summary: QI Residential - FY25-26 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Fort Myers Academy
Rite of Passage, Inc.
(Contract Provider)
2515 Ortiz Avenue
Fort Myers, Florida 33905
Review Date(s): August 26-29, 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:
Rosa Flores, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Lidia Lanns-Clarke, Regional Workforce Education Coordinator, South Region (Standard (2)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Education
Standard 2)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Peter Keelan, Office of Education, Southeast Education Coordinator (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Fort Myers Academy MQI Program Code: 1494
Provider Name: Rite of Passage, Inc. (ROP) Contract Number: 10879
Location: Collier County / Circuit 20 Number of Beds: 28
Review Date(s): August 26-29, 2025 Lead Reviewer Code: 182
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
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 72 (Revised August 2025)
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 72 (Revised August 2025)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 72 (Revised August 2025)
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 72 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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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 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education 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 7 of 72 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 72 (Revised August 2025)
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.0 7
.0 8
.0 9
.1 0
.1 1
.1 2
.1 3
.1 4
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* T h e D e
p ro g ra m o
in d ic a to
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l *
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra
re s id e n tia l, p ro b a tio n ).
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Program Overview
Fort Myers Academy is a twenty-eight-bed program, for thirteen to eighteen-year-old females,
located in Fort Myers, Florida. The program is operated by Rite of Passage, Inc. (ROP), through
a contract with the Department of Juvenile Justice (DJJ). The program provides Intensive
Mental Health (IMH) Treatment Services. Additional treatment services provided include group,
family, and individual therapy. In addition, the program fosters each youth by providing youth
with mental health treatment groups which include Moral Reconation Therapy (MRT), Dialectical
Behavioral Therapy (DBT), Skillstreaming the Adolescent, Impact of Crime (IOC), group process
therapy, trauma groups, anger management groups, conflict resolution, clinical education group
forums, and/or other psycho-educational training groups. Program administration is comprised
of a program director, director of group living/training coordinator, and an administrative
assistant. Case management and mental health services at the program are provided by the
director of clinical services. The program has one transition service manager, two case
managers, two non-licensed therapists, one full-time licensed therapist, one pro re nata (PRN)
therapist, one recreation therapist, and one contracted psychiatrist. The program is licensed
under Chapter 397 through the Department of Children and Families (DCF) to provide
substance abuse services to adolescents. Medical services are offered Sunday to Saturday
from 7:00 a.m. to 6:00 p.m. and are provided by the regional health service administrator (HSA)
who is a registered nurse (RN), one licensed practical nurse (LPN), and a contracted medical
doctor who serves as the designated health authority (DHA). Educational services are provided
by Florida Virtual Schools (FLVS) through the Florida Scholars Academy (FSA), and Florida
Youth College (FYC) for career and technical education. The layout of the program includes the
administrative office, a master control office, lobby, a kitchen with an attached cafeteria, two
classrooms, a multipurpose room, and a youth living unit. All meals are prepared on-site. The
program has thirty-six security cameras providing coverage with the capability to store video for
up to thirty-days. All cameras were operational at the time of the annual compliance review. At
the time of the annual compliance review, the program had two vacant positions, which included
two full-time dietary workers.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 72 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures to ensure all newly hired staff,
volunteers, and interns receive an initial background screening prior to contact with youth. The
program had twenty-seven new staff hired during the annual compliance review period. All
twenty-seven records reflected an eligible background screening from the Agency for
Healthcare Administration (AHCA) Clearinghouse through the Department’s Background
Screening Unit (BSU) was received prior to contact with youth or access to confidential records.
There were no staff screenings which required an exemption prior to working with youth. In all
reviewed staff records, background screenings were completed prior to the date of hire, criminal
histories were reviewed, and each new direct care staff completed a pre-employment
assessment tool. Each of the applicable direct care staff received a passing score on the pre-
employment assessment tool. Each of the newly hired staff’s records contained a signed
contraband attestation form. Reviewed documentation confirmed the program reviewed the
Department’s Central Communications Center (CCC), the Staff Verification System (SVS), and
the criminal background results for each new staff prior to hiring. The program reported there
were seven applicable volunteers at the time of the review, and initial background screenings
were completed and reviewed with no discrepancies. The Annual Affidavit of Compliance with
Level 2 Screening Standards was signed and submitted to the BSU on January 6, 2025,
meeting the annual requirement.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a written policy and procedures to ensure all staff, volunteers, and interns
receive a background rescreening every five years from the initial hire date. The program’s
policy is to submit information to the Department’s Background Screening Unit
(BSU)/Clearinghouse at least ten days prior to the staff’s anniversary date. The program did not
have any applicable staff requiring a five-year background rescreening during the annual
compliance review period. There were no volunteers, interns, or contracted workers applicable
for a rescreening during the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 72 (Revised August 2025)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures addressing each youth’s rights, staff’s
rights, and others’ rights to feel safe and secure in an abuse-free environment. The program’s
policy ensures the program takes immediate action to address incidents of physical,
psychological, and emotional abuse. The program has a zero-tolerance policy regarding any
abuse. The program’s policy outlines the reporting procedures for all staff to follow when a youth
requests to report abuse. The policy and procedures for abuse reporting mandates any staff
who has knowledge of, or has a reasonable suspicion a youth has been, is being, or is in
danger of being abused, to immediately report the allegation to the Florida Abuse Hotline, for
youth under the age of eighteen, or the Department’s Central Communications Center (CCC),
for youth eighteen years of age or older. The program’s administration manages youth and staff
needs and provides directions to each on how to access the Florida Abuse Hotline. Five
reviewed staff personnel records reflected each staff reviewed the program’s code of conduct
and signed the acknowledgement form. The Florida Abuse Hotline and the CCC telephone
numbers were observed to be posted throughout the program. A telephone located in the main
hallway of the living area is designated for youth to contact the Florida Abuse Hotline or the
CCC, if youth feel they have been abused or neglected. The program had a total of thirty-nine
incidents reported to the CCC during the review period. The program had eight incident reports
alleging physical, psychological and/or emotional abuse toward a youth during the annual
compliance review period. Two of the eight incidents were substantiated, and six incidents were
found to be unsubstantiated at the time of the annual compliance review. Reviewed
documentation confirmed the program’s management took corrective action and/or followed up
with substantiated incidents of abuse or neglect. There were three Prison Rape Elimination Act
(PREA) investigations and two resulted in investigations with the Department’s Office of the
Inspector General (OIG). Each investigation was closed as unfounded or unsubstantiated at the
time of the annual compliance review. There were no applicable cases for any potential human
trafficking victims, children of sexual exploitation, or labor trafficking reported. An interview with
the program director (PD) confirmed the program’s practice and confirmed the program’s policy
requires staff to report all incidents of abuse and are mandated to call the Florida Abuse Hotline
at any time. Additionally, the program incorporates trauma-responsive practices as the mental
health and substance abuse needs of the youth are identified at admission. An interview with
the PD reported the program’s general standards of conduct is outlined within the staff policy
and all allegations of abuse towards youth are reported. The PD indicated staff adhere to a code
of conduct, as acknowledged by the review and signing of a code of conduct form during their
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orientation, which is maintained in the staff personnel records. The program completed a
Trauma Responsive and Caring Environment (TRACE) self-assessment on May 16, 2025. Five
youth were interviewed, and each indicated they feel safe in the program, and stated they have
never been stopped from reporting abuse to the Florida Abuse Hotline and/or from contacting
the CCC. Five youth were asked if they knew the contact information for the Florida Abuse
Hotline, three youth stated they did know the contact number, and two youth stated they did not
know the number; however, each of the five youth indicated the number is accessible and
posted throughout the program. Five interviewed youth indicated staff are respectful when
talking to them. Each of the youth indicated they have never heard staff use profanity. Five
interviewed youth denied having been asked to, or exchanged emails, telephone numbers, or
social media information with any staff. Five staff were interviewed, and each staff was
knowledgeable and able to explain the process for allowing staff and youth to call the Florida
Abuse Hotline or the CCC to report suspected abuse. Each staff indicated they have never
observed a coworker telling a youth they could not make an abuse call. Five staff were
interviewed, and four stated they have never heard a coworker use profanity when speaking to
a youth and one youth stated occasionally.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures to ensure program-related occurrences
which place at-risk, or have the potential to place at-risk, the health, safety, or welfare of the
public, youth, staff, visitors, the security of the program, or the reputation of the program are
reported to the Department’s Central Communications Center (CCC) and handled appropriately
and in a timely fashion. The program reported thirty-nine incidents to the CCC during the annual
compliance review period. A review of five CCC reports confirmed each incident had the
incident date, time, and CCC number, with the time the program became aware of the incident.
Each incident was reported to the CCC within the required two-hour time frame and
documented in the program’s incident report logbook, as required. There were no additional
internal incidents or grievances noted during the annual compliance review which should have
been reported to the CCC and were not. The program did not have an annual compliance
review last year; therefore, the program was not applicable for experiencing an increase of
reportable incidents to the CCC since the last annual compliance review. An interview with the
program director (PD) indicated the incident reporting process is to notify the CCC and/or the
Florida Abuse Hotline within two hours of the reportable incident or learning of the incident.
When the PD/designee is notified of any incident, it is determined if the incident is CCC
reportable by a review of the Department’s CCC reportable incidents criteria. The PD/designee
shall obtain necessary information and contact the CCC within the two-hour time frame and
updates are made as necessary. Youth eighteen years of age or older are permitted to contact
the CCC upon request to report incidents of abuse or neglect. The PD and administrative staff
are primarily the reporting staff; however, any staff can make a CCC report. For abuse
reporting, all staff are mandated reporters and can contact the Florida Abuse Hotline at any
time. Youth who request to contact the Florida Abuse Hotline are provided with the opportunity
to do so immediately upon request. Management ensures staff are knowledgeable in the
procedures for contacting the Florida Abuse Hotline and the CCC. Incidents are reviewed with
staff during meetings and staff are notified if there are any changes to the facility operating
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procedures (FOPs). Additionally, staff receive training during pre-service and annual trainings
on incident reporting.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program maintains a written policy and procedures to ensure the proper use of Right
Interactions (RI) techniques by staff. The program submitted all RI incident data to the
Department on or before the fifteenth of every month during the annual compliance review
period. The program’s RI training plan was submitted to and signed by the Department’s Office
of Talent, Leadership, and Culture on December 8, 2024. The program had fifty-six incidents of
utilizing RI during the annual compliance review period. Five RI Reports were reviewed, and all
reports were completed by the end of the staff’s shift and included statements from all staff
involved. Mechanical restraints were not utilized in any of the RI incidents. None of the five RI
Reports indicated the need for medical attention. None of the reports resulted in an allegation of
abuse. All five reports reflected a review by an RI certified instructor/supervisory staff. The
reviewed reports confirmed a post-RI interview was conducted with each youth by the program
director (PD) or designee to assess the need for further medical review. All five reports were
reviewed by the administrator or designee within seventy-two hours of the incident. The
program did not have any RI incidents for a previous annual compliance review for comparison,
as this review was the program’s first annual compliance review. The program’s RI rate during
the previous quarter was 10.55, which is higher than the statewide Residential RI rate of 2.57.
Five pre-service and five in-service training records were reviewed and indicated all staff
received RI training. An interview with the PD confirmed RI incidents are reviewed to determine
the trends and factors, to review all uses of physical interventions, uses of mechanical restraints
and other factors such as excessive force, level of response, and correlation for types of
incidents. The RI Reports are reviewed and discussed during the daily management team
meetings. An interview with five staff was completed, and each staff explained the program’s
policy and procedures and indicated having utilized RI techniques.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program maintains a written policy and procedures outlining the pre-service training and
certification requirements for all new staff. According to the program’s policy and procedures,
staff must complete a minimum of 120 hours of required training within the first 180 days of their
hire date. Training documentation was available for review within the Department’s Learning
Management System (SkillPro). An informal interview was conducted with the program director
(PD) confirming all direct care staff are Right Interactions (RI) certified prior to providing direct
care to the youth. These staff are included in the program’s staff-to-youth ratio. Pre-service
training is provided through a combination of instructor-led, web-based courses, and on-the-job
training. Five staff training records were reviewed for pre-service training. A review of five staff
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pre-service training records verified all five staff exceeded the required pre-service training
requirements within 180-days of employment to include cardiopulmonary resuscitation (CPR),
first-aid, automated external defibrillator (AED), RI, ethics, suicide prevention, facility operating
procedures (FOPs), emergency procedures, child abuse reporting, Prison Rape Elimination Act
(PREA), human trafficking, active shooter preparedness, adolescent development and behavior,
balanced approach to rehabilitative justice, the Department’s Central Communications Center
(CCC) incident reporting, civil rights, communication, confidentiality/Health Insurance Portability
and Accountability Act (HIPAA), diversity, the Department of Juvenile Justice (DJJ) history, as
well as individualized job specific training. Additional trainings included Equal Employment
Opportunity, gang awareness, infection control/bloodborne pathogens, information security
awareness, the Department’s Juvenile Justice Information System (JJIS), mental health and
substance abuse, Motivational Interviewing (MI), quality report writing, safety, security, and
supervision of youth, sexual harassment, standards of conduct, trauma responsive practices,
and addressing workplace dilemmas one on one. There was one training for information
security awareness, which was not completed/documented in SkillPro for one staff member. All
other staff trainings for all five reviewed staff were documented in SkillPro. All five staff
completed all required essential skills training prior to contact with any youth. Documentation
confirmed all trainings were delivered by qualified trainers and documented in SkillPro. The
program only had one staff member who was applicable for supervisory training, and all sixteen
hours of required supervisory training in the required topics was completed. A review of three
staff training records for staff who are still within their first 180 days of hire, confirmed they are
complying with their training plans. The program submitted a pre-service training plan which
was approved and signed by the PD on December 10, 2024, the Department’s regional
residential director on December 16, 2024, the Department’s assistant secretary of residential
services on December 10, 2024, and the director of the Department’s Office of Talent,
Leadership, and Culture on January 14, 2025.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a written policy and procedures ensuring all staff maintain the necessary
training to meet the needs of the program and youth in their care. Five staff training records
were reviewed for in-service training. A review of the five staff in-service training records
confirmed staff exceeded the hours for the in-service training requirements, which included
active shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking, information security awareness, professionalism,
interpersonal communication, the Right Interactions (RI) certification update, sexual
harassment, trauma responsive practices, suicide prevention, and Prison Rape Elimination Act
(PREA). Each staff had current certifications in first-aid, CPR, AED, and RI. All staff completed
training in professionalism and ethics, including standards of conduct, infection control,
emergency response, blood borne pathogens, and the Exposure Control Plan. Additionally,
reviewed records confirmed staff completed training in mental health, substance abuse,
women’s health, and prenatal and neonatal education. A review of two applicable supervisory
staff confirmed each staff completed the required eight-hours of supervisory annual training.
Documentation confirmed all trainings were delivered by qualified trainers and documented in
the Department’s Learning Management System (SkillPro). The program maintains an annual
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in-service training calendar which is updated as changes occur. The program’s in-service
training plan was submitted, approved, and signed by the program’s designee on December 10,
2024, the Department’s regional director (RD) on December 16, 2024, and the Department’s
Office of Talent, Leadership, and Culture on January 14, 2025.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a written policy and procedures to ensure the grievance process is
outlined for the youth to formally file complaints regarding conditions, treatment, services, and
the actions of program staff and other youth which are in violation of the youth’s rights. Staff are
trained on the grievance process as a part of the program’s pre-service training plan. Youth are
encouraged to resolve issues and complaints through informal communication with program
staff utilizing the grievance procedure. The policy ensures complaints are reviewed in a fair and
expeditious manner and are resolved in the best interest of the youth, the program, and the
Department. The program’s grievance process includes informal, formal, and appeal phases for
youth to submit a grievance. In the informal phase, when the youth have concerns, they are
encouraged to make all efforts to reach a resolution for the complaint. The youth may present
an informal grievance to any staff and all staff shall make every reasonable effort to discuss the
youth’s concerns or complaints and assist the youth in resolving the issue. The formal and
appeal phases include the documented intervention of administrative staff. Youth are informed
of the grievance process at the time of admission. According to the policy and procedures, the
program has seventy-two hours to process informal and formal grievances. All youth have
access to the grievance forms, as they are available to youth and are located in the living area.
The program had forty-nine grievances filed during the annual compliance review period. A
review of five formal grievances was conducted and each was resolved within one day of the
youth submitting a grievance and none were applicable for requiring an appeal. Each of the
reviewed grievances were completed as required and met the required time frames. A review of
five staff pre-service training records confirmed each completed grievance training. Five youth
were interviewed, and each youth confirmed grievance forms are placed throughout the
program. Each youth stated they can request assistance to complete a grievance form and were
knowledgeable in the grievance process. Five staff were interviewed, and each staff stated
grievance forms are placed throughout the program, four staff indicated youth can request
assistance in completing the form and the process has three phases, and two staff indicated a
supervisor and/or the program director (PD) will review the grievances. The interviewed PD was
knowledgeable and able to explain the informal, formal, and appeal grievance processes.
1.09 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program maintains a written policy and procedures for delinquency interventions and
facilitator training to address the youth’s needs. A review of the contract indicated the program is
required to conduct and implement interventions for each youth, which include evidence-based
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practices, promising practices, or practices with demonstrated effectiveness. Reviewed
documentation verified the program offers non-clinical, non-primary groups, which are offered to
the youth as required. The program provides non-clinical interventions such as, Impact of Crime
(IOC), Positive Skill Development (PSD), Positive Organizational Culture (POC), life/social
skills, and active parenting, when applicable. A review of training documentation found twenty-
three staff facilitated and were trained to deliver the curricula. The program’s case managers are
trained to facilitate the IOC rehabilitative justice group. A review of the activity schedule
indicated the youth are provided with structured, planned programming, or activities for at least
sixty percent of awake hours. A review of the program’s activity schedule, the group sign-in
sheets, and documentation supported groups were being conducted. Documentation revealed
all groups were provided as outlined in the contract. An interview with the program director (PD)
confirmed these intervention models and services are provided to address the needs of all youth
entering the program. An interview with the designated mental health clinician authority
(DMHCA) confirmed the program provides interventions to address the needs of the youth
through facilitating evidence-based, promising practices, and other intervention/training groups
to address the priority needs of each youth.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures which ensure interventions or instruction
focusing on developing life and social skill competencies in youth are provided. The program
identifies youth in need of services by reviewing the risk and criminogenic needs. The program’s
delinquency interventions used for life skills training include Skillstreaming the Adolescent,
Moral Reconation Therapy (MRT), and Dialectical Behavioral Therapy (DBT). Interventions are
evidence-based, a promising practice, or practices with demonstrated effectiveness. Each
youth’s time is spent in structured, therapeutic activities, devoted to the delivery of treatment
services targeted to address identified risk, criminogenic behaviors, and treatment needs. The
program provided life and social skills intervention services addressing communication,
interpersonal relationships and interactions, non-verbal conflict resolution, anger management,
and critical thinking, which included problem-solving and decision making. The program
addresses the needs of the program’s targeted gender group to include health, hygiene, the
physical environment, life and social skills training, and leisure and recreational activities in a
group setting. A review of the program’s activity schedule, handouts, and group sign-in sheets
verified groups were held, as required. In addition to the life skills intervention services, the
program incorporated additional life skills, and organized the youth participation with community
service and/or arranged for public speaker events for the youth. Five youth were asked what life
skill group/activities they participate in at the program. Three youth indicated they participate in
Impact of Crime (IOC), two youth indicated substance abuse and other group activities, and one
youth indicated they participate in a group for coping skills. Each of the youth indicated they
have practiced the skills learned. An interview with the designated mental health clinician
authority (DMHCA) confirmed youth life skills groups are provided and implemented by using a
structured, individualized, and evidence-informed approach to address the needs of the youth
through evidence-based, promising practice, and practices with demonstrated effectiveness.
The interviewed program director (PD) confirmed youth attend and participate in mental health
and delinquency groups at least five days a week. Additionally, the PD indicated mental health
groups are facilitated by trained licensed therapists and delinquency groups are facilitated by
case management staff.
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1.11 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program maintains a written policy and procedures ensuring the provision of activities and
instruction intended to increase youth awareness and empathy for crime victims/survivors and
reintegrate individuals into society as law-abiding citizens through various treatment and support
programs. The program provides rehabilitative justice awareness to youth through delinquency
interventions, specialized services, gender-specific, life skills, rehabilitative justice, and other
offered groups/activities. Impact of Crime (IOC) is designated as a Standardized Program
Evaluation Protocol (SPEP). The program provides IOC and additional restorative and
rehabilitative justice awareness activities. For details related specific to IOC service delivery,
please refer to the annual SPEP report. The program offers rehabilitative services, such as
participation in local community service, and through public speakers. The program provided
pictures and documentation of the guest speaker event documenting the participation of the
youth. The program has a vegetable/butterfly garden, which allows the youth to plant fruits and
vegetables as well as flowers. Reviewed documentation and on-site interviews confirmed the
program youth participate in community service and community relationship building projects
through rehabilitative justice programming. Additionally, the program offers the youth Moral
Reconation Therapy (MRT), Cognitive Behavioral Therapy (CBT), and Dialectical Behavior
Therapy (DBT) which address rehabilitative justice topics for youth while in the program. In an
interview with five youth, four youth confirmed they are currently participating in MRT, as their
rehabilitative justice group, and two youth indicated they are participating in other groups such
as CBT and DBT. Each of the five interviewed youth indicated they have learned a new skill and
have practiced the skill outside of the group. An interview with the program director (PD)
indicated youth entering the program participate in IOC rehabilitative justice groups, positive skill
development, and positive organizational culture development. Additionally, each youth is
provided with the opportunity to participate in community service projects within the program, as
well as in the community. An interview with the designated mental health clinician authority
(DMHCA) confirmed the program provides rehabilitative justice services to youth twice a week,
which is facilitated by a trained case manager. Additionally, the DMHCA, indicated youth are
provided the opportunity to practice learned skills during their group meetings.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures which outlines how staff identify,
document, and update alerts, how alerts are communicated to staff, and how alerts are entered
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into the Department’s Juvenile Justice Information System (JJIS). The alerts help staff identify
youth who pose a risk to security or safety including escape, youth with assaultive or violent
behaviors, suicide-risk, mental health issues, food allergies, and special diets. Alerts are
identified at the time of admission either through an interview with the youth and/or a review of
supporting documentation within the admission packet. Alerts are then entered into JJIS and
added to the program’s internal alert system. The program has an alert board in the conference
room, which documents all youth alerts. A review of five youth case records revealed each
youth alert was entered into JJIS and was consistent with the program’s internal alert system for
each youth. All required alerts were documented in the logbooks. The observed internal alert
lists were posted in the kitchen, medical, and the training/break room which identified security
and/or escape risks, mental health and applicable suicide risks, medical alerts, and allergies. An
interview with the program director (PD) indicated the program’s internal alert process starts
during admission, where medical, mental health conditions, medication, allergies, and all other
needs for emergency care and treatment can be identified. The PD reported the program has an
internal alert system which reflects all safety and security alerts, in addition to all medical,
dietary, and mental health alerts, which are updated weekly or as needed. An interview with the
nursing staff indicated all medical staff are responsible for updating the medical alerts. Five
interviewed staff reported they are informed of all youth alerts during shift briefing meetings,
supervisor/management meetings, the alert board in the training/conference room, during
intake/orientation, by reviewing the logbook, and through email or other verbal communications.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains a written policy and procedures to ensure the maintenance and storage
of Individual Healthcare Records (IHCRs), mental health and substance abuse records, and
case management records for each youth at the program. A review of five IHCRs, individual
case management records, and mental health/substance abuse records confirmed the records
were labeled and contained the youth’s name, Department identification number (DJJID), date
of birth, county of residence, and committing offense. Each individual youth case management
record contained the required sections to include legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and a miscellaneous section. All youth records were labeled “Confidential” and secured in a
locked room or file cabinet also labeled “Confidential” and inaccessible to youth.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program maintains a written policy and procedures ensuring the program has a community
advisory board meeting at least once every ninety to 120 days. The policy indicates the program
director (PD) shall solicit active involvement of interested community partners. The program’s
last advisory board meeting was held on July 8, 2025, and the next advisory board meeting had
not yet been scheduled at the time of the annual compliance review. The program provided a
contact list of members identified for their community advisory board. The advisory board list
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consisted of representatives of law enforcement agencies, judiciary, local community business,
faith-based members, a school board member, and a local victim advocacy agency; however,
attempts for recruiting a parent/guardian of a youth formerly involved in the juvenile justice
system are ongoing. The PD was continuing to solicit and recruit members of the community, in
order to maintain a collaborative partnership with the Department and local stakeholders in the
community. The program provided documentation of recruitment letters and correspondence of
invitations and recruitment to interested community partners. A review of the sign-in sheets,
agendas, and meeting minutes confirmed the program-maintained documentation of their email
and mailed recruitment efforts for involvement from a law enforcement representative, a school
board representative, a faith-based community member, a community business member, a
member of the judiciary, and other community partners. The program maintains a community
advisory board binder. An interview with the PD confirmed the program’s community advisory
board is held on a quarterly basis and they have some members of the community on the board;
however, the recruitment efforts are still ongoing. Telephone communication with a local
community partner who serves as a board member was not conducted during the annual
compliance review week, as the board members did not have any available contact telephone
numbers. An informal interview with the PD indicated the community board members are all
contacted through email communication.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures for evaluating staff, performance standards,
and the frequency of evaluations. Staff are evaluated at ninety-days for first year staff and
annually for all additional staff on their established performance standards. A review of five staff
position/job descriptions were conducted and determined each staff’s performance standards
were clearly identified. Five staff personnel records were reviewed, and each staff received an
annual performance evaluation, as required, which was based on established performance
standards. In addition, a review of position descriptions for five staff revealed each staff’s
performance standards were clearly identified and the performance standards matched the job
descriptions. The program’s contract requires a recreation therapist, and reviewed
documentation confirmed the recreation therapist’s credentials, schedule, and services met the
requirements of the contract. An interview with the program director (PD) confirmed the program
has a system in place for evaluating staff and to ensure staff are assessed fairly and
consistently. The PD indicated the program’s process provides feedback on strengths and areas
for improvement while supporting professional development. The PD indicated staff are
evaluated at least once annually, and staff are provided with feedback and areas in need of
improvement. The PD indicated when the program was experiencing challenges with staff
turnover and staff morale, the program implemented several morale-building activities to
promote team cohesion, recognition, and staff well-being. Additionally, the program has
emphasized structured communication and staff support systems. An interview with five staff
was conducted, and three staff reported they receive yearly evaluations, two stated evaluations
are provided every six months, and one staff stated they had been recently hired.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
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of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program shall implement all items or services either negotiated or outlined in the contract,
Memorandum of Negotiation, and applicable Award Letter. These items typically exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code. The items
include life skill trainings, community service, staff pre-screening, academic assistance, religious
and spiritual opportunities, recreational therapy such as art therapy, music/dance therapy, yoga,
and gardening. Additionally, the program utilizes a pre-assessment tool to screen applicants
before they are hired. The program has organized a butterfly/vegetable garden, which allows
the youth to plant fruits, vegetables, and flowers. The program has a yoga instructor who comes
to provide yoga and meditation services to the youth once a week. Reviewed documentation
and on-site interviews confirmed the program youth participate in community service and
community relationship building projects through rehabilitative/restorative justice programming.
The program utilizes the Berke Pre-Assessment to screen applicants before they are hired. Five
youth were interviewed, and each youth stated they receive and actively participate in the
contracted condition services which are being provided. An interview with the program director
(PD) confirmed all value-added items and negotiated items are provided as required by the
contract. The interviewed PD indicated the program implements contract-negotiated items as
outlined in its agreement with the Department which include career and technical education
(CTE) services, gender specific services, prudent parenting classes when applicable,
gardening, religious services, and dance/music groups which are provided to help youth
develop interests, aptitudes, and workforce readiness skills.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The program’s trend analysis and internal database tracks various
operation and safety and security data to include Right Interactions (RI), incident reports,
intakes, releases, physical interventions, grievances, behavior management milestones,
transports, vocational certifications, youth, staff, and family surveys. This daily process and
outcome information is aggregated into monthly totals, displayed in interactive dashboards
specific to each program, and provided back to the corporate office and the program
management for the purposes of tracking trends and informing risk management. Additionally,
through the Trauma Responsive and Caring Environment (TRACE) initiative, youth and staff are
surveyed annually. Data and surveys are evaluated for both protective trends as well as
forecasting trends which can impact compliance or programming. Results are analyzed and
guide the program’s action plans which affect all aspects of programming. Information is shared
with staff during the monthly all staff meetings. Documentation of meeting minutes and emails to
the Department confirmed this practice. The management team dedicates time to using data to
inform and educate staff, providers, and stakeholders on a quarterly basis. The findings from
data trend analyses are utilized to determine recruitment strategies, positive morale
approaches, to update the policy and procedures, to improve youth supervision techniques, staff
training, to review rehabilitative justice programs, and to review individual and family services.
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This ensures data is collected and actively used to strengthen service delivery, improve youth
outcomes, and enhance overall program effectiveness.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a written policy and procedures regarding initial contact with the
parent/guardian and court notification after each youth’s admission. Five youth case
management records were reviewed, and each contained documentation in the chronological
notes indicating the parent/guardian was contacted by telephone and informed of each youth’s
arrival and program information within twenty-four hours of admission. Each of the five youth
case management records contained written notification to the youth’s parent/guardian within
forty-eight hours of the youth’s admission to the program. Each of the reviewed case
management records contained documentation verifying the program notified the youth’s
committing court, juvenile probation officer (JPO) and the post-residential counselor, when
applicable, within five working days of the youth’s admission to the program.
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 maintains a written policy and procedures regarding youth orientation. Five youth
case management records were reviewed. All five youth case management records indicated
the program provided each youth with an orientation within twenty-four hours of admission. The
orientation included all required elements such as services available, the daily schedule,
expectations and responsibilities, the written behavior management system (BMS), which was
posted and provided in the resident handbook, access to medical and mental health services,
access to the Florida Abuse Hotline, the zero-tolerance policy regarding sexual misconduct,
special accommodations, the right to be free from sexual misconduct, and items considered to
be contraband. The orientation included the performance planning process involving the
development of goals for each youth to achieve, dress code and hygiene practices, procedures
on visitation, mail, use of the telephone, expectations for release from the program, community
access, grievance procedures, emergency procedures, a program tour, living unit assignments,
and treatment team assignments. The program had one youth admission scheduled during the
annual compliance review week. Observations verified the youth’s orientation included all of the
elements as outlined in the program’s policy. Five youth were interviewed, and all youth
confirmed receiving an orientation within twenty-four hours of admission. Each youth indicated
the orientation to the program included program rules, procedures, and schedules. Each youth
confirmed they received the youth handbook, met with staff, and called their parent/guardian.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures to address consent for youth who are
eighteen years of age or older. The policy requires the program to obtain written consent from
any eighteen-year-old youth prior to providing or discussing any information related to the
youth’s physical or mental health screenings, assessments, or treatments with the youth’s
parent/guardian. A review of five youth case management records found two were applicable for
the youth being eighteen years of age or older; therefore, an additional youth record was
reviewed to meet the sample size. All three applicable records contained the signed written
consent for the eighteen-year-old youth which was executed before providing or discussing
information related to the youth’s physical or mental health screenings, assessments, or
treatments with the parent/guardian.
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 maintains a written policy and procedures to address the classification process
and reassessment for activities. The program’s classification includes a review of physical
characteristics, age, maturity level, identified special needs including medical and mental health,
developmental, intellectual, and physical disabilities, history of violence, applicable gang
affiliation, criminal behavior, sexual aggression, vulnerability to victimization, youth’s perception
of vulnerability, and the potential for, or history of human trafficking. In addition, classification
included identified or suspected medical, suicide, escape, or security risk. Safety and security
risks are identified to assist the staff in guiding the decision-making process determining each
youth’s living unit assignments, room assignment, and the staff assigned to the youth. Five
youth case management records were reviewed. All five reviewed youth records identified
suicide and medical suspected risk factors. None of the five reviewed records identified escape
and security as risk factors. A review of the Department’s Juvenile Justice Information System
(JJIS) alerts, and the program’s internal alerts confirmed all five youth had issues affecting the
youth’s classification. The medical and suicide risk factors identified during the classification
process were immediately entered into the program’s internal alert system and in JJIS. The
program’s policy regarding reclassification states staff may reclassify youth at intervals
throughout the youth’s length of stay. Staff reclassify youth when warranted based upon
changes in the youth's supervision status, new or updated alerts, behavioral concerns, and
relevant information provided to the treatment team to ensure safety and security of the youth
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and program. A review of five youth reclassifications found each youth had increased privileges
or freedom of movement. All five youth reclassifications allowed for participation in work projects
and/or other activities involving tools. None of the reviewed youth were applicable for
participation in off-site activities. The program director (PD) was interviewed and stated youth
placement is guided by the program’s classification system, which prioritizes safety, security,
and individualized treatment needs. At admission, youth undergo a thorough review of the
commitment packet, JJIS alerts, physical health screening, Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) mental health screening, Vulnerability to Victimization
and Sexually Aggressive Behavior (VSAB) screening, and the suicide risk assessment. These
assessments directly inform room and unit assignments to ensure youth are placed in
environments which match their needs and reduce risks related to mental health, physical
health, cognitive functioning, age, and prior victimization. Youth may be reclassified as needed
to address behavioral or safety concerns.
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 maintains a written policy and procedures regarding gang identification and
notification of law enforcement. Five youth case management records were reviewed, and one
was applicable for gang identification and notification to law enforcement. The program had no
additional applicable youth during the annual compliance review period. The applicable youth
case management record documented the youth was identified with a suspected gang affiliation
at the Detention center prior to the youth’s arrival to the program. The program notified local law
enforcement, the education provider, and the youth’s juvenile probation officer (JPO) regarding
the youth’s suspected gang affiliation. A gang alert was entered into the program’s internal alert
system and there was an alert in the Department’s Juvenile Justice Information System (JJIS)
for the youth.
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 maintains a written policy and procedures regarding gang prevention and
intervention strategies. The program’s policy and procedures address providing program youth
an opportunity to develop plans to disaffiliate with criminal street gangs. Five youth case
management records were reviewed, and one was applicable for suspected gang affiliation. The
program had no additional applicable youth during the annual compliance review period. The
program provides Impact of Crime (IOC) groups to bring gang prevention and awareness to
each youth in the program and documentation verified the youth was participating in IOC
groups. The youth’s performance plan did not include relevant goals and objectives relating to
gang intervention strategies. The interviewed program director (PD) indicated all youth are
screened upon admission for gang membership or affiliation. Findings are documented in the
master control logbook and internal communication board. Youth identified as having gang
involvement are referred for gang prevention and intervention activities, based on screening
data, observed behaviors, or expressed interest in gang activity. The PD/designee collaborates
with the team on intervention strategies appropriate to the youth’s individual needs. To deter
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gang activity, the program uses gang awareness education, prevention programming, and
ongoing staff monitoring.
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 maintains a written policy and procedures to address the completion of the
Residential Assessment for Youth (RAY) and reassessments. The policy requires the
completion of an initial RAY within thirty days of admission to the program, the completion of a
reassessment at least ninety days after completion of the initial RAY, and at least every ninety
days after each subsequent reassessment. Five youth case management records were
reviewed, and all five records were applicable for RAYs, and four records were applicable for
reassessments. One youth was not applicable as the youth had not reached the ninety-day time
frame from their initial RAY. Each of the five applicable records documented the initial RAY was
completed within thirty days of admission. Each of the four applicable records had a RAY
Reassessment completed. All four youth RAY Reassessments were completed at least every
ninety-days after the completion of the initial RAY. The program maintained all reassessment
documentation in the youth’s official case management record for all four applicable youth.
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 maintains a written policy and procedures to address the completion of a Youth
Needs Assessment Summary (YNAS) within thirty days of admission. Five youth case
management records were reviewed, and each record contained a YNAS which was completed
within thirty days of the youth’s admission to the program. Each YNAS was documented in the
Department’s Juvenile Justice Information System (JJIS). Each YNAS documented the 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.
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The program maintains a written policy and procedures to address the development of the
performance plan, goals, and plan transmittal. The treatment teams are required to develop an
Individualized Performance Plan (IPP) within thirty days of the youth’s admission to the
program. Five youth case management records were reviewed. Each of the applicable records
contained an initial IPP completed by the program within thirty days of the youth’s admission.
Each initial IPP was developed after the initial Residential Assessment for Youth (RAY) and
Youth Needs Assessment Summary (YNAS). Each performance plan was developed by the
treatment team and all relevant members participated during the development, including the
treatment team leader, parents/guardians, the youth, administrative representative, living unit
representative, treatment staff, education staff, and any relevant parties who had significant
responsibility in goal completion. All five youth case management records had a signature sheet
attached to the original IPP. A review of five case management records found the goals in each
record were individualized and based on prioritized needs, reflecting the risk and protective
factors identified during the initial assessment. Four of the five reviewed youth records included
each youth’s top three criminogenic needs identified in the RAY. One youth record addressed
two of the top three criminogenic needs. One of the top three criminogenic needs was changed
due to the youth's current level of maturity, demonstrated aggression, and challenges in
relationships with family members, peers, and staff. The treatment team determined addressing
the youth’s attitudes and behaviors should take priority over employment-related goals. All five
performance plans contained target dates for completion of goals, youth responsibility to
accomplish goals, and the program’s responsibilities to assist the youth to achieve the goals.
Each of the performance plans were signed by the youth, treatment team leader, and all parties
who had significant responsibilities in goal completion. All five of the youth’s initial IPPs did
reference the specific delinquency interventions based on the RAY results. None of the five
youth initial performance plans required court-ordered sanctions which were reasonably able to
be completed in the program. Four of the five performance plans included transition goals for
the youth to complete prior to release from the program, and one youth’s performance plan did
not have a transition goal. Five youth case management records were reviewed and each
included documentation a transmittal letter and a copy of the plan was sent to the committing
court, parent/guardian, and the juvenile probation officer (JPO). Five interviewed youth stated
they participated in the development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program maintains a written policy and procedures ensuring revisions to a youth’s
performance plan. A review of five youth case management records included additional
education and mental health plans which were incorporated into the youth’s Individualized
Performance Plan (IPP). A review of five youth case management records revealed one youth
was applicable for an IPP revision; therefore, an additional two youth records were reviewed. All
three IPPs were revised due to youth demonstrating progress towards completing a goal. None
of the youth’s IPPs were revised due to newly acquired information which was revealed. None
of the IPPs were applicable for revisions based on the Residential Assessment for Youth (RAY)
Reassessment results, for youth demonstrating lack of progress towards completing a goal, or
facilitating transition activities during the last sixty days of the youth’s stay.
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program maintains a written policy and procedures to address the requirements for
completion of Performance Summaries every ninety days. Performance Summaries are due
within ninety days of signing the youth’s performance plan, or earlier, if requested by the
committing court. The policy requires the treatment team to prepare a Performance Summary
prior to the youth’s release, discharge, or transfer from the program. The Performance
Summary provides information to the youth, parent/guardian, juvenile probation officer (JPO),
and other parties related to the status of each performance goal and describes the youth’s
overall adjustment to, and performance in the program. Five youth case management records
were reviewed and three were applicable for the completion of at least one Performance
Summary and transmittal. Two youth were in the program less than ninety days and a
Performance Summary was not due. Each of the three reviewed Performance Summaries were
completed within ninety days of the performance plan. Each of the three applicable reviewed
summaries contained all elements required including the youth’s status on each goal, treatment
progress, academic status, behavior, level of motivation/readiness to change, interaction with
peers, interaction with staff, adjustment to the program, and positive/negative events. All three
of the applicable records indicated youth were given the opportunity to read and add comments
to their Performance Summaries. All three youth’s Performance Summaries indicated a copy of
the summary was provided to the youth, and the original summary was in the youths’ case
management record. Each of the reviewed summaries were signed by the treatment team
leader, additional treatment team staff, the program director (PD) or designee, and the youth.
Each of the applicable reviewed summaries were filed in the youth’s case management record.
A review of three applicable youth case management records verified each included a cover
letter stating the Performance Summary was sent to the committing court, the youth’s juvenile
probation officer (JPO), and their parent/guardian within ten working days. Three closed youth
case management records were reviewed for release summaries. All three reviewed records
contained a copy of the original summary sent at least forty-five days prior to the youth’s
anticipated release date, along with the Pre-Release Notification (PRN) to the JPO. Each
summary contained the justification for release. One of the three youth reviewed was applicable
for a direct discharge from the program and a discharge summary was sent to applicable
stakeholders. All three closed records included documentation a release summary and the PRN
were sent at least forty-five days prior to release from the program. All three closed records
included a signed copy of the PRN in the youth record. All three applicable youth records
included documentation the parent/guardian was notified of the youth’s planned release. All
three reviewed closed records included documentation of an exit Residential Assessment for
Youth (RAY) which was completed once the PRN was approved. None of the three closed
records were applicable for the Sexually Violent Predator Program (SVPP). One of the three
reviewed youth records required a Victim Notification of Release letter to the victim or designee
at least ten days prior to the youth’s release. Documentation verified a victim letter was mailed
at least ten days prior to the youth’s release from the program.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures regarding parental involvement in case
management services. Documentation supported the program makes efforts to include the
parent/guardian in the assessment process, development of the youth’s performance plan,
progress reviews, formal treatment team meetings, and transition planning. If the
parent/guardian is unable to attend the meetings in person, they are afforded the opportunity to
participate by telephone or conference call or are able to provide verbal or written input prior to
the meeting. At the time of the annual compliance review a treatment team meeting was
observed and the parent/guardian was called and participated by telephone. A review of the
youth’s progress notes revealed the program reaches out to the parent/guardian to facilitate
involvement by telephone, by email, and/or a letter will be sent to the residence.
Parents/guardians are encouraged to participate in treatment team meetings, transition
meetings, exit meetings, and to participate in family day activities. The interviewed program
director (PD) stated the program actively promotes family involvement beginning at admission.
Families are encouraged to participate in treatment team meetings, performance planning,
transition planning, family therapy sessions, and reunification conferences. Case managers are
required to document all efforts to involve families or caregivers, ensuring communication is
consistent and meaningful. The program ensures legal consent requirements are met before
sharing medical or substance abuse information with parents or guardians. This comprehensive
approach supports strong family engagement in case management and prepares youth and
families for community reintegration. Five youth were interviewed, and each stated their
parent/guardians were involved in case management activities by telephone during treatment
team meetings, and during family therapy.
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 maintains a written policy and procedures to address the provision of intervention
and treatment teams to ensure representatives from the program’s administration and
residential living unit, education, and others responsible for overseeing the provision of
intervention and treatment services are included in the treatment team meetings. The treatment
teams are required to meet every thirty days to formally review each youth’s performance, to
include Residential Assessment for Youth (RAY) Reassessment results, progress on
Individualized Performance Plan (IPP) goals, and positive and negative behavior, including
behavior which resulted in physical interventions, when applicable. The policy requires the case
manager to conduct informal reviews of each youth’s performance bi-weekly. The case
manager meets with the youth during informal reviews and incorporates input from treatment
team members, as needed. The policy identifies the case manager to be the treatment team
leader. The program’s treatment team members consist of the case manager/treatment team
leader, youth, and representatives from program administration, education, the youth’s living
unit, mental health treatment, education, and medical. The youth’s parent/guardian or the
Department of Children and Families (DCF) case worker, the transition case manager, and the
juvenile probation officer (JPO) are included as part of the treatment team, when applicable.
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Five youth case management records were reviewed. Each of the records documented formal
treatment team reviews were held at least every thirty days. Treatment team documentation
included the youth’s name, date of review, comments from treatment team members, progress
in the program, progress of goals, behaviors, skills, treatment progress, and RAY
Reassessment results. All five case management records had documentation showing informal
reviews were conducted bi-weekly. Documentation of informal reviews included the youth’s
name, date of review, comments from treatment team members, progress in the program,
progress of goals, behaviors, skills, RAY Reassessment results, and treatment progress. Each
of the reviewed records documented the notification to the required participants of the treatment
team meetings and who attended. If the parent/guardian and/or JPO did not participate in the
treatment team meeting, there was documentation to show attempts to contact the
parent/guardian and JPO. All forms contained signatures from required team members. During
the annual compliance review week, a treatment team meeting was observed, and observations
confirmed all required participants were present at the meeting. Five interviewed youth reported
the staff review each youth’s performance on their performance plan, goals, behavior, and
treatment progress. Four of five interviewed youth indicated they felt they can demonstrate the
skills learned in the program and were able to articulate their involvement during treatment team
meetings. One youth stated they were not at the program long enough to have a treatment team
meeting.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program maintains a written policy and procedures addressing transition planning,
conferences, and Community Re-Entry Team (CRT) meetings. Three closed youth case
management records were reviewed, and a transition conference was held for one of the three
youth at least sixty days prior to the targeted release date, and one was two days late. One
youth’s transition conference staffing was held thirty days late. The youth was being discharged
from the program due to loss of jurisdiction; however, due to the youth’s behavioral problems
the program’s transition services manager (TSM), the juvenile probation officer (JPO), and the
juvenile probation officer supervisor (JPOS) decided to delay the transition conference until the
youth’s behavior and school grade point average (GPA) improved. The TSM reported the
youth’s behavior and school GPA improved, helping the youth achieve a successful discharge
from the program. All required and applicable treatment team members including the youth,
treatment team leader, and the program director (PD) or designee attended the transition
conference in each of the reviewed youth case management records. Each reviewed record
documented the youth’s JPO, parent/guardian, education staff, and any other pertinent parties
were invited to attend the transition conference and all required parties participated either in
person or by telephone. Each transition conference included a review of transition activities on
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the youth’s performance plan, any revisions in the performance plan, identified target
completion dates, and identified persons responsible for completion of transition activities. The
treatment team leader obtained attendees’ dated signatures, representing their
acknowledgement of the transition goals and accountability for completion. A copy of the plan
was sent with a request for return with signature to anyone not in attendance who had a
responsibility for completion of transition goals for all three reviewed closed records. All three
closed records indicated the plan was transmitted electronically to the JPO. A review of three
closed records verified a CRT meeting was conducted prior to the youth’s release. The youth
and case manager participated in the CRT meeting. Documentation verified all the stakeholders
were invited to participate 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 maintains a written policy and procedures addressing the assembly of an Exit
Portfolio to assist each youth once they are released back into the community. Three closed
youth case management records were reviewed and the Exit Portfolio for each youth was
initiated and discussed during the transition conference. Reviewed documentation revealed the
applicable Exit Portfolios included a copy of the transition plan, calendar with all dates, times,
and locations of upcoming community appointments, all educational and/or vocational
certificates earned in the program, and a resume. One of three youth reviewed had the state-
issued identification card, social security card, and a birth certificate in the Exit Portfolio. One of
three youth reviewed had a social security card and a birth certificate in the Exit Portfolio. The
youth was to obtain the state-issued identification card with the after-care provider after release
from the program. For one youth, a request was sent to the parent/guardian for the youth’s
social security card, birth certificate, and state-issued identification card; however, the youth was
released from the program before the parent/guardian responded with the information. One of
three reviewed Exit Portfolios included a sample employment application, and two did not
include an employment application. Reviewed documentation indicated the Exit Portfolio was
completed and given to the youth upon release from the program. The youth’s case
management records reflected the program staff forwarded the Exit Portfolio information to the
juvenile probation officer (JPO).
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program maintains a written policy and procedures regarding an exit conference for each
youth to review the status of goals developed at the transition conference and to finalize the
release plan. Three closed youth case management records were reviewed and the exit
conference for two of three youth was conducted after the program notified the juvenile
probation officer (JPO) of the release and at least fourteen days prior to the youth’s release.
One youth record indicated the exit conference was conducted six days late. Each exit
conference included a summary of pending transition goals, date of the conference, and
signatures of all applicable participants. A review of the Department’s Juvenile Justice
Information System (JJIS) revealed the date of admission and date of termination documented
in the case management record for each youth correlated with JJIS. Reviewed documentation
for each record validated the status of transition activities established at the transition
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conference were reviewed and updated during the exit conference. For each reviewed record,
all required and applicable members participated in the exit conference. Each exit conference
was held separately from the transition and Community Re-Entry Team (CRT) meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process in place to promote constructive input by youth. The program
has multiple opportunities and systems which exist for youth to share input on programming,
concerns, improvements, systemic issues and recommendations, including but not limited to
monthly student surveys, Request to Speak forms, formal and informal treatment team
meetings, town hall meetings, a problem resolution process, student government, and grievance
forms. The grievance forms are maintained in the multi-purpose room, along with the form drop
box. Youth can submit the form when seeking a discussion with a staff or when requesting any
needed item. Observations during the annual compliance review week confirmed the forms
were located in the multi-purpose room. The program’s town hall meetings are held monthly.
The meetings include a discussion of program issues and/or youth are given an opportunity to
speak about any issues. Agendas and sign-in sheets were observed of these meetings and
validated the program’s practice. Youth complete monthly surveys and meal surveys. Surveys
capture information concerning staffing, programmatic issues, and food at the program. Results
are passed to program administration for review. Reviewed documentation during the annual
compliance review week validated the program’s practice. Five youth were interviewed, each
youth confirmed they are able to provide youth input at the program during town hall meetings,
student government, and through the advisory board. The interviewed program director (PD)
stated the program has a formalized youth input process with multiple avenues for participation.
Youth may share concerns, feedback, or recommendations through student surveys, student
government, town hall meetings, treatment teams, contributor club, safety meetings,
maintenance requests, problem resolution processes, grievance forms, and through direct
requests to speak with staff. These systems ensure youth have regular opportunities to voice
input on systemic issues and to recommend improvements which enhance the quality of life for
both youth and staff.
2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program maintains a written policy and procedures which address educational access. A
review of the program’s logbooks reflected classes were held in accordance with the program’s
schedule with minimal interruptions. Nine randomly selected dates, one for each month during
the annual compliance review period, of logbooks were reviewed. Eight of nine reviewed dates
showed the students arrived to the first period class on time or early. One of the dates reviewed,
showed the youth arrived twenty-two minutes late to their first class. A review of video
surveillance footage from August 8, 15, and 21, 2025, showed one of the six classes arrived two
minutes late to the first period and four classes exceeded the scheduled morning fifteen-minute
break by one to six minutes each reviewed day. Youth are able to earn academic credits for
their participation, for attending classes, as well as for completed assignments. In an interview,
the lead educator stated the program’s educational instructional schedule was adhered to.
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Office of Accountability and Program Support Page 31 of 72 (Revised August 2025)
2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has established policies and procedures related to implementation of career and
technical education services. The provider states that Florida Ready to Work-Soft Skills
certification, Occupational Safety and Health Administration ten-hour (OSHA-10) certification,
and cardiopulmonary resuscitation (CPR) certifications are to be completed by each student
within three months of program entry. Additionally, youth shall complete a certification training
from the master credential list prior to release. Career and technical education certifications
were received for four youth in cosmetology, five youth in culinary arts, one youth in digital and
interactive media, one in drafting and design, one youth in earth and space, nineteen youth for
Safe Serve certifications and two food manager certifications. Services are provided Monday
through Friday, 5:00 p.m. to 6:00 p.m. and Saturday and Sunday 5:00 p.m. to 7:00 p.m. The
transition service manager (TSM) is certified to provide CPR and the additional certifications are
completed using a digital platform. The provider’s contract states youth will have the opportunity
to be awarded certifications in food safety, Microsoft information technology, non-violent
communication, and active parenting. A review of five youth case management records
reflected four completed the Florida Ready to Work Soft Skills certification. Two of the five youth
case management records documented completion of the OSHA-10-hour training. Four of the
five youth case management records included evidence of CPR certifications. In all five records,
Florida Ready to Work-Soft Skills, and CPR certifications were completed after three months of
the youth’s entry to the program. In an interview with five youth, three youth reported no career
and technical education services were provided by the residential program. The program
director (PD) reported career and technical education courses are offered by a web-based
career certification preparation platform, and through community partners. Progress reports
were reviewed and reflected coursework in accounting, health sciences, food management, and
exercise science.
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Office of Accountability and Program Support Page 32 of 72 (Revised August 2025)
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 written policy and procedures requiring a designated mental health
clinician authority (DMHCA). The program’s contract requires a DMHCA to be on-site at least
forty hours each week. The DMHCA is a licensed mental health counselor (LMHC) with a free
and clear license in the State of Florida with an expiration date of March 31, 2027. The DMHCA
is responsible for the coordination and implementation of mental health and substance abuse
services in the program. As part of the assigned responsibilities, the DMHCA ensures consistent
and appropriate mental health and substance abuse services are provided. The DMHCA’s
license was displayed within the program, as required. The program’s contract requires the
provision of Intensive Mental Health (IMH) Treatment Services. Reviewed documentation and
an interview with the DMHCA verified the DMHCA was on-site weekly to ensure the appropriate
coordination and implementation of mental health and substance abuse services provided to the
youth, as required by the contract. The DMHCA and the program director (PD) reported the
second LMHC serves as the back-up DMHCA as needed. The back-up DMHCA is an LMHC in
the State of Florida with a free and clear license which expires on March 31, 2027. An interview
with the DMHCA indicated the role of the DMHCA is to coordinate and the implementation of
mental health and substance abuse services at the program, in addition to providing oversight,
leadership, and quality assurance to ensure all services meet the individualized needs of youth
while aligning with Department standards. The DMHCA is responsible for supervising clinical
staff, reviewing treatment plans, monitoring and guiding treatment planning, and ensuring
evidence-based practices are implemented consistently and with fidelity. The DMHCA
coordinates with direct care staff, medical providers, educational staff, and community partners
to maintain an integrated approach to care. Communication with program staff takes place
during weekly treatment team meetings and clinical supervision sessions where youth progress,
challenges, and treatment goals are reviewed in depth.
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 maintains a written policy and procedures which establishes requirements for
qualified professionals in the delivery of mental health and substance abuse services. The
program’s designated mental health clinician authority (DMHCA) serves as the program’s
supervisor for all on-site clinical staff. The DMHCA ensures licensed clinical staff perform
services they are qualified to provide based on education, training, and experience in
accordance with the job description. An informal interview with the program director (PD)
verified the practice. The program’s contract requires one additional licensed mental health
professional to be on-site. The program has one full time licensed mental health counselor
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Office of Accountability and Program Support Page 33 of 72 (Revised August 2025)
(LMHC) who holds a free and clear license in the State of Florida with an expiration date of
March 31, 2027. In addition, the program has one pro re nata (PRN) licensed clinical social
worker (LCSW) with a flexible schedule whose license expires March 31, 2027. Copies of all
licenses were available and displayed on-site. The program has a contract with a clinical
psychiatrist. A review of mental health licenses which included the LMHC, LCSW, the
psychiatrist, and clinical psychologist verified each had a license which was free and clear in the
State of Florida. The clinical psychiatrist holds a free and clear license in the State of Florida
with an expiration date of March 31, 2026. The program is licensed under Chapter 397 through
the Department of Children and Families (DCF) to provide substance abuse services to
adolescents. The license was observed and displayed in the lobby with the program’s physical
address listed and had an expiration date of February 27, 2026.
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 maintains a written policy and procedures which establish requirements for
qualified professionals in the delivery of mental health and substance abuse services. An
informal interview with the designated mental health clinician authority (DMHCA) verified they
supervise non-licensed clinical staff, ensuring the non-licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. A review of clinical supervision logs during the annual compliance review
period verified clinical supervision was documented on the program’s supervision logs and
included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. Documentation
verified the non-licensed clinical staff received clinical supervision for each week they provided
services. The non-licensed clinical staff were in accordance with the contract, and the staff were
on-site for forty hours each week. The program is licensed under Chapter 397 through the
Department of Children and Families (DCF) to provide substance abuse services to
adolescents. The license was displayed in the lobby with the program’s physical address listed
and had an expiration date of February 27, 2026. The program’s contract requires one DMHCA,
one licensed mental health professional, one recreation therapist, two behavior analysts, and
two non-licensed therapists. A review of the two non-licensed therapists’ education
documentation reflected each clinical staff held a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or a related human
services field. The non-licensed staff providing clinical services are employed by a service
provider which was licensed under Chapter 397. Reviewed documentation confirmed the non-
licensed mental health clinical staff who conducted Assessments of Suicide Risk completed
twenty hours of training and supervised experience in assessing suicide risk, mental health
crisis intervention, and emergency mental health services. All training was documented on the
Department’s Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of
Suicide Risk form. The program reported no vacancies during the annual compliance review
week.
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Office of Accountability and Program Support Page 34 of 72 (Revised August 2025)
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 maintains a written policy and procedures regarding mental health and substance
abuse admission screening. The program’s policy requires staff to administer comprehensive
mental health evaluations, a biopsychosocial evaluation or an update shall be administered by a
licensed mental health professional or a mental health clinical staff person working under the
direct supervision of a licensed mental health professional, upon a youth’s admission to the
program. A review of five youth mental health and substance abuse records indicated all youth
received a Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) on their
date of admission. All five youth records documented the clinical staff reviewed available
information to include the commitment packet, reports, mental health records, and any
documentation of human trafficking. All five youth were referred for a comprehensive evaluation
and an Assessment of Suicide Risk (ASR) regardless of results on their MAYSI-2. The ASR was
conducted on the same date as admission. Reviewed documentation verified each staff who
completed the MAYSI-2 was trained, and the MAYSI-2 was completed in the Department’s
Juvenile Justice Information System (JJIS). Each youth’s MAYSI-2 indicated a need for further
assessment. It is the program’s practice to refer all youth for additional assessments regardless
of the screening results. None of the reviewed MAYSI-2s documented the need for crisis
intervention, or emergency services. None of the reviewed MAYSI-2s indicated an assessment
was needed due to the “suicide ideation” category; however, it is the program’s practice to
complete an ASR for all youth upon admission to the program. All five youth records verified
each youth was referred for an ASR and comprehensive evaluation, and each included the
reason for the referrals, which was to gather and review information to assist in developing the
youth’s individualized treatment plan. None of the youth were placed on precautionary
observation (PO). The designated mental health clinician authority (DMHCA) and the program
director (PD) were notified of each youth’s admission screening result. An interview with the PD
reported the screening process to identify youth at risk for mental health and substance abuse
problems and suicide are completed during admission. All youth undergo comprehensive
mental health, substance abuse, and suicide risk screenings. This process includes a review of
records, direct screening measures, and assessments for urgent or emergency needs.
Screenings are conducted using standardized instruments and procedures to ensure
consistency and accuracy. The goal is to identify mental health concerns, substance abuse
issues, suicide risk, and co-occurring conditions as early as possible. Youth identified as
requiring further evaluation are promptly referred for clinical assessment and appropriate
treatment services. This ensures each youth receives equitable and timely access to mental
health and substance abuse services.
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 written policy and procedures to establish an assessment and
evaluation process to guide the development of each youth’s individualized treatment plan. The
program ensures the mental health and substance abuse needs of the youth are identified
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through a comprehensive mental health and substance abuse evaluation process. Each youth
receives an in-depth assessment within the first thirty days of residential placement. All
reviewed assessments were completed by a licensed mental health professional or mental
health clinical staff working under the direct supervision of the licensed mental health
professional. The program’s practice is to incorporate the findings of the Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) and intake packet into each assessment.
Five youth mental health and substance abuse records were reviewed, and each youth had a
new mental health and substance abuse evaluation completed within thirty days of admission. A
consent was obtained for each youth service. Clinical staff obtained consent for substance
abuse services for all five reviewed youth records. All evaluations were completed by non-
licensed staff and reviewed by a licensed clinical staff within ten calendar days. Each of the
comprehensive evaluations contained all required elements including identifying information,
reason for the evaluation, relevant background information, behavioral observation, a Mental
Status Exam, documentation of an interview, discussion of findings, diagnostic impressions
which included the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, patterns of alcohol and/or drug abuse, how alcohol and other drugs are affecting the
major life areas, and risk factors for continued use of alcohol and/or drugs and
recommendations. An interview with the designated mental health clinician authority (DMHCA)
confirmed the process for obtaining the comprehensive mental health and/or substances during
the initial screening.
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 maintains a written policy and procedures to establish individualized treatment
planning processes which guide service delivery. The program’s treatment planning focuses on
the provision of mental health and substance abuse interventions and treatment to reduce or
alleviate youth’s symptoms of mental disorder and/or substance abuse impairment. At
admission youth are assigned to an intervention and treatment team comprised of the youth,
representatives from program administration and residential living unit, and others responsible
for the delivery of delinquency interventions and treatment services for the youth. The treatment
team is responsible for assessing the youth’s rehabilitative treatment needs, assisting in the
development and implementation of the youth’s performance plan and for youth receiving
mental health, substance abuse and/or developmental disability services assisting in
developing, reviewing, and updating the youth’s individualized and initial mental
health/substance abuse treatment plans. A review of five youth records reflected an initial
treatment plan was developed within seven days of admission, or for youth prescribed
psychotropic medication, within seven days of the initial psychiatric diagnostic interview. Each
reviewed initial plan was documented on the program’s form and included all elements of the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each initial plan was
completed by the non-licensed mental health staff working under the direct supervision of the
designated mental health clinician authority (DMHCA) and was signed by the DMHCA within ten
days of completion. Each initial plan was signed by the youth and all treatment team members
who participated in the development of the plan. Each individualized plan documented the
participation of the assigned juvenile probation officer (JPO) and the parent/guardian by
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telephone. Each of the five records indicated the initial plan included the need for a psychiatric
evaluation. The program’s practice is to refer all youth for a new psychiatric evaluation
regardless of medication status. All youth were applicable for being on medication at the time of
the individualized plan development and the plan clearly listed the medication details and
monitoring frequency. Prescribed services included individual and group therapy, family therapy,
psychiatric services as needed for five youths, and medication management for three youth.
The treatment plan goals and objectives were individualized for each youth. The program
completed an individualized treatment plan for each youth within thirty days of admission. Each
applicable individualized plan was documented on the program’s form and included all elements
of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. Five
records were reviewed, and each were applicable for individualized treatment plan reviews. All
of the treatment plan reviews were completed every thirty days, except for one, which was
twenty days late. An interview with the DMHCA confirmed the program’s process to ensure
services are provided and further indicated the youth’s progress and goals are reviewed and
updated in the youth’s individualized treatment plan on a monthly basis during the youth’s
treatment team meetings.
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 maintains a written policy and procedures regarding discharge and transition
planning requirements for mental health and substance abuse treatment services. Discharge
planning processes begin at the time of admission and are included within the initial screening,
assessment and treatment plan development processes. Initial discharge planning and a
tentative projected release date are established for each admitted youth. The treatment team
will regularly review the youth’s individualized mental health and substance abuse treatment
plan through monthly treatment plan review processes. The treatment plan review will be
documented using the Department’s Individualized Mental Health/Substance Abuse Treatment
Plan Review form. Five reviewed youth records indicated each youth was assigned to a
treatment team upon arrival to the program. Documentation revealed the treatment team
included youth, program administration, a staff from the residential living unit, education,
medical staff, mental health/substance abuse staff, and the parent/guardian. All youth records
had Authority for Evaluation and Treatment (AET) forms which were appropriately completed.
The program is licensed under Chapter 397 to provide substance abuse services to
adolescents. Each reviewed youth record indicated the youth was applicable for substance
abuse treatment, and received counseling provided by a licensed qualified professional or a
non-licensed substant abuse clinical staff in accordance with the youth’s initial or individualized
substance abuse treatment plan. All requiring substance abuse treatment had signed Youth
Consent for Substance Abuse Treatment forms. All reviewed mental health or substance abuse
treatment notes were documented on the program’s form and included all the information on the
Department’s Counseling/Therapy Progress Notes form. Each mental health and substance
abuse record reviewed had documentation to support the youth received individual counseling.
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Each record confirmed services were provided as stipulated in the youth’s treatment plan. The
youth records indicated all the youth received psychosocial skills training and the program notes
indicated the youth received services as stated on their treatment plans. Three closed youth
records were reviewed for discharge summaries/plans. Each discharge summary/plan was
documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. None of the reviewed closed records indicated any youth were on suicide alert
or precautions at the time of release. The discharge summaries for all three records indicated
what future services would be needed. Reviewed documentation verified the program provided
a copy of the discharge summary/plan to the assigned JPO and provided a copy to the youth
and parent/guardian upon release. An interview with the designated mental health clinician
authority (DMHCA) confirmed the programs process for the use of individualized treatment
planning for both mental health and substance abuse needs.
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 written policy and procedures to establish a delivery protocol for
intensive specialized treatment services. The focus of treatment services includes targeting and
reducing/alleviating the youth’s risk and needs allowing youth to improve functioning and
reintegrate within the community. Mental health and substance abuse treatment is provided on-
site through the provision of Intensive Mental Health (IMH) Treatment Services. IMH Treatment
Services is the primary clinical treatment component used within the program to address the
mental health and substance abuse needs of the youth in care. IMH Treatment Service
programming offered at the program includes, interviews, records review, initial screening
processes, clinical assessment and evaluation, treatment planning and review, individual,
group, and family therapy, daily therapeutic activities, behavior motivation, medical/psychiatric
services, services provided by the psychiatrist, crisis intervention and crisis management,
suicide prevention services, substance abuse treatment groups as indicated for youth requiring
such services, and twenty four hour response capability with access to an acute care setting
and mental health and substance abuse emergency management services. The program
provides substance abuse and mental health services through group therapy, individual therapy,
family therapy, and psychiatric services. The program has a Chapter 397 license through the
Department of Children and Families to provide substance abuse treatment services to
adolescents. A review of the program’s contract and an interview with the designated mental
health clinician authority (DMHCA) confirmed the program is providing groups which include
Moral Reconation Therapy (MRT) three days weekly, Skillstreaming the Adolescent once a
week, Dialectical Behavior Therapy (DBT) once a week, and Impact of Crime (IOC) twice a
week. A review of the counselor’s caseloads confirmed the counselor to youth ratio is limited to
one to ten, as required by contract. Reviewed staff credentials, confirmed all non-licensed
clinical staff held at minimum a master’s level degree. Reviewed documentation confirmed
individual therapy was conducted weekly and family therapy was completed twice a month. The
program reported there is a substance therapy group, held weekly. Reviewed documentation
indicated psychiatry services were provided at least weekly. The program provides four mental
health and substance abuse groups, on a weekly basis. A review of youth records, youth
interviews, group sign-in sheets, and an interview with the DMHCA verified the individual, group,
and family therapy were part of each youth’s treatment plan. Documentation indicated
therapeutic services are held at least five times a week. The program has an agreement with a
psychologist to provide services on-site at least once a week. The designated mental health
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clinician authority (DMHCA) indicated the DMHCA and psychiatrist meet at least once a week to
discuss youth receiving psychiatric services. The program reported no youth missed services
due to being on medical quarantine. Five interviewed youth reported participating in individual
and family therapy services, and participating in groups at the program, at least on a weekly
and/or bi-weekly basis. Five interviewed staff indicated the direct care staff does not facilitate
any mental health or substance abuse groups and two reported only therapists facilitate the
mental health groups. An interview with the DMHCA confirmed the program provides mental
health and substance abuse treatment services. The program provides group counseling five
days a week, individual counseling weekly, family therapy bi-weekly, and substance abuse
therapy weekly. Supportive counseling and crisis interventions are provided as needed. An
interview with the program director (PD) reported the program provides IMH Services for youth
identified through the Department’s screening and placement criteria. Services include
comprehensive clinical assessments and evaluations, development and review of individualized
treatment plans Individual, group, and family therapy sessions, daily therapeutic and
psychoeducational activities integrated with behavior motivation psychiatric services, medication
management, crisis intervention and suicide prevention services, and substance abuse
treatment groups. The specialized services ensure youth with complex behavioral health needs
receive appropriate and effective treatment throughout their placement.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a written policy and procedures regarding the implementation of a
Suicide Prevention Plan, which describes the essential components and provides guidelines for
the identification, management, and assessment of a potential suicide or at-risk youth. Potential
suicide-risk or at-risk youth refer to youth who have a history of or demonstrate behaviors which
indicate they are thinking about or contemplating suicide; however, are not acutely suicidal.
Acutely suicidal youth who attempt suicide or present an imminent threat of suicide must be
treated as an emergency and the program’s Emergency Response Plan shall be implemented.
The program maintains a Suicide Prevention Plan which was last signed and reviewed by the
program director (PD), on August 1, 2025. A review of the plan reflected, and included the
identification, assessment, staff training, suicide precautions, levels of supervision, referral,
communication, notification, documentation, immediate staff response, and a review process.
The review process for suicide attempts and mortality review included circumstances
surrounding the event, procedures relevant to the incident, relevant training received by
involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
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The program maintains a written Suicide Prevention Plan which serves as the program’s suicide
prevention procedures. The Suicide Prevention Plan addresses the program’s suicide
prevention services, suicide precautions and observation logs, as well as suicide prevention
training. The program’s practice is to complete an Assessment of Suicide Risk (ASR) for all
youth admitted to the program. A review of five youth records was conducted and indicated two
youth were applicable for suicide precautions; therefore, an additional record was requested
and reviewed. Two youth were placed on precautionary observation (PO) due to staff
observation. One was placed during the admission screening based on a review of their history,
and an immediate ASR was completed on the Department’s form by a licensed clinician. Each
reviewed ASR included the PO start date, ASR referral date, and was completed on the
Department’s ASR form. All three records included the level of supervision. There was
documentation the parent/guardian and juvenile probation officer (JPO) were notified of each
youth being placed on PO status. Documentation verified mental health staff provided daily
supportive services while each youth was on PO. Two assessments were completed by non-
licensed clinical staff under the supervision of a licensed mental health professional. Reviewed
documentation confirmed the ASRs were completed within twenty-four hours of each
screening/concern. The discontinuation of close supervision was documented in the program’s
logbook and the actual date/time the clinicians conferred with the program director (PD) or
designee, and licensed mental health professional was recorded on the ASR in the date/time
sections. A review of the Department’s Juvenile Justice Information System (JJIS) reflected
accurate alerts were entered and updated as required. A review of each of the youth Follow-Up
ASRs indicated suicide precautions were discontinued, and the youth was stepped down to
close supervision, prior to transitioning to a normal routine and standard supervision, after the
designated mental health clinician authority (DMHCA) completed the FASR. Each youth’s
record indicated a FASR was completed on the Department’s form. Upon the completion of an
FASR, suicide precautions could be discontinued for the applicable youth, and the youth were
stepped down and placed on close supervision. The discontinuation of suicide precautions was
the result of a documented conference with the PD, and the DMHCA, in each applicable record.
A review of JJIS reflected accurate alerts were entered and updated as required. A review of the
program’s logbooks and assessments supported administration staff provided instructions
regarding suicide precaution decisions. Logbooks documented the placement and removal of
PO and close supervision. Documentation supported youth on suicide precautions were able to
participate in activities with other program youth in the specified safe housing areas. An informal
interview with the PD confirmed there were no youth placed on PO within the last thirty days;
therefore, video observations could not be conducted during the annual compliance review
week.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated as non-
applicable.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
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The program maintains a written policy and procedures requiring staff to always maintain at
least constant supervision of the youth on precautionary observation (PO) and to document their
observations of the youth on the Suicide Precautions-Observation Log in intervals which do not
exceed thirty minutes. A review of five youth records was conducted and indicated two youth
were applicable for suicide precautions; therefore, an additional record was requested and
reviewed. A review of three PO events indicated supervision was documented on the
Department’s Suicide Precautions-Observation Log. The applicable reviewed youth records
identified each youth as being a suicide risk after staff observations and confirmed they were
placed on PO. Each youth record contained documentation where a Suicide Precautions-
Observation Log form was maintained for the duration of when the youth was placed on PO.
Youth behaviors were documented in real time and did not exceed the thirty-minute intervals for
each youth. Each youth was applicable for warning sign observations, and notification to the
mental health clinicians were clearly documented. Each reviewed log documented safe housing
requirements and were reviewed and signed by the shift supervisor and the mental health
clinical staff.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan which requires all staff who work with
youth to receive six hours of annual training on suicide prevention and implementation of suicide
precautions. Suicide prevention trainings completed in the Department’s Learning Management
System (Skillpro) are included in the six hours of annual suicide prevention training. All staff who
work with youth must be trained in suicide precautions and emergency response procedures
and participate in mock suicide drills quarterly, on each of the two shifts. A review of five pre-
service and five in-service training records documented program staff completed the required
six hours of suicide training. The program has a total of two suicide kits which were located in
master control and the laundry room near the medical office. The suicide kits are co-located with
the program’s first-aid kits. The program requires mock suicide drills for each shift at least once
on a quarterly basis. The program director (PD) reported the program maintains a
comprehensive Suicide Prevention Plan, which is reviewed annually, and requires all staff to
receive suicide prevention training. Training includes recognition of warning signs,
implementation of suicide precautions, and appropriate emergency response procedures. In
addition, the program conducts mock emergency response drills which simulate suicide
attempts or self-inflicted injuries. These drills reinforce staff readiness, ensure consistency in
emergency protocols, and verify the staff can respond effectively to protect each youth’s safety.
A review of suicide drill documentation during the annual compliance review period reflected the
program conducted a quarterly drill on each shift as required. Reviewed drills consistently
included the use of lifesaving measures to include the use of cardiopulmonary resuscitation
(CPR), suicide kits, first-aid kits, and the automated external defibrillator (AED). Reviewed video
observations for drills, confirmed each drill was simulated, and the youth were not utilized in any
of the suicide prevention drills. The PD reported the program’s practice is to review the drills
during the monthly staff meetings. Staff who did not participate in a quarterly drill have the
opportunity to review each drill scenario and procedures in an effort to understand the process
and receive the necessary training to respond to an incident of a suicide attempt, or serious self-
inflicted injury. Five staff were interviewed and asked, in the case of a youth expressing suicidal
thoughts, what is the direct care staff responsible for. Each staff indicated they are responsible
for notifying mental health services, providing sight and sound supervision, searching the
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youth’s room for sharp objects, and documenting the supervision. Additionally, three staff stated
staff are responsible for securing the youth and completing reports. Five staff were interviewed
and asked where the program’s suicide response kits were maintained, and each staff indicated
the kits are located in the master control room and within the youth’s living area/module.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written policy and procedures to outline operation procedures for crisis
intervention. Crisis intervention shall be provided to youth in crisis in the least restrictive means
possible to protect the safety of the youth, safety of staff and others while maintaining control
and safety of the program. The Crisis Intervention Plan was signed and reviewed by the
designated mental health clinician authority (DMHCA) on September 1, 2024. The plan
addresses mental health crisis intervention services and crisis assessments. A review of the
plan confirmed it included notification and alert systems, means of referrals, communication,
supervision, documentation, mental health supportive services, and review. An interview with
the program director (PD), confirmed the program’s practice for training, and/or conducting drills
which includes emergency response to suicide attempts and other emergencies requiring
response. Five staff were interviewed, and each reported medical emergency and suicide drills
are conducted monthly on each shift.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program maintains a written Crisis Intervention Plan addressing mental health crisis
intervention services and Crisis Assessments. A review of five youth records found none were
applicable for a Crisis Assessment; therefore, additional records were requested, and the
program reported only one youth was applicable during the annual compliance review period.
One youth record was reviewed, and the Crisis Assessment was conducted immediately as
required. The Crisis Assessment contained the reasons for assessment, a Mental Status
Examination and interview, determination of danger to self or others, initial clinical impressions,
supervision and treatment recommendations, and recommendations for follow-up. The Crisis
Assessment was completed by a licensed clinical staff. A mental health alert was entered into
the Department’s Juvenile Justice Information System (JJIS), and the youth was placed on
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precautions after the completion of a Crisis Assessment due to the youth posing a safety and
security risk, and the youth remained on alert until a follow-up Crisis Assessment and/or follow-
up Mental Status Examination was completed. The youth was not required to be placed on one-
to-one supervision and was placed on constant supervision while on the mental health alert.
The youth observation logs were reviewed and confirmed the logs were completed correctly.
The youth was not required to be sent off-site for the Crisis Assessment. The youth’s Follow-Up
Crisis Assessment was conducted by a non-licensed mental health clinical staff and was
reviewed and signed by a licensed mental health staff. The youth was not an alleged victim of a
Prison Rape Elimination Act (PREA) incident.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written policy and procedures outlining the emergency mental health
and substance abuse procedures for youth who are believed to be in imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for Mental Health and Substance Abuse Emergencies requires
youth to receive the highest quality of care, safety, and management. A review of the plan
confirmed all requirements were included. The program’s Emergency Response Plan was
signed and reviewed by the designated mental health clinician authority (DMHCA) on
September 1, 2024.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program maintains a written policy, procedures, and plan regarding Baker and Marchman
Acts. The purpose of the plan is to outline mental health and substance abuse emergency
procedures and ensure youth who are believed to be an imminent danger to themselves or
others because of mental illness or substance abuse impairment receive emergency mental
health or substance abuse services. The program had a total of three Baker Acts during the
annual compliance review period. Reviewed documentation indicated there were three incidents
of self-harm, of which two of the applicable incidents, involved the same youth with two separate
incidents. Each event resulted in a Baker Act and the youth were placed on supervision at the
time of discovery. Each youth was placed on one-on-one supervision by the mental health staff
and taken out of the program. Mental health staff and the program director (PD) authorized
transportation. Each youth was maintained on precautionary observation (PO) until an
Assessment of Suicide Risk (ASR) and a Mental Status Examination were completed. Two of
the three reviewed ASR’s were completed by a licensed mental health staff, and one of the
youth’s ASRs was completed by a non-licensed staff and reviewed by a licensed staff. An
interview with the designated mental health clinician authority (DMHCA), confirmed the
program’s practice for referring and assessing youth who appear acutely suicidal, and the
immediate safety measures taken to ensure the youth’s safety. The DMHCA indicated, if a
youth presents with any signs of suicide-risk, the youth shall be placed on constant supervision,
be referred/assessed by a mental health professional, and a comprehensive suicide risk
assessment will be completed to determine the level of risk and appropriate interventions. If the
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assessment indicates imminent danger, the youth may be referred to an appropriate higher level
of care, such as a crisis stabilization unit or Baker Act facility. The DMHCA provided the
program’s procedures for notification to the PD, parent/guardian, and other applicable agencies.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures regarding on-going safety planning process for each
youth. The Safety Plan shall identify stimuli which has both positive and negative effects on the
youth. A review of five youth records confirmed each contained a Safety Plan. Each youth had a
Safety Plan completed within fourteen days of admission. All Safety Plans were jointly prepared
by the youth, parent(s)/guardian(s) or family member, the program’s clinical staff. Each plan
incorporated recommendations from previous or current clinical assessments or screening
instruments and incorporated trauma responsive practices. Each plan was reviewed and
updated at least every thirty days. All Safety Plans included warning signs, baseline behaviors,
coping strategies, crisis recognition, intervention strategies, and a debriefing process. Safety
Plans were reviewed by unit staff and plans were maintained in youth records located in the
mental health office. Five interviewed youth confirmed they participated in the development of
their Safety Plan. An interview with the program director (PD) reported each youth has an
individualized Safety Plan developed in collaboration with the youth, their family,
parent/guardian, and clinical staff. Safety Plans are reviewed and updated regularly to reflect
changes in a youth’s triggers, coping skills, or progress in treatment. Furthermore, updates
occur at admission and within the first few days of placement, during treatment, whenever new
risk factors or triggers are identified, in coordination with treatment plan reviews, when clinically
indicated by changes in the youth’s behavior, when safety needs are identified, or as the result
of family input. This ensures the Safety Plans remain current, relevant, and effective, supporting
the youth’s emotional and physical well-being.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program maintains a written policy and procedures which requires a contracted health
authority to provide on-site medical services to youth in the program. The program currently
maintains an independent contractor agreement with a State of Florida physician to serve as the
designated health authority (DHA). The DHA holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida. The DHA had a
clear and active license in the State of Florida, which expires on January 31, 2027, with
specialty training in pediatrics. A review of the Florida Department of Health records confirmed
the DHA had no disciplinary cases and/or public complaints on record. The program does not
utilize an advanced practice registered nurse (APRN) or physician’s assistant (PA) for clinical
duties. Reviewed documentation indicated the DHA was on-site at least once a week, with a
week defined as the seven-day period beginning on Sunday and ending on Saturday. At no time
did more than nine days pass between on-site visits, a review of DHA sign-in sheets during the
annual compliance review period indicated the DHA was on-site for a minimum of two hours a
week. The program has a back-up DHA. The back-up DHA is a licensed physician with a clear
and active license in the State of Florida expiring on January 31, 2027. A review of the
program’s contract and policy and procedures indicated there was no inclusion or approval from
the Department’s Office of Health Services for tele-medicine/tele-health services other than for
tele-psychiatry. Tele-health was only utilized for mental health services by the psychiatrist, and
authorization was provided in writing on November 12, 2024, by the Department’s nursing
services director. Tele-health was only utilized for youth who agreed to participate in tele-health
sessions. There were no instances of tele-health used to perform a Comprehensive Physical
Assessment (CPA), and all medical services were provided in person. An interview with the
DHA indicated their role is to evaluate initial CPAs after admission, sick visits, and for chronic
conditions. Additionally, they review all policies and procedures, coordinate with the nursing
staff off-site as needed, order appropriate lab tests, review them, and refer to specialists when
appropriate and contact specialists when warranted. During an interview the DHA stated they
are on-site once each week and when they are on vacation or during scheduled absences there
is a back-up DHA arranged to cover.
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 written policy and procedures for licensed medical staff. The
program’s contract with the Department outlines the requirements for a health service
administrator (HSA) and for additional coverage to be provided by a registered nurse (RN). The
program has one HSA who is a full-time RN, and one full-time licensed practical nurse (LPN)
on-site. A review of nurse licensure credentials for nurses who provided services during the
annual compliance review period confirmed licenses were clear and active. Each held a current
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certification in cardiopulmonary resuscitation (CPR) and first-aid. The contractually required on-
site total hours each week between the two nurses is eighty hours, which is forty hours for the
HSA and forty hours for the LPN. Currently the program has one full-time RN who serves as the
HSA and one full-time LPN. The program has struggled to retain an HSA, so oversight has been
provided by the regional nurse during the annual compliance review period. Reviewed
documentation confirmed the Department’s Office of Health Services (OHS) approved the
program to have one HSA/RN and one LPN due to the difficulty the program has had retaining a
RN/HSA at the program.
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 a written policy and procedures for a medical facility operating
procedure (FOP) for all health-related procedures and protocols utilized. The designated health
authority (DHA) and program director (PD) signed and dated all respective treatment FOPs. The
reviewed policies and procedures confirmed the DHA signed on July 28, 2025, the PD signed
on July 28, 2025, and the psychiatrist signed on July 31, 2025. Reviewed documentation
confirmed the nursing staff reviewed, signed, and dated the cover page of all FOPs, healthcare
protocols, and other procedures listed on July 28, 2025. The annual review of medical FOPs
and protocols was conducted on July 28, 2025. Reviewed documentation indicated all newly
employed healthcare personnel received a comprehensive clinical orientation to the
Department’s healthcare policies and procedures, given by a registered nurse (RN) or
designated healthcare professional. All approval of treatment protocols or standing procedures
were written and were authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) for all youth admitted into the program. Five youth records
were reviewed for an AET. Three of the five youth were applicable for an AET, and two youth
were over the age of eighteen upon admission. A review of each applicable Individual
Healthcare Record (IHCR) indicated the original AET form was filed in the youth’s IHCR with a
legible copy, or the word “COPY”’ clearly stamped on each AET. Each AET form was signed by
the youth’s parent/guardian. None of the reviewed IHCRs were applicable for an additional court
order filed. Each reviewed AET form was valid and was signed by a Department representative.
One youth turned eighteen after admission, and all four youth currently eighteen years of age or
older IHCRs had a signed release of information. None of the reviewed youth were applicable
for being in the care of the Department of Children and Families (DCF). An interview with the
nurse indicated the policy for obtaining a new or current AET is to reach out to the youth’s
assigned juvenile probation officer (JPO) to request assistance in reaching out to the parent or
guardian to obtain an AET. The nurse stated the policy for documenting consent for youth who
are eighteen years of age or older is for the youth to sign their own consents upon their
eighteenth birthday.
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4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures to ensure the parent/guardian is notified of
significant changes in the youth’s condition and obtain consent when new medications and
treatments are prescribed. Five youth Individual Healthcare Records (IHCRs) were reviewed for
parent/guardian notifications. Each reviewed IHCR was applicable and confirmed
documentation of parent/guardian notification for over-the-counter (OTC) medications beyond
those covered by the Authority for Evaluation and Treatment (AET). Consent was provided by
the parent/guardian and written notifications were sent utilizing the Department’s Parental
Notification of Health-Related Care form. New medication was ordered at the time of intake for
each reviewed youth, and documentation indicated attempted contacts to the parent/guardian in
the progress notes. Written notifications were sent utilizing the Department’s form. Each youth
was applicable for psychotropic medication at the time of admission. Each reviewed IHCR
confirmed staff witnessed all telephone call attempts and conversations for psychotropic
medications. Whenever a new psychotropic medication was prescribed or discontinued, or the
drug dosage was significantly changed, the parent’s/guardian’s verbal consent for psychotropic
medication was documented on page three of the Clinical Psychotropic Progress Note (CPPN).
None of the reviewed youth were in the care of the Department of Children and Families (DCF).
Each of the five reviewed IHCRs confirmed vaccinations were verified within thirty days of the
youth’s admission. The program reported they did not have any youth applicable for religious
exemptions for immunizations. An interview with the nursing staff indicated parental notifications
are to be made for medications not covered by the AET. It was reported the process for
documenting parental/guardian exemption from immunizations is for the religious exemption
form to be completed with the county health department and authorized there. Then a copy shall
be filed in the IHCR. Medical exemptions must be in a letter signed by the youth's physician or
on the health department’s exemption form indicating the reason.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures regarding youth healthcare admission
screenings and rescreening each time the physical custody of the youth changes. A review of
five youth Individual Healthcare Records (IHCRs) confirmed each youth had a Facility Entry
Physical Health Screening (FEPHS) completed on the date of admission by a registered nurse
(RN) or licensed practical nurse (LPN). None of the FEPHS forms were completed by direct
care staff. None of the youth were applicable for a change in physical custody. An interview with
the nursing staff indicated newly admitted youth are seen by medical staff upon entering the
program for screening, and the nursing staff is notified when youth are admitted to the program
by receiving an email from the commitment manager. The nursing staff stated the admission
screening is completed by an RN and an LPN. If the admission screening is completed by direct
care staff, the nurse documents their review on the FEPHS form within twenty-four hours.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a written policy and procedures requiring each youth admitted into the
program to receive a healthcare orientation. Five youth Individual Healthcare Records (IHCRs)
were reviewed, with each documenting a general healthcare admission orientation was
provided. Reviewed documentation confirmed the youth’s orientation topics included access to
medical care, sick call, what constitutes an “emergency” and when to notify staff, medication
processes to include side effect monitoring, the right to refuse care and how it is documented,
what to do in the case of a sexual assault or attempted sexual assault, the non-disciplinary role
of the healthcare providers, and standard universal precautions. According to the programs
contract, the frequency of health education includes a comprehensive monthly health education
program in recurring cycles and each youth receives the benefit of all topics during their length
of stay. The program’s Health Education Orientation Package form listed all reviewed topics to
include seatbelt usage, alcohol and drug related problems, sexually transmitted
disease/infections, tobacco products, including smoking cessation, dental hygiene and dental
care, basic personal hygiene, immunizations, infection control, prevention of sexual and other
physical violence, nutrition, physical fitness, and breast self-examinations, which was signed
and dated by the youth. The Health Education Orientation Package form addressed parenting
skills, and prenatal, postpartum, and parenting education.
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 written policy and procedures to ensure the designated health
authority (DHA) is notified when youth are admitted to the program. Each reviewed youth
Individual Healthcare Record (IHCR) confirmed the youth had a known or suspected chronic
condition upon admission and confirmed a referral to the physician was made. None of the
youth were identified as in need of emergency care upon admission. Reviewed documentation
confirmed notification to the DHA/designee was documented in the youth’s chronological
progress notes within the IHCR, and the DHA was notified within twelve hours of admission, and
no later than noon the day following admission. Each youth was taking psychotropic medication
upon admission, and there was documentation the psychiatrist was notified in each instance. In
an interview with the nursing staff, it was stated for youth admitted with serious or chronic
conditions, the process and timeframe for notifying the DHA is within twelve hours of admission.
The medical staff is responsible for notifications to the DHA, and the notifications are
documented in the admission progress notes.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a written policy and procedures ensuring nursing staff shall complete
the Department’s Health-Related History (HRH) form prior to the Comprehensive Physical
Assessment (CPA). A review of five youth Individual Healthcare Records (IHCRs) found each
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youth had a new HRH completed on the day of admission prior to the CPA being completed.
Each reviewed HRH was completed by a registered nurse (RN). Each HRH was reviewed by
the designated health authority (DHA) as indicated by a checkbox on the CPA. An interview with
the nurse confirmed the program’s practice for completing the HRH within seven days.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring each youth admitted shall receive
and/or shall have on record a current Comprehensive Physical Assessment (CPA) and Health
Related History (HRH) form no later than seven calendar days of admission into the program.
Five youth Individual Healthcare Records (IHCRs) were reviewed, and each included a new
CPA completed by the designated health authority (DHA) within seven days of admission on the
Department’s form. Each of the CPAs documented the appropriate Medical Grade for the
reviewed youth. There was no indication of any missing or incomplete elements on any of the
reviewed CPAs. All five-youth refused part of the examination, and each CPA documented the
refusal and included the youth’s signature by the applicable portion of the CPA examination.
Additionally, four records documented the clinician deferred a gynecological examination due to
the youth having no symptoms. One female youth was not applicable due to not being sexually
active. Each reviewed CPA had all sections complete in full utilizing “O” and/or “X”. The results
of each youth’s Tuberculosis Skin Test (TST) was documented on the CPA and the
Department’s Infectious and Communicable Disease (ICD) form and on the program’s
TST/Purified Protein Derivative (PPD) form. Reviewed documentation confirmed the
Department’s Problem List was updated as needed. An interview with the program’s nurse
confirmed the CPA is completed by the DHA during admission and updated as needed.
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 written policy and procedures requiring all youth admitted to be
clinically screened and medically evaluated for sexually transmitted infections (STIs). The policy
states the program shall routinely offer counseling, testing, and referrals for medical treatment to
all youth at risk of human immunodeficiency virus (HIV) infection. Confidential HIV testing shall
be conducted for all youth recommended for testing based upon the clinician assessment, risk
assessment, or upon youth request. Five youth Individual Healthcare Records (IHCRs) were
reviewed, and three youth were clinically screened and evaluated for STIs. Two of the five youth
were not applicable to be screened. Each applicable youth required further evaluation and was
referred to the medical doctor (MD). Each referral was documented on the STI screening tool
and testing was ordered; however, the testing was not performed/completed due to each
applicable youth refusing. The program maintains a written policy and procedures reflecting HIV
test results are only disclosed to the youth and the youth’s legally authorized representative,
healthcare providers during the course of consultation, diagnosis, or treatment of the individual,
the Department of Health for purposes of reporting and control of spread of disease, health
facility staff committees conducting program monitoring, evaluation, and service reviews,
medical personnel who have been subject to a significant exposure, and healthcare facility
personnel or agents for the healthcare provider who have a need to know in the course of
patient care activities or administrative operations. The local health department provides pre
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and post-test counseling services. Five youth were interviewed and asked if they can request an
HIV test, and each youth stated yes. An interview with the nurse indicated all youth are
screened upon admission and either elect or decline testing. Additionally, referrals and testing is
documented on the STI form and practitioner order within thirty days. The STI screenings,
evaluations, referrals, and testing is documented in the lab section and health education section
of the IHCR. An interview with the nursing staff indicated if a youth has been out of the
program's physical custody for more than thirty days, the youth are rescreened upon
readmission and offered HIV testing. Additionally, the nurse indicated, HIV
consents/declinations and test results are kept in the confidential medical chart/record and not
included on any internal alert or problem list.
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 written policy and procedures ensuring all youth in the program are
able to make sick call requests and have their complaints treated appropriately through the sick
call system. Sick call care, including dental complaints, shall be available to all youth two times
a day, seven days each week. Sick call care shall be provided by licensed healthcare
professionals, pursuant to their scope of practice and according to protocols approved by the
designated health authority (DHA). When a licensed healthcare professional is not on-site, the
shift supervisor shall review all sick call requests as soon as possible, and within two hours after
the request is submitted. Any complaint of severe pain, including dental pain, shall be treated as
an emergency, with an immediate referral to the program’s healthcare staff or DHA. Emergency
dental care services, to include complaints of severe pain, shall be provided by a licensed
dentist. Sick call forms were observed in the multi-purpose/dayroom hallway in a wall-mounted
slot which is accessible by youth. Five youth Individual Healthcare Records (IHCRs) were
reviewed, and none were applicable for similar sick call complaints for three or more times
within a two-week period. Each youth completed a Sick Call Request form, and the forms were
completed by a registered nurse (RN). If sick call care is conducted by a licensed practical
nurse (LPN) it is reviewed by the RN. Each Sick Call Request form was filed in the youth’s IHCR
in reverse chronological order. No youth were in restricted housing of any kind. Each Sick Call
Request form and/or progress notes was documented in accordance with Florida Administrative
Code and on the Sick Call Index. Each of the youth’s sick calls were documented on the
program’s Sick Call Referral Log and the dates listed on the Sick Call Index corresponded to the
completed Sick Call Request forms located in the IHCR. A review of the daily schedule, posted
schedule, and nurse interview confirmed sick call was conducted daily. Sick call care is provided
daily Monday through Friday at 7:45 a.m. and 8:30 a.m. Saturday and Sunday. The sick call
hours are posted in the living unit and day room, and only licensed nurses conduct sick call
requests; however, in the event the nurse is not available the program has a procedure where a
trained non-licensed staff/supervisor can conduct the sick call. The shift supervisor reviews all
sick call requests as soon as possible and within four hours after the request is submitted when
there is not a licensed nurse on-site. All Sick Call Request forms are available to youth at any
time. The program has an exam table and equipment to perform sick calls. During the annual
compliance review week, observations of a youth sick call was not conducted. An interview with
the nurse indicated a youth can submit a sick call at any time by placing the form in the sick call
box. The box is monitored by the nurse at a minimum of once a day and youth are assessed
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within twenty-four hours. Supervisors are to check the box every two to four hours and notify
appropriate after-hours medical staff. The nurse reported the process for youth requesting to
see a nurse and/or physician for health complaints consists of the youth having forms available
and boxes are accessible during bathroom breaks, meal breaks, after education, between
groups, and during free time. According to the nursing staff interview RNs and LPNs routinely
conduct sick call, the LPN notifies the RN immediately and documents the notification on the
sick call form, and the RN reviews the sick call. The DHA conducts sick call if sick call is
scheduled when they are on-site. Sick call is conducted inside the medical office daily Monday
through Sunday. Additionally, the nursing staff stated there are DHA approved treatment
protocols for the program. Five youth were asked how quickly they can see a nurse once youth
make a sick call request. Four youth reported within one day, and one reported they never
requested a sick call; however, they knew the process.
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 written policy and procedures ensuring the provision of episodic care
and first-aid care. The program will provide twenty-four-hour emergency medical, mental health,
substance abuse, and dental care to all youth. All staff who have direct contact with or provide
supervision to youth, including transporters, shall be trained in sick call complaints which are
emergency complaints and proper emergency on-site emergency notification procedures and
care, to include transfer procedures to facilitate the immediate transfer of youth who require
emergency medical, mental health, and dental care services. The program director (PD) shall
ensure all telephones within the program have access to outside lines to ensure unimpeded
access to the emergency use of 9-1-1. Five youth Individual Healthcare Records (IHCRs) were
reviewed for on-site first-aid or episodic care. Two youth were not applicable and three were. All
reviewed first-aid/episodic care was provided by a licensed healthcare staff and documented in
the progress notes under the notation of episodic care. All notes were completed in subjective,
objective, assessment, and plan (SOAP) format. None of the episodic or first-aid care was
provided by non-healthcare staff. The program has seven first-aid kits located in master control,
classroom area, the kitchen, case management/clinical area, maintenance, laundry room, and
the transport van. The program has a process for ensuring contents are maintained and stored
in accordance with guidelines, to prevent expiration or deterioration, and are replenished as
needed. Reviewed documentation indicated the nurse checks the first-aid kits monthly.
Observations of three first-aid kits found each was fully stocked with designated health
authority-approved contents. A review of the first-aid kit binder confirmed the first-aid kits were
being monitored as required. The program has two automated external defibrillators (AEDs)
located in the administrative hallway and laundry room. The AED procedures are located in both
areas. Nurses check to ensure the AED batteries and pads are operable. During the annual
compliance review week, the nurse conducted a self-test of the AED in front of the regional
monitor. There were no issues observed. Reviewed documentation confirmed the AED batteries
expire in April 2028. The pads expire on March 11, 2027. The batteries and pads were last
changed in April 2023. A list of emergency numbers including the Poison Control Center was
posted and accessible for non-licensed and licensed staff and inaccessible to youth. Reviewed
documentation confirmed the authorized direct care staff were appropriately trained on the
administration of the epinephrine auto-injector. A review of five staff training records confirmed
they met episodic, first-aid, and emergency care training requirements. The program has two
operational shifts. A review of the program’s mock emergency medical drills reflected
announced and unannounced drills were conducted on each shift as required during the annual
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compliance review period. Emergency medical drills included the demonstration of
cardiopulmonary resuscitation (CPR), first-aid, and the AED, as required. Reviewed
documentation confirmed direct care staff had the opportunity to participate in at least one
emergency “man down” drill within the annual compliance review period. Video observations
found drills are simulated episodic care events. An episodic care event observation was not
conducted at the time of the annual compliance review, as one did not occur. The program has
a policy and procedures on the use, access, and inventory of NARCAN®. NARCAN® is to be
stored in the medical cart and staff are trained on how it is administered. Only medical staff and
supervisors have access to NARCAN®. The program documents the inventory of NARCAN® in
the over-the-counter binder. Five staff were interviewed, and each reported they are personally
allowed to call 9-1-1 if a youth has an emergency. Five youth were interviewed, and each
reported they can request to see a doctor and/or a dentist if needed. An interview with the nurse
reported the program has seven first-aid kits located in master control, classroom area, the
kitchen, case management/clinical area, maintenance, laundry room, and the transport van. The
nurse reported youth who are sent off-site for emergency care are tracked through the episodic
log. The interviewed nurse reported the medical staff check to ensure the AED batteries and
pads are operable. The nurse reported emergency drills are conducted each shift monthly, with
CPR/first-aid drills conducted quarterly. It was reported the process for documenting on-site
episodic care is to document the care on a progress note in SOAP format and then document
the event on the Episodic Care Log.
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 written policy and procedures ensuring timely referrals, coordination,
and documentation of medical services to off-site health providers for youth with emergent or
non-emergent needs. Five youth Individual Healthcare Records (IHCRs) were reviewed, and
each youth was applicable for off-site care. Reviewed documentation confirmed the Summary of
Off-Site Care Consultation Report form was utilized and filed in each applicable IHCR and
documented on the Episodic Care Log. Parental notifications were documented in each IHCR.
The designated health authority (DHA) reviewed and signed/initialed the off-site care findings,
instructions, and information for each youth. Three of the five youth required a follow-up
appointment, and documentation confirmed each youth received the follow-up appointment in a
timely manner. An interview with the nurse reported youth who are sent off-site for first-aid or
emergency care needs are tracked on off-site summary reports and filed in the IHCR. It was
reported all hospital orders are flagged and provided for review when the DHA is on-site. The
informally interviewed nurse reported medical staff track follow-up testing, referrals, and
appointments on the DHA internal medical tracker.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a written policy and procedures ensuring youth who have chronic
conditions receive regularly scheduled evaluations with the required follow-up. All youth
identified with chronic medical conditions shall have treatment plans/physician progress notes
which specify a youth’s particular course of therapy, identify the role of the qualified health
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professionals in carrying it out, and are updated as indicated. The program shall ensure youth
who have chronic illnesses receive regularly scheduled evaluations and necessary follow-up. A
review of five youth Individual Healthcare Records (IHCRs) confirmed all five youth were
identified on the Facility Entry Physical Health Screening Form (FEPHS) with a chronic
condition during their intake admission. None of the youth were identified as having a
communicable disease. Each youth was taking a prescribed medication on an ongoing basis. All
applicable youth were undergoing treatment for a physical health condition. Each youth was
classified with an appropriate Medical Grade between two and four, or a Medical Grade five for
youth who were additionally taking psychotropic medications. Each of the youth were placed on
the program’s Chronic Illness List. A review of progress notes found each of the youth received
periodic evaluations at least every ninety-days. None of the applicable youth were taking anti-
tuberculosis medications, and there were no pregnant youth during the annual compliance
review period. Periodic evaluations were conducted prior to a prescription renewal, change, or
expiration, when applicable. Each of the reviewed youth was applicable for an off-site
evaluation. There were no indications of lapses in care or missed periodic evaluations in any of
the reviewed records. The Department’s Problem List for each youth was updated in
accordance with Florida Administrative Code. An interview with the program director (PD)
reported the formalized procedures in place to review the important youth medical issues with
the healthcare staff, is to conduct a review during the daily management meetings, where staff
review important youth medical issues and coordinate with program leadership. Clinical staff
and administration ensure oversight through the program’s continuous quality improvement
(CQI) meetings. An interview with the nurse reported once youth are identified, the youth is
placed on the medical tracker for monitoring due dates. An interview with the designated health
authority (DHA) indicated they ensure periodic evaluations for youth with chronic conditions.
Evaluations are completed every ninety days and they are tracked by the chronic condition’s
tracker and documented in the youth’s progress notes.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures which outline the process of how
medications are to be received, stored, inventoried, and administered in a safe and effective
manner. Medications shall be provided pursuant to a physician’s order written in the Individual
Healthcare Record (IHCR). Parenteral medications shall only be administered by a licensed
healthcare staff who has experience in the administration of such medications unless the youth
has routinely administered their own medication prior to admission to the program, and if
individually approved by the nursing manager and the program director (PD). Five reviewed
youth IHCRs confirmed youth were admitted with medication, which was verified prior to being
accepted into the program. Each applicable youth’s prescription verification was included in the
chronological progress note. Documentation confirmed the designated health authority
(DHA)/designee and psychiatrist were contacted to obtain the order to resume the specified
medications prescribed prior to admission. The DHA placed an order on the Practitioner Order
form for all continued medications. Each Medication Administration Record (MAR) clearly
indicated medication start and stop dates. It was confirmed staff initialed each administered
medication entry. There were no undocumented explanations for a lapse or errors in medication
administration. Reviewed documentation confirmed nursing staff documented weekly side-effect
monitoring on the MAR. Four of the five youth were applicable and signed the Refusal of
Treatment form indicating the refusal of medication. Each applicable MAR clearly documented
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the refusals. Each reviewed MAR documented all required elements to include youth name,
Department identification number (DJJID), date of birth, youth allergies, precautions, Medical
Grade, medical alerts, current picture of the youth, and youth’s initials. None of the reviewed
youth were applicable for parenteral medication. Each youth reviewed was prescribed
psychotropic medications upon admission. The program’s practice is to notify the DHA upon
admission and for the youth to receive an Initial Diagnostic Psychiatric Interview within fourteen
days of admission. Documentation showed each youth received an initial diagnostic psychiatric
interview within fourteen days of admission, as required. Reviewed documentation confirmed
each youth received a medication monitoring/review every thirty days as required and confirmed
there were no standing orders for psychotropic medications, no emergency treatment orders for
psychotropic medication, and no pro re nata (PRN) orders for psychotropic medications. During
the annual compliance review week, one medication administration was observed with no
issues noted. The youth was escorted to the medical office by direct care staff. The Six Rights
of Medication Administration were verified by the registered nurse (RN). The RN administered
the medication as required and did not pre-pour any of the medications. Five youth were
interviewed, and four reported the nurse gives them medication and one responded they do not
take any medication; however, they know the nurse conducts medication administration. An
interview with the nurse reported the program’s process to verify a youth’s medication is through
verifying orders upon admission and examining medication for a youth specific label, original
packaging, and a current prescription for administration. The DHA or psychiatrist is contacted to
continue or hold the medication. According to the nursing interview, the program uses a
preprinted pharmacy MAR. Additionally, non-healthcare staff may provide medications to youth;
however, they are trained by the health services administrator (HSA).
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a written policy and procedures for the provision of psychiatric services
within the program. The program’s contracted psychiatrist is responsible for psychiatric
evaluations, consultation, medication management, and medical supportive counseling. A
review of the psychiatrist’s license indicated they held an osteopathic physician license which
was free and clear in the State of Florida with an expiration date of March 31, 2026. The
psychiatrist is available for emergency consultation twenty-four hours a day, seven days a
week. The psychiatrist provided psychiatric services briefly as a representative of treatment
team and psychiatric recommendations for youth are incorporated into evaluations and planning
at the program. The program did not utilize a back-up psychiatrist during the annual compliance
review period. The program does not use a psychiatric advanced practice registered nurse. A
review of the psychiatric sign-in logs verified the psychiatrist was on-site weekly. Reviewed
documentation indicated the psychiatrist actively participated in, managed, and supervised
psychotropic medication services in the program. The program utilizes tele-psychiatry services
when needed. The psychiatrist reported they are completing the Initial Diagnostic Psychiatric
Interview for new admissions and follow-ups for medication management and referrals as
needed. The interviewed psychiatrist reported they are on-site weekly and are on call twenty-
four hours daily as needed. The psychiatrist reported they have no concerns with services
provided at the program. During an informal interview the designated mental health clinician
authority (DMHCA) reported they meet with the psychiatrist to discuss youth receiving
psychiatric services weekly when they are on-site. A review of five youth Individual Healthcare
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Records (IHCRs) indicated each was applicable for psychiatric services. Each of the five
applicable youth entered the program with prescribed psychotropic medications. Each youth
was referred for a psychiatric interview, and each youth received a diagnostic interview within
fourteen days of admission. Each of the youth’s reviewed Initial Diagnostic Psychiatric
Interviews included history, a Mental Status Examination, a Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment recommendations, prescribed
medications, explanation for the need of medications, target symptoms, initial treatment goals,
potential side effects, and frequency of medication management. Each youth was referred for a
psychiatric interview upon admission. Each of the reviewed Initial Diagnostic Psychiatric
Interviews resulting in the prescription of psychotropic medication or changes to the youth’s
existing psychotropic medication regimen, was documented on page three of the Department’s
Clinical Psychotropic Progress Note (CPPN). Reviewed documentation confirmed each youth
was applicable for a psychiatric medication review and each youth was seen by a psychiatrist at
least every thirty days. None of the reviewed records were applicable for a psychiatric
evaluation update. Each instance where page three of the CPPN was used, the psychiatrist
documented the identifying data, diagnosis, target symptoms of each medication, effects of the
medication, medication dosage, dosage range, frequency, route of administration, side effects,
adherence to the medication regime, height, weight, laboratory findings, and whether there was
telephone contact with the youth’s parent/guardian. Reviewed documentation confirmed each
CPPN was signed and dated by the psychiatrist. Each IHCR documented monitoring for Tardive
Dyskinesia on a monthly basis as indicated on the CPPN. None of the reviewed records were
applicable for the use of tele-psychiatry.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a written policy and procedures specifying the requirements for storage
and inventory of medications and sharps and safeguarding all medication, which is inaccessible
to youth at the program. The medical equipment classified as sharps included syringes,
needles, scissors, and suture removal kits, and each was secured and inventoried utilizing a
routine perpetual inventory with a descending count as each sharp is being utilized and
disposed. Observations of all medical equipment classified as sharps confirmed they were
secured and inventoried utilizing a routine perpetual inventory descending count as required. All
medications were identified and secured in the locked area designated for storage of
medications. The medication cart was clean and organized with stock items separate from
youth-specific medications. All controlled substances had a perpetual inventory and were stored
separately from other medications. Each medication was stored in a separate, secured area
which was inaccessible to youth. Observations of the medication storage area confirmed the
program’s practice to store narcotics in the secured medication cart behind two locks.
Medications which required refrigeration were stored in a secured refrigerator, which is used for
medication only. The program’s process for the destruction and disposal or return of expired or
discontinued medications is for the medications to be mailed back to the pharmacy for credit, or
a chemical disposal agent is used for disposal, and disposals are logged in the disposal binder.
Perpetual and weekly inventories of all sharps and stock over-the-counter (OTC) medications
were completed as required. Perpetual inventories with running balances were maintained on all
controlled substances with a shift-to-shift inventory conducted by the registered nurses (RN).
Reviewed documentation confirmed the program has a list of supervisory level, non-healthcare
staff who are trained in the delivery of OTC medications for when nursing staff are not on-site.
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All trainings were delivered by an RN. During the week of the annual compliance review, an
observation of counts was conducted for three OTC medications, three controlled medications,
and three sharps, and the inventory counts were accurate. Observations found all medications
were securely stored in the medical clinic inaccessible to youth. The program’s procedures for
when there are count discrepancies, is for the nurse to notify the designated health authority
(DHA) and the program director (PD) if any discrepancies are found in the weekly inventory
counts. An interview with the nurse reported staff conduct counts twice daily before shift and at
the end of the shift. Additionally, when a discrepancy is found the DHA, and the PD are notified.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a written policy and procedures ensuring infection control which
includes an Exposure Control Plan. The plan is in compliance with the guidelines established by
the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control
and Prevention (CDC). The infection control policy was last reviewed and signed by the
designated health authority (DHA) and program director (PD) on September 1, 2024. The plan
covers common infectious diseases of childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), infectious diseases caused by blood-borne pathogens, other
outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant micro-
organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. The program
provides staff with the opportunity for Hepatitis B immunizations and access to protective
equipment. The plan includes a process for needle stick post-exposure evaluation. In the event
of an incident, the PD has a process in place to establish a separate file containing all
documents for youth and staff who experienced a facility or occupational exposure. An interview
with the nursing staff, reported a copy of the program’s Exposure Control and Infection Control
Plans are maintained in the medical office and master control. The nurse and the PD reported
the program has not had any instances which required notification to the local county health
department, CDC, and/or the Department’s Central Communications Center (CCC) since the
program began services. Licensed healthcare staff conduct infection control training for the
program. The program has not had any reportable infectious diseases during the annual
compliance review period.
4.20 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program maintains a written policy and procedures to ensure the provision of prenatal care
to all pregnant youth. Health education is to be provided to both youth and staff. A review of five
Individual Healthcare Records (IHCRs) found none of the youth were pregnant at the time of the
annual compliance review. The program indicated they have not had any pregnant youth during
the annual compliance review period. A review of training sign-in sheets indicated non-
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healthcare staff involved in the supervision or treatment of pregnant youth received in-service
education on girl’s healthcare, teen pregnancy, and pregnancy complications annually. A review
of the training curriculum indicated the in-service training included observation and monitoring of
emergency care needs/symptoms of possible miscarriage. The program maintains nursing
protocols and treatment plans for pregnant youth. An interview with the nursing staff/health
services administrator (HSA) indicated services provided to pregnant youth, when applicable,
include health education on alcohol and drug use, smoking, nutrition, sexually transmitted
diseases, contraceptive use, prenatal care, birthing process, post-partum care, basic baby care,
child/infant development, parenting skills, shaken baby syndrome, anger management, time
management, and after care planning. Pregnant youth are to receive a special diet and weekly
check-ups for weight and nutritional status updates. Nursing staff indicated, with verbal consent,
youth are tested for pregnancy upon admission.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures for maintaining safety and security by
requiring all program staff to always know the location of all youth through active supervision,
monitoring, and utilizing emergency counts. The program’s policy requires staff-to-youth ratios
to be one-to-six during awake hours and one-to-eight during sleep hours. A review of the
program’s policy confirmed the staff shall maintain active supervision of each youth, including
any behavior changes, engage in a full schedule of constructive activities, and consistently
apply the behavior management system (BMS). 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. During the annual compliance review week observations were conducted
of youth supervision. Observations included line movements, youth head counts, classroom
activities, mental health groups, youth searches, meal activities, and outdoor/indoor recreation
activities. In addition, observations were made of youth preparing and coming from a medical
transport, an admission, and youth being released from the program. An observation of a
youth’s release was conducted, including the review of the exit portfolio, with the clinical
manager, case manager, youth and parent/guardian, the review/receipt of medication, and
receiving copies of all pertinent documentation. An observation of a line movement confirmed
staff were keeping continual count of all youth in their group by having youth count when
walking through a door. An informal interview with three staff confirmed staff immediately knew
the number of youth they were supervising. The observations ensured staff-to youth ratios were
maintained, as required. Observations of interactions between program staff and youth reflected
the interactions were positive and consistent with the program’s BMS. A tour of the program
verified the program and living units were clean, graffiti free, with no unusual odors, and well
maintained. The daily schedule, grievance, sick call, and Request to Speak forms were posted
in the dayroom and living unit accessible to each youth. Youth were always observed engaging
in activities during the annual compliance review week. A perimeter check was conducted, and
the program’s privacy fencing appeared to be in good repair. Video observations of ten-minute
checks confirmed youth supervision continues during sleep hours. A review of the Department's
Central Communications Center (CCC) reports confirmed, during the annual compliance review
period, there were no escapes reported.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures for implementation of the behavior
management system (BMS) and staff training. The program’s policy requires all staff to be
trained in the BMS. A review of documentation confirmed all required parties involved in the
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development, implementation, and on-going and maintenance of the BMS. The policy and
procedures include a protocol where staff are provided feedback regarding the implementation
of the BMS. The program has an agreement with the education provider related to the BMS.
The education staff were trained on the BMS by the program director (PD). A review of five
youth case management records confirmed the youth orientation and handbook included the
program’s BMS. A review of staff job descriptions showed they included implementation of the
program’s BMS. All the staff records included documents which confirmed the BMS training was
completed. While conducting a program observation tour, the BMS posters and signage was
present on each living module and throughout the program. The BMS has not changed during
the annual compliance review period. The BMS included all the required elements. The
program’s BMS did not include increased length of stay, denial of youth basic rights, promotion
of group punishment, punishment of youth by other youth, and/or disciplinary confinement.
Observation of youth and staff interactions confirmed youth basic rights and services are not
being denied with the BMS. Youth BMS incentives include canteen, playing board games on
Fridays, receiving hair supplies, extra hygiene items, decorative socks, and participating in
“Diamond Day” activities. An informal interview with the PD indicated the youth’s most recent
“Diamond Day” event included participation with a local nail salon. Interviewed youth stated,
youth who maintain at the Contributor level can participate in the “Diamond Day” outings. An
interview with five staff confirmed youth basic rights cannot be taken away as a behavior
consequence. Each staff reported the program utilizes a point and level system with rewards
and consequences. Additionally, youth have a total of three element goals each week, and
youth can lose points due to not meeting their personal goals. Youth are informed if they did not
meet their goals or consequences of their behavior during the treatment team meetings held
weekly. An interview with five staff indicated youth can receive BMS incentives which include
extra soap, hair supplies, canteen, and attending the “Diamond Day” activities. An interview with
five youth confirmed staff are consistent with the BMS. Additionally, youth confirmed they
receive level drops and write-ups as a consequence for negative behaviors. Youth meeting their
weekly goals are rewarded with canteen, extra hygiene products, and diamond outings. All five
youth were able to explain how they move from each level. Youth indicated the levels start at
Orientation for fourteen weeks. The next levels are Novice and Intern which are between four
and five weeks. All youth who are in transition and pending to be released will remain on the
Contributor level. Each of the interviewed youth indicated they are not allowed to punish the
other youth. A review of an interview with the PD confirmed the program uses a status-based
BMS. The PD indicated, the system motivates youth through progression levels Orientation,
Novice, Intern, Contributor, and Program Achievement/Transition. The PD stated the youth
rewards and consequences are monitored by staff providing daily positive feedback, praise, and
documentation towards progression. Supervisors monitor logs and weekly reviews to ensure
positive reinforcement far exceeds disciplinary actions, meeting the program’s standard of at
least a five-to-one ratio of rewards to consequences. According to the PD, all staff are trained,
provided direct supervision, and performance evaluations on the BMS to ensure consistency.
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.
This program does not use room restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures in place to conduct and document ten-
minute checks during sleep hours, or at other times such as during an illness to ensure the
safety and security of each youth. The program has a total of thirty-six video surveillance
cameras. All cameras were operational at the time of the annual compliance review. Video
recordings are stored for thirty days. An informal interview with the program’s director of living
confirmed the program has two shifts which start at 6:00 a.m. and end at 6:00 p.m. for the first
shift, and 6:00 p.m. to 6:00 a.m., for the second shift. Staff are required to conduct room checks
every ten-minutes and document the time of the check on the Ten-Minute Check Log when
youth are sleeping. A video review of ten-minute checks from the overnight shift and from each
living unit, for a total of nine samples verified staff were conducting checks every ten-minutes
and documented the times accurately on the Ten-Minute Check Log. A review of thirty-six Ten-
Minute Check Logs since the last annual compliance review over various days, times, and shifts
indicated the ten-minute checks were completed within the required frequencies. An interview
was conducted with the program director (PD) and indicated the program has thirty-six
operational security cameras. Video footage is maintained in the system for thirty days. Any
incidents occurring at the program have a video recording uploaded and stored in compliance
with policy. An interview with five staff indicated, all room checks are conducted at a minimum of
five-minute intervals while youth are in their sleeping rooms.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a written policy and procedures for census, counts, and tracking of
youth at various times throughout the day. The program’s policy requires the program to have a
chronological record of the daily youth census. In addition, the policy indicated counts are
conducted during power outages, escapes, program disturbances, or any other disruptions
which may occur. A review of the Continuity of Operations Plan (COOP) verified program staff
must always account for the whereabouts of the youth in the care and custody of the program.
This includes the need for continual head counts to be conducted minimally, at the beginning of
each shift, during any emergency situation, and at regular intervals. The program implements
and monitors youth using an accounting system of scheduled, unscheduled, and emergency
counts. Observations conducted during the annual compliance review week and a review of
program logbooks for the annual compliance review period confirmed the youth daily census
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counts, head counts, and youth movements were documented at the beginning of each shift
and after each outdoor activity. In addition, the master control operator documented the
headcount in the program’s logbook. A logbook review for ten randomly selected dates and
times, for census counts and tracking was conducted during the annual compliance review
period. Documentation validated head counts and movements were conducted at the beginning
of each shift, after outdoor activities, after transfers, during emergency situations such as
program disturbances, and during actual and/or simulated drills. For one reviewed day, youth
movements were not documented in the logbook. Five staff were interviewed, and each
confirmed the youth counts are conducted prior to youth movements, at the beginning and end
of the school day, during clinical groups, and when youth are in their sleeping rooms at night. In
addition, all staff reported when a youth count cannot be reconciled all movements stop, an
emergency headcount is conducted, contact is made with various departments in an attempt to
locate the youth, supervisors conduct a perimeter check, and all movement remains stopped
until the count is reconciled. If the count cannot be reconciled, the program must contact the
Department's Central Communications Center (CCC).
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures for documenting chronological events,
incidents, headcounts, shift changes, group movements, and activities in the master control
logbook. The program’s policy requires the program to maintain one logbook in master control
and all the program staff to be briefed when coming on-duty. During the annual compliance
review, a total of nine logbooks were reviewed. All nine logbooks were bound with number
pages, had no destroyed or removed entries, entries were made in ink with no erasures or
white-out areas, and errors were struck through with a single line and initialed by the staff
correcting the error. Reviewed entries included the dates and times of the events, with the
names of the staff and youth involved, brief descriptions of the events, and the names and
signatures of the staff making the entries with the exception of one reviewed day. A review of
the logbooks confirmed the program documented emergency situations, incidents with use of
mechanical restraints, special instructions for supervision of youth, population counts,
information regarding escapes or attempts of escape, transports, requests by law enforcement
to access youth, admissions, releases, the education schedule, notations of youth arrival to and
departing from school and recreation areas, perimeters security checks, and calls to the Florida
Abuse Hotline and the Department’s Central Communications Center (CCC). The program does
not have a separate logbook to document all internal incidents reported to the Florida Abuse
Hotline and the Department's CCC. Shift reports are maintained in the master control logbook. A
review of the logbook demonstrated staff signed and dated the shift logbook in
acknowledgement they have reviewed or been verbally briefed about its contents.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
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• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures for assignment, inventory, tracking, and
storage of program keys. The program’s policy requires all staff to follow the guidelines and to
be trained on the key control policy. The program’s policy includes key assignment and usage
including restrictions, inventory and tracking of keys, secure storage of keys not in use,
procedures addressing missing or lost keys, and reporting and replacement of damaged keys.
The program director (PD) has overall responsibility for key control management. Program keys
are maintained in master control on a board with the corresponding tracking number.
Observations made throughout the annual compliance review week found all staff surrendered
their personal keys upon entering the program and keys were stored within the master control
office. Observations conducted during the annual compliance review week found staff were
assigned program keys and logged assignments in the key log. During the annual compliance
review week, observations made confirmed staff were aware of program keys in their
possession, with the exception of one incident. During a vendor visit to the program, the
physical plant/maintenance manager escorted the pest control vendor to the bathroom area
where the physical plant manager placed and left the program keys on the bathroom sink
leaving them unattended, while still in the vicinity of the bathroom, and did not have them on
their person, as required by policy. The issue was addressed with the PD and a corrective
action was taken in an effort to address and retrain the staff. The process for reporting or
replacing lost or damaged keys is for the staff to complete an incident report. The physical plant
manager receives the incident report, removes the broken key from the key ring and replaces it
with a new key. If the lock is broken and a locksmith vendor is needed, the physical plant
manager will contact the locksmith vendor for repair and/or replacement. The program had no
incidents regarding lost/broken keys reported to the Department's Central Communications
Center (CCC) during the annual compliance review period. All program keys are maintained
within the master control area, which is located at the entrance of the program. Keys are
maintained inside a locked cabinet within the master control room, and are only accessible by
the master control staff, and administration. The program has a list of staff who are assigned
permanent keys. The PD, clinical director, director of group living, physical plant manager, and
master control operator are assigned permanent keys. A sample of four random key rings were
observed assigned to the kitchen manager, a teacher, the human resource staff, and the clinical
director. All keys were logged in the key logbook, and each included the correct number of keys
on the key rings. An informal interview with staff from mental health, case management, and a
coach counselor confirmed all three staff knew the key functions to all their assigned keys. An
interview with five staff confirmed each staff are assigned program keys by the master control
operator, all visitor’s personal keys are placed in the lock box, and all staff reported the youth do
not have access to staff keys.
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
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non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to identify materials considered to be
contraband and to prevent prohibited items from entering the program. The program’s policy
identifies the items considered to be contraband including sharps, escape paraphernalia,
tobacco products, lighters, electronic or vaporless cigarettes, and unauthorized food or clothing.
The program has a system in placed to prevent contraband from entering the program which
includes defining items/materials considered contraband, providing youth with the list, informing
youth of consequences if contraband is found, searching the physical plant and program
grounds, searching youth, and searching incoming and outgoing mail. The program has a
contraband sign located outside the program’s main gate with the contraband attestation
statement on it. A review of the program’s visitor’s log in the main lobby confirmed the log
includes a contraband attestation statement. A total of twenty-seven staff have signed the
attestation forms during the annual compliance review period. The contraband statement
addresses consequences for any staff who is found in possession of contraband and the
provision for law enforcement to be notified if there is evidence of unlawful activity. The program
clearly identifies contraband, to include, and not limit to sharps, escape paraphernalia, tobacco
products, lighters, electronic or vaporless cigarettes, and unauthorized food or clothing. The
program’s policy is to confiscate the contraband and turn items over to law enforcement. All
incidents of contraband must be reported to the Department's Central Communications Center
(CCC). Searches are documented frequently in the program’s logbook, incident reports, and
search reports. A review of the program director (PD) interview confirmed the program enforces
strict procedures for preventing, detecting, and removing contraband. Staff are trained to
conduct routine searches of youth, visitors, property, grounds, and the program. All contraband
is documented, secured, and disposed of in accordance with the Department’s policy. Any
illegal contraband is turned over to law enforcement for proper handling. A total of five staff were
interviewed about the program’s process for searching youth rooms, and all five staff confirmed
the youth rooms are randomly searched at a minimum of two times a week.
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 maintains a written policy and procedures for searches and full body visual
searches to be conducted to ensure no contraband is being introduced into the program. The
program’s policy requires searches to be conducted throughout the program including searches
of youth, visitors, property, staff, and the program’s physical plant. During the annual
compliance review week youth searches were observed. Youth were searched in the main
hallway leaving class, departing the cafeteria, after outdoor recreation, when leaving the
medical office, and after completing groups. Observation was made of a youth departing and
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returning from an off-site medical appointment. In all observations staff treated youth with dignity
and respect. Two female staff were observed explaining and instructing a newly admitted youth
through the search process minimizing the youth’s stress and embarrassment. A video review of
five randomly selected dates and times indicated the staff and visitor’s searches were not being
conducted in accordance with policy and/or the Right Interactions (RI) training manual. One
video observation showed four visitors/volunteers entered the program, completed the sign-in
process, were electronic wand searched, and removed their shoes; however, none of the
visitors were pat searched. In addition, the visitors possessed bags which were not
clear/transparent, and the program staff did not properly search the bags prior to allowing entry
to the secure area. On another video observation, during a weekly visitation, a parent/guardian
visiting the youth entered the program, turned in their personal keys to the staff, and the visitor
was searched with the electronic wand; however, a pat down search was not conducted, nor did
the visitor remove their shoes prior to entering the secure floor. Another video observation was
conducted for the program’s scheduled family day. The parent/guardian visitors entered the
program and handed their personal keys to the program staff. The staff was observed showing
the visitors the contraband attestation form/sign, and the visitors were electronic wand searched
and proceeded to remove their shoes. However, the program staff did not complete a pat down
search on two of the visiting family members. Additionally, the male visitor was not asked to
remove his hat for a search prior to entering the secure floor. Five interviewed youth all stated
they are searched leaving outdoor activities, after meals and after visitation, and three youth
stated they are searched when items are missing, when returning from off campus, after work
details, or after any movement. Five interviewed staff all reported youth are searched after every
movement throughout the program.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures to ensure all program vehicles used to
transport youth are properly maintained. The program’s policy requires each vehicle to have a
safety inspection annually. The program has a total of two vehicles used to transport youth. A
review of documentation confirmed one transportation vehicle was not operational at the time of
the annual compliance review. Observations were conducted of the vehicles, and they appeared
to be maintained. Both vehicles were inspected annually, secured, had maintenance records,
contained a fire extinguisher, seatbelt cutter, window punch, appropriate number of seatbelts,
and the door to the youth passenger area could not be opened from the inside. The first-aid kits
are not kept in the vehicles and are brought in the vehicle by staff for transport. Only one of the
transportation vehicles contained a safety screen. An observation of one vehicle used to
transport youth found it had the appropriate number of seatbelts, a seatbelt cutter, a window
punch, up-to-date fire extinguisher, and a first-aid kit with items approved by the designated
health authority (DHA). A random check of five staff personal vehicles during the annual
compliance review week was conducted to ensure vehicles were locked and secured when not
in use. One of the five vehicles checked was found to be unlocked and was secured after it was
reported to the program director (PD).
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures for secure transportation of youth off
program grounds. The program’s required policy is to always maintain custody and control of
youth and to ensure active supervision and safety during transports. An observation of a
transport was conducted during the week of the annual compliance review and confirmed the
staff used the vehicle checklist to ensure all safety items were present for the transport including
the first-aid kit and program issued cellphone. Staff conducted a search of the vehicle and
search of the youth, the staff-to-youth ratio was within the contract requirements, youth were
secured, wearing seatbelts, and observations confirmed the staff rode in the back with the
youth. The program’s policy states youth are not permitted to drive program or staff vehicles.
An interview with the program director (PD) indicated the program is not a high-risk program
and does not require safety screens in the program’s transportation vehicles. An interview with
five youth confirmed none of the youth have ever been handcuffed to any part of the vehicle and
have never seen anyone place contraband in a transport vehicle. A review of five staff
interviews confirmed all five staff indicated they are provided with a two-way radio and cellular
telephone for transports. The five interviewed staff reported the safety equipment in the
transport vehicles consist of fire extinguishers, a first-aid kit, seat belt cutter, and a window
punch. Two staff reported the ratio is two-to-one and three staff indicated the ratio during
transports is two-to-five. All staff confirmed the vehicle is searched prior to and after use for
transports. The interviewed staff indicated during a transport, the emergency response is to pull
over, contact the supervisor/PD, and to dial 9-1-1, if needed. Four of the five staff stated the
transportation vehicle has a safety screen and one staff indicated the vehicles do not have a
safety screen. Additionally, staff stated one staff rides in the back of the vehicle with the youth
during a transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures to ensure safety and security of the
physical plant, grounds and perimeter. The program’s policy requires weekly safety and security
audits to be conducted by the program director (PD) or designee and documented on the Safety
and Security Audit Inspection form. The director of living and the physical plant manager are
responsible for ensuring weekly safety and security audits are conducted, reviewed, and
submitted to the Department, and to ensure verification of all deficiencies, corrections, and
implementations are in compliance. A review of the program’s Safety and Security Audit
Inspection forms during the annual compliance review period confirmed the physical plant
manager conducted weekly safety/security inspections. The physical plant manager conducted
perimeter checks at the beginning of each day and after youth returned from recreation. A
review of the program logbook confirmed the perimeter checks were documented daily. A
review of deficiencies entered in the Department’s Juvenile Justice Information System (JJIS)
verified there were no deficiencies assigned regarding safety and security audits during the
annual compliance review period. An interview with the PD indicated the program identifies and
tracks safety and security deficiencies through daily shift reports, supervisory checks, incident
reports, and monthly safety inspections.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures to address the tool management system
which ensures youth do not use tools or equipment as a weapon or security breach. The
program’s policy requires all tools in the program including maintenance, vocational, food
services, and medical equipment to be inventoried and kept in a secure location. The program’s
facility operating procedures (FOPs) require the staff and youth to be trained on the intended
safe use of tools. A documentation review of the Tool Inventory Sheet confirmed all tools
including sharp-edge and pointed tools are inventoried daily prior to being used for work and
following work activities. Machetes, bowie knives, or other long blade knives are prohibited on
the physical plant. In instances of suspected or missing lost tools, the program’s policy is to go
into lock down, no staff or youth are permitted to depart the building, and all available staff begin
a search for the missing tool. If the tool is not found, the program director (PD) will contact the
Department's Central Communications Center (CCC). The program has a policy and
procedures for missing/lost tools and for tools requiring disposal. An informal interview with the
physical plant manager confirmed tools are destroyed at the program in the tool shed. The tool
is then disposed of in the dumpster located in the exterior of the program. The destroyed tool is
then removed from the Tool Inventory Sheet. The destroyed tool is not placed back on the
inventory sheet until the tool is replaced. An observation and inventory of ten tools was
conducted. Five tools were inventoried from the kitchen and maintenance shed, and
observations confirmed all tools were secured with the correct markings for easy identification
and inventoried correctly. Five inventoried tools from the kitchen included the spoon, whisk,
scissors, pizza cutter, and serrated knife. Five inventoried tools located in the maintenance tool
shed were the weed-eater, pipe cutter, crowbar, allen key sheet, and a plunger. The program
has a sign-in and sign-out log for Class A and Class B tools.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth are handling tools
safely and are supervised appropriately to prevent injuries to other youth and staff. The
program’s policy requires the staff and youth to be trained on the intended safe use of tools. The
program youth are allowed to use Class B tools and non-hazardous tools only. A review of the
program’s policy confirms the policy includes supervision requirements when youth use tools
and issuing tools to youth and staff, including an assessment to determine a youth’s risk to self
or others. The policy established the ratios, tool distribution process, and collection procedures
during special work projects. The ratio of one staff to five youth when activities involve usage of
tools is required. During the annual compliance review week, youth were observed cleaning the
cafeteria with brooms and were observed mopping the floor with no issues noted. No additional
tool usage was observed. A review of five youth case management records confirmed all five-
youth signed and acknowledged the rules and regulations regarding tool usage. Five
interviewed staff indicated youth are allowed to use scrub brushes, mops, and brooms for
cleaning purposes and youth are not allowed to use kitchen knives, saws, or an axe. Five
interviewed youth indicated the only tools they are allowed to use are cleaning tools such as
mops and brooms.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures for outside contractors. The program’s
policy requires all private contractors to receive written instructions detailing responsibilities
regarding tool management and contraband. The program procedures when an outside
contractor enters the program, is for all vendors to sign-in the visitor’s logs, and the vendor is to
be searched electronically and physically. All tools and equipment brought into the program will
be searched and inventoried on the Outside Contractor On-Site Worksheet. The contractors will
be escorted by the physical plant manager. During the annual compliance review a pest control
vendor entered the program. Observations confirmed the vendor was physically and
electronically searched. The staff conducted a search of the vendor’s bag; however, did not
complete the tool inventory check of the vendors tool bag, who was then allowed to enter into
the secure floor prior to completing the Outside Contractor On-Site Worksheet. However, an
additional observation reflected the vendor proceeded to fill out the Outside Contractor On-Site
Worksheet and had the tools and chemicals inventoried. An informal interview with the staff
conducting the search stated the vendor usually completes and fills out the form and the
physical plant manager inventories the items. A review of the sign-in sheet/logbook, and three
randomly chosen work invoices verified the contractors were on-site on the same date the
documents were signed. The Outside Contractor On-Site Worksheets confirmed the tools were
checked upon entering and departing the program, restricted tools were not allowed, any
missing tools had a follow-up, and youth were restricted from the work area while the vendor
was on-site. A review of the work project logs confirmed all vendors signed a contraband
attestation agreement prohibiting unauthorized items from being brought into the program.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a written policy and procedures to ensure youth and staff are prepared
for fire, safety, and evacuation emergencies. The program has a written Continuity of
Operations Plan (COOP) which was approved by the Department. The program’s COOP
addresses fire, safety, and evacuation emergency processes and the frequency of conducting
drills at random times, and under varied conditions. A review of documentation since the start-
up monitoring in December 2024, confirmed fire drills were conducted on each of the shifts on a
monthly basis, as required. The program conducted emergency COOP drills which included fire,
riot, severe weather, flooding, hostage situations, chemical spills, medical situations, and bomb
threats. Documented drills included the type of drill, date and time, participants, a brief scenario,
and findings. Observations during the program tour confirmed the fire evacuation routes and
egress plans were posted throughout the program. The program has a total of eleven fire
extinguishers which were all tagged with annual inspection dates. Five staff were interviewed,
and each stated they have participated in suicide, medical, fire, bomb, active shooter, and
COOP drills. Five interviewed youth all indicated they have been instructed on what to do in
case of a fire. An interview with the program director (PD) indicated the program conducts
regular emergency preparedness drills in accordance with policy. The PD confirmed all COOP
drills conducted included fire, chemical spill, severe weather, disturbance/riot, bomb threat,
hostage situation, flooding, and terrorist threat scenarios.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a written policy and procedures requiring the development of a
Continuity of Operations Plan (COOP), which is updated as necessary, and maintained in
compliance with state law and Department policy. The program’s COOP is available to all staff
and is located in master control. A review of the COOP validated the plan was reviewed on
February 24, 2025, and submitted and approved by the Department on March 6, 2025. The
COOP plan addresses alternative relocation sites approved by the Departments regional
director/designee and provides for basic care and custody of youth in the event of an
emergency or disaster. The program’s Emergency Disaster Preparedness Plan and COOP are
combined. The program has provisions of equipment and supplies maintained in the event of an
emergency. During the program tour, observations of emergency supplies included batteries,
flashlights, a radio, and a satellite telephone which is maintained in the program director’s (PD)
office. Additionally, food, drinks, and collapsible water bottles were located in the kitchen and
within the tool shed. The program maintains an administrative hard copy record for each youth
in case of an emergency. A review of five youth hard copy records confirmed each contained
the youth’s name, Department of Juvenile Justice identification number (DJJID), admission
date, date of birth, gender, and race. The records documented the name, address and
telephone number of the parent/guardian, emergency contact, community judge, state attorney
and public defender, circuit judge, victim notification information, physical description of youth,
overall health status, and personal physician. An interview with the PD confirmed the COOP is
located in master control, where it is always accessible to all staff. Staff are trained on the
COOP, and it is used during emergencies.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a written policy and procedures for storage and inventory of all
flammables, toxic, poisonous, and caustic materials. The program’s policy is for all flammable,
poisonous, and toxic items to be stored in a secure area not accessible to youth. Toxic items
were stored and observed in the locked tool shed inaccessible to youth. Observation of the
storage area indicated it was clearly marked as containing hazardous chemicals and was
securely locked. Chemicals are inventoried on the Chemical Inventory Log. A review of the
inventory logs confirmed the inventory lists are maintained. The program director (PD), director
of group living, human resources manager, case managers, clinical director, medical staff,
recreation therapist, coach counselor, dietary staff, physical plant manager, shift supervisor, and
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the therapeutic manager are authorized to handle flammable, toxic, and poisonous items and
dispose of the items. In addition, the program maintains a written policy and procedures to
ensure all flammable, toxic, caustic, and poisonous items are disposed appropriately. The
disposal procedures are in accordance with the Occupational Safety and Health Administration
(OSHA) Standards, and in accordance with the Safety Data Sheets (SDS). Additionally, items
are disposed of twice a year at the local county waste facility. Used mop water, liquid waste,
and used beverages are disposed down the plumbing drains. In an informal interview the
physical plant manager confirmed, in the event of a chemical spill, master control will be notified
of the location, the air ventilation will be shut down, all efforts will be made to contain the spill,
and the program staff will contact poison control and/or any other outside assistance. A review
of the storage area verified the number and type of chemicals were maintained on the inventory
list. A random sample of ten chemicals verified nine chemical counts matched the inventory
logs, and one chemical inventory was updated during the annual compliance review. All the
chemicals were secured. The SDSs were present for eight of the ten items reviewed. During the
annual compliance review week, the physical plant manager was able to replace the two
missing chemical SDSs. An interview with the PD confirmed flammable, toxic, caustic, and
poisonous items are stored in secure, labeled containers, within locked cabinets or designated
storage areas.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. The program’s policy states youth are not
permitted 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. Youth are strictly prohibited from the maintenance area where toxic items and chemicals
are stored. During the annual compliance review week, there were observations of youth
cleaning, verifying youth were not using any chemicals. Five youth were interviewed, and four
youth stated they have not used cleaning chemicals or products, one youth stated they have
used paint, and one youth stated they have used laundry soap.
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:
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 72 (Revised August 2025)
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures for allowing visitation and
communication for youth at the program. The program’s policy requires the program to provide
opportunities for communication and engagement with the youth and family. The visitation
schedule was observed posted on the living unit, lobby, and dayroom wall. The program has
designated the dayroom for the visitation area. Visitation sessions are offered on Saturday and
Sunday from 2:00 p.m. to 4:00 p.m. The program’s policy states the case manager will mail an
admission letter to the youth’s parent/guardian within forty-eight hours of admission to the
program, which includes the visitation rules and information. A review of five randomly selected
youth case management records confirmed a copy of the mailed document was in each youth
record with a corresponding letter. The case managers maintain the records of all visitors who
attend the visitation on the Visitation Document Summary packet. A review of three random
Visitation Document Summaries confirmed the packet consisted of a sign-in sheet, copies of
identification cards of each visitor, and a youth search log. During an informal interview with a
case manager, they indicated the program provides visitation to youth every weekend. The
program organizes family day events for family members who cannot attend during regular
visitation days, and family event days allow family to visit and engage with their youth in the
program. The most recent family day was held on August 23, 2025. In addition, the case
manager confirmed youth contact their families through weekly telephone calls. The case
management team has created a schedule for five youth a day to make telephone calls. A
review of weekly telephone logs confirmed telephone calls are conducted Monday through
Friday. The youth are provided with two mailing stamps a week to correspond with family
members. According to the case manager, the program receives necessary information for any
youth with a history of human trafficking from the assigned juvenile probation officer (JPO). The
program has access to a translation service provider when the need exists for services or
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 72 (Revised August 2025)
information in a language other than English. Five youth were interviewed, all five youth stated
they are allowed to call their parent/guardian. An interview with the program director (PD)
indicated the program ensures youth whose primary language is not English have equal access
to services and programming. Supports include a translation service, written materials are
provided in the youth’s primary language when possible, and collaboration with school staff is
conducted to ensure academic instruction and assignments are accessible to non-English
speakers.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. The program’s policy requires the program to provide 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.
Daily observations of youth during the annual compliance review week confirmed youth were
engaged in large muscle activity daily. Youth were observed walking around the recreation yard
an exercising on yoga mats. A review of the staff roster confirmed the program has a recreation
therapist, who met all requirements for the position. The program’s activity schedule was
observed posted throughout the living units and common areas of the program. An informal
interview with the recreation therapist and reviewed documentation of five youth records verified
recreation therapy is part of each youth’s initial wellness plan. The recreation therapist added,
during the treatment team meeting, youth have a discussion on the progress of the wellness
goals. Five youth were interviewed, and each youth indicated they are provided at least one
hour of physical activity which includes playing football, basketball, and walking. Five staff were
interviewed, each indicated youth participate in outdoor-football, basketball, volleyball, board
games, virtual reality headset activities, and career training daily.
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 practices confirm the program does not use controlled
observation room; 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 practices confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 72 (Revised August 2025)
The program’s policy, procedures, and practices 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 72 of 72 (Revised August 2025)

report_type: QI Residential

program_name_raw: Fort Myers Youth Academy

rule: Indicator 5.09

excerpt: Searches and Full Body Visual Searches

rating: Limited Compliance