. Two
youth required a court order for medical treatment, which was signed by a judge and filed in the
medical section of each IHCR. All AETs were signed by a Department representative. Two
youth were eighteen or older, and a documented release of information was included in each of
their IHCRs. All AET forms were verified in the Department’s Juvenile Justice Information
System and confirmed to be valid. The health services administrator was interviewed and
explained the procedures for obtaining a new or updated AET involves notifying the juvenile
probation officer when a current AET is missing or invalid.
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 maintains a policy and procedures to ensure parent/guardian notification of
significant changes in a youth’s medical condition, and to obtain consent when new medications
or treatments are prescribed. A review of seven individual healthcare records (IHCRs)
confirmed the program notifies the parent/guardian of any changes and secures consent for
new treatments or prescriptions. Two youth were eighteen years of age and documentation
indicated the parent/guardian was notified with youth consent. There were Consent forms
signed by each youth and were documented in the IHCR. For one youth, progress notes
documented attempted contact with the parent/guardian following a new medication order.
Parent/guardian consent was documented in the youth Individual Healthcare Record (IHCR).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 69 (Revised September 2022)
Written notifications were completed using the Department’s Parental Notification of Health-
Related Care form. One youth was taking psychotropic medications at admission. Two youth
required notification to the Department of Children and Families (DCF); in these cases, a court
order authorized all treatment and procedures. All reviewed records confirmed vaccinations
were verified within thirty days of each youth’s admission to the program. None of the youth
required consent for vaccinations prior to administration. All youth had up-to-date
immunizations, and none qualified for a religious exemption. The program accesses
immunization records through the Florida SHOTS system. The medical department is notified
prior to a youth’s arrival and attempts to verify immunization records are made before or within
thirty days of admission. The health services administrator (HSA) was interviewed and
described the notification process. Each time a new prescription or treatment is issued, verbal
notification is provided to the parent or guardian, followed by written notification by mail to
ensure timely communication. In cases of illness or injury requiring treatment, calls are made to
the designated health authority (DHA), facility administrator (FA), parent/guardian, a designated
person, and the Central Communications Center (CCC). For youth prescribed psychotropic
medication, the psychiatrist and nursing staff call the parent/guardian to obtain verbal consent,
then mail page three of the psychotropic notification form to collect written consent if changes
are made. The HSA stated youth receive vaccinations at the Health Department, and
immunization records are obtained through Florida SHOTS and reviewed promptly.
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 maintains a policy and procedures to ensure youth are screened upon admission
for healthcare concerns requiring referral for further assessment by medical staff. A review of
seven individual healthcare records (IHCRs) confirmed each youth had a completed Facility
Entry Physical Health Screening (FEPHS) form. All forms were completed by a registered nurse
(RN) on the day of admission. The facility administrator (FA) confirmed none of the youth
reviewed had been out of the Department’s physical custody. The health services administrator
(HSA) was interviewed and stated a nurse evaluates each newly admitted youth within twenty-
four hours. Nursing staff are notified of new admissions by the clinical director, who receives
updates from the commitment manager. Medical staff complete the admission screening. The
HSA explained when a direct care staff member completes the initial screening, a nurse reviews
the form and documents the review in the medical history section under Medical Staff. If there is
a change in custody, the youth is seen by medical to complete a new FEPHS.
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 receive an orientation to the
general process of healthcare delivery services. A review of seven Individual Healthcare
Records confirmed each youth received a healthcare orientation upon admission.
Documentation in each record included all required topics related to healthcare services. The
Orientation to Healthcare Services forms were signed by a registered nurse confirming
completion of the process.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 69 (Revised September 2022)
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 a youth admitted to the program requires emergency care or routine
medical notification in line with Department requirements. A review of seven Individual
Healthcare Records (IHCRs) confirmed appropriate DHA notifications were made for each
admission. Three youth had a known or suspected chronic condition upon admission. One
youth was taking psychotropic medication prior to admission to the program. None of the youth
required emergency care at the time of admission. All seven records documented notifications
to the DHA and, when applicable, to the psychiatrist. The registered nurse manager was
interviewed and explained youth admitted with serious chronic conditions require immediate
DHA notification. The health services administrator (HSA) stated medical staff, or a youth care
worker is responsible for making the notification, which is documented in the nurse's admission
notes. A review of the program’s contract confirms health education is provided monthly on a
recurring cycle.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures to ensure the standard Department’s Health-Related
History (HRH) form is used for all youth admitted into their physical custody. A review of seven
youth individual healthcare records (IHCRs) was completed to determine if the Department’s
HRH form was utilized for all youth admitted into the physical custody of a department. Each
IHCR reviewed had a completed and/or updated HRH form, completed within seven days of
admission. Each HRH was completed prior to the Comprehensive Physical Assessment. Each
HRH was reviewed by the designated health authority. The registered nurse (RN) manager was
interviewed and confirmed the facility RN is responsible for completing the HRH within seven
days of admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a policy and procedures to ensure the standardized Comprehensive
Physical Assessment (CPA) form is used for all youth admitted into the program. A review of
seven Individual Healthcare Records (IHCRs) confirmed each youth had a completed CPA prior
to admission, which was reviewed by a registered nurse (RN) upon intake. Each CPA was
signed and dated on the day it was reviewed and documented on the Department’s official form.
The Designated Health Authority (DHA) reviewed and signed the CPA for all reviewed records.
Each youth’s medical grade was documented on the CPA, and all required sections were
marked appropriately. Problem Lists were updated in all seven records. Each IHCR included
documentation of at least one verified tuberculosis skin test (TST), with results matching both
the CPA and the Infectious and Communicable Disease Form. The health services
administrator (HSA) was interviewed and explained the DHA completes a new CPA annually for
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 69 (Revised September 2022)
youth with Medical Grades 2 through 5, and every two years for those with Medical Grade 1.
TST screenings are completed within seventy-two hours of admission and verified yearly using
the TB risk assessment and questionnaire.
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 to ensure all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). A review of seven Individual Healthcare
Records (IHCRs) confirmed all youth were clinically screened and evaluated for STIs. No further
evaluation was required for any of the reviewed youth. Each youth was offered counseling and
testing for human immunodeficiency virus (HIV). Six declined testing, and one youth completed
it. Although all seven provided written consent, only one youth proceeded with testing. Consent
forms were maintained in the respective IHCRs. For each youth who completed HIV testing, the
result was filed in a sealed envelope marked Confidential and signed by the practitioner. No
alerts were posted regarding HIV status for any youth. The program’s procedures reflect state
law, ensuring HIV test results are disclosed only to the youth and authorized entities under
Florida Statutes. A local agency provides both pre-test and post-test counseling along with
testing services. The registered nurse (RN) manager was interviewed and confirmed all youth
are screened for STIs, with required forms completed. When further evaluation is indicated,
urine samples are collected and sent to an external laboratory in a timely manner.
Documentation of STI screenings, evaluations, referrals, and test results are maintained in each
IHCR and youth’s progress notes. Youth are rescreened using the STI screening tool if they
have been out of the Department’s physical custody for more than thirty days. HIV test results
are filed in the laboratory section of the IHCR in a sealed envelope with the DHA’s signature
placed over the seal. All seven-youth interviewed confirmed they can request an HIV/AIDS test
at any time.
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 have access to the sick call
process and receive appropriate care for their health concerns. A review of seven Individual
Healthcare Records (IHCRs) confirmed no youth submitted similar sick call complaints three or
more times within a two-week period. Each record included Sick Call Request forms filed in
reverse chronological order, documented in compliance with the Health Services Rule. None of
the youth were in restricted housing at the time of their requests. All sick call requests were
completed by each youth and addressed by a licensed nurse. Each record showed
documentation on both the Sick Call Index and the Sick Call Referral Log. A review of the daily
sick call schedule posted, and a nurse interview confirmed sick call is conducted twice daily at
9:00 a.m. and 4:00 p.m., as contractually required. Sick call hours are clearly posted outside
and inside the front door of the medical room, and in each dormitory. Only licensed nurses
conduct sick call. When no medical staff are on-site, a supervisor reviews submitted Sick Call
Request forms within four hours. Forms are available to youth in the dining hall, dormitories, and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 69 (Revised September 2022)
group room. During the annual compliance review week, no sick call events occurred; therefore,
no observations were conducted. All seven youth were interviewed and indicated they are seen
by a nurse immediately upon submitting a request. The health services administrator (HSA)
explained youth submit requests by placing completed Sick Call Request forms in the box
outside the clinic, and each is addressed within twenty-four hours. The HSA also noted the
Designated Health Authority (DHA) conducts sick call when on-site. All sick call is conducted in
the clinic. Youth presenting with the same complaint three or more times in two weeks are
referred to the DHA. The DHA has approved all treatment protocols used during sick call.
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 addressing episodic and emergency care,
including first-aid maintenance, storage, and the use, access, and inventory of Narcan. There
were no episodic care events observed during the annual compliance review week. The
program maintains six first-aid kits: one in master control, one in the kitchen, and four in the
medical clinic. Each kit contains contents approved by the Designated Health Authority (DHA).
Monthly checks were completed by nursing staff throughout the annual compliance review
period, as required, and included verification of expiration dates. An automated external
defibrillator (AED) is mounted outside the administration building with procedural instructions
attached. Review of documentation for the annual compliance review period confirmed monthly
checks were completed by nurses. AED pads and batteries were replaced on August 16, 2024.
During observation, the AED was found to be in working condition, with batteries expiring on
September 30, 2029, and pads on March 8, 2026. Emergency medical drill documentation was
reviewed and confirmed drills were conducted at least quarterly on each shift, simulating
scenarios requiring immediate first-aid, cardiopulmonary resuscitation (CPR), and activation of
emergency procedures for life-threatening situations. The review confirmed direct care staff
participated in at least one drill annually which included the use of CPR. A review of the only
applicable drill scenario during the annual compliance review week, confirmed the drill was
simulated as required. Training records confirmed authorized direct care staff received
instruction from a registered nurse on the administration of the epinephrine auto-injector. No
first-aid events occurred during the annual compliance review week, so episodic care could not
be observed. Narcan is inventoried perpetually and weekly, with access limited to supervisory
staff. All non-healthcare staff were trained in Narcan use prior to the annual compliance review
week. Interviews with seven staff members confirmed each knew to call 9-1-1 in a medical
emergency. All seven youth interviewed state they can see a dentist or doctor when needed.
The health services administrator (HSA) confirmed the location of all first-aid kits and the AED,
including procedures for use. The HSA explained episodic care is documented on both the
Episodic Care form and the Episodic Care Log. When non-healthcare staff provide care,
documentation is completed on the Department’s designated form. Any youth transported off-
site for emergency care is recorded on the Off-Site Care Log. The HSA also stated emergency
medical drills are conducted monthly. Emergency contact numbers are posted in the clinic, alert
book, and non-healthcare protocol book. These postings are accessible to staff and remain
secure from youth access.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 69 (Revised September 2022)
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 maintains a policy and procedures ensuring timely referrals and coordination of
medical services with off-site healthcare providers. A review of seven Individual Healthcare
Records (IHCRs) showed five youths received off-site medical care. For all five cases, the
Department’s Summary of Off-Site Care Consultation Report form was completed and properly
filed. Each off-site visit was recorded in the Off-Site Care Log, with parental notification efforts
documented when applicable. The IHCRs included discharge paperwork, off-site care findings,
instructions, and other relevant documents, all reviewed and signed or initialed by the
Designated Health Authority (DHA) two youth required follow-up testing, referrals, or
appointments. These were monitored, and both youths received timely and appropriate follow-
up care. The Registered Nurse (RN) Manager interview indicated the Off-Site Care Log and
Master Control logbook are used to track youth sent off-site for first-aid or emergency care. The
DHA is notified of discharge orders and determines which orders nurses must follow. Telephone
orders are documented in the IHCR and on each Medication Administration Record. Nurses flag
all off-site care orders for DHA follow-up during the next on-site visit. Nursing staff use the
communication book, outlook calendar, and Sick Call Log to track follow-up testing, referrals,
and appointments.
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 with chronic conditions receive
regular evaluations and necessary follow-up care. A review of seven Individual Healthcare
Records (IHCRs) revealed three youths with identified chronic conditions. None of these youths
had a communicable disease, were taking anti-tuberculosis medication, or received an off-site
periodic evaluation. Two of the three applicable youths were prescribed and taking ongoing
medication. All three had a Medical Grade between two and five and were included on the
chronic illness list. Two youths received periodic evaluations at least every ninety days. One
youth did not receive a ninety-day evaluation due to being in jail at the time the evaluation was
due. Each IHCR was reviewed for documentation of completed periodic evaluations, and all
included an updated Problem List, as required. During the facility administrator (FA) interview,
the program’s policy was reiterated regarding formal procedures used by healthcare staff to
review significant youth medical concerns with the FA and program staff, a process conducted
at least weekly. The designated health authority (DHA) confirmed during an interview, youth
with chronic conditions receive evaluations every ninety days, which is tracked using the
medical tracker. The registered nurse manager explained youth with chronic conditions are
added to the alert log and scheduled for follow-up visits with the DHA every ninety days.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 69 (Revised September 2022)
The program has a policy and procedures to ensure medications are received, stored,
inventoried, and administered safely and effectively. Compliance is demonstrated through
observation and review of documentation related to medication handling processes. Seven
Individual Healthcare Records (IHCRs) were reviewed. One youth was identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form and in the chronological
progress notes as being admitted with medication. Documentation confirmed each youth’s
medications were verified before admission. The designated health authority (DHA) and/or
psychiatrist was contacted to obtain an order to resume medications prescribed prior to
admission for the applicable youth. All medications had current, valid orders and were
administered in accordance with active prescriptions. Each time a medication was continued,
discontinued, changed, or newly prescribed; the DHA issued an order using a Practitioner Order
form. None of the youth were housed in restricted settings. All seven youth were eligible to
receive over the counter medications not listed on the Authority for Evaluation and Treatment
form. Over the counter medications were administered following approved protocols or by
practitioner order. The program uses a pre-printed pharmacy Medication Administration Record
(MAR), which includes all required elements. A review of MARs showed staff initialed each
administered medication, and weekly side-effect monitoring was consistently documented. No
unexplained gaps or errors were found in medication administration. In cases where licensed
healthcare staff were unavailable, non-healthcare trained staff assisted in medication delivery
for two youths. Two youths refused medication during the review period. These refusals were
clearly recorded on the MAR. None of the reviewed youth required parenteral medication. One
youth was prescribed psychotropic medication at admission, and both the DHA and psychiatrist
were notified on the same day. The psychiatrist completed an Initial Diagnostic Psychiatric
Interview within fourteen days of each youth’s admission. All applicable youth received
medication monitoring and reviews every thirty days, as required. No standing orders or
emergency treatment orders were issued for psychotropic medications. During the annual
compliance review week, medication pass was observed for four youth. Medication
administration was performed solely by the nurse. Each youth was escorted individually by
direct care staff and approached the nurse one at a time. The nurse confirmed the Six Rights of
Medication Administration by reviewing the MAR before administering each dose. Medications
were prepared and administered by the same staff member, with no medications pre-poured or
stored in alternative containers. Both the nurse and youth initialed the MAR following each
administration. Seven youth were interviewed. All stated a nurse administers their medication
and described the process accurately. The registered nurse (RN) Manager interview confirmed
staff review MARs, orders, and previous facility documentation to verify medication when youth
are admitted. This information is recorded on the Health-Related History (HRH), Facility Entry
Health Screening (FEHS), DHA notification, and the nurse’s admission note. Only licensed
healthcare staff are permitted to verify medications at admission; non-healthcare staff are not
involved in this process. The health services administrator (HSA) also confirmed the use of pre-
printed pharmacy MARs include all required elements. Non-licensed healthcare staff receive
training from the Health Services Administrator on proper medication administration, and a list of
trained staff is maintained in the medical department and in the over the counter medication
book.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 69 (Revised September 2022)
The program maintains a policy and procedures requiring all medical equipment classified as
sharps, along with stock medications, to be secured and inventoried using a routine perpetual
descending count as each sharp is used and disposed of, or as medication is administered. An
observation of the program’s medical area confirmed sharps and stock medications are secured
and inventoried accordingly. Medications were stored in a locked cabinet designated for medical
storage. The medication cart was clean, well-organized, and separated youth-specific
medications from stock items. Controlled substances were maintained under a perpetual
inventory and stored separately from other medications. All sharps and medications were
secured in a locked area inaccessible to youth. Narcotics and other controlled substances were
stored behind two locks and were also inaccessible to youth. No medications requiring
refrigeration were present. The program uses Rx Destroyer to dispose of expired or
discontinued medications. Documentation in the internal medical logbook verified this disposal
method. A review of sharps and over the counter medication inventories confirmed perpetual
and weekly inventory processes are in place. The health services administrator (HSA) reported
sharps are counted weekly, and all controlled substances are inventoried during two shift-to-
shift counts daily. These daily counts were documented in the medical logbook. The HSA also
explained the Six Rights of Medication Delivery are taught to all staff and included in the
program’s policies. A list of supervisory-level, non-healthcare staff trained in assisting with
medication self-administration was provided. Training is delivered by the on-site RN, both as
needed and annually. An observation of the RN counting three controlled substances showed
counts matched the inventory records with no discrepancies. A similar observation of three
sharps was completed without issue. An observation of three over the counter medication
counts shows all medications are accurately accounted for, with no exceptions noted. During
the interview, the HSA described the medication disposal process. Non-controlled medications
are destroyed using Rx Destroyer by two staff members, following a waste count and
documentation. Controlled medications must be destroyed by the consultant pharmacist using
the Rx Destroyer solution. These substances are stored in a secure area behind three locks.
The program holds a current agreement with a consultant pharmacist and has a policy
addressing medication destruction procedures.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a policy and procedures for infection control aligned with Occupational
Safety and Health Administration (OSHA) federal regulations and Centers for Disease Control
and Prevention (CDC) guidelines. These policies include protocols for prevention, containment,
treatment, and reporting requirements related to infectious diseases. The policy also outlines
procedures for post-exposure evaluation following needle-stick incidents. The infection control
procedures were reviewed and signed by the Designated Health Authority (DHA) on April 11,
2025, by the facility administrator (FA) on April 4, 2025, and by the registered nurse (RN) on
June 8, 2024. During the annual compliance review period, no infectious disease incidents
required notification to the local county health department, the CDC, or the Department’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 49 of 69 (Revised September 2022)
Central Communications Center. The FA maintains the ability to create a separate file for youth
and staff who experience facility or occupational exposure. The exposure plan remains available
to all staff. During the FA interview, infection control and exposure control plans were discussed.
The plan is kept in the clinic, and a registered nurse provides training to staff during pre-service
orientation and on an annual basis. The nurse interview confirmed a copy of the exposure
control plan is available to nurses and located in medical and master control for all staff. The RN
explained nurses and the staff educator deliver training on infection control and exposure
control to staff. Nurses also conduct infection control education for youth at the time of
admission.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 69 (Revised September 2022)
Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a policy and procedures requiring all program staff to promote safety
and security by maintaining active supervision of youth to include interacting positively with
youth, engaging youth in a full schedule of constructive activities, closely observing behavior of
youth, and consistently applying the program’s behavior management system (BMS). The
program’s contract requires staff-to-youth ratios to be one-to-eight during awake hours and one-
to-twelve during sleep hours. The ratio for off-site activities, transportation, and visitation is one
staff to five youth. The program staff are required to account for the whereabouts of youth under
their supervision and ensure staff-to-youth ratios are in compliance with contract requirements.
A program tour verified the daily youth activity schedule was posted throughout the program and
is designed to keep youth engaged in a full schedule of activities. Observations of staff
supervision for four days during the annual compliance review week included classroom
activities, line movement, school breaks, youth head counts, mental health groups, youth
searches, and outdoor/indoor recreation activities. The observations ensured staff-to-youth
ratios were maintained, as required. A tour of the program verified the program and living units
were clean, well maintained, graffiti free, and with no window coverings on windows. A
perimeter check was conducted, and fencing appeared to be in good repair. Staff and youth
were appropriately attired. During outdoor activities and/or movement, observations verified staff
were strategically positioned to ensure proper supervision of youth and to ensure there were no
physical obstructions in their view of the youth. Observations of interactions between program
staff and youth reflected the interactions were positive and consistent with the program’s BMS.
An informal interview with three staff verified each staff knew the number of youth they were
supervising. Video observations of youth were conducted during sleep hours. The observations
verified youth to staff ratios were in compliance.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the implementation and training of
the program’s behavioral management system (BMS), which included all required parties in the
development, implementation, and on-going maintenance of the system. The policy includes a
protocol where staff are provided feedback of the implementation of the BMS. There is an
agreement between the program and the school related to the BMS. Documentation reflected
both the program and education staff were trained in the BMS by the facility administrator (FA)
and compliance manager. A review of seven youth case management records found all to
contain a signed Orientation Form which includes a review of the BMS and a signed copy of the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 69 (Revised September 2022)
youth handbook receipt, which also includes a detailed description of the BMS. Seven reviewed
position descriptions confirmed each job’s function includes implementation of the program’s
BMS. A review of seven staff pre-service training records found staff completed training in the
program’s BMS. Observations found the BMS is posted throughout the program in each dorm
and provided in the youth handbook. A review of the policy, youth handbook, and BMS
documentation demonstrated the system has not been updated or changed since the last
annual compliance review. The BMS is a system which outlines youth behavioral expectations,
rewards and consequences, and a level system which has a gradation component. The process
also includes explaining to youth the reasons for any sanctioning, gives the youth the
opportunity to explain their behavior, opportunities for staff and youth to discuss the impact of
behavior on others, reasonable reparations of harm caused to others, discussions of alternative
behaviors, promotes positive dialogue and peaceful conflict resolution, and minimizes
separation of youth from the general population. The BMS included all required elements and
does not include consequences which increase length of stay, denial of a youth’s basic rights or
services, promotion of group discipline, punishment of youth by other youth, or disciplinary
confinement. A review of the BMS documentation found youth are monitored daily throughout
each activity and assigned points based on adherence to the expectations. Staff provide
justification for low scores and/or positive feedback on the back of the card. Incentives are
designed with youth and applied to the BMS based a progression system. Consequences are
also on a progression system and based on severity. Rewards are offered at a minimum of four
positive to one negative consequence and demonstrate youth can earn extra privileges,
recreational activities, movies, additional time in the game room, additional telephone calls,
participate in outings, and buy items from the program’s point store. Staff and youth interactions
were observed for adherence to the BMS, to include negative consequences and positive
rewards, where consequences were in direct relation to the seriousness of the inappropriate
behavior. Seven staff were interviewed, and each staff indicated they received training in the
BMS and was able to articulate an understanding of the system. The staff collectively reported
youth are rewarded with canteen, off-campus outings, incentive nights and movie night. All
seven staff also reported youth are informed of the consequences and they are able to explain
their behavior immediately with staff during the problem behavior reporting process and during
treatment teams. Seven interviewed youth were able to articulate the rewards and
consequences of the BMS, as well as how to move from level to level. Five of the youth
indicated staff are consistent, using rewards the same with two youth stating the BMS is applied
differently. All interviewed youth confirmed they are never allowed to discipline other youth. The
FA interview indicated an understanding of the program’s BMS.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Failed Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 69 (Revised September 2022)
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 maintains a policy and procedures to ensure ten-minute checks are conducted
when the youth are asleep or in their rooms. The program has a total of fifty-eight cameras
which were all operating at the time of the annual compliance review. The program’s video
recording has a thirty-day storage capacity. 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. Checks are documented on the program’s ten-minute check logs with the time of each
check noted in real time along with the initials of the staff conducting each check. A review of
nine separate video footage samples which include two shifts and two dormitories of ten-minute
checks and ten-minute check logs, documented by staff reflected several discrepancies. On
April 9, 2025, dormitory one from 10:00 p.m. to 10:30 p.m., found staff conducted a check at
10:11 p.m. and the next check was conducted at 10:25 p.m. with staff walking halfway down the
dormitory only checking the right side, no other checks were completed, yet the ten-minute
check log showed checks occurring every ten-minutes. On April 9, 2025, dormitory one, staff
conducted a check at 11:45 p.m. with no other checks being completed during the half-hour
period reviewed on video. The ten-minute check log had ten-minute checks documented every
ten-minutes. On April 10, 2025, dormitory 2 from 2:00 a.m. to 2:30 a.m. found staff conducted a
check at 2:27 a.m. with no other checks being completed. A review of the ten-minute check log
found ten-minute checks to have been documented every ten-minutes. On April 11, 2025,
dormitory 2 from 2:30 a.m. to 3:00 a.m., found one check to be completed at 2:58 a.m. with no
other checks being completed. A review of the ten-minute check log found checks to have been
documented every ten-minutes. On April 12, 2025, dormitory 2 from 11:00 p.m. to 11:30 p.m.
found ten-minute checks to have been conducted at 11:07 p.m. and 11:17 p.m. with no other
checks being conducted. A review of the ten-minute paper check logs found ten-minute checks
to have been documented every ten-minutes. A call was made by the program, during the
annual compliance review week, to the Department’s Central Communications Center to report
the falsification. The facility administrator(FA) interview indicated the program has fifty-two
cameras and video is stored for thirty-five days. Four of seven interviewed staff indicated room
checks are conducted every ten minutes. Three of the seven staff indicated room checks are
conducted every seven to ten minutes.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures to ensure youth are always accounted for
through a system of physically counting the youth at various times throughout each day. The
program’s policy is to conduct formal head counts at the start of each shift, each hour and after
outdoor activities. In addition, the policy indicates counts are conducted following an emergency
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 53 of 69 (Revised September 2022)
situation. A review of the Continuity of Operations Plan verified program staff must always
account for the whereabouts of the youth in the care and custody of the program. This includes
the need for continual head counts to be conducted minimally, at the beginning of each shift,
during any emergency, and at regular intervals. Twelve randomly selected dates and times in
the program’s logbook were reviewed for census counts during the annual compliance review
period. Documentation validated head counts and movements were conducted at the beginning
of each shift, after outdoor activities, and during actual and/or simulated drills. There were no
emergency situations, such as program disturbances, on the dates reviewed. In addition, the
program logbooks included documentation of new youth admissions, releases, daily census
counts, youth movements, and youth temporarily away from the program. There were no youth
transferred from the program. Observations made during the annual compliance review week
indicated it is the program’s practice to conduct hourly youth counts. Seven staff were
interviewed and three of seven stated counts are conducted every hour. Two of the seven staff
stated as soon as they enter the dorm, they conduct a count. One of the seven stated every
hour a formal count is conducted with informal counts being conducted every thirty minutes.
One of the seven staff stated counts are conducted every half hour to hour and master control
asks for counts.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures requiring a chronological record of routine events,
incidents, activities, and emergency situations in a logbook in accordance with Florida
Administrative Code. A review of the program logbooks confirmed the program’s logbooks were
bound with pre-printed and numbered pages. Observations and a review of logbooks during the
annual compliance review period found logbook entries were documented in ink with no
erasures or white-out errors. Errors were typically struck through with a single line, dated, and
initialed by the staff correcting the error. Reviewed documentation of randomly selected days
within the logbooks reflected each entry included the date and time of the event, the names of
the staff and youth involved, a brief description of the event, and the name and signature of the
staff making the entry. Exceptions being noted were missing supervisor signatures for three out
of the twelve months reviewed and one occasion in March 2025 where staff did not sign the
logbook. The logbook, as well as the program’s activity schedule, showed there was minimal
interference of educational instruction, reflected youth arrive and depart school on time, and
indicated recreation was conducted as scheduled. The program does not utilize shift reports. A
review of the logbooks demonstrated staff documented the required events, incidents, and
activities. The logbook included documentation of incidents, counts, perimeter checks, youth
transports, drills, youth admissions, releases, and calls to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). Exceptions noted were one CCC report
not being documented in the logbook.
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;
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 69 (Revised September 2022)
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures for assignment, inventory, tracking, secure storage,
missing or lost, and damaged program keys. Keys are bound on a tamper resistant ring which
includes a brass-colored tag with the number of keys and a key/tracking number. Program keys
are maintained in master control in a wall cabinet with the corresponding key number which can
be locked if necessary. Master control is secured, and youth do not have access. The program
has a daily key log to track keys. The log indicates the name of staff and what type of key they
are to be assigned according to their position. The program maintains a master inventory list of
program keys. A random check of five different sets of program keys compared to the inventory
list indicated the keys were accounted for and the master control staff knew which area each
key was assigned to. Active keys are assigned to direct care staff while restricted keys are
designated for medical staff, kitchen staff, case managers, and therapists. Observations
indicated the program’s practice is when direct care staff arrive to the program, personal keys
are placed inside of the box located outside of master control. Medical staff, kitchen staff, case
managers, and therapists receive their respective restricted keys from master control after their
personal keys are placed in the box. Both the master control operator and staff receiving a
program key initial the key log before and again at the end of the shift when the keys are
returned. A review of the key logs and logbooks during the annual compliance review period
verified this practice. There were no permanent issued keys assigned to any staff at the time of
the annual compliance review. This was verified by the facility administrator (FA) and master
control staff informal interviews. Any damaged key is reported to the shift supervisor and a
maintenance request form is completed, which is then given to the FA along with the broken key
to be replaced. A random check of three staff’s keys verified the number of keys on each key
ring matched inventory and each staff knew the key’s function. A review of the Department’s
Central Communications Center reports during the annual compliance review period indicated
there were no incidents related to key control. Seven staff were interviewed and were able to
explain the program’s key control process. Six of seven staff stated they give keys to master
control upon entry. Seven staff stated personal keys are securely stored, three of seven staff
stated program keys are assigned to staff; one of seven staff stated they turn in phones and car
keys to master control and one of seven staff stated telephones go in one box in administration
and personal keys in another box.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 69 (Revised September 2022)
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and youth, which is
clearly explained in the program’s policy and procedures, and resident handbook. The policy
also states any staff who is found in possession of contraband in a program will be subject to
disciplinary action up to, and including, dismissal, as well as procedures regarding notification of
law enforcement for items considered illegal as defined in Florida Statutes. During the annual
compliance review period the program had one Central Communications Center (CCC) incident
report related to confiscated contraband introduced by staff. The program’s policy and
procedures and the youth handbook define items and materials considered contraband when
found in the possession of youth, provides youth with a list of contraband which meets the
indicator requirements, and informs youth of the consequences if found with contraband. The
prohibited list includes personal mobile telephones and/or equipment and/or electronic devices
capable of taking pictures and/or audio/video recordings, which are prohibited in the secure
area. The list also includes unauthorized articles of clothing and food, controlled substances,
prescriptions or non-prescription drugs and any firearm or explosive device. Program policy and
the youth handbook also explains the searching of the physical plant, facility grounds, youth and
staff, and incoming and outgoing mail. The program maintains Room Search Forms which
document any contraband findings and documents these findings in the program logbook. A
review of Contraband Forms from April 2024 to April 2025 were completed and no illegal
contraband was found. Items not considered illegal contraband was documented on the
Contraband Search Form as well as the disposition of the item. Any item not considered illegal
contraband will be sent to the youth’s home or retained at the program until the youth’s release.
Staff and supervisory staff were able to explain the contraband procedures. The contraband
notice is posted, and states law enforcement will be contacted for anyone bringing in
contraband and a criminal report will be filed. This practice was confirmed through an interview
with facility administrator (FA). The Visitors Log and Outside Contractors sign-in form includes
the contraband attestation statement. Staff personnel records for the twenty-three new staff
hired since the last annual compliance review, all had a signed copy of the contraband
attestation form. The FA stated in the event illegal contraband items are discovered, the
program will immediately contact local law enforcement and the CCC. All instances of
contraband items and the disposal of contraband items will be documented appropriately after
being discarded or turned over to local law enforcement or investigating agency. Seven staff
were interviewed and each stated at a minimum, searches are conducted daily.
5.09 Searches and Full Body Visual Searches Limited Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to ensure searches and full body visual searches are
conducted according to Florida Administrative Code at the time of admission, after off-campus
activities, and visitation. The parent/guardian is notified of searches during visitation by way of
the parent/guardian intake letter, which is mailed at the time of each youth’s admission. Youth
are searched before all movement, during a new admission, during readmission, after returning
from visitation, when returning from off-campus activities and/or appointments, when suspected
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 69 (Revised September 2022)
of having contraband, or when a youth is determined to be a security risk. The program
conducts searches as a method to prevent the introduction of contraband and unauthorized
items into the program. The policy indicates searches of youth are conducted after off-site
transports, after visitation, before moving youth from an outside area into the building, and prior
to moving youth from the building to an outside area. There were observations of searches
made during line movements, returning from an off-campus appointment, and before moving
from the building to an outside area during the annual compliance review week. There were no
off-campus activities or visitation to observe during the annual compliance review week. Youth
Search and Full Body Visual Search Forms were reviewed and confirmed the program conducts
full body visual searches at the time of admission, other off-site appointments and visitation.
Searches were documented in the program’s logbook. Observations made throughout the
annual compliance review week validated youth are provided instructions regarding the search,
searches were conducted by staff of the same gender as the youth, were conducted in a
manner as to not degrade the youth and were based on the Right Interactions training manual.
Video review of staff and visitor searches found three of seven searches were not completed.
On April 7, 2025, two staff entered the program and were not searched, on April 9, 2025, one
staff entered and was searched properly, and one staff was not searched. On April 11, 2025,
April 13, 2025, and April 14, 2025, searches of staff and visitors were completed as required.
Seven staff were interviewed, and each staff was knowledgeable of the program’s policy
regarding the search procedures. Seven youth were interviewed and reported youth searches
occur when they cross any door.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures requiring the program vehicles to be properly
maintained, contain safety and emergency equipment, and be operated in a safe manner. 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 seatbelts, a seatbelt cutter, a
window punch, a fire extinguisher, and an approved first-aid kit. At the time of the annual
compliance review, the program had two operational vans used to transport youth. Both
transportation vans were equipped with fire extinguishers, approved first-aid kits, seatbelt cutter,
window punch, and the appropriate number of seatbelts. Doors for both vans in the youth
passenger area cannot be opened from the inside. The safety screen is not applicable as the
program is non-secure. Both vans passed inspections during the annual compliance review
period. The program maintains a log which had documentation of completed weekly vehicle
inspections. The results of the vehicle inspections are documented and stored in the program’s
vehicle maintenance log/binder. A random check of ten personal vehicles and the program’s
transportation vehicles were conducted during the annual compliance review week. The
personal vehicles and both of the transportation vehicles were found to be locked when the
annual compliance review team conducted random checks.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 69 (Revised September 2022)
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 safety and security of youth and the
community during transportation of youth, and to ensure the appropriate staff-to-youth ratio is
maintained while youth are transported off program grounds. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. The approved
driver list is in the administrative area by the facility administrator’s (FA’s) office. Reviewed
documentation verified all approved drivers had a valid driver’s license. The program is not
applicable for providing secure transportation for secure high-risk and secure maximum-risk
youth, or non-secure youth determined to be at greater risk. Youth are not permitted to drive
program or staff vehicles as written in policy. An observation was conducted of the vehicles, and
they were found to be in working order. Observations of a transport, during the week of the
annual compliance review, confirmed the staff-to-youth ratio was within the contract
requirements, both staff and youth wore seatbelts, and at least one staff was the same gender
as the youth. An interview with the FA confirmed the program’s transportation process. Seven
staff were interviewed, and each were able to articulate the correct ratio to be maintained during
transports. Each staff stated youth are secured with seatbelts, One of seven staff stated they
are provided a two-way radio and six stated they are provided a two-way radio and a telephone.
All staff reported transport vehicles are searched for contraband prior to and after each use, and
they are not allowed to use personal vehicles to transport youth. One staff stated they would call
the FA during a transport emergency, four staff stated they would call 9-1-1 and three stated
they would call the supervisor. Seven youth were interviewed and all seven stated they have
never been secured to any part of the vehicle. All seven-youth stated they have not seen staff
place contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures requiring the maintenance of a safe and secure
physical plant, grounds, and perimeter. The program has designated the facility administrator
(FA) and/or designee as the staff responsible for conducting the weekly safety and security
audits. The weekly safety and security audits include the inspection of the program’s camera’s,
radios/communication devices, keys, locks and doors, vehicles, and living areas to include
youth rooms and bathrooms. A review of the programs Preventative Maintenance Checklist and
Safety Inspection Logs during the annual compliance review period confirmed the FA conducts
weekly safety/security inspections. Findings are documented on the Weekly Safety Inspection
Report. All deficiencies are tracked, and efforts are made to correct any deficiencies noted.
During the annual compliance review period, there were no inspections missing or any
discrepancies. The forms documented safety and maintenance repairs needed and the date
and time the repairs were completed, or due to be completed. All inspection forms were
reviewed and signed by the FA. The program had ongoing efforts for any repairs. An interview
with the FA confirmed safety and security audits are discussed during the morning management
meeting, all staff meetings and supervisors meeting.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 69 (Revised September 2022)
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 to address the proper identification, control, and
management of tools to ensure youth do not use tools or equipment as weapons or security
breaches. The reviewed policy addresses the issuance, inventory, and control of equipment and
tools. The policy prohibits specific tools including machetes, bowie knives, and long blade
knives. The program has a policy and procedures for missing/lost tools and for tools requiring
disposal. The program has identified the facility administrator (FA) and the physical plant worker
as the program’s tool control manager. The policy classifies tools into two categories, Class A
tools and Class B tools. Class A tools are hazardous with sharp edges or points with a high
potential to be used as a weapon to inflict serious bodily harm such as knives, hammers, screw
drivers, and electric drills. Class B tools do not have sharp edges or points such as brooms,
mops, and scrub brushes. A review of inventory logs and the tool storage room verified tools are
securely stored when not in use, easily marked for identification, and are inventoried prior to and
following work activities. Observations found the maintenance office to be organized, neat, and
clean. All tools were observed to be maintained in a secured location. All Class A tools were
stored on the maintenance office walls with a shadow outline to easy identify if a tool is missing.
All Class A tools were in good repair and accounted for. All Class A tools are inventoried daily
by the physical plant worker except on days when the maintenance office is not accessed. The
physical plant worker was using a pre-tallied tool inventory to conduct his daily inventory, this
was fixed the same day. This was the physical plant workers first week on-site and he was in
the process of switching the inventories over to active inventories. Class B tools are inventoried
daily by program staff. The FA reviews the inventories monthly. A review of the inventory sheets
validated this practice. The program has a sign-in and sign-out log for Class A and Class B
tools. All tools were properly identified and inventoried during the annual compliance review
period. A review of ten tools and corresponding inventories validated inventories were accurate,
with one exception: the inventory had ten screwdrivers and there were twelve counted. This was
updated immediately. A review of seven pre-service training records indicated all staff were
trained on the safe use of tools. During an informal interview, the program’s physical plant
worker was aware of the proper procedures to follow if tools are missing or damaged.
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 use tools safely and are supervised
appropriately to prevent injuries to themselves, other youth, and staff. The program’s policy and
procedures included supervision requirements, issuance and collection of tools to youth and
staff, established ratios during activities involving tools and disciplinary work projects, and
searches. The program does not participate in off-campus work projects or disciplinary work
projects. Class B tools which include mops, brooms, toilet brushes, and scrub brushes are
inventoried daily by staff to ensure each is accounted for. A review of the Class B Tool Inventory
Log sheets confirmed the program’s practice. A risk assessment of each youth’s risk to self and
others is required to determine their eligibility to use Class B tools. Seven youth case
management records were reviewed, and all indicated youth have been trained on the proper
usage of tools. A signed acknowledgement form is filed in each youth’s case management
record indicating the training was provided. An informal interview with case management staff
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 69 (Revised September 2022)
indicated risk assessments are completed monthly, and risk reassessments are completed if
youth are required to participate in on-site chores, such as cleaning the dormitory or working in
the kitchen. During the annual compliance review week, video footage was observed which
involved youth and the use of tools. One youth was observed sweeping the common area of the
dormitory with a broom while being monitored by one staff; one youth was observed using a
mop and mop bucket to mop the common area of the dormitory while being monitored by one
staff. Based on the observations, the staff to youth ratios when youth were using tools was
accurate. Seven youth were interviewed, and each confirmed youth are allowed to use a mop,
broom and a scrub brush. One youth stated he was able to use a rake, and one stated he has
cleaned a knife in the kitchen. A follow-up interview with the dietary worker indicated all food
prep is done prior to the youth entering the kitchen, knives are cleaned and stored away in the
locked cabinet. Seven staff were interviewed, and each confirmed youth are allowed to use a
mop and a broom. Five of seven staff confirmed youth can use a scrub brush.
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 establishing guidelines for outside contractors who
come on-site to complete repairs. When a contractor or vendor enters the program, they sign
the Outside Contractor Form which lists unauthorized items as well as listing the tools they will
be entering the program with. The facility administrator (FA) or designee inspects all tools upon
the arrival of outside contractors and is responsible for providing approval if such tools are
required. The program’s guidelines for external workers include checking of tools upon arrival
and departure, searching of all vendors prior to entering the program, tool restriction while in the
program, missing tool follow-up, and restriction of youth from the work area. The outside
contractor completes the program’s Outside Contractor Form upon entrance to the program,
where they list what tools are needed to complete the work order. Maintenance staff will review
the form and sign once the tools are inventoried and approved. Upon exiting the program, the
Outside Contractor Form is reviewed, all tools are verified, then the Form is signed. Any tools
required to be used within the program are inventoried and recorded on the Outside
Contractor’s Form before and after the repair is completed. Reviewed documentation for five
project invoices showed the vendors signed the outside contractor form, an inventory of tools
was completed when they arrived and left, and the inventory was documented. The FA must
give approval for any tools or other non-permitted items if required.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to ensure fire safety and evacuation drills are
conducted, and youth and staff are prepared for immediate implementation or mobilization in the
event of an emergency or disaster. A review of the program’s Continuity of Operations Plan
(COOP) revealed the program is required to conduct monthly fire drills on each shift. COOP
drills are conducted semi-annually on each shift as written in the COOP plan. A tour of the
program, during the annual compliance review week, found fire evacuation routes and egress
plans were posted throughout the program. The program has twelve fire extinguishers and
reviewed documentation reflected all were inspected annually. A review of drill documentation
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 69 (Revised September 2022)
for the annual compliance review period indicated the program conducted one monthly fire drill,
on each shift except for February 2024 and July 2024, second shift. A total of twenty-four of
twenty-six required fire drills were completed. At a minimum COOP drills were conducted semi-
annually on each shift. The COOP drills included emergency drills, active shooter, escapes,
medical situations, mental health situations and severe weather. Reviewed documentation for
all drills contained the type of drill, date and time, participants, brief scenario, findings, and
recommendations. Seven interviewed youth reported they have been instructed on what to do in
case of a fire. Four youth stated drills are conducted monthly. One youth stated drills are
conducted twice a month. One youth stated staff take youth out to the basketball court, line
youth up and have their backs face the facility. Seven staff were interviewed and asked what
drills they participated in within the past twelve months and staff stated they have participated in
medical drills, fire drills, bomb threat drills, suicide drills, medical emergency drills and escape
drills. An interview with the facility administrator confirmed they do monthly fire drills, medical
drills and COOP drills 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 policy and procedures requiring the development of a Continuity of
Operations Plan (COOP) which is updated as necessary and maintained for the continuity of
essential functions of the provider in the event an emergency prevents occupancy of the primary
program location, in compliance with state law and the Department’s policy. The COOP
addresses phases of a disaster plan as well as emergency management including
preparedness, response, and recovery. The COOP addressed emergencies including fire
prevention and evacuation, severe weather, major disturbances, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The COOP details alternative housing plans in case the program is required to
vacate due to an emergency or disaster. A review of the COOP validated the plan was
submitted and approved by the Department on March 26, 2025, and provides for basic care and
custody of youth in the event of an emergency or disaster. The facility administrator (FA)
interview indicated the staff have access to the program’s COOP and it is in the FA and master
control offices. The program has the necessary supplies such as under clothing, clothing,
shoes, and bedding readily available in case of an emergency evacuation, which is maintained
within the storage room. The food supplies are in the kitchen. The program maintains an
administrative hard copy with critical identifying information for each youth in case of an
emergency. The program’s hard copy records are easily accessible and mobile in the event of
an emergency resulting in the program relocating quickly or in the event needed information
cannot be accessed electronically for all youth in the program. A review of seven youth case
hard copy records confirmed each contained the youth’s name, a photograph, Department
identification number, admission date, date of birth, gender and race, overall health status,
address, and parent/guardian contact information which included name, address, telephone
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 69 (Revised September 2022)
number of the person with whom the youth resides and their relationship to the youth, and
person(s) to notify in case of an emergency. In addition, the hard copy records contained the
youth’s assigned juvenile probation officer, committing judge, state attorney, and public
defender.
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 addressing storage and inventory, to ensure all youth
and staff are safe from the effects of the unauthorized use of flammable, poisonous, toxic, and
caustic materials. The program’s physical plant worker/ facility administrator (FA) maintains a
monitoring system to ensure compliance with flammable, poisonous, and toxic items. The
program maintains a list of staff who are permitted to handle the flammable, poisonous, toxic
and caustic items. The chemical inventory is completed daily and documented on the Chemical
Inventory Sheet. A tour of the program and observations found the program stored the
flammable materials in a flame-resistant locked cabinet located outside of the program. A review
of the flammable, poisonous, and toxic items list verified the items were securely stored. Toxic
cleaning items and materials are located within a secure cabinet outside of the program which
was inaccessible to youth. A review of six cleaning items/ flammable chemicals verified all
seven chemical inventories were accurate. Copies of each Safety Data Sheet are maintained in
the locked cabinets with the chemicals. The program has an approved list of staff authorized to
handle flammable, poisonous, and toxic items which include maintenance staff, the FA, the
assistant facility administrator (AFA), shift supervisors, and food service staff. The FA stated
chemicals are disposed of at the local county waste disposal site meeting Occupational Safety
and Health Administration (OSHA) requirements.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Program youth are strictly prohibited to use, handle,
or clean dangerous or hazardous chemicals, respond to chemical spills or clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste.
Observations confirmed all chemicals were maintained behind at least one locked door/cabinet
and youth do not have access to areas where items are being stored. Youth do not have access
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 69 (Revised September 2022)
to these items and are supervised by staff during daily cleaning. During the annual compliance
review week, youth were observed by video on two separate instances cleaning and did not use
chemicals. Four of seven interviewed youth reported not using any chemicals and/or cleaning
products. Three youth stated they used paint, one youth stated they used laundry soap, and one
youth stated they used bleach. A follow-up interview with the youth who used bleach stated he
works in the kitchen and was learning how to prepare dish water for cleaning.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures to allow visitation and communication for youth
while in the program. The visitation procedures are posted on the wall in the lobby and the
dormitories. The visitation and communication procedures are covered in the resident
handbook, parent/guardian handbook and addressed on the orientation checklist. The program
utilizes staff translators or the linguistic line with live translators if necessary. The visitation
schedule was posted in the lobby. Visitation documentation indicated visitation is being offered
on the weekends as required by policy. If the parent or guardian needs alternative visitation,
they can contact the case manager and request a day and time. The visitation, telephone and
correspondence logs were reviewed. The logs showed youth have contact with only approved
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 69 (Revised September 2022)
persons. Incoming and outgoing mail is searched and recorded in the correspondence logs,
then given to the youth’s case manager who delivers the mail to the youth and has them open
the mail in front of them. There were no youth applicable for a history of human trafficking;
therefore, the program is not required to request clarification from youth’s juvenile probation
officer about any parent/guardian past or current human trafficking investigation involvement. If
the parent/guardian needs an alternative visitation arrangement, they can contact case
management to request a date. Seven youth confirmed youth can make weekly calls to their
parent/guardian and send/receive written correspondence. The facility administrator confirmed
the linguistic line is used for translation services.
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 to ensure each youth has a variety of recreation and
leisure activities. A review of the staff roster confirmed the program has a recreation therapist,
who met all requirements for the position. The program’s recreation calendar designates an
activity for the youth to participate in during outdoor recreation each day, as well as a calendar
of alternative activities if recreation is indoors. The program’s activity schedule is posted
throughout the dorms and common areas of the program. All activities promote social and
cognitive skill development, creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. Youth are provided with at least one hour of large muscle activity daily.
Reviewed documentation of the logbook and daily activity schedule confirmed the program has
a range of supervised and structured indoor and outdoor recreation and leisure activities for the
youth, for at least one hour daily. Observations made throughout the annual compliance review
week validated youth are provided with at least one hour of indoor or outdoor recreation and
leisure time. Recreational therapy was included in the seven youth mental health treatment
plans. Seven interviewed staff indicated the program provides youth with at least one hour each
day of recreational activities. Three staff indicated one hour of recreation is provided and youth
participate in activities such as basketball, football, kickball and exercise rope. Three staff
indicated they were night staff and they were not familiar with the exact requirement. One staff
indicated recreation is an hour and a half, and activities include basketball, volleyball, football
and exercise. Seven youth were interviewed and each indicated they are allowed to participate
in basketball, football, soccer, studio and stretches.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 69 (Revised September 2022)
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 69 (Revised September 2022)
Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program’s contract requires career and technical education (CTE) services to be provided
to youth. The program shall establish a relationship with a technical college as part of the
Hillsborough County Public School System, which will allow youth to take classes toward a
number of certifications either on campus or online. The program’s services include
certifications in ServSafe Food Handler, first-aid/cardiopulmonary resuscitation
(CPR)/automated external defibrillator (AED), Florida Ready to Work - Soft Skills, and
Occupational Safety and Health Administration-10 (OSHA-10) General Industry training. As a
result of the CTE services offered at the program, thirty youth have received first-aid/CPR/AED
services, twenty-one participated in OSHA-10, and five youth participated in ServSafe Food
Handler training program. The number of youth who have completed a certification or received a
certificate of completion for CTE services are thirty in CPR/first-aid, sixteen in OSHA-10, and
five in ServSafe Food Handler. The program indicated there were no youth who participated in
the Florida Ready to Work Soft Skills during the annual compliance review period. According to
the program’s schedule, eligible youth can receive CTE services every Monday to Friday
between 9:00 a.m. to 3:00 p.m. and periodically on weekends for all youth. A review of the
schedule and interviews during the annual compliance review week confirmed CTE services are
available. CTE instruction is provided online. The program’s transitional case manager is listed
as the administrator to assist youth to enroll in the online ServSafe and OSHA-10 courses.
These courses are not delivered at the program; however, are offered virtually. An independent
company delivered the first-aid/CPR/AED course to the youth. OSHA-10 serves as a base level
certification which can lead to multiple industry certifications from the American Welding Society
(AWS) and the National Center for Construction Education and Research (NCCER), both of
which are identified on the master credentials list. Seven youth were interviewed, and five youth
indicated educational services are being provided to them at the program and the remaining two
stated no because they have already achieved their high school equivalency diploma. The
interview with the facility administrator confirmed CTE services such as first-aid/CPR/AED,
OSHA-10, and ServSafe Food Handler are being provided to youth according to the school
schedule. A review of seven youth case management records confirmed all seven youth
completed First-Aid/CPR/AED and one youth is currently enrolled in OSHA-10.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 69 (Revised September 2022)
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide for educational access. The program
integrates education into the daily schedule. A random sample of three videos and three
logbook reviews showed youth on day one, in classroom one came to class twelve minutes late
and returned from lunch at 1:32 p.m. making them late by twenty-seven minutes and on day two
classroom one came to school seven minutes late and left five minutes early for lunch. The
remaining scheduled day the schedule coincided with the education contract provider’s
scheduled times. In addition, randomly selected logbook entries since the last annual
compliance review were reviewed and youth were transitioned to class accordingly with little
deviation. In a review of the youth interviews, all seven interviewed youth stated there were no
interruptions during the school day.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS) which
ensures the integrity of the required minimum instruction time distributed over a twelve-month
period. The district approved calendar and daily school schedule were reviewed, which
incorporated the required 250 days of instruction, with twenty days used for teacher planning,
and a minimum of twenty-five hours of instruction weekly and was approved by the Department
on April 29, 2024. Youth are enrolled in academic courses through Florida Scholars Academy
and receive credit, as appropriate, when courses are completed. A sample of three videos and
three logbook reviews showed the educator was present in the classroom for the duration of
each school day. The lead teacher was interviewed and provided the program’s education
schedule.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
the length of stay and classification of youth in the program. The career education program does
include Type 1 through Life Management Skills and Personal Finance and Money Management
courses. The career education program also includes Type 2 through career and technical
education (CTE) course offerings which provide exploration and knowledge of occupations
within those specific careers. A career strengths and interest questionnaire is given by the
residential provider and are completed by each youth upon entry. Each CTE course offered by
the education provider includes soft skills for those specific careers, such as communication,
interpersonal and decision-making skills. The interview with the lead educator indicated career
education services and assessments are delivered by the residential provider, as opposed to
the Florida Scholars Academy.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 69 (Revised September 2022)
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
According to the contract, the contracted educational provider is required to develop an
Education Transition Plan for each youth. Three closed case records were reviewed; only one of
the three records contained an Entry Education Transition Plan; the remaining two records did
not have an Entry Education Transition Plan. Many youth entered the program before July 1,
2024, when the new education provider, Florida Virtual School (FLVS), began their contract;
therefore, they would not have had an Education Transition Plan developed by the provider. All
of the required key personnel were involved in each of the three youth’s transition activities.
Each of the three youth’s Exit Education Transition Plans addressed each of the required
elements. Seven youth were interviewed and four stated they participated in the development of
their Education Transition Plan while the remaining three youth stated they do not have a
transition plan yet. Three of the seven youth stated the program is preparing them for their high
school equivalency diploma, high school, vocational school, employment, and/or college very
well, three youth stated well, and the remaining youth stated not well. Two lead educators were
interviewed, one indicated they help youth develop Education Transition Plans and the plans
are completed with each youth within ten days of arrival, while the other lead educator stated
they do not assist youth with developing Education Transition Plans. Both lead educators
indicated a 504 Plan, Individual Education Plan, English Language Learner, and tier two
interventions are addressed in the youth’s Education Transition Plan.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has procedures in place to provide for qualified
instructional staff. A review of eight teacher personnel records confirmed all hold active
credentials as listed on the Department of Education website. Five of eight teachers were
teaching in-field and the remaining two teachers were not. . Three of the teachers were teaching
out-of-field courses which included Algebra 1, English 1 & 2, Health Management, and Diploma
in Teaching. There was no documented approval obtained by the school board for any of the
three teachers who were teaching out-of-field courses. A review of the three youth’s schedules
confirmed all teachers were accurately listed. A review of the out-of-field personnel parent
notification letters confirmed no notifications were sent out prior to October 14, 2024, and none
of the letters accurately reflected the courses, or teaching assignments outside of the teacher’s
field of expertise. Furthermore, none of the provided letters were specific for the three youth
case records reviewed. Each letter was a blanket letter and did not address the specific youth,
or the specific courses which were out-of-field.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 69 (Revised September 2022)
Three closed case management records of youth identified with employability as a goal at the
time of release were reviewed. Each record contained a referral to the Florida Youth College
(FYC). Seven youth were interviewed and none of the seven youth indicated they were
participating in post-secondary education; however, three of the seven youth stated they are
awaiting appointments. The interview with the lead educator indicated all students are referred
to FYC upon completion of their high school equivalency diploma or high school diploma. The
instructional leader for the Florida Scholars Academy indicated when students graduate, a
request is submitted to FYC for the youth to pursue further education
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Three closed case management records of youth identified with employability as a goal at the
time of release were reviewed. Each record included documentation to support the day, date,
and time of their orientation to Florida Youth College (FYC). All three youth records contained a
career plan based on the interests and aptitude of each youth, as well as a copy of the youth’s
admission and registration to a postsecondary program. Two of three youth records reflected
both thirty-day and sixty-day follow-ups occurred, and the remaining record was not applicable
for any follow-ups. The interview with the instructional lead indicated all students are referred to
FYC upon completion of their high school equivalency diploma (GED) or high school diploma.
Additionally, youth have the option to obtain a regular eighteen credit or twenty-four credit
diploma or a GED.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 69 (Revised September 2022)

report_type: QI Residential

rule: Indicator 1.07

rating: Limited Compliance

rule: Indicator 1.08

excerpt: In-Service Training

rule: Indicator 3.13

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)

rating: Failed Compliance

rule: Indicator 5.09

excerpt: Searches and Full Body Visual Searches