summary: QI Residential - FY24-25 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Developing Opportunities through Vocation and Education (DOVE) Academy
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
5270 Ezell Road
Graceville, Florida 32440
Review Date(s): February 18-21, 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:
Kayshala Patterson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, Education Coordinator (Standard 6)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Carlametress Harrell, Regional Workforce Education Coordinator (Standard 6)
Donovan Mobley, Office of Accountability and Program Support, Operations Coordinator
(Standard 2)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: DOVE Academy MQI Program Code: 1102
Provider Name: Twin Oaks Juvenile Development, Inc. Contract Number: 10774
Location: Jackson County / Circuit 14 Number of Beds: 40
Review Date(s): February 18-21, 2025 Lead Reviewer Code: 227
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, (6) Educational
Services 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
5.04 Ten Minute Checks * 3.14 Mental Health Crisis Intervention Services *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 71 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 71 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 71 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Failed
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 71 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 71 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Limited
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 71 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Indicator Ratings
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
\\
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 71 (Revised September 2022)
Program Overview
The Developing Opportunities through Vocation and Education (DOVE) Academy is a forty-bed
program, for fourteen- to eighteen-year-old females, located in Graceville, Florida. The program
is operated by Twin Oaks Juvenile Development, Inc., through a contract with the Department.
The program provides services including Mental Health Overlay Services (MHOS), Substance
Abuse Overlay Services (SAOS), Intensive Mental Health Services (IMH), and vocational
education services. In addition, the program fosters each youth by providing Impact of Crime
(IOC), Moral Reconation Therapy (MRT), Dialectical Behavior Therapy (DBT), and Seven
Challenges. Additional treatment services provided include team building, decision making,
interpersonal relationships, non-violent conflict resolution, communication skills, identifying and
avoidance of high-risk situations, appropriate interactions, anger management, critical thinking,
human sexuality, searching and applying for jobs, problem solving, goal setting, planning,
decision making skills, personal appearance/hygiene, stress management, self-esteem, and
preparing budgets. Program administration is comprised of a program director (PD), assistant
PD, and administrative assistant. Case management services are provided by two case
managers and one transitional specialist. Medical and mental health staff at the program include
four clinical coordinators, one designated health authority (DHAs), one licensed mental health
counselor (LMHC) who serves as the designated mental health clinician authority (DMHCA),
two full-time registered nurses, one full-time licensed practical nurse, and one part-time
registered nurse. According to the contract, the required on-site hours for nursing are Director of
Nursing (DON) for forty hours, and Registered Nurse (RN) for eighty hours weekly. The DHA is
contracted to be on-site for a minimum of two hours weekly and is on-call twenty-four hours a
day, seven days each week. The psychiatrist is required to be on-site twice monthly and is
available twenty-four hours a day. A review of the work schedules confirmed the hours are
being met. Sick calls are offered Monday through Friday from 6:30 a.m. to 7:15 a.m. and 12:05
p.m. to 1:05 p.m. and 5:00 p.m. to 6:00 p.m., and Saturday and Sunday from 8:00 a.m. to 9:00
a.m. and 12:00 p.m. to 1:00 p.m. and 5:00 p.m. to 6:00 p.m. Educational services are provided
by Florida Virtual School (FLVS) and Florida Youth College (FYC). The program has sixty-two
operating security cameras providing coverage. At the time of the annual compliance review,
the program had three vacant direct care staff positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 71 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a policy and procedures for volunteers, mentors, and interns who work
with the youth less than ten hours a month requiring sight and sound supervision and any staff
or volunteers, mentors, and interns who work more than ten hours a week to complete a
background screening. The program submitted their Annual Affidavit of Compliance with Level 2
Screening Standards was completed and sent to the Department’s Background Screening Unit
on January 17, 2025 and the education provider Florida Virtual School (FLVS) submitted theirs
on January 28, 2025. The program hired fourteen new staff during the annual compliance
review period. All fourteen staff had a background screening completed prior to contact with the
youth and access to confidential youth records. None of the staff were applicable for an
exemption. Two of the fourteen staff had a break in service as indicated in the Department’s
Staff Verification System (SVS) and both received a new background screening. A pre-
employment assessment and passing scores were completed by twelve of the fourteen staff.
The remaining two staff were not applicable for administration of a pre-employment assessment
tool as they were not direct care staff. All reviewed staff had been added to the Clearinghouse
employee roster. All new staff also had a signed contraband attestation form located in their
personnel records.
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.)
Four staff were eligible for five-year background rescreening. The five-year re-screenings were
completed every five years based upon the Clearinghouse Prints Expiration Date for all four
staff. The re-screenings were submitted to the Department’s Background Screening Unit and
Clearinghouse at least ten business days prior to the five-year anniversary.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 71 (Revised September 2022)
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.
Seven staff records were reviewed and all seven included a signed Code of Conduct. The
Florida Abuse Hotline and the Department’s Central Communications Center (CCC) numbers
were observed to be posted throughout the program. The program’s steps to report abuse
include calling the Florida Abuse Hotline, calling the CCC, notifying a supervisor, and then
logging the call in the abuse call binder. If necessary, an internal investigation will be initiated.
The program had a total of four incidents of alleged abuse reported to the Department’s Central
Communications Center (CCC) related to physical, psychological, or emotional abuse since the
last annual compliance review. The program completed their Trauma Responsive and Caring
Environment (TRACE) self-assessment on June 5, 2024. Seven youth were interviewed, and all
reported they feel safe at the program. All seven also reported they have never been stopped
from calling the Florida Abuse Hotline and they all know where the number is located in the
program. All seven reported staff are respectful when talking to youth. Five youth reported never
hearing staff use profanity when speaking with youth; one youth reported they have heard staff
use profanity once, and one youth reported they have heard staff use profanity occasionally. All
seven reported they have not exchanged emails, telephone numbers, or social media contact
information with staff. Seven staff were interviewed, and all were able to explain the process for
allowing a youth to call the Florida Abuse Hotline or the CCC if the youth is 18 years of age or
older to report suspected abuse. None of the staff reported having observed another staff telling
a youth they could not call the Florida Abuse Hotline. Six staff reported they have never
observed a co-worker using profanity when speaking to youth. The remaining staff reported they
have occasionally observed a co-worker using profanity when speaking to youth. The program
director was interviewed and included the policy and procedures for the staff’s Code of Conduct.
The program director included all the information contained within the Code of Conduct used by
the program. The program uses the Adverse Child Experiences (ACE) Trauma Informed
Questionnaire with each youth during the intake process. The program director included the
program’s policy and procedures in the interview for incident reporting and how staff and youth
are knowledgeable about contacting the Florida Abuse Hotline and CCC.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 71 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had a total of four incidents of alleged abuse reported to the Department’s Central
Communications Center (CCC) related to physical, psychological, or emotional abuse since the
last annual compliance review. In each of the reviewed incidents, there was evidence
management took immediate action to address incidents of physical, psychological, and
emotional abuse. Documentation reviewed clearly identified corrective actions were taken by
management. The program director indicated any staff suspected of allegations of abuse will be
immediately suspended and/or removed from contact with youth pending an internal
investigation. The leadership team will take immediate action and address any such allegations.
The program director and provider have and abide by a zero-tolerance of abuse of youth in the
program.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of thirty-six incidents reported to the Department’s Central
Communications Center (CCC) during the annual compliance review period. Five of the thirty-
six were reviewed. All five of the incidents were reported within two hours and documented in
the program logbook. The program has experienced an increase in the number of reportable
incidents to the CCC. The program director was interviewed and indicated the increase is due to
a specific youth at the program being diagnosed with psychogenic seizures and other youth at
the program being Baker Acted, which required the CCC to be notified.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
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 had thirty Right Interaction (RI) incidents during the annual compliance review
period, five of which were reviewed. Each report was completed by the end of the staff’s
workday and included statements from all staff involved. All five reports reflected the report was
reviewed by a supervisor and a RI instructor or RI-certified supervisor. All RI incident reports
were reviewed by the administrator or designee within seventy-two hours of the incident. None
of the reports involved mechanical restraint, injuries, or allegations of abuse. Monthly
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 71 (Revised September 2022)
summaries were maintained by the program of all RI incidents submitted to the Department’s
regional office by the fifteenth of each month. The program’s RI plan was updated by the
provider on April 29, 2024, and approved by the Department’s regional director on May 3, 2024.
The number of RI incidents from the previous annual compliance review was twenty-seven,
which does not reflect the program experienced an increase of five or more PARs/RIs since the
last annual compliance review. The program’s PAR rate for the last quarter was 6.14 for the
intensive mental health youth and 2.49 for the substance abuse youth , which is above the
statewide PAR rate of 1.71. The program director was interviewed and included the program’s
policy and procedures for monitoring RI incidents and use of force. Six of seven interviewed
staff reported they use RI, and each were familiar with the policies and procedures. The
remaining staff reportedly has not used RI, but is familiar with the program’s policies for RI.
1.07 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.
Program staff who are considered direct care staff and are counted in the staff-to-youth ratio
includes direct care staff and the team leaders. The program submitted a pre-service training
plan, which was provided for review. The training plan was approved by the highest-ranking
official at the program, the regional director for the Department’s Residential Services, and the
director of the Department’s Office of Talent, Leadership, and Culture. Seven staff were
reviewed for pre-service certification requirements. All seven staff completed more than the
required 120 hours of training within the first 180 days of employment. All seven staff completed
the essential skills trainings which include Child Abuse Recognition, Reporting, and Prevention,
cardiopulmonary resuscitation (CPR), first aid, automated external defibrillator (AED),
emergency procedures, program operating procedures, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, ethics and code of conduct, Right Interactions
(RI), and suicide awareness and prevention prior to having contact with youth. The following
additional trainings were completed by each of the seven staff: active shooter preparedness,
adolescent development and behavior, balanced approach to restorative justice, the
Department’s Central Communications Center (CCC) Incident Reporting, civil rights,
communication, Confidentiality/Health Insurance Portability and Accountability Act (HIPPA),
Department of Juvenile Justice (DJJ) Legacy/History, Equal Employment Opportunity (EEO),
gang awareness, human trafficking intervention, infection control/bloodborne pathogens,
information security awareness, the Department’s Juvenile Justice Information System (JJIS),
mental health and substance abuse, safety security and supervision of youth, sexual
harassment, effective and respectful treatment of youth, and trauma responsive practices. Six of
the seven staff completed quality report writing. The remaining staff did not complete this
training. None of the staff completed Motivational Interviewing (MI). The program provided
documentation to support ongoing efforts to schedule the training. The training is currently
scheduled for March 27, 2025. Additionally, the program’s shadowing requirement was
completed by all seven staff. All seven staff also completed trainings in stress management for
staff, adolescent healthcare, behavior management and modification, positive reinforcement
techniques and strategies, risk factors and triggers relating to youth with a history of
victimization, risk factors and triggers relating to homicidal risk and homicidal prevention,
immediate access to emergency medical, the program’s treatment model, and Trauma
Responsive and Caring Environment (TRACE) self-assessment. All seven staff completed the
following trainings as required by other rules or manuals: grievance process, infection control,
exposure control plan, behavior management system, and intended use of safe tools. All seven
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 71 (Revised September 2022)
staff also completed all required specialized services training. One of the newly hired staff was
hired as a supervisor and completed an additional sixteen hours of training in the areas of
coaching, leadership, and personal accountability. All instructors were qualified in the curricula
provided to the program staff. The Department’s Learning Management System (SkillPro)
indicated all requirements were completed and entered into SkillPro for six staff of the seven
staff. The remaining staff was missing the Quality Report Writing training.
1.08 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.
Seven staff training records were reviewed for in-service training requirements. All seven
records included documentation the staff completed the mandatory training topics of active
shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking, information security awareness, mental health and
substance abuse, Prison Rape Elimination Act (PREA), Right Interactions (RI), professionalism,
interpersonal, communication, and ethics, sexual harassment, suicide awareness and
prevention, trauma responsive practices, emergency response and emergency drills, infection
control, bloodborne pathogens, and exposure control plan during the annual compliance review
period. All seven staff completed over the required twenty-four hours of training. All seven staff
also completed training for prenatal and neonatal staff education. Three of the staff were
reviewed for the completion of the required supervisory training. All three staff completed over
the required eight hours of training in coaching, leadership, and personal accountability. The
supervisory staff also completed medication administration for non-licensed staff training. The
Department’s Learning Management System (SkillPro) indicated all requirements were
completed for seven staff. All instructors were qualified to provide the trainings. The program
submitted and implemented an annual in-service training calendar. The highest-ranking official
at the program, the regional director for the Department’s Residential Services, and the director
of the Department’s Office of Talent, Leadership, and Culture all signed/approved the training
plan.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures for the grievance process which includes training on
the process. The program’s grievance process includes an informal, formal, and appeal phase.
The informal phase permits the youth to resolve the complaint or condition with the staff
involved. This must be done by the end of the staff’s shift. If in the informal phase the grievance
is not resolved, it will be submitted to the shift leader by the end of the staff’s shift. In the formal
phase, the shift leader will investigate the facts of the grievance and submit a decision within
seventy-two hours of receiving the grievance. The shift leader shall consult other members of
the team. Both the youth and shift leader will sign and date the form. The shift leader will return
the grievance to the youth, and the youth will place the grievance in the grievance box located in
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 71 (Revised September 2022)
the cafeteria. The appeal phase starts if the youth is not in agreement with the solution offered
by the shift leader, the grievance officer shall review the grievance with the staff and youth
separately and issue a decision within seventy-two hours. The program had twenty-four
grievances during the annual compliance review period. A review of five grievances revealed an
informal phase was documented and all moved into the formal phase. One of the five was not
resolved during the formal phase, continued to the appeal phase, and was resolved within the
required time frames. Seven youth were interviewed. All seven youth were able to articulate the
grievance process and where forms are located. Seven staff were interviewed. All seven staff
were able to explain the program’s youth grievance process. An interview with the program
director (PD) revealed there are procedures in place to allow the youth to grieve, in writing, the
actions of program staff or their peers, as well as conditions or circumstances of care and
treatment which are a violation of their rights. The PD verified the program is following their
policy and procedures with informal, formal, and appeal phases.
1.10 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.
A review of the program’s contract found the program’s primary groups are Moral Reconation
Therapy (MRT), Dialectical Behavior Therapy (DBT), Seven Challenges, and Impact of Crime
(IOC). These groups are facilitated by the program’s therapist and are reviewed by the
Department’s Office of Fidelity, Accountability, and Support and the Office of Health Services;
therefore, are not applicable for this indicator. The supplemental groups required of the program
include gossip girl, coping with anger, anger management, seeking safety, and life skills. A
review of the group schedule and sign-in logs confirmed groups are being provided as required.
These groups are conducted by team leaders with a high school education. The staff’s
education and work experience were considered when determining the delivery of intervention
services. The program director (PD) reported no formal training is required. Applicable groups
were provided as outlined in the contract table. A review of the program’s activity schedule
confirmed the program is providing structured, planned programming, or activities at least sixty
percent of the youth’s awake hours. The program provided documentation staff were trained on
EQUIP but never taught the group. The program has amended the contract to remove this
group as a requirement. An interview with the PD revealed IOC, MRT, and DBT are delinquency
intervention models or strategies which are evidence based, a promising practice, or a practice
with demonstrated effectiveness and have been implemented to address the priority needs of
youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 71 (Revised September 2022)
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing life and social skills training provided for
youth. The program offers Aggression Replacement Training (ART), Moral Reconation Therapy
(MRT), Impact of Crime (IOC), and Seven Challenges which are all life skills interventions and
primary services; therefore, they are not applicable for the annual compliance review and will be
detailed in the Department’s Office of Fidelity, Accountability, and Support’s annual report.
Seven youth were interviewed. All youth reported participating in a life skills group. Five youth
reported participating in Boys and Girls Club, and two youth reported participating in IOC. An
interview with the program director revealed all youth participate in groups daily. Special focus is
placed on the needs of each youth’s relationships with family members, peers (pro-social,
antisocial, dating), adults outside of the family (positive role models, mentors), and authority
figures in order to build positive relationships and establish safe and appropriate boundaries. An
interview with the designated mental health clinician authority (DMHCA) revealed youth are
provided an opportunity to practice skills they have learned in groups in all areas of the
program.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s Impact of Crime (IOC) groups are considered primary services which is a
promising practice; therefore, not applicable for this annual compliance review and will be
detailed in the Department’s Office of Fidelity, Accountability, and Support’s report. In addition to
these restorative justice groups, youth conduct positive youth justice model with the Boys and
Girls Club. The youth participate in knitting blankets for nursing homes and pregnant mothers,
conduct community service by food distribution, catering, and cleaning up at events. A speaker
from a local victim advocacy program comes in monthly to speak to youth. A review of sign in
sheets revealed youth are active in the Boys and Girls Club. Seven youth were interviewed. Six
of the youth stated they participate in IOC as a restorative justice group/activity while at the
program. The remaining youth did not provide a response to this question. An interview with the
program director (PD) revealed, the program places an emphasis on mental health issues
specific to girls, such as victimization, neglect, abandonment, depression, domestic violence,
motherhood, and others which might be identified during the comprehensive assessment
process. Emphasis is also placed on addressing substance abuse issues specific to girls,
including effects of substance abuse on families, differing physical and mental effects of
substance abuse, and how to prevent relapse, whether it be through triggers, environment, or
physiological or mental withdrawal. All youth at the program are guided toward taking full
responsibility for their criminal actions, antisocial behavior, and harm to others. Activities and
instruction are provided to increase the awareness of, and empathy for, crime victims and
survivors. The PD reported youth are held responsible for harm caused to the program
community. All youth, through the behavior modification system, will be taught restorative justice
principles and will be held accountable for restoring community relationships within the program
whenever harm has been imposed. Additionally, youth will participate in community service
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 71 (Revised September 2022)
projects, such as serving at local events, cleaning up, participating in food drives, and
crocheting blankets for the elderly and homeless.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a policy and procedures outlining the internal alert system. The policy
and procedures include how the alert system is communicated, which is through daily
debriefings between shifts, daily shift report, and the internal alert system clip board. Any staff
member can place a youth on alert status in the event of a significant incident where the youth
is exhibiting behavior which presents a significant health, safety, or security issue. The
procedures also include how to remove the youth from the internal alert system. For mental
health alerts ad/or suicide risks, a qualified mental health professional is the only person who
can remove this alert. Medical staff are the only ones able to remove a youth from a medical
alert. The program director or designee is responsible for removing a youth from the alert
system for safety and security risks. A review of youth alerts confirmed the program placed
youth on the alerts system as outlined in their policy and procedures. Seven youth were
reviewed for alerts. Three of the seven were applicable for alerts. The remaining four youth did
not have any new alerts in the Department’s Juvenile Justice Information System (JJIS) since
their date of admission to the program. All three youth had appropriate alerts entered into JJIS .
The alerts were also entered into the program logbook. All alerts entered in JJIS matched the
program’s internal alerts. The program director was interviewed regarding medical issues being
reviewed and the internal alert system process. The program director reported medical issues
are reviewed weekly during all staff meeting or as often as needed. The program director also
included the policy and procedures regarding the program’s internal alert process which
includes who is responsible for entering and closing out alerts in JJIS and how management
reviews the alerts. The nursing staff was interviewed regarding the program’s internal alert
system. The director of nursing (DON) is responsible for updating the medical alert system
within JJIS. The nursing staff is also responsible for updating internal alerts within the program.
Seven staff were interviewed regarding notification of youth alerts for mental health, medical,
and security purposes. Four staff indicated they are informed of the youth's alerts by the daily
shift report. One staff indicated alerts are reviewed in the observation log. The remaining staff
indicated alerts are reviewed in a book in the supervisor's office.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 71 (Revised September 2022)
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains separate youth records for mental health, case management, and
medical for each youth. All youth records were labeled confidential. The individual case
management record contained youth’s name, Department identification number (DJJID), date of
birth, county of residence, and committing offense. Each record contained sections labeled as
legal information, demographics and chronological information, correspondence, case
management and treatment team activities, and miscellaneous, as required. All records were
observed to be secured in a locked file cabinet when not being used. The cabinet was labeled
confidential.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program had an open deficiency for advisory board during the annual compliance review
period, which was closed on December 20, 2024; therefore, documentation was reviewed after
the deficiency was closed. The program’s community advisory board is scheduled to meet for
this quarter on March 6, 2025. The program director provided documentation of actively
recruiting advisory board members from the judiciary community, community partners, business
community, school board, faith community, LGBTQIA+ community, victim services community
representative, and parent/guardian of youth who were previously in the juvenile justice system.
The program director was interviewed regarding the community advisory board. The program
director was able to share the program’s policy and procedures regarding the community
advisory board. An interview with a board member confirmed their participation in the program’s
community advisory board meetings and indicated the next meeting is scheduled for March 6,
2025. The program conducts meetings every three months and members are notified of
meetings through email. The board member reported they enjoy participating in the meetings,
wish to continue, and believes the program generally care about the youth they serve.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which indicates staff are to receive evaluations on
performance annually. Three different job descriptions were reviewed, and evidence was found
each staff position had clearly identified performance standards. Seven staff personnel records
were reviewed and found each had a completed annual evaluation as required. Performance
standards for all seven staff matched the job descriptions for each staff member reviewed. A
review of the provider’s contractual agreement was done in comparison with the program’s
current vacancy list and found the program maintained the required positions. The program
director was interviewed regarding staff turnover and staff morale. The program director
included the program’s policy and procedures for staff communication, annual evaluations, and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 71 (Revised September 2022)
recruitment and retention. The program director was also asked about the performance
evaluation process for staff. The program director included the same policy and procedures and
indicated Dove staff are evaluated annually by their immediate supervisor. Additionally, all staff
are expected to conduct themselves professionally and dress appropriately for the job they are
performing. Also, the Employee Handbook outlines the dress code and behavioral expectations.
Further, the program has a system of evaluating staff, at least annually, based on the
established performance standards. Seven staff were interviewed. One staff indicated they
receive a formal evaluation of their performance based on performance standards yearly, four
staff indicated they receive a formal evaluation of their performance based on performance
standards every ninety days, one staff indicated they have had two formal evaluations since
they have been at the program, and the remaining staff indicated they have not had a
performance evaluation.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of special contract conditions revealed the program’s education services shall include
SMART technology, flexible seating, and a driving simulation program. An interview with the
lead teacher revealed the driving simulator was previously taken from the program due to being
purchased with Title V funds, which is a rural grant and ineligible to transfer into Florida
Scholar's Academy. In addition, SMART Technology and flexible seating was unable to be
continued when Florida Scholar’s Academy began services. The contract also outlined the
EQUIP curriculum (cognitive behavioral therapy) named gossip girl would be led by direct care
staff and supervisors. A review of documentation revealed the staff were trained on EQUIP;
however, it was never initiated due to its complicated nature, and staff were having trouble
teaching it. At the time of the annual compliance review gossip girl was taught by direct care
staff without the EQUIP portion. This was agreed upon by the Department’s Office of Fidelity,
Accountability, and Support and a contract revision has been completed. The program provides
faith-based opportunities by having a local ministry come in twice a month and a review of
vehicle logs indicated youth can attend church off-site at least once a month. The program is
partnered with Boys and Girls Club which is provided seven days a week. A review of sign in
sheets, and crafts created by youth revealed Boys and Girls Club is an active part of the
program as required. The positive youth justice model includes community service
opportunities, opportunities for restoration, parent/guardian involvement, and mentoring. The
welding classes are taking place as required; however, no youth have received the welding
certification. An interview with the program director revealed the program implements 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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 71 (Revised September 2022)
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program’s practice for data trend includes the program director collecting data throughout
each month on the following areas of the program: bed utilization, physical interventions, youth
behavior, Bakers Acts, Prison Rape Elimination Act (PREA), injuries, risk management/
Commission on Accreditation of Rehabilitation Facilities (CARF), incentive trips, transportation,
Department of Transportation (DOT), training, and community service hours. This
documentation is provided to the provider’s management staff, who compiles all the data into a
spreadsheet for the program. This information is shared with staff and posted on the wall within
the administration building at the program. The data trends are also discussed during staff
meetings as evidenced by meeting minutes. Internal meetings are facilitated at the program on
Monday of each week, which was confirmed by a review of the documentation. The data trend
information is maintained at the corporate office and shared with the management team during
the monthly meetings. As the data trends change, the program staff and corporate staff discuss
ways to improve in those areas.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 71 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
Seven reviewed case management records had documentation verifying each youth’s
parent/guardian was contacted by telephone within twenty-four hours of the youth’s admission.
All seven reviewed case management records included written notification of each youth’s
parent/guardian within forty-eight hours of admission. All seven reviewed case management
records reflected program staff notified the committing court and assigned juvenile probation
officer (JPO) of each youth’s arrival on the day of admission in writing.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the youth orientation process. A program
orientation was conducted for all seven reviewed youth case management records within
twenty-four hours of admission. Orientation included expectations and responsibilities of each
youth, written behavioral management system, access to medical and mental health and
substance abuse services, access to the Department’s Central Communications Center (CCC)
and Florida Abuse Hotline, zero tolerance regarding sexual misconduct, what is considered
contraband and illegal items and consequences for having these items, performance plan
process, hygiene and dress code, procedures for visitation, mail, and telephone usage, each
youth’s anticipated length of stay, goal completion, expectations for release, access to
community, grievance process, fire drills and emergency procedures, facility tour, health
education topics, services available, daily schedule, living unit, and treatment team assignment.
Seven interviewed youth each indicated the orientation process started within twenty-four hours
of arrival. Each youth stated orientation included program rules, procedures, and schedules.
The youth admission orientation process was not observed due to no admissions occurring
during the annual compliance review week.
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.
One of the seven reviewed records were applicable for written consent of youth eighteen years
of age or older; two additional records were reviewed. A review of three records found
documentation in all records for youth consent to provide physical and mental health information
to their parents/guardians.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 71 (Revised September 2022)
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures outlining the classification process for youth upon
admission to the program and completion of reassessments as necessary. A review of five
records found documentation in all records addressing each youth’s gender, height, weight,
physical stature, age and maturity level, special needs, history of violence, gang status, criminal
behavior, sexual aggression or vulnerability to victimization, perception of vulnerability, potential
or verified human trafficking history, and risk factors for medical, suicide, escape, and security.
All seven records demonstrated each youth was assigned to a living unit and room based on the
program’s classification system. Seven reviewed records each included the Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB) documents. The program utilizes an
alert system which staff have access to and provides updated information on each youth,
including medical, mental health, suicide, sexual predator, aggression, and escape or security
risks. Each record documented a review of the Department’s Juvenile Justice Information
System (JJIS) Alert List for any issues affecting classification. Any special needs or risk factors
identified during or after the classification process were immediately entered into the program’s
internal alert system. Six of seven reviewed records included reclassification forms, the
remaining youth was not applicable for a reclassification. All six documented reclassification
prior to the addition of privileges including an increase in freedom of movement, participation in
work projects or other activities, and participation in off-campus activities. The program director
(PD) interview indicated a pre-admission staffing will be held by members of the treatment team
for each youth prior to their admission, when possible, which will be used to guide the staffing,
and documentation will be completed and placed in the youth's case management record upon
completion. The PD reported the therapist and case manager will be assigned during the
staffing and a dorm will be tentatively assigned. At the time of admission, the case manager
reviews the youth’s record, intake packet, history, collateral contacts, and initial interactions
during orientation. The case manager will make the final dorm assignment based on the
recommendation of the treatment team during the pre-admission staffing and their interaction
with the youth upon admission. All newly admitted youth shall be screened using the VSAB prior
to room assignments. The PD also reported the VSAB screening tool will be utilized to
determine the youth’s potential risks, which will be entered into JJIS.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 71 (Revised September 2022)
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.
None of the seven reviewed case management records were applicable for gang identification
and notification. During the annual compliance review period, there were no youth applicable for
gang identification.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to address a youth’s participation in gang prevention
and intervention activities. During this annual compliance review period, there were no youth
applicable for gang identification prevention and intervention. Any youth identified to be a gang
member or have gang affiliations or are at a high risk of gang involvement will participate in
Impact of Crimes groups weekly. In addition, a goal shall be included into their individual
performance plan pertaining to gang membership and/or affiliation containing interventions and
strategies of gang prevention and intervention. The program director interview indicated all new
intakes will be interviewed for any gang affiliation during the admission and orientation process,
this information is passed on to the leadership team, as well as documented on the
classification form and revised if new information is obtained while the youth is in the program.
In addition, if the youth is found to have a gang affiliation throughout their stay, the classification
form will be revised. If a youth has been identified as a gang member or suspected of criminal
gang activity, the notification must be made to the youth’s home county by the program unless
the notification has been made before her placement. If a youth expresses the desire to
disaffiliate with a criminal street gang, by either the initial gang assessment or verbally at any
time, the program will help develop a plan to do so.
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.
A review of seven youth case management records found documentation in all records verifying
the Residential Assessment for Youth (RAY) was completed within thirty days of admission. All
initial assessments were maintained in the Department’s Juvenile Justice Information System
(JJIS). Five of seven reviewed records were applicable for ninety-day reassessments. All five
records had reassessments completed every ninety days as required and were applicable for
additional reassessments deemed necessary by the intervention and treatment team. All five
youth case management records maintained all reassessment documentation as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 24 of 71 (Revised September 2022)
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.
A review of seven youth case management records verified each record included a Youth
Needs Assessment Summary (YNAS) completed in the Department’s Juvenile Justice
Information System (JJIS) within thirty days of each youth’s admission. Each record
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.
Each of the seven reviewed youth case management records included performance plans which
were completed within thirty days of admission in the Department’s Juvenile Justice Information
System (JJIS) and done after completion of the Youth Needs Assessment Summary (YNAS).
Documentation in each of the seven youth case management records indicated team members
were present to provide input to the performance plans. Each of the seven youth interviews
reflected each youth participated in the development of their performance plan. All performance
plan goals were measurable and included target completion dates. The individualized goals
included in each performance plan were based upon the prioritized needs reflecting the risk and
protective factors identified ensuring the initial assessment process. Each goal identified specific
delinquency interventions based on the Residential Assessment for Youth (RAY) results.
Performance plan goals also identified responsibilities of staff and youth. The performance
plans included the top three criminogenic needs identified in the YNAS and transition goals, and
targeted court-ordered sanctions which could be reasonably initiated or completed while the
youth was at the program. Seven interviewed youth reported they knew what performance plan
goals they are working on. All seven youth case management records included performance
plan transmittal letters which were sent out to all applicable parties within the required time
frame. Performance plans were signed by the treatment team leader, youth, and other parties
who have responsibilities in goal completion. Original performance plans were maintained in all
seven youth case management records. Each of the seven youth confirmed they received a
copy of their performance plan.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 25 of 71 (Revised September 2022)
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.
Six of seven reviewed case management records were applicable for performance plan
revisions. Each youth’s treatment team was involved in determining the need for performance
plan revisions. Revisions were made based on goal progress, new information revealed, and
Residential Assessment for Youth (RAY) Reassessment results. Three youth were applicable
for reassessments to facilitate transition activities and received reassessments as required.
Each applicable youth had additional plans, including academic or treatment plans, incorporated
into the performance plan. In addition, the program advised one youth was served by the
Department of Children and Families (DCF). Documentation verified the youth’s performance
plan coordinated with the APD or DCF plan for related issues.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
Four of seven reviewed case management records were applicable for Performance
Summaries, the remaining youth had not been in the program long enough to receive a
Performance Summary. Each applicable Performance Summary included each youth’s status
on each performance plan goal, overall treatment progress, behavior, academic status and
credits earned in the program if the youth was a high school student, including performance,
and behavior in school, significant events, interactions with peers and staff, level of motivation
or readiness to change, overall treatment progress, and all other required elements. All four
Performance Summaries were done within ninety days of the performance plan signatures.
Reviewed documentation in the four applicable records indicated the youth was allowed to read
and add comments prior to signing the summary, the youth received a copy of the summary,
and the original summary was filed in the youth’s record. Each Performance Summary was
signed and dated by all required parties and sent within ten business days to the committing
court, juvenile probation officer, parent/guardian, and Department of Children and Families
(DCF) caseworker, if applicable. A review of three closed case management records verified
each release summary included the justification for release, discharge, or transfer. All three
release summaries included the justification for release and Pre-Release Notification (PRN).
The release summary and PRN were sent at least forty-five days prior to release. A signed copy
was maintained in each youth’s record. None of the youth were applicable for the court
objecting to their release. Once approved, the program provided written notification to each
youth’s parent/guardian. Each closed case management record contained an Exit Residential
Assessment for Youth (RAY). None of the youth were applicable for the Sexually Violent
Predator Program and none required victim notification to be sent. Original Performance
Summaries and copies of release summaries were in each youth case management records.
An informal interview with the case manager indicated youth receive copies of their
Performance Summary.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 71 (Revised September 2022)
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.
Seven reviewed case management records included documentation confirming program staff
attempted to involve parent/guardian in the assessment process, performance plan
development, and progress review. Parents/guardians were provided with opportunities to
attend or participate in these events. If unable to attend, the parent/guardian is provided the
opportunity to participate by telephone or video conferencing, or to provide verbal or written
input prior to the meeting. A treatment team meeting was observed, and the parent/guardian
participated by telephone. The program director (PD) interview indicated program staff
encourage and facilitate involvement of the youth’s parent/guardian in the case management
process, including assessments, performance plan development, progress reviews, treatment
team meetings and transition planning. Six interviewed youth stated their parent/guardian is
called for to participate in treatment team meetings. One youth stated their treatment team took
place the next day.
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.
Seven youth case management records were reviewed for formal and informal treatment team
reviews. In each record, the case manager and therapist were identified as treatment team
leaders. The treatment team for each youth included the youth, administration representative,
case manager, living unit representative, education, clinical staff, medical staff, juvenile
probation officer (JPO), parent/guardian, and transition service manager (TSM) when
applicable. Participants were present or provided written input. Team members actively
participated or provided input for meetings. The youth’s JPO and parent/guardian participated
by telephone. Each reviewed case management records included formal treatment team
reviews completed at least once every thirty days as required. Six of seven reviewed records
were applicable for informal bi-weekly treatment team meetings and included all required
elements. Treatment team reviews included youth name, review date, attendees, input from
team members, how youth are progressing, youth behavior, any physical interventions, and
Residential Assessment for Youth (RAY) Reassessment results when applicable. All other
elements were included in the treatment team documentation as applicable, and the
documentation was maintained in each youth’s record. The youth’s treatment team members,
JPO, and parent/guardian were invited and encouraged to participate in youth formal treatment
team reviews. A treatment team meeting was observed which included applicable members and
a review of the youth’s treatment plan to determine their anticipated release date. Each of the
seven interviewed youth reported they have an opportunity to demonstrate learned skills and
youth progress is discussed during formal treatment team meetings. Seven interviewed youth
indicated they are allowed to demonstrate their learned skills and discuss their progress in
treatment team meetings. Each youth stated staff talk about their performance to include
progress on performance plan goals, positive and negative behavior, and treatment progress.
Six youth stated they are given a self-report to show the skills they have learned in the program.
One youth stated treatment team has not taken place yet due to recently being admitted into the
program
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 71 (Revised September 2022)
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Three closed case management records were reviewed for transition planning and the
Community Re-Entry Team (CRT) meeting. Transition conferences were conducted at least
sixty days prior to each youth’s scheduled release date. The youth, treatment team leader,
program director or designee, juvenile probation officer (JPO), parent/guardian, medical, and
education staff were invited and participated in each youth’s transition conference. During the
transition conference the team conducted a review of the transition activities on each youth’s
performance plan, revised the performance plan as necessary, identified additional transition
activities as needed, identified target completion dates, and identified persons responsible for
completion. A copy of each plan was sent to each applicable party not in attendance at the
transition conference with a request for return with a signature. The treatment team leader
obtained participant signatures or electronic acknowledgement of responsibilities. All three
closed case management records included supporting documentation indicating the program
and youth participated in the CRT meeting prior to release and an invitation sent through email
was maintained within the youth records.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management records were reviewed for Exit Portfolios. Documentation
indicated the Exit Portfolio was discussed and initiated for the youth during the transition
conference for all three youth. The three closed case management records included all required
documents except for a state-issued identification card, Social Security card, or birth certificate.
The Exit Portfolio was provided to each youth and juvenile probation officer (JPO). The youth
were not applicable for requirements specific to youth in a secure maximum risk program. The
program did not have any additional requirements related to the Exit Portfolio included in their
contract. Each Exit Portfolio was verified during the exit conference.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 28 of 71 (Revised September 2022)
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed case management records were reviewed for Exit Conference requirements. Exit
Conferences were conducted for each youth after notification to the juvenile probation officer
(JPO) and at least fourteen days prior to anticipated release date. Reviewed documentation in
each youth’s case management record confirmed the JPO, parent/guardian, education
representative, intervention and treatment team leader, and other pertinent parties participated
in each youth’s Exit Conference. All three Exit Conferences were documented in each youth’s
case management record and held separately from the transition conference and Community
Re-Entry Team meetings. The status of transition activities established at the transition
conference and plans finalized for the youth’s release were reviewed. Each document included
youth’s dates of admission and termination documented within each youth’s record compared to
the Department’s Juvenile Justice Information System (JJIS). The Exit Conference documents
included a review of transition conference goals, a summary of pending transition goals,
provisions for continuation of education and/or employment, evidence the youth’s case manager
and parent/guardian are aware of the plan, documents, and post-release discharge plans, and
signatures for all required parties. The youth’s JPO and parent/guardian participated by
telephone.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to promote formal constructive input by youth. A
review of program youth advisory council documents reflected youth can provide input and
feedback concerning services, community, improvements, and staff and youth quality of life.
Documentation supported these meetings were held quarterly. All seven interviewed youth
indicated input can be provided through request to speak forms, youth advisory, and community
meetings. The program director (PD) interview stated the program strives to provide the youth
opportunities to develop self-advocacy, leadership, teamwork, and empowerment skills. Youth
will be provided the opportunity to provide feedback regarding the services they receive, daily
programming, as well as any treatment relative to their stay at the program. Youth will
participate in the development of the behavior modification system (BMS)/handbook to provide
them the opportunity to have ownership and take responsibility for their community. Youth are
chosen by the youth advisory council in conjunction with the PD. Meetings are held quarterly or
as needed with the PD and/or designee. Youth advisory representatives will serve for the
duration of their stay or until they become ineligible.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 71 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor and holds a valid and active license in the State of Florida. The
DMHCA’s license expires on March 31, 2025. The DMHCA was on-site weekly during the
annual compliance review period and ensured appropriate coordination and implementation of
mental health and substance abuse services were taking place as required. The program
provides specialized treatment services and the DMHCA is the single licensed health
professional responsible for the coordination and implementation of mental health and
substance abuse services. The DMCHA’s position description was reviewed and included all
required information. The program has a back-up DMHCA who has an active and valid license
which expires March 31, 2025. The DMHCA was interviewed and reported being employed full-
time and is on-site Monday through Friday for forty hours a week. The DMHCA is also on-call
twenty-four hours a day seven days a week.
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 designated mental health clinician authority (DMHCA) serves as the clinical supervisor in
the program. The program does not have additional licensed mental health and substance
abuse clinical staff outside of the DMHCA. A review of the staff roster confirmed clinical staffing
is in accordance with the program’s contract. The program has a psychologist who is on-site for
one to two hours weekly and as needed. The psychologist holds a valid and active license in the
State of Florida which expires May 31, 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 designated mental health clinician authority (DMHCA) serves as the clinical supervisor in
the program. The DMHCA ensures all non-licensed staff are performing services they are
qualified to provide based upon education, training, and experience. The DMHCA provided the
weekly supervision records for review. All non-licensed therapists received one hour a week of
face-to-face direct supervision as evidenced by a review of the supervision logs. All direct
supervision was recorded on a form developed by the program and included all required
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 71 (Revised September 2022)
elements form the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professional Direct Supervision Log form. The program has a Chapter 397
license located in the front lobby of the administration building. The Chapter 397 license expires
on July 6, 2025. The program’s contract includes has four non-licensed clinical staff. A review of
staff rosters confirmed four clinical staff were employed during the annual compliance review
period. There were no vacancies for clinical staff during the annual compliance review period. All
four hold a master’s-level degree from an accredited university in the field of counseling, social
work, psychology, or related human services field. The program maintains a chapter 397 license
and the staff are working under the direct supervision of a qualified professional. The DMCHA
provided training documentation for Assessments of Suicide Risk (ASR). All non-licensed staff
received twenty hours of training for conducting ASR and were supervised in assessing suicide
risk, mental health crisis intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Seven youth mental health and substance abuse records were reviewed for the mental health
and substance abuse admission screening. All seven youth were given a Massachusetts Youth
Screening Instrument – Second Version (MAYSI-2). All seven records included documentation
the screener reviewed available information to include the commitment packet and existing
reports for documentation of mental health and/or substance abuse problems. Three different
staff conducted the MAYSI-2 screenings, and all were formally trained as evidenced by a review
of the Department’s Learning Management System (SkillPro). All seven screenings were
completed in the Department’s Juvenile Justice Information System (JJIS) on the day of
admission. One screening was dated on August 20, 2024; however, when the designated
mental health clinician authority (DMHCA) was asked about the discrepancy, it was reported the
date entered was incorrect on the MAYSI-2, but it was completed on the date of admission. All
seven assessments were completed in full, and all required further assessment. Referrals were
made to the DMHCA due to the assessments indicating a need for further assessments as
evidenced by a review of the youth records. The program director ensured an ASR was
completed within twenty-four hours for all seven youth. None of the youth were placed on
Precautionary Observation as a result of the ASR upon admission to the program. All seven
youth records included a MAYSI-2 assessment referral form which indicated the youth were
referred for and ASR and comprehensive evaluation along with the reason for each referral. The
program director developed a policy and procedures for the implementation of standardized
admission/intake mental health and substance abuse screening process. The policy included
the standardized screening process which included a review of the commitment packet
information, reports, records, administration of the MAYSI-2 in JJIS, referrals identified by
screenings, staff training in mental health and substance abuse issues and the administration of
the MAYSI-2, and a standardized process for referrals of the youth when identified as in need of
further mental health and/or substance abuse evaluation to an appropriate service provider, or
when immediate attention is needed to a hospital or Baker Act or Marchman Act receiving
facility. The program director was interviewed regarding the screening process to identify youth
at risk for mental health and substance abuse problems and suicide. The program director
stated the mental health and substance abuse needs of the youth at the program are identified
through a comprehensive screening process which ensures appropriate referrals are made
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 71 (Revised September 2022)
when youth have identified mental health and/or substance abuse needs or are identified as
potential suicide risks. All youth receive an ASR within twenty-four hours of admission. This is
completed by a clinical coordinator under the direct supervision of the DMHCA. All youth newly
admitted to the program are referred for mental health and substance abuse evaluation and
treatment after the initial screening is completed. The program has opted to use the MAYSI-2
rather than the Clinical Mental Health/Substance Abuse Screening process for the purposes of
screening all youth who are admitted to the program. The program provides a broad spectrum
of mental health and substance abuse services driven by screenings and assessments
conducted upon admission, which are designed to assess the clinical needs of each youth.
Clinical personnel will utilize highly researched screening instruments such as the MAYSI),
substance abuse placement measure, and the Adverse Childhood Experiences Questionnaire
(ACE) to assess for childhood trauma and the mental health and substance abuse level of
functioning for children (CFARS).
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.
Seven youth mental health and substance abuse records were reviewed for the mental health
and substance abuse assessment and evaluation documentation. All seven records included
documentation the program completed a new and combined mental health and substance
abuse evaluation for the youth upon admission. All seven evaluations were completed within
thirty calendar days of admission. All seven records included signed consents for substance
abuse services. Non-licensed staff completed the mental health and substance abuse
evaluations for all seven youth. All evaluations were reviewed and signed by the designated
mental health clinician authority (DMHCA) within ten calendar days after the evaluation was
conducted. All reviewed evaluations included identifying information of the youth, reason for the
evaluation, relevant background information, behavioral observation, mental status exam,
documentation of an interview being conducted, discussion of findings, diagnostic impression
which included the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V),
and recommendations.
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.
Seven youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All seven reviewed initial treatment plans were developed on the
day of admission. All initial treatment plans included all required elements from the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Three of the seven
youth entered the program on psychotropic medications, and all three initial treatment plans
included psychiatric services. All reviewed initial treatment plans were signed by the clinical staff
completing the form. Six of the seven initial treatment plans were completed by non-licensed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 71 (Revised September 2022)
clinical staff, and all were reviewed and signed by the clinical supervisor within ten days of
completion. The remaining initial treatment plan was developed by the clinical supervisor. The
initial treatment plans reviewed were signed by the youth, treatment team leader, and program
management. Three of the seven treatment plans included psychiatric services due to the three
youth entered the program on psychotropic medications. The remaining four youth did not enter
the program on medications, but the reviewed individualized treatment plans included
psychiatric services if needed during the youth’s stay at the program. Seven individualized
treatment plan reviews included all elements from the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form. All seven records included
documentation treatment plan reviews were completed every thirty days as required. All
reviewed treatment plans and reviews included signatures from the youth, treatment team
leader, program management, living unit representative education, medical staff, and a
Department of Children and Families case worker for one youth. The treatment plan reviews did
not include signatures for the juvenile probation officers (JPO); however, a review of the
treatment team documentation showed the JPOs were present by telephone during the
treatment plan reviews and this was indicated on the treatment team signature pages. All dates
of the treatment teams matched the treatment plan review dates. Four out of the seven youth
records included documentation the parents were present during the treatment plan review
dates. Three youth records did not include documentation of parent/guardian attendance for the
treatment plan reviews. A Review of the treatment team documentation revealed attempts were
made for the parents/guardians of these youth during treatment team meetings. All
individualized treatment plans included prescribed services, goals, and objectives which were
individualized for each youth. All mental health services are primary services, and
documentation is reviewed by the technical assistance specialist. A review of three groups on
video was observed and revealed all required groups were being held on the scheduled days at
the scheduled times for the correct length of time.
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.
Seven youth mental health and substance abuse records were reviewed for treatment. All seven
records included documentation the youth was assigned a treatment team upon arrival to the
program. Documentation revealed the treatment teams were comprised of the youth, program
administration, residential living unit representative, education, medical staff, mental health staff,
and parents/guardians. Six of the seven youth records reviewed indicated the youth were in
need of substance abuse treatment services and all six received substance abuse treatment in
the program. One youth was not applicable for substance abuse treatment services. Six of the
seven youth had a properly executed Authority of Evaluation and Treatment (AET). One of the
six youth was eighteen years of age but had a properly executed AET in the record. One youth
was involved with the Department of Children and Families (DCF) and a court order was located
in the youth’s record. All youth receiving substance abuse treatment services had a signed
Youth Consent for Substance Abuse Treatment. One youth was not receiving substance abuse
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 71 (Revised September 2022)
treatment at the time of the annual compliance review but had a consent in the record in the
event the youth would need substance abuse treatment while in the program. All reviewed
mental health treatment notes included all elements of the Department’s Counseling/Therapy
Progress Notes form. All seven youth were receiving individual psychotherapy and/or
counseling and psychosocial skills training. A review of the progress notes revealed all seven
youth were receiving services as stipulated in the individualized treatment plans.
Three youth mental health and substance abuse records were reviewed for discharge planning.
All three closed records included the discharge plans which was documented on the
Department’s Mental Health and Substance Abuse Treatment Discharge Summary form. The
discharge summaries included documentation of future services needed. A review of the three
discharge summaries revealed they were discussed with the youth, parents/guardians, and
juvenile probation officers (JPO) during the exit conference. A copy of the discharge summaries
was provided to the youth, JPOs, and parents/guardians.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
Comprehensive mental health and substance abuse services are provided to all the youth at the
program who meet the eligibility requirements for mental health overlay services (MHOS)/
substance abuse overlay services (SAOS) and intensive mental health (IMH) services. The
program is recognized to provide thirty-two of forty beds with MHOS and/or SAOS. Additionally,
the program is recognized to provide Specialized Treatment Services which include eight IMH
beds. The DMHCA is on-site for forty-hours each week and licensed mental health staff is on-
site, at least five days a week. The DMHCA and program director are on-site some weekends.
The program does utilize a licensed psychologist who is on-site, at least once a week and
provides services to the youth and staff when needed. None of the youth missed any clinical
groups or services due to being in medical quarantine. The counselor caseloads for MHOS
youth are no more than eleven. All non-licensed staff holds a master’s-level degree, which was
evidenced by a review of their degrees maintained at the program. The program provides
individual therapy, at least once every two weeks and more often when needed, family therapy
is provided, at least monthly and more often when needed. The psychiatrist provides services,
at least once every two weeks. Clinical group therapy for the primary services is scheduled, at
least four days per week. The program also provides supplemental clinical services to the youth
when needed. The clinical staff who work with the SAOS youth have caseloads of no more than
eleven youth. The SAOS youth attend four substance abuse groups four times per week. The
clinical staff who work with IMH youth have caseloads of no more than eight youth. The youth
attend five mental health and substance abuse groups each week. The program’s required
clinical groups are Dialectical Behavior Therapy (DBT) and Moral Reconation Therapy (MRT).
Seven youth were interviewed and reported they are all receiving family and/or individual
counseling. Three youth reported receiving the services once a month, three youth reporting
receiving the services weekly, and one youth reported receiving the services three or four times
since being admitted to the program. Seven staff were interviewed and asked if they or other
direct care staff facilitate any mental health or substance abuse groups. All seven staff reported
they do not facilitate these groups. he designated mental health clinician authority (DMCHA)
was interviewed and reported the program provides substance abuse treatment overlay
services, intensive mental health treatment services, and mental health overlay services. The
program director was interviewed regarding the specialized services provided at the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 71 (Revised September 2022)
The program demonstrates specialized treatment services are provided in accordance with
Florida Statute, Administrative Rule, and contract.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program utilizes a psychiatric mental health nurse practitioner (PMHNP) who is board
certified and has a clear and active license in the state of Florida. The PMHNP is on-site
Monday through Friday for four to six hours each visit and is also available for emergencies.
The psychiatric PMHNP provides face-to-face psychiatric services and shares information with
the treatment team regarding the status of each youth receiving psychiatric services. The
evaluation and treatment recommendations for the youth are incorporated into the youth
treatment plans. The psychiatric PMHNP’s credentials were reviewed and matched the
information on the Department of Health website. The Collaborative Practice Protocol is kept
on-site and was reviewed with no issues. A review of the sign-in and out logs confirmed the
psychiatrist is on-site for one day a week for a minimum of four hours. There were no weeks
missed during the annual compliance review period. The psychiatric PMHNP actively
participates in, manages, and supervises psychotropic medication services in the program. The
psychiatric PMHNP was interviewed regarding services and responsibilities at the program. The
psychiatric PMHNP reported providing psychiatric assessments, diagnosing, prescribing,
monitoring, and crisis intervention assistance at the program. The psychiatric PMNHP also
collaborates with staff to develop treatment plans for the youth. The psychiatric PMHNP
confirmed being on-site weekly for a minimum of four hours. The services provided at the
program include psychiatric evaluations of all youth and completing clinical psychotropic
progress notes, medication management and follow-ups, along with monitoring side effects and
efficacy of medications. The psychiatric PMNHP meets face-to-face with the designated mental
health clinician authority (DMHCA) on a weekly basis and telephonically as needed. The
psychiatric PMHNP has a formalized procedure to meet with the healthcare staff face-to-face
weekly and telephonically as needed to staff important medical issues pertaining to the youth
who receive psychiatric services at the program. The psychiatric PMHNP meet with the medical
staff, social workers, therapists, teachers, and any other pertinent staff. The psychiatric PMHNP
has no concerns or issues with the program. The DMHCA was interviewed and reported
meeting with the psychiatric PMNHP on a weekly basis. Seven youth records were reviewed for
psychiatric services. Three of the seven were applicable for review. All three youth had
psychotropic medications when they were admitted to the program and were referred for a
psychiatric interview. The Initial Psychiatric Interview was conducted within fourteen days of
admission for all three youth. All three Initial Psychiatric Interviews included the youth history,
mental status examination, the Diagnostic and Statistical Manual of Mental Disorders – Version
Five (DSM-5) diagnosis, treatment recommendations, prescribed medications, the explanation
for the need of the medication, target symptoms, initial treatment goals, potential side effects,
risk and benefits of taking the medication, and frequency of medication monitoring and
management. All three interviews were documented on the Department’s Clinical Psychotropic
Progress form and included all information on the Clinical Psychotropic Progress Note (CPPN).
The form was clearly marked “Initial Psychiatric Interview” on each of the interviews reviewed.
Two of the three youth had a medication change which was reflected on page three of the
CPPN. All three youth received medication reviews by the psychiatric PMNHP every thirty days
or as prescribed. Page three of the CPPNs included any changes made to the youth’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 71 (Revised September 2022)
medication after the review for two of the three youth reviewed. All elements were included on
the CPPN forms reviewed for all three youth. The program does not utilize tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures for a suicide prevention plan and includes
suicide prevention procedures. The plan included identification and assessment of youth at risk
of suicide, staff training, suicide precautions, levels of supervision, referrals, communication,
notifications, documentation, and immediate staff response. The plan also includes all elements
of the review process for suicide attempts and mortality reviews. The suicide prevention plan
was reviewed and signed by the program director and designated mental health clinician
authority on June 24, 2024.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Seven youth mental health and substance abuse records were reviewed for suicide prevention
services. One of the seven youth were applicable for review. Two additional records were
provided for review to make a total of three records applicable. All three youth were determined
to be at-risk through staff observation. One of the precautionary observation (PO) logs did not
have a staff statement as to why the youth was placed on PO. The designated mental health
clinician authority (DMHCA) and program director were notified. All three youth received an
Assessment of Suicide Risk (ASR), which was documented on the Department’s form. Two of
the youth were placed on one-to-one supervision and the third youth was placed on constant
supervision. Two of the three initial ASRs included documentation the parents/guardians were
notified of the youth’s potential suicide risk. One youth was involved in the Department of
Children and Families (DCF). The ASR included documentation the DCF caseworker was
notified. A review of the ASRs showed none of the assigned juvenile probation officers (JPO)
were notified of the risk status for each youth. It was documented the mental health staff
provided supportive services. Two of the ASRs were completed by non-licensed staff who work
under a licensed mental health professional. The third ASR was completed by the DMCHA. One
youth was moved to close supervision after the initial ASR, one youth was placed on Baker Act
status, and the third youth was continued on PO. All three ASRs were completed within twenty-
four hours of screening and/or behaviors observed. The non-licensed mental health staff
conferred with the DMHCA and program director prior to the youth being moved to close
supervision. A follow-up ASR was completed for all three youth prior to each youth being
removed from PO and transitioned to close supervision. The reviewed follow-up ASRs were
documented on the Department’s form. All three youth were maintained on the level of
supervision until a follow-up ASR was completed and noted the level of supervision could be
discontinued and stepped down to close supervision. Close supervision was maintained for all
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 71 (Revised September 2022)
three youth until it was determined to be no longer necessary by the DMHCA and a conference
was held with the program director. The evidenced showed the program is following the written
suicide plan. A review of the Department’s Juvenile Justice Information System (JJIS) revealed
one of the three youth had an alert entered and when the youth was placed on PO. This alert
was also closed properly in the system. One youth did not have an alert entered in JJIS. The
system was down when the third youth was placed on PO; therefore, an alert could not be
entered. There was evidence in the program logbooks of each youth being placed on PO to
include any instructions related to the ASR findings and decisions. All three youth were allowed
to participate in specific activities while on PO, which was documented in the designated safe
housing portion of each ASR and follow-up ASR. Three days of video review was conducted to
ensure youth were being properly observed while on suicide risk. There were no issues noted
regarding the observations.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “Non-
Applicable.”
3.13 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.
Seven youth mental health and substance abuse records were reviewed for suicide precaution
observation (PO) logs. One of the seven youth were applicable for review. Two additional
records were provided, for a total of three records. All three records included documentation the
PO logs were maintained for the duration each youth was on suicide precaution. A review of the
PO logs revealed supervision, and observations were documented in real time and not
exceeding thirty-minute intervals. Two of the three youth had documented warning signs on the
PO logs. All PO logs were reviewed and signed by each shift supervisor as evidenced by
signatures and dates on each PO log.
3.14 Suicide Prevention Training (Critical) Failed 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 four suicide response kits, which include the knife-for-life, wire cutters,
and needle nose pliers. The kits are located in each laundry room of the dorms and one in the
administration building. All suicide kits are co-located with first-aid kits. All fourteen reviewed
staff members received training for suicide prevention. A review of suicide drills revealed they
were reviewed with staff no less than quarterly on all shifts. The drills were not simulated with
the staff during the annual compliance review period. An informal interview was held with the
program director and assistant program director. The assistant program director stated the drills
are written out and reviewed with staff. When the review was completed, the staff signed the drill
sheet. The program director stated the staff were re-trained on simulated drills last year. All
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 71 (Revised September 2022)
scenarios included suicide attempts or serious self-injury. Due to the drills not being simulated,
there has not been practice of cardiopulmonary resuscitation (CPR) semi-annually. The program
director was interviewed regarding suicide prevention training. The program director included
the program’s policy and procedures for suicide drills. Seven staff were interviewed about
medical emergency and suicide drills. One staff reported being involved in the drills once a
month. Six staff did not provide definitive answers regarding when drills were conducted. One
reported every six months, but had not participated in the drills yet, one staff could not
remember, one staff stated they are done frequently, but was not sure how often. Another staff
reported participating in them rarely, not ever month, one staff reported being involved in a fire
drill about a month ago, and the sixth staff reported they have participated in drills “here and
there”.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a combined mental health crisis intervention and emergency mental health
and substance abuse services plan, which was provided for review. The required elements,
notification and alert system, means of referral, communication, supervision, documentation,
and review procedures were all included in the plan.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Seven youth mental health and substance abuse records were reviewed for crisis assessments.
One of the seven youth were applicable for review. The program had one other youth who was
applicable for review and the youth record was provided for a total of two records. Both records
included documentation a Crisis Assessment was conducted within twenty-four hours for each
youth based upon the youth’s needs. The reviewed Crisis Assessments included the following
elements for both youth: reason for assessment, mental status examination and interview,
determination of danger to self and others, initial clinical impressions, supervision and treatment
recommendations, recommendations for follow-up, and notification to parents/guardians. Both
Crisis Assessments were completed by the designated mental health clinician authority
(DMHCA). One youth had an alert entered timely within the Department’s Juvenile Justice
Information System (JJIS). The second youth did not have an alert entered timely. Both youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 71 (Revised September 2022)
remained on alert until a follow-up Crisis Assessment was completed. One-to-one supervision
was documented on the Department’s Mental Health Alert-Observation Log for the duration the
youth were at-risk. One of the two youth were placed on Baker Act status. Once the youth
returned from the center, the youth was placed on constant supervision until a mental health
clinical staff reviewed the off-site assessment and provided a Follow-Up Crisis Assessment.
Both youth had a Follow-Up Crisis Assessment conducted by a non-licensed clinical staff, and
each were reviewed and signed by the DMHCA. Neither of the youth were involved in a Prison
Rape Elimination Act (PREA) incident.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a combined emergency mental health and substance abuse plan and crisis
intervention plan, which was provided for review. The plan included immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services, transport for emergency Mental Health Evaluation and/or
Substance Abuse Treatment under Chapter 397, documentation, training, and review.
3.18 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.
Seven youth mental health and substance abuse records were reviewed for Baker and/or
Marchman Act documentation. None of the seven records reviewed were applicable and
therefore a request was made for additional applicable youth records. The program had two
additional applicable youth sent off-site for a Baker Act during the annual compliance review
period. When each youth was determined to need emergency care the designated mental
health clinician authority was immediately notified and the youth were placed on precautionary
observation. Both youth were taken out of the program and transported by local law
enforcement as authorized by the program. When the youth returned to the program, both were
placed on precautionary observation and received a mental status examination as evidenced by
documentation in the records. The Assessments of Suicide Risk (ASR) were completed by non-
licensed staff and were reviewed by the DMHCA. The youth’s level of supervision was
maintained until an appropriate assessment was conducted.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Seven youth mental health and substance abuse records were provided for review of safety
plan documentation. All seven youth records included documentation a safety plan was
completed within fourteen days of admission. All seven plans included documentation the plan
was jointly prepared by the youth, parents/guardians, and clinical staff. The reviewed safety
plans included recommendations from current clinical assessments and screenings. Six of the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 71 (Revised September 2022)
seven youth had their safety plans updated every thirty days. One youth was missing an
updated safety plan for one month. An informal interview with the designated mental health
clinician authority (DMCHA) and therapist indicated the therapist was out of town during the
month’s treatment team meeting and therefore the safety plan was not updated. All reviewed
safety plans included warning signs, baseline behaviors, crisis recognition, coping strategies,
intervention strategies preferred by the youth, and a debriefing process. Safety plans are
reviewed by all staff who have contact with the youth. Safety plans are in the youth records and
master control. Seven youth were interviewed and all reported participating in the development
of their safety plans.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 71 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The designated health authority (DHA) is a licensed physician and holds an unrestricted license
meeting all requirements for independent and unsupervised practice in the State of Florida. The
DHA’s license expires January 31, 2027. The DHA has specialty training in family practice.
There was no indication the DHA had any disciplinary cases or public complaints on record. The
program does not employ a physician’s assistant (PA) or advanced practice registered nurse
(APRN). The contract stipulates the DHA must be on-site at least once a week for a minimum
duration of two hours a visit. A review of sign-in/out logs during the annual compliance review
period confirmed the DHA was on-site at least once a week, except for one week. The DHA was
on vacation the week of Independence Day and utilized the back-DHA this week. The back-up
DHA holds an unrestricted license and meets all requirements for independent and
unsupervised practice in the State of Florida. The back-up medical doctor license expires
January 31, 2027. The DHA conducted all administrative duties. There was no indication the
program used any type of tele-medicine services during the annual compliance review period.
An interview with the DHA revealed they perform comprehensive physical assessments (CPAs),
reviews policy and procedures, helps develop medical policy, conducts chronic clinic
evaluations, reviews records from outside tests, and ensures medical providers are available.
The DHA also conducts acute care medical visits if indicated or referred by nursing staff. The
DHA is on-site weekly and communicates with the program by telephone, text, and email. The
DHA is available by personal cell phone twenty-four hours a day, seven days a week. The DHA
provides on-site clinical services. The DHA reviews all off-site care findings, paperwork,
instructions, and signs and dates the information once he has reviewed it. The DHA is physically
available at the facility weekly and meets with nursing staff to see youth and review any
pertinent issues.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a total of three registered nurses (RN) and one licensed practical nurse (LPN)
for all on-site coverage. Licensed healthcare professionals provide direction to the LPN and
review all medical cases daily with the LPN, including on-call consultation. All nurse licensure
credentials were clear and active, according to Florida Department of Health (DOH). Two of the
licenses are valid through April 2026, one valid through July 2025, and one valid through
December 2025. All nursing staff have a current cardiopulmonary resuscitation (CPR)
certification. According to the contract, the required on-site hours for nursing are: Health Service
Administrator (HSA) for forty hours, and RN for eighty hours weekly. A review of the work
scheduled confirmed the hours are met.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 71 (Revised September 2022)
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) conducted an annual review of all treatment facility
operating procedures (FOP). The DHA last signed and dated the FOPs on January 9, 2025. The
program director also conducted an annual review, signed, and dated the treatment FOPs on
January 9, 2025. In addition, the psychiatrist completed an annual review, signed, and dated the
respective treatment FOPs on April 24, 2024. A review of the nursing staff found one nurse had
not reviewed, signed, and dated the cover page on which the medical FOPs were listed. This
nurse is on call only and has not worked since November 2024. The FOP was revised on
January 4, 2025. Two newly employed health care staff received a comprehensive clinical
orientation to the Department’s health care FOP, which was given by a registered nurse. A
review of approved treatment protocols and standing procedures was authorized by the DHA,
as required.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of an Authorization for Evaluation and Treatment (AET) form. Six of the seven youth were
applicable for an AET; the remaining youth was in the custody of Department of Children and
Families and had a court order filed in IHCR as required. Each of the six youth had either an
original AET or one stamped with the word “copy” and filed within the IHCR, as required. One of
the six AETs was for a “youth over 18 years of age,” which documented the release of
information and did not require a parent/guardian signature. The remaining five AETs had
parent/guardian signatures, and there was no indication a parent/guardian refused to sign the
AET. All six AETs were signed by a department representative. All AETs were observed to be
valid.
An interview with nursing staff revealed the policy for obtaining a new or current AET is to obtain
it from the Department’s Juvenile Justice Information System (JJIS); if it is not available, contact
will be made with Juvenile Probation Officer (JPO) to obtain a current AET. Documenting youth
consent for those aged eighteen years or older involves having them sign an AET for those
eighteen years of age or older.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of the parental notification/consent. Four of the seven youth were applicable for parental
notification of over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). In each of the four applicable cases, there was documentation
of consent provided by the parent/guardian. All four youth had written notifications sent to their
parent/guardian utilizing the appropriate Department forms. Three of the four youth had
documentation within progress notes noting an attempt to contact the parent/guardian when
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 71 (Revised September 2022)
medication was ordered. The remaining youth was missing documentation when initial new
medication was ordered in progress notes. All four youth were applicable for taking psychotropic
medications upon admission. For each of the youth prescribed psychotropic-type medication,
staff witnessed all telephone call attempts to the parent/guardian, as documented by two nurse
initials at the end of the progress note. Each of the four youth on psychotropic medication,
whether new, discontinued, or significantly changed, had parental/guardian verbal consent
documented on page three of the Clinical Psychotropic Progress Note (CPPN). None of the four
applicable youth reviewed were under the care of the Department of Children and Families
(DCF). All seven youth had documentation verifying the youth’s vaccinations within thirty days of
admission. None of the youth were required to obtain new vaccinations or request a religious
exemption. An informal interview with on-site nursing confirmed the program utilizes the Florida
Shots website or the Department’s Juvenile Justice Information System (JJIS) for verification of
youth vaccinations.
An interview with nursing staff revealed parental notifications are made for OTC medications not
covered by AET, immunizations not covered by AET, changes in youth medical status, off-site
emergency care, hospitalizations, surgeries, invasive procedures, and off-site medical
treatment. Guardians are contacted within twenty-four hours of obtaining new orders for youth.
In the case of an emergency, guardians are contacted once the youth is stabilized. The guardian
is contacted immediately, followed by a written notification when the youth has an illness or
injury requiring medical service. All verbal attempts, contacts, consents are documented and are
followed up by a written consent form. Two nurses are required for consent. If a youth needs
vaccination, they are taken to the Jackson County Health Department. Immunization records
are obtained through the Department’s Juvenile Justice Information System (JJIS); if not
available, the Florida Shots portal is utilized, and vaccinations are reviewed as soon as they are
received. The guardian must complete the Religious Exemption From Immunizations’ form
provided by the Jackson County Health Department, have it signed, and submit the form to the
program.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of healthcare admission screening and rescreening form. Each of the seven IHCR’s contained a
Facility Entry Physical Health Screening (FEPHS) form, which was completed on the date of
admission. Five of the seven FEPHS were completed by a registered nurse (RN), and the
remaining two were completed by the licensed practical nurse (LPN). None of the FEPHS were
completed by direct care staff. None of the seven youth were applicable for a change in custody
lasting greater than twenty-four hours.
An interview with nursing staff revealed medical staff are to see youth within twenty-four hours
of admission. New youth are brought to medical immediately for an admission intake screening.
Licensed medical staff complete the admission screening. A FEPHS re-screening shall be
conducted every time the youth leaves the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 71 (Revised September 2022)
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of youth orientation to healthcare/education services. All youth had documentation for the
completion of orientation to healthcare services upon admission to the program. The youth’s
orientation included all necessary topics and was signed by each youth and healthcare staff,
acknowledging the completion of orientation. Health Education is conducted monthly by the
director of nursing (DON), as stipulated in the contract. Health Education includes all necessary
topics and is documented in each youth’s IHCR, as required.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of notification to the designated health authority (DHA) and/or designee. Five of the seven youth
were found applicable for having a chronic condition. None of the five youth were identified as
in-need of emergency care upon admission. All five youth had documentation of a referral being
sent to the DHA within twelve hours of the youth’s admission. Three of the five applicable youth
were taking psychotropic medication upon admission, while the remaining two did not take
psychotropic medication. The three applicable youth admitted on psychotropic medications had
documentation of the psychiatrist being notified.
An interview with nursing staff revealed for youth admitted with serious or chronic conditions,
the DHA is notified immediately upon admission. Licensed medical staff conduct the notification,
and all notifications are documented in the chronological 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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of the Health-Related History (HRH) form. All seven reviewed youth IHCRs contained an HRH
completed within seven calendar days of admission. Each of the seven reviewed HRHs was
completed prior to completion of the Comprehensive Physical Assessment (CPA); as evidenced
by signature and date. All the HRHs were reviewed by the designated health authority (DHA);
this was indicated by the checkbox on the CPA. An interview with nursing staff revealed the
HRH is completed by licensed medical staff and is completed before or at the time of the CPA.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 71 (Revised September 2022)
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of a Comprehensive Physical Assessment (CPA). All reviewed CPAs were completed on the
Department’s CPA form, as required. All seven youth had a current CPA on file at the time of
admission; however, the program’s facility operating procedures indicate a new CPA will be
completed regardless of whether one is in the youth’s IHCR at the time of admission. All seven
reviewed CPAs were completed within seven calendar days of the youth’s admission to the
program. Each of the new CPAs was completed by the designated health authority (DHA). All
seven reviewed CPAs documented the correct medical grade. Six of the seven CPAs indicated
a gynecological examination was “not medically necessary”; therefore, no consent or refusal
form was required. The remaining youth did not have “youth refused,” “not medically necessary”
or similar term on the CPA as required; however, after further review, it should have been
marked “not medically necessary.” None of the youth had a gynecological examination
completed. All youth had their signatures documented on CPAs. Each section of the CPA was
marked respectively with an “O” or an “X” accordingly. Five of the seven youth had the
Department’s problem list updated, as required. The remaining two youth were not applicable
for an update. All seven youth had at least one verified tuberculosis skin test (TST) documented
in the IHCR. All TST results matched on the CPA and Infectious and Communicable Disease
(ICD) forms.
An interview with nursing staff revealed a new CPA is conducted within seven days of
admission to program. A new CPA is conducted after one year at program with chronic
conditions and every two years for no chronic conditions. TB screenings shall be completed
within seventy-two hours of admission if they have not been completed in last twelve months.
For female youth, gynecological exams are not routinely completed due to the absence of
clinical indications by the DHA or youth refusals.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of sexuality transmitted infections (STI) screening. All seven youth were screened and evaluated
for STIs. Five of the seven youth were applicable for further evaluation and were referred to the
designated health authority (DHA). Three youth refused further testing and signed a refusal form
located in their IHCR. The remaining two youth were referred to the DHA, and the referral was
documented on the STI screening tool. In each of the cases, testing was ordered and
performed. One youth had testing, and results documented on the Infectious and
Communicable Diseases (ICD) form while the other youth did not. None of the youth were out of
the Department’s physical custody; therefore, re-screening was not required. All seven youth
were offered Human Immunodeficiency Virus (HIV) counseling, testing, and/or evaluation, as
indicated by a signature on “HIV Youth Consent form” with box checked “yes” or “no” for
consent. One youth consented and received HIV testing. The youth had HIV results filed in a
sealed envelope marked “confidential.” The sealed envelope was signed by DHA. The youth
received pre/post counseling from a certified HIV instructor from Jackson County Health
Department, which was documented in the Health Education record. The youth’s confidentiality
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 71 (Revised September 2022)
was protected by not including the youth’s HIV status and any other STI diagnosis in the
program’s internal alert system. Pursuant to Florida Statute, Chapter 381, the program has a
policy and procedures which addressed HIV testing results, and are only disclosed to youth and
statutorily identified entities.
Interviews were conducted with seven youth , and six youth stated they could ask for an
HIV/AIDS test, while the remaining youth stated they could not. A review of all seven IHCRs
revealed all seven youth had an STI screening completed at admission, and all signed the
Human Immunodeficiency Virus Youth Consent form with a "yes" or "no" box checked. An
interview with nursing revealed STI Screening tool is used for all youth at admission. Testing is
offered to youth with or without risk factors and is typically performed within twenty-four hours.
The STI Screening tool, The Infectious and Communicable Disease form, and the physician
order form are completed. Youth are re-screened if they have been out of the program's
physical custody for more than thirty days and/or if symptoms are present, using the STI
screening tool. HIV results are kept in a sealed envelope, and proof of the practitioner is
documented on the envelope. "Confidential" is stamped on the outside of the envelope, and
others are not permitted to unseal the envelope. All youth are allowed access to testing and
education. A certified HIV counselor shall conduct the HIV pre-counseling, testing, and post-
counseling. The process is documented using the Health Education Record or Chronological
notes.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of sick call process. All seven youth records were applicable for the sick call review. None of the
reviewed youth presented with similar sick call complaints three or more times within a two-
week period. Seventeen sick calls were reviewed; the youth completed an individual Sick Call
Request form each time. In each of the sick calls, the nurse completed the Sick Call Request
form. Eight of the sick calls reviewed were completed by a licensed practical nurse (LPN) and
were reviewed daily by the registered nurse (RN). The sick calls were each found filed in the
IHCR in reverse chronological order. None of youth had been in restricted housing during the
annual compliance review period. The reviewed sick call forms were documented in accordance
with the Florida Administrative Code. Each sick call reviewed was documented on the Sick Call
Index. All the sick calls were documented on the program’s Sick Call Referral log. The dates
listed on the Sick Call Index corresponded to the completed Sick Call forms located in each
IHCR.
A review of the daily schedule, along with the posted schedule and nurses’ interviews, confirmed
sick call was conducted as required by contract requirements. Sick call hours were posted
outside the medical clinic, in the cafeteria, and in each dorm. Sick call is available seven days a
week, from 8:00 a.m. to 9:00 a.m., 12:00 p.m. to 1:00 p.m., 3:00 p.m. to 4:00 p.m. Licensed
nurses will conduct sick if available; however, the program has procedures whereby the shift
supervisor reviews all sick call requests as soon as possible and within four hours after the
request is submitted. Sick call forms are available to youth in each dorm, cafeteria, and nurse’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 71 (Revised September 2022)
office. An exam table and equipment are used to perform sick calls. No sick calls occurred
during the on-site annual compliance review.
Seven youth were interviewed and two youth stated they can be seen for a sick call request
immediately, while the remaining five youth reported they are seen within one day. An interview
with the nursing staff revealed the youth fill out a sick call request and place it in the box. The
youth are seen within four hours of the sick call being placed. If an LPN conducts the sick call,
then an RN reviews it within twenty-four hours. The DHA does not conduct sick calls on-site.
After three complaints within a two-week time frame, the youth are referred to the DHA. The
program has DHA approved treatment protocols and does not have restricted housing or
confinement.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of an episodic, first aid, and or emergency care situation. None of the youth were applicable for
completion of an episodic, first aid, and or emergency. Three additional youth records were
requested and two were provided. Both youth required on-site episodic care. Each of the
medical incidents was conducted by licensed healthcare staff. The healthcare staff documented
each case in subjective, objective, assessment, and plan (SOAP) format. There were no cases
of episodic, first aid, or emergency being provided by non-healthcare staff. The program’s
episodic and emergency care procedures were reviewed with no issues.
The program maintains sixteen first aid kits, three of which are utilized for transportation. First
aid kits are located in the medical office, each case manager’s office, each dorm, the
administration office, the break room, the kitchen, culinary, education, the supervisor’s office,
and laundry room. Additionally, the program maintains four burn kits located in the medical
office, the kitchen, culinary, and the laundry room. On-site healthcare staff confirmed a monthly
review of first aid kits is conducted to ensure contents are maintained and stored in accordance
with guidelines to prevent expiration and are replenished as needed. A review of three first aid
kits located in the medical office, the break room, and the supervisor’s office confirmed kits are
fully stocked with designated health authority (DHA) approved contents. Additionally, a review of
monthly tracking sheets demonstrated on-going monitoring of first aid kits occurs as required.
The program has one automated external defibrillator (AED) which is kept in the supervisor’s
office. The operating procedures for the AED are located with the AED in supervisor’s office and
in the medical office. Nursing staff check the AED to ensure the batteries and pads are
operable, as evidenced by their daily log sheets. There is no indication the AED is monitored by
an outside provider. The medical staff conducted a self-test on AED with no issues, and the AED
had a green battery indicator light. The AED batteries are due to expire January 2027, and it is
unknow when they were last changed. The AED pads are due to expire in May 2025 and were
last changed in January 2023. A list of emergency numbers was found in the medical office,
accessible to all staff and inaccessible to youth. A sign-in sheet dated January 30, 2025,
confirmed fifteen supervisors and team leads were appropriately trained in the administration of
the epinephrine auto-injector. The training was conducted by the director of nursing (DON). A
total of seven staff training records documented the completion of episodic, first aid, and
emergency care training.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 71 (Revised September 2022)
A review of the program’s episodic, first aid, and/or emergency care drill documentation
reflected drills were completed on each of the two shifts. The drills were completed monthly
during the annual compliance review period and were all documented and maintained in the
medical drill binder. All direct care staff participated in at least one drill, which included the use
of cardiopulmonary resuscitation (CPR). A video review of six medical and suicide drills
indicated none were simulated and were just reviewed with staff. Additionally, the drills did not
simulate an episodic care event, which calls for immediate first aid and/or administration of CPR
techniques and the initiation of the emergency procedures to follow when a life-threatening
emergency occurs. The program maintained documentation for all emergency drills. The drills
consisted of unannounced type and were conducted at least quarterly on each shift, as outlined
in contract. No episodic care events occurred during the on-site annual compliance review.
The program maintains a policy and procedures regarding the use and access of Narcan.
During the annual compliance review, it was revealed healthcare staff conduct an inventory of
Narcan on a weekly basis and policy was updated to reflect this information. Narcan is stored in
the supervisors’ office, the medial cart, and the remaining doses in the medical office in a locked
cabinet. Healthcare staff, supervisors, and team leads have access to Narcan. Each staff
member has access to Narcan and has received training as required.
Seven youth were interviewed and six youth stated they can see a doctor or dentist if needed,
while the remaining youth stated they could not see a doctor or dentist if requested. A review of
all IHCRs indicated all youth signed the orientation packet which explained sick call procedures
and all youth have made at least one sick call request. An interview with seven staff was
conducted regarding 9-1-1 calls. Three staff stated they are personally allowed to call 9-1-1 if
the youth have a medical emergency; one staff stated they would call the nurse, and the
remaining three staff stated they would call over the radio to have someone do it. An interview
with nursing staff revealed first aid kit are located in all dorms, the kitchen, medical, laundry,
case manager offices, break room, supervisor's office, culinary, and education closet, for a total
of sixteen kits. On-site episodic care is documented on the episodic form, and the department
form is utilized if non-healthcare staff assess youth. Youth who are sent off-site are tracked
through the episodic logbook.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of off-site care referrals. One youth was applicable for off-site care referrals. Two additional
youth records were requested, and two were provided. All three IHCR reviewed were applicable
and required some type of off-site care. In each instance of off-site care provided, a Summary of
Off-Site Care Consultation Report form was found filed in the youth’s IHCR. One of three was
applicable for off-site emergency care and was documented in the episodic care log. All three
cases had documentation of parental notification efforts. One of the three was applicable for
discharge documents, and the designated health authority (DHA) reviewed and signed the off-
site care findings. One of the three youth required a follow-up appointment and received the
appropriate follow-up care.
An interview with nursing staff revealed youth are tracked by an episodic logbook when sent off-
site for emergency care needs. All off-site summaries and off-site orders must be reviewed and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 71 (Revised September 2022)
then signed off by DHA. Off-site information is flagged in the youth’s IHCR for the DHA to
review. The follow-up testing, referrals, and appointments are documented in chronological
notes indicating the youth received timely follow up care as needed.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of chronic condition periodic evaluations. Five youth were found applicable for having a chronic
condition. All five youth were identified during the Facility Entry Physical Health Screening
(FEPHS) upon admission. None of the youth had been identified as having a communicable
disease. All five youth were taking medication on an on-going basis. Two of the five youth were
undergoing treatment for a physical health condition. Two of the five youth were classified with a
medical grade between two and four. None of the youth were identified as pregnant. All five
were placed on the chronic list; however, one youth was removed prior to the ninety-day review
as chronic issues were resolved. The four applicable youth received a periodic evaluation at
least every ninety-days as required. There was no indication of any youth requiring anti-TB
medication. Each of the four youth had periodic evaluations conducted prior to renewing a
prescription medication which expired. None of the youth required an evaluation to be
conducted off-site; therefore, a designated health authority (DHA) follow-up was not required.
There were no indications of lapses in care or missed periodic evaluations. All five youth had the
Department’s Problem List updated in accordance with Florida Administrative Code.
An interview with the program director revealed medical issues with healthcare staff are
reviewed weekly during the Management Team Meeting. An interview with the DHA revealed
periodic evaluations are a minimum of every three months, but some conditions may require
more frequent evaluations depending on level of care and oversite needed. A log of those youth
with chronic conditions is maintained by nursing staff with dates of next scheduled visit. An
interview with nursing staff revealed chronic conditions are monitored by using log periodic
evaluations performed no less than once every three months.
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.
A review of seven youth Individual Healthcare Records (IHCRs) was conducted for completion
of medication management. All seven youth were found applicable for being admitted to the
program on medication. All seven youth had a completed Facility Entry Physical Health
Screening (FEPHS) form. In addition, prescription verification was included in each of the
youth’s progress notes and the prescription medication verification checklist. The designated
health authority (DHA) and psychiatrist were contacted to resume the specified medications
prescribed prior to admission. All prescribed medications for each of the seven youth had a
current valid order and were administered according to valid prescriptions. All medications
prescribed had a practitioner order form completed by the DHA. The program does not have
restricted housing. Four of the seven youth were applicable for being prescribed over-the-
counter (OTC) medication not listed on Authority for Evaluation and Treatment (AET) form and
were administered according to approved protocols or the Practitioner’s Order unless the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 49 of 71 (Revised September 2022)
parent/guardian prohibited the administration of OTC medications. The Medication
Administration Record (MAR) was used to document all medications and treatments for all
reviewed IHCRs, , which included all information required by Florida Administrative Code. Two
of the seven youth were applicable for receiving medication from trained non-healthcare staff.
Staff and youth initialed each administered medication entry as required. There were no
undocumented explanations for lapses or errors in medication administration. Each youth
reviewed had minimum weekly side-effect monitoring documented on the MAR. Two of the
seven youth were applicable for refusal of medication. The refusal treatment form was signed
each time and placed in youth’s IHCR as required. Each refusal was clearly documented on the
MAR. All seven youth had multiple MARs completed during the annual compliance review
period and a review revealed each had all required elements. None of the reviewed youth
required parenteral medication. Five of the seven youth reviewed were applicable for having
prescribed psychotropic medication upon admission to the program. There was documentation
in the IHCR indicating the psychiatrist was notified of the youth’s admission. The youth received
an initial diagnostic psychiatric interview within fourteen days of admission. All five youth
prescribed psychotropic medications were in receipt of medication monitoring every thirty days
as required. There were no standing orders for psychotropic medications observed. There was
no indication of any emergency treatment orders for psychotropic medications observed. There
was no indication of any pro re nata (PRN) orders for psychotropic medications observed.
A medication administration pass was observed during the annual compliance review. The youth
was escorted to the medical clinic by direct care staff. The youth approached the nurse
administering medication individually. The medical staff identified themselves and the purpose
for the youth’s visit. In addition, the medical staff asked for the youth to identify themselves by
providing their name, date of birth, and allergies. The medical staff also prepared the
medications and reviewed any allergies and alerts with the youth. The Six Rights of Medication
Administration were observed to have been conducted by the medical staff administering the
medication. The prescription medication was never pre-poured from its original packaging and
placed in another container for subsequent administration. The medical staff provided the youth
water and medication. The youth took the medication along with the water and swallowed the
pill. The medical staff had the youth open their mouth and performed a visual check. The
medication pass was documented on the youth’s MAR.
An interview with seven youth was conducted regarding medication administration. Six youth
reported they receive medication from the nurse, while the remaining youth stated they do not
take medication. An interview with nursing staff revealed the process for verifying the youth’s
medication involves reviewing the MAR, verifying with the guardian, and ensuring only
medications from a licensed pharmacy with a current patient specific label are permitted into the
program. The standard Department MAR is utilized. The non-healthcare staff who provided
medication are trained by the director of nursing (DON). Medication pass is conducted from 6:30
a.m. to 7:30 a.m., 5:00 p.m. to 6:00 p.m., and 9:00 p.m. The facility has a modified Class II
pharmacy permit. Medications and prescriptions are procured through a provider.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 71 (Revised September 2022)
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The equipment in the medical clinic classified as sharps was observed to be secured and
inventoried utilizing a routine weekly perpetual inventory. Three sharps were observed and
counted. The final count listed on the program’s inventory matched the actual count observed.
All observed medications were identified and secured in a locked area designated for storage of
medications. The medication cart was observed to be clean and organized. Three over-the-
counter (OTC) medications were observed and counted, and the final count listed on the
program’s inventory matched the actual count observed. Controlled medications were observed
to be stored behind two locks as required. Two controlled medications were observed and
counted, and the final count listed on the program’s inventory matched the actual count
observed. Medications which require refrigeration were stored in a secured refrigerator which is
used for medication only. Supervisory-level, non-healthcare staff are trained by the director of
nursing (DON) in the delivery and oversight of medication administration. A review of the sign-in
sheet confirmed training was conducted on January 30, 2025, for fifteen supervisors and team
leads. The program’s process for the destruction and disposal or return of expired or
discontinued medications is it would go to the pharmacist if it came from the pharmacy. The
pharmacist visits the program monthly. If the medication did not come from the pharmacy, then
two nurses will use the Deterra mixture to destroy medication and document it. If there is a
discrepancy with inventory, then the nurse will try to reconcile count. If there is still a
discrepancy, the program director will be notified, and a call to the Department’s Central
Communications Center (CCC) will be conducted.
An interview with nursing staff revealed the consultant pharmacist will take expired/discontinued
medications back to pharmacy and OTC medications are destroyed. All controlled substances
are kept behind two locks with two different keys. The program has an agreement with a local
consultant pharmacist. They come on-site monthly, and review Medication Administration
Records (MARs), check the medication cart, and conduct quarterly reviews. The program
maintains a copy of the pharmacy consultant’s license on-site.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program’s infection control procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to federal regulations and the
Centers for Disease Control (CDC) and Prevention guidelines. The infection control procedures
were reviewed last by the designated health authority (DHA) February 24, 2024, by the program
director February 23, 2024, by the director of nursing (DON) February 23, 2024. The infection
control practices included all required elements. Hepatitis B immunizations and protective
equipment is available to all staff. There were no instances in which the local county health
department, Center for Disease Control and Prevention (CDC), and/or the Department’s Central
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 71 (Revised September 2022)
Communications Center (CCC) had to be notified for an infectious disease during the annual
compliance review period. The program has an exposure control plan. The written exposure
control plan included all required elements, in addition addresses a process for post-needle
stick exposure. The exposure control plan is available to all staff and located in the medical
clinic and program director’s office. The plan was last reviewed and signed annually by the
program director February 23, 2024, and designated health authority (DHA) February 24, 2024.
The program director has an established separate file maintained for any youth or staff who may
have experienced a facility and or occupational exposure.
An interview with the program director revealed the Exposure Control Plan is located in the
program’s policies and procedures manual and is reviewed annually or as needed. An interview
with nursing staff revealed the Exposure Plan is located in the medical office. The infection
control training is conducted by the DON. Infection control training is provided to youth within
seven days of admission and at least once a year. The Exposure Control training is conducted
by the DON. The Jackson County Health Department is used for routine services. All
medications are kept in a locked medication cart and weekly inventory is performed.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has policy and procedures requiring they provide access to prenatal care for all
pregnant youth Since the last annual compliance review, no pregnant youth have been enrolled
in the program. In the event a pregnant youth is identified, all relevant education will be
documented in each youths Individual Healthcare Records (IHCRs) under the Health Record
section. Non-healthcare staff involved in the supervision or care of pregnant youth will receive
annual in-service training on girls’ healthcare, led by a licensed nurse. This training will cover
topics such as the observation and management of emergency care needs and symptoms
related to potential miscarriage, if applicable. An interview with nursing staff confirmed the
director of nursing (DON) is responsible for providing healthcare education to non-healthcare
staff. Education provided to the youth includes prenatal care, the birthing process, sexually
transmitted infections (STIs), basic baby care, postpartum care, child and infant development,
and parenting skills.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 71 (Revised September 2022)
Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a policy and procedures addressing youth supervision. The program
has a one staff to eight youth ratio during daytime activities and a one staff to eight youth ratio
during nighttime. For the intensive mental health component, the program has a one staff to five
youth ratio during daytime activities and a one staff to five youth during nighttime. The program’s
policy and procedures consider active supervision as the need for a nurturing environment
where staff in direct supervision consistently interacts with youth in a positive caring manner,
consistently monitoring the youth's self-management and any behavioral changes. Staff are to
vigilantly supervise youth, maintain control of youth, and provide for the safety of youth. Staff to
youth ratios were observed during the annual compliance review. Ratios were observed during
movements to and from school, lunch breaks, bathroom breaks, and medication pass, the
program was in compliance with their ratio at all times. An informal interview was conducted
with three random staff. Each staff was able to accurately provide the number of youth being
supervised. The program’s daily activity schedule is posted on each living unit. Visual
observation confirmed youth were engaged in a full schedule of activities. Observation of youth
rooms confirmed there were no obstructions of staffs’ line of sight. Staff observed youth during
sleeping hours as documented on ten-minute check logs.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the implementation of the behavior
management system (BMS). Documentation review confirmed appropriate parties were involved
in the development, implementation, and on-going maintenance of the BMS. There are
protocols in the program’s BMS where staff are provided feedback regarding the implementation
of the BMS. The program’s assistant program director is responsible for providing joint training
with education staff. Seven you case management records were reviewed to confirm orientation
included a review of the program’s BMS. Each record contained evidence of the program’s BMS
was included in orientation. A total of fourteen training records were reviewed to confirm staff
training on the program’s BMS. Each record contained documentation of completed BMS
training. The program’s BMS is posted in each living unit and is accessible to youth. The
program’s BMS is also included in youth handbooks. The program has had no changes or
updates to its BMS during the annual compliance review period. Documentation review
confirmed the program’s BMS contains required elements such as promoting safety, respect,
and fairness, promoting and protecting youth rights, positive and negative consequences,
constructive disciplinary actions and opportunity for positive reinforcement. The BMS further
incorporates recognition of accomplishments and behaviors at a four to one ratio, promotes
socially acceptable means for youth to meet their needs, a process for explaining to youth the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 53 of 71 (Revised September 2022)
reasons for sanctions, youth having the opportunity to explain their behaviors, opportunities for
staff and youth to discuss the impact of behaviors on others, reasonable reparations for harm
caused, discussions of alternate behaviors, promotion of positive dialog and peaceful conflict,
and minimized separation of youth from population. Documentation review of the program’s
BMS confirmed practices such as denial of a youth’s basic rights, promotion of group
punishment, punishment of youth by another youth, increased length of stay, or disciplinary
confinement were not included. Visual observation confirmed staff and youth interactions were
not in adherence to practices. The program’s BMS includes a process wherein staff explain to
youth the reason for sanctions imposed prior to the end of staff’s workday and the youth is given
an opportunity to explain behaviors exhibited and staff and youth discuss the impact behaviors
may have on others, reasonable reparation for harm caused and alternate acceptable
behaviors. Incentives provided by the program include incentive trips, canteen/point store items,
telephone calls, and special activities.
Seven staff were interviewed. Each staff was able to articulate the program's BMS. Each staff
was able to describe the types of rewards the program provides as part of the BMS. Some
examples provided were off campus outings and canteen items. Each staff articulated basic
rights of youth cannot be taken away consequently. Each staff was able to articulate how youth
are informed of the consequences and how youth are able explain their behaviors.
Seven youth were interviewed. Six of seven youth reported consequences for bad behaviors
result in a major behavioral write-up. The remaining youth stated they did not know. All youth
were able to provide examples of rewards which could be earned at the program. Examples
provided were outings, point store items, incentive trips, certificates, and gift bags. Each youth
reported staff are consistent with rewards and consequences they give because of behaviors.
Each youth was able to explain the differences between each level and how they move from
level to level. Each youth reported they are not allowed to punish other youth.
The program director was interviewed and was able to explain and policy and procedures on the
BMS system, how rewards are monitored, how the program ensures rewards outnumber
consequences at a minimum of four to one, how consequences are monitored, and how the
program monitors staff implementation of 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.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated as non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 71 (Revised September 2022)
5.04 Ten-Minute Checks (Critical) Limited Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a total of sixty-two cameras, of which all were properly functioning. The
program’s surveillance system has the capability of maintain recorded footage for a maximum of
thirty days. A sample of video footage, as well as logs from each living area were reviewed for a
duration of thirty-minute increments to verify ten-minute checks were conducted as required. A
total of nine samples of days for video review were completed of youth ten-minute observation
checks. At least four checks were observed for each of these nine days. Six of the nine days
had no exceptions noted. The following exceptions were identified for the remaining three days:
one night had a gap between checks of twelve minutes, one night had a gap between checks of
sixteen minutes, and the remaining night had a gap between checks of fourteen minutes.
Corresponding documentation for all three of these incidents found each of the three staff
documented the checks were done in less than ten-minute increments, thus resulting in
falsification of the documentation. Contact with the Department’s Central Communications
Center (CCC) was made to report the incident. Seven staff were interviewed. Each of the seven
staff reported youth are checked every ten minutes.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures addressing census, counting and tracking of
youth. The program’s policy and procedures dictate youth are always accounted for through a
system of physically counting youth at various times throughout the day. The program will
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. An observation of a head count was conducted during the annual compliance
review. The master control operator called for a headcount. All movement of youth stopped and
headcount for each area containing youth was conducted. The headcount was tallied and an all
clear was given. A review of the program’s logbooks for the annual compliance review period
was conducted. Reviewed documentation confirmed counts are conducted at the beginning of
each shift, after each outdoor activity, and during emergency situations. Each logbook entry
contained documentation of total daily census, headcounts, youth movements, new admission
and releases, and youth temporarily away from the program. Seven staff were interviewed. Six
of seven staff reported counts are conducted every hour. The remaining staff reported counts
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 71 (Revised September 2022)
are conducted often, more than twice a day. Each staff reported a recount is conducted when
headcounts are not reconciled. Each staff was able to explain when emergency counts are
conducted. Some examples provided were when something is suspected to be off, fire drills,
weather drills, and youth escapes.
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 policy and procedures addressing logbook entries and shift reports.
Documentation review confirmed each logbook was bound with numbered pages and all entries
were made in ink with no erasures. There were no entries which were destroyed or removed.
There were no errors which required being stricken through. All entries included dates and times
of events, brief description of events and staff and youth names involved. All applicable entries
requiring notification to the Florida Abuse Hotline or the Department’s Central Communication
Center (CCC) were documented. The program does not store logbooks in living areas.
Reviewed shift reports confirmed each contained a summary of events, incidents, and activities
documented in the program’s central logbook. Review of the program activity schedule and
logbooks confirmed documentation of minimal interference of educational instruction, classes
being conducted as scheduled, youth arriving and departing on time, and recreational activities
being conducted as scheduled. Documentation review confirmed entries of emergency
situations, incidents including the use of restrains, population counts at the beginning and end of
each shift, perimeter security checks, transports away from the program including destination
and names of staff and youth involved, request by law enforcement to access youth, and
admissions and releases. There were no reviewed entries related to the removal of youth from
mainstream population or escapes or attempted escapes.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a policy and procedures addressing key control. Documentation review
confirmed the program’s policy and procedures includes key assignment and usage, inventory
and tracking, secure storage of keys when not in use, procedures for missing keys and
procedures for reporting and replacement of damaged keys. The distribution of keys was
observed during the annual compliance review. Upon arrival to the program, visitors sign in and
provides personal keys to the master control operator. The master control operator then
provides a chit to the visitor in exchange for their keys which are placed in the secure lockbox in
master control. All program keys are maintained within the key lockbox located in master control
except for permanent assigned keys. Restricted keys are specified only for certain staff and
maintained in master control. Staff who are assigned permanent keys will sign an agreement
indicating these keys have been assigned. Upon arrival to the program, staff will provide their
personal keys to the master control operator/supervisor and personal keys will be stored within
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 71 (Revised September 2022)
the lock box. Upon end of shift, staff will retrieve their personal keys from the master
control/supervisor. If separation from the program occurs, the appropriate section within
agreement document will be completed by the safety and security officer. Staff receiving keys
must sign indicating receipt. The master control operator also signs indicating distribution of
keys. Staff personal keys are placed within the lockbox replacing the key ring provided to staff.
Upon return, the staff and master control operator initials indicating keys have been returned.
Documentation of the interaction is maintained in the key tracking log. The program’s key
inventory was reviewed to ensure inventory matched the actual key ring in use. An observation
of the key storage areas was conducted. The storage area is in master control/supervisors’
office. The key storage is secured when not in use. The program’s practice for reporting and
replacing damaged keys is the key control or assistant key control officer is notified. The master
key will be taken to the local hardware store and copied. The replacement key will be placed
back into rotation. In the event of lost or missing keys, the shift leader is immediately notified.
The shift leader notifies the program director and initiates a search. The investigation and
results are documented on an internal incident report and submitted to the program director.
During the scope of the annual compliance review period, the program had a total of two
incidents reported to the Department’s Central Communications Center related to key concerns.
Corrective action of re-training was provided to staff. A sample of key rings were observed and
compared to the key inventory. Each key ring observed matched compared to the inventory.
Three staff were informally interviewed in reference to their assigned keys. Each staff was able
to correctly identify the number and function of each key. Seven staff sere interviewed and each
was able to articulate the program's process for personal and program 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
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 policy and procedures addressing the introduction of contraband into
the program. The program’s policy and procedures define items which are considered
contraband. The program provides youth with a list of items which are considered contraband
and informs youth of consequences if found with contraband which are located within the youth
handbook provided during intake. The program policy and procedures address search of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 71 (Revised September 2022)
physical plant, the facility grounds, searching youth, and searching incoming and outgoing mail.
The program’s visitation log contains a contraband attestation statement. The program hired a
total of fourteen new staff since their last annual compliance review. All fourteen new
employees’ records contained a signed contraband attestation form. The program’s policy and
procedures address any staff who is found in possession of contraband will be subject to
disciplinary action including dismissal as outlined in Florida Administrative Code and law
enforcement is contacted if any item considered illegal contraband is found. The program’s
policy and procedures clearly delineate items which are considered contraband. The program
maintains documented evidence of confiscated contraband. Confiscated items of contraband
found discovered on youth is maintained in the youth’s record. A review of the Department’s
Central Communications Center confirmed the program had one reported incident of illegal
contraband being discovered and the item was turned over to law enforcement. Documentation
review confirmed non-illegal items of contraband was documented within youth case notes. A
review of the program’s facility logbooks and search reports confirmed the frequency, quality,
and results of searches.
The program director was interviewed and was able to explain and provide policy and
procedures regarding how contraband and illegal contraband is handled and disposed. Seven
staff were interviewed, and each staff was able to articulate the process for youth room
searches. Staff indicated rooms are searched at least every shift, randomly, every day, and
whenever youth are returning from school.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures addressing searches ensuring no contraband is
introduced into the facility. Youth were observed being searched prior to and returning from
school, return from transport, return from off-center activities, and after access to tools or
equipment. During the search process, youth were observed being treated with and respect. All
searches were conducted by the appropriate number of staff and gender. Searches were
determined to be thorough. Staff explained the purpose and the extent of the search to youth.
Each search was conducted as required by the Right Interactions manual. Youth searches were
not able to be observed during visitation hours, admission, prior to transports, and prior to
access to equipment and tools as they did not occur while the review team was on-site. Video
observation of staff and visitors was unable to be observed as the program does not have
surveillance equipment located in the visitor/staff entry area where searches are conducted.
Seven staff were interviewed. Each of the seven staff reported youth are searched after every
movement. Seven youth were interviewed. Each of the seven youth was able to articulate when
they are searched. Examples provided were when going and coming, every day, a lot when
going from one place to another, and every time we walk out the door.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 71 (Revised September 2022)
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures addressing proper maintenance and
documentation of vehicles used to transport youth. The program has four vehicles which are
used to transport youth. A total of five staff vehicles and the four program vehicles were checked
to ensure they were properly secured when not in use. Each vehicle was properly secured and
locked when not in use. There was documented evidence which confirmed an annual inspection
of each vehicle, identified and corrected deficiencies, and each contained maintenance records.
Visual observation confirmed each vehicle contained an annually inspected fire extinguisher,
Department approved first aid kit, seatbelt cutter, window punch, and appropriate number of
seatbelts. All youth passenger areas doors were unable to be opened from the inside. None of
the program transport vehicles required a safety screen.
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 policy and procedures addressing transportation of youth ensuring
staff to youth ratio, and safety and security of staff and youth. Based on the program’s policy
and procedures, and informal interviews, a cellular telephone and or communication device is
issued to the transporter. The program’s policy calls for a one staff to five youth ratio, excluding
the driver. Visual observation following a transport confirmed the appropriate staff to youth ratio
and there was one staff of the same gender on the transport. Youth and staff were observed
wearing seatbelts and no youth was attached to any part of the vehicle. The program’s practice
to ensure staff operating a vehicle has a current and valid driver’s license consists of the human
resources (HR) manager compiling a list of each employee once a year. From the compiled list,
the HR manager takes note of each employee’s license expiration date. The program is
automatically notified by the Florida Department of Motor Vehicles when an employee becomes
disqualified.
Seven staff were interviewed. Six of seven staff reported youth are secured with a seatbelt. The
remaining staff reported they have never participated in a transport. Each staff reported a
cellular phone is provided to transport staff. Six of seven staff was able to articulate safety
equipment in a transport vehicle. Staff provided examples such as handcuff key, knife for life,
first-aid kit, gloves, mask cellular phone, and window punch. The remaining staff was unable to
provide examples and reported they had never participated in a transport. Each staff reported
staff are not allowed to use personal vehicles to transport youth. Each staff reported transport
vehicles are searched for contraband after each use. Each staff was able to explain the
emergency response process during transport and the staff to youth ratios during transport.
Seven youth were interviewed. Six of the seven youth reported never being handcuffed to any
part of the vehicles. The remaining youth reported they have never been on a transport. All
youth reported never having seen anyone place contraband in a transport vehicle.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 71 (Revised September 2022)
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 policy and procedures addressing weekly safety and security audits to
ensure a safe and secure physical plant, grounds and perimeter. The program’s policy and
procedures indicate who is responsible for conducting weekly security audits and safety
inspections. These duties are assigned to the assistant program director. The program’s policy
and procedures include the development and implementation of corrective actions warranted
because of safety and security deficiencies identified during inspection, and an internal system
which verifies deficiencies are corrected and existing systems are improved, or new systems put
in place as need to maintain compliance. Documentation review for the annual compliance
review period was conducted and confirmed weekly safety and security audits were conducted
as required, and preventive maintenance schedules and repairs were conducted as outlined in
Florida Administrative Code. Confirmation was also provided by the residential safety and
security specialist.
The program director was interviewed and reported the safety and security officer will conduct a
weekly audit which is documented on the facility security audit and safety inspection form. Any
deficiencies found during the audit or safety inspection will be documented in the section
provided, and an anticipated date of correction documented. The information is also logged on
the facility maintenance action plan which is reviewed by the program director or assistant
director weekly and then monthly during the monthly facility call with Department. A
maintenance request will be submitted if applicable to the maintenance supervisor and noted on
the audit form for tracking purposes. Additionally, it is the role of the assistant director or safety
and security officer to ensure safety and security deficiencies are identified and resolved in a
timely manner, failure to do so may result in a written reprimand at the program director's
discretion. Safety and security deficiencies which are identified and not resolved in a timely
manner may result in a written reprimand at the program director's discretion.
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 policy and procedures addressing tool inventory, issuance, control,
and management to ensure youth do not use tools or equipment as weapons or security
breaches. All tools are inventoried prior to and following work activities, and all tools which are
pointed or contain sharp edges are inventoried daily. Machetes, bowie knives or other long
bladed knives are prohibited. The program’s procedures for missing tools calls for immediate
notification of the tool control manager to include a written tool report completed by supervising
staff. All youth who have access to the tool will be held at their respective work site until a
thorough search has been conducted. If it is determined the missing tool has been linked to
reportable incident, the Department’s Central Communication Center will be notified within the
required timeframe. In the event a tool becomes dysfunctional or otherwise broken, a tool report
must be submitted to the tool control manager by the end of the workday. The dysfunctional tool
will be immediately removed and turned into the tool control manager along with the tool report.
If the tool is repairable, the tool control manager will submit a maintenance request or repair the
tool. If the broken tool is not repairable, the tool control manager shall submit a purchase
request to the site administrator. Tools identified as being dysfunctional or unsafe must be
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 71 (Revised September 2022)
disposed away from the program. Tool disposals are only completed by the tool control
manager. The tool control manager will maintain a tool disposal log which will document each
time a tool is removed. A total of ten tools, four from the kitchen, three from culinary, and two
from living units were reviewed to compare with inventory. In each area, all tools were secured
and had marking for easy identification. The inventory, which is tracked daily, was compared to
actual items present. Observation confirmed the inventory in each area for each item was
accurate.
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 policy and procedures ensuring youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures contain all
required elements including supervision requirements, tool issuance to staff and youth including
an assessment of youth’s risk, established ratios, tool distribution and collection, and search
criteria during work projects. The program has a one staff to five youth ratio during activities
requiring tool usage, including vocational training. The program does not participate in
completing disciplinary work projects. During the annual compliance review, an observation of
distribution and tool usage was unable to be observed. A visual observation of youth being
searched after return from work projects was conducted. No issues with search procedures and
ratios were observed. Seven youth records were reviewed for included documentation ensuring
proper training on the intended and safe usage of tools. Six of seven youth records contained
documentation of a completed risk assessment. The remaining youth record did not contain a
completed risk assessment as the youth is currently an escape and security risk. The youth is to
be assessed after being appropriately re-assessed for escape and security risk. Seven staff
were interviewed, and each staff reported youth are allowed to use mops and brooms. Seven
youth were interviewed. Each of the seven youth reported the only tools they were allowed to
utilize was mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures addressing requirements for outside
contractors. The program’s policy and procedures state all outside contractor will be required to
read the program's tool control policy and sign an agreement letter to become a vendor. The
business card of the vendor shall be attached to the signed agreement. Vendors should
maintain a personal inventory of all tools before working. The contractor should always keep
their tools with them or in clear view and should not allow youth to handle any tools. Before
leaving, the vendor will complete a tool verification form indicating all tools are secured and
accounted for. A sample of three sign-in sheets for outside contractors was reviewed. Each
sign-in sheet included the vendor’s name and company represented. Each sign-in sheet also
contained the number and type of tool being utilized on the job. Each sign-in sheet contained
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 71 (Revised September 2022)
signature of vendor upon departure and ending tool inventory count. The program’s guidelines
for outside contractors includes tool check in upon arrival and departure, tool restrictions, youth
restriction from work area and missing tool follow-up. A sample of three project invoices were
reviewed. Two of three completed invoice dates and vendor sign in dates matched. The
remaining vendor completed invoice date did not match the vendor sign in date of service
completed. An informal interview was conducted with the assistant program director who
reported the program at times does not receive vendor invoices on the date of completed
service. Documentation review confirmed the program inventoried the tools and equipment of
vendors upon arrival and departure. Personal cell phones/electronic devices with picture, audio
and video functions are prohibited.
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 policy and procedures addressing fire, safety, and evacuation drills.
Documentation review confirmed the program conducts Continuity of Operation Plan (COOP)
drills monthly on each staffing shift monthly on a rotating basis. Documentation review
confirmed the type of drill, date, time, participants, brief scenario, findings, and
recommendations were included within drill documentation. Visual observation confirmed fire
evacuation routes and egress plans were posted throughout the program. The program has a
total of twenty-four fire extinguishers. Documentation review and visual observation confirmed
the annual inspection.
Seven staff were interviewed. Six of seven staff reported having participated in fire drills. One of
the six staff also reported having participated in tornado drills. The remaining staff reported
having participated in an emergency drill related out of control youth. Seven youth were
interviewed. Six of seven youth reported they have been instructed on what to do in case of a
fire. The remaining youth reported they have not been instructed on what to do in case of a fire.
Two of the seven youth reported drills are conducted every two weeks. One of seven youth
reported drills are conducted once a month. One of seven youth stated they have participated in
drills four times since admission. One of seven youth reported having participated in drills twice
since admission. One of seven youth reported having not participated in a drill in a while. The
remaining youth gave no response. The program director was interviewed and reported the
conducts fire, safety, and evacuation drills to ensure youth and staff are prepared for immediate
implementation or mobilization in the event of an emergency or a disaster. Drills are conducted
monthly to include “mock” mental health drills, which are done quarterly. The program conducts
a wide variety of emergency drills at various times and on each shift.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 71 (Revised September 2022)
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 Disaster and Continuity of Operations Plan (COOP). The program’s
(COOP) plan is readily available to staff, and a copy is in the program director’s office, the staff
training area, medical, supervisors’ office, clinical director’s office, and in human resources. The
program’s COOP was reviewed and updated on April 19, 2024. The COOP plan addresses
alternate relocation sites approved by the Department. The program’s Emergency Disaster
Preparedness Plan and COOP is a combined plan. Review of documentation confirmed the
COOP plan was submitted and approved by the Department’s regional director on May 3, 2024.
The program’s equipment and supplies required are stored in the program’s kitchen and supply
storage areas and include items such as dry goods and toiletries, electronic communication
devices, water, and clothing. The program also maintains an emergency evacuation trailer with
supplies which is located at headquarters. Seven youth records were reviewed critical
identifying information. Each youth record contained all required elements to include youth’s full
name, Department of Juvenile Justice Identification Number, date of admission, date of birth,
fender, race, name, address, contact information of parent/guardian, emergency contact
information, juvenile probation officer contact information, committing judge, state attorney,
public defender contact information, committing offense and circuit, notation of jurisdiction,
physical description, overall health status, and youth photograph. The program utilizes both
hard copy as well as electronic copy youth records and information to be utilized in the event of
an emergency evacuation. The program director was interviewed and reported the COOP is
accessible to staff and is in the program director's office, supervisors’ office, training building,
medical, and human resources office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedures addressing the storage and inventory of
flammable poisonous, toxic items, and materials. The program’s policy and procedures state all
flammable, poisonous, toxic and caustic materials must be stored in secure areas which are
inaccessible to youth. Observation confirmed flammable, poisonous, and toxic items and
materials were always secured and were not accessible to youth. Direct care, administrative,
medical, education and maintenance staff are authorized users of flammable, poisonous, toxic
items and materials. The program’s policy and procedures on the disposal of flammable, toxic,
caustic, and poisonous items state any hazardous materials will be disposed of in accordance
with local and state regulations. An informal interview with the assistant program director was
conducted and informed any materials needing to be disposed of are taken to the local waste
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 71 (Revised September 2022)
management facility. Prearrangements are not required. According to documentation review,
the program’s disposal procedures are in accordance with Occupational Safety and Health
Administration (OSHA) standards. Documentation review confirmed hazardous waste is
disposed of in accordance with Safety Data Sheets (SDS), and hazardous liquid waste is stored
in hazardous materials storage area. According to the program’s policy and procedures, liquid
waste such as dirty mop water and unused beverages are dumped in mop sinks located in the
back storage area of each dorm and in the kitchen. Residual grease is placed in a separate
container for disposal. There were no chemical spills reported by the program during the annual
compliance review period. The program’s policy and procedures include once becoming aware
of a chemical spill, staff shall immediately notify master control of the spill location, the shift
supervisor shall direct the shutdown of air handlers and ventilation system, and close windows
and doors at the discretion of the on-scene supervisor or program director, and outside
assistance shall be contacted as necessary. A sample of inventory of ten items was conducted.
Documentation and visual observation review confirmed the actual count of each item and the
ending count on the inventory matched. All items were secure, and each item contained an
SDS. The program director was interviewed and was able to explain and provide policy and
procedures for the disposal practice of flammable, toxic, caustic, and poisonous items.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures addressing youth handling and supervision for
flammable, poisonous, toxic items, and materials. The program’s policy and procedures state
Youth are not allowed to use, handle or access dangerous or hazardous chemicals or respond
to chemical spills. Youth will not be permitted to clean, handle or dispose of any other person's
biohazardous material, body fluid or human waste. The program maintains strict control of
flammable, poisonous, and toxic items and materials, youth are not allowed to use, handle, or
clean-up dangerous or hazardous chemicals and youth do not clean, handle, or dispose of any
person’s bio-hazardous material, body fluid, or human waste. Youth access to areas where
items are used or stored is restricted. A visual observation of youth during daily cleaning
activities was unable to be conducted. Seven youth were interviewed. Each of the seven youth
reported not having used any chemicals or cleaning products.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 71 (Revised September 2022)
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water related activities; therefore, this indicator is rated
as non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedure addressing visitation and communication for
youth while in the program. The program’s visitation schedule is posted throughout the living
units within the activity schedules. Visitation schedules are also posted within youth handbooks
as well as within orientation packets which are provided to guardian upon youth admission. The
program’s policy and procedures related to visitation, youth correspondence and mail use is to
promote, encourage and enable visitation and communication between youth in the program
and their families or significant others. Youth will have an opportunity to visit with family and
their identified community- based support system. A review of the program’s visitation log and
schedule confirmed the program’s adherence. A review of the telephone logs and schedules
confirmed telephone calls are offered one time per week. Youth are offered the opportunity for
mail correspondence two times per week. The program offers alternate visitation arrangement
when necessary. Review of telephone logs and mail correspondence confirmed youth are given
the opportunity to communicate with family members by mail and telephone. An informal
interview was conducted with case management staff, and it was confirmed the program does
not currently have any active youth who have a history of human trafficking. Outgoing mail is
searched by staff prior to mailing. The program currently uses line language as a third-party
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 71 (Revised September 2022)
language service entity. Seven youth were interviewed. Each of the seven youth reported they
are allowed to call their parent/guardian or send letters. The program director was interviewed
and reported language line as the service in place for youth whom English is not their primary
language.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures which addresses recreation and leisure
activities. The program’s activity schedule documents a range of supervised structured activities
and outdoor recreation and leisure activities for youth at least for one hour a day. The activity
schedules include activities which incorporate large muscle activity. A review of the program’s
logbook indicated recreational actives were conducted as scheduled and activities promote
social and cognitive skill development, creativity, teamwork, healthy competition, mental
stimulation and physical fitness. Observed recreational activities verified the program takes
precautionary measures to prevent overexertion, heat stress, dehydration, frostbite,
hypothermia, and exacerbation of existing illness or physical injury. Youth were observed on the
recreation areas engaging in physical activities. Youth were appropriately attired and
appropriately being supervised. A review of the program’s contract confirmed the requirement of
a recreational therapist. The program’s recreational therapist’s credentials, schedule, and
services provided to youth were reviewed and met all requirements. Seven youth case
management records were reviewed to ensure a recreational therapy goal was included in
performance plans. Each record contained evidence of a recreational therapy goal. Seven youth
were interviewed. Each of the seven youth reported physical activities are provided for at least
one hour. Examples provided by youth consisted of kickball, basketball, football, walking on the
track, volleyball and boys and girls club activities. Seven staff were interviewed. Each of the
seven staff was able to articulate types of activities youth participate in. Examples provided
were kickball, boys and girls club activities, card and board games, basketball, kickball, coloring,
and track walking.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated as non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated as non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 71 (Revised September 2022)
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated as non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 71 (Revised September 2022)
Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
According to the program’s contract, the Career and Technical Education (CTE) services
required to be provided are Digital Information and Foundations of Programming. These trades
are offered during random days and times to avoid conflict with the school schedule. There is
currently one instructor who provide services. The Welding Instructor position is currently open.
The program director reported the position has been vacant for about six weeks. Additionally,
services have not been provided to the youth during this time. Their qualifications include
Florida Vocational Certification. Currently, twenty-nine youth are enrolled in coursework towards
earning an industry certification. Sixty-five youth received each of the CTE services provided
during the annual compliance review. Five youth received their Cardiopulmonary Resuscitation
(CPR)/First Aid certificates￼twenty-three youth received Occupational Safety and Health
Administration (OSHA)-10 certification, and thirty youth have earned the Florida Ready to Work
Soft Skills certificates during the annual compliance review period.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide for educational access. The center
provides education services through Florida Virtual School (FLVS) and the 250-day calendar,
which is distributed over twelve months, including twenty days used for teacher training and
planning was reviewed.
A review of five random dates in the logbook showed the daily class schedule was being
followed. Further review of logbook entries and video footage for three days verified the youth
were attending school as scheduled.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 71 (Revised September 2022)
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS) and the
250-day calendar, distributed over twelve months, including twenty days used for teacher
training and planning. A review of the daily school schedule revealed the center provides six
fifty-minute class periods daily, fulfilling the weekly requirement of twenty-five hours of
instructional time. Seven youth were interviewed, and all seven reported they attend school
Monday through Friday. All seven felt the school was preparing them either well or very well
regarding preparation towards General Education Development platform (GED), high school,
vocational, employment, and/or college. One youth out of the seven stated there are occasional
interruptions during the school day but did not specify what those interruptions were. The
interview with the instructional leader reported there is minimal interference with educational
services.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
the length of stay and classification of youth in the program. The career education program
provided meets the above requirements including Type 2 and Type 3 levels, as well as
communication, interpersonal, and decision-making skills.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The educational provider’s contract indicates they are required to develop an Education
Transition Plan for each youth. The program’s education services are provided by Florida Virtual
School (FLVS), which began their contract on July 1, 2024. None of the closed youth records
were applicable for the current provider as they entered the program prior to July 1, 2024. None
of the current program youth had an Education Transition Plan initiated, as required, by the
FLVS staff. It was reported FLVS has recently created an Education Plan Template and trained
their staff to implement the development of a plan for each youth moving forward.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 71 (Revised September 2022)
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has procedures in place to provide qualified instructional
personnel. Two educational instructional personnel were reviewed, and both had a valid Florida
educator’s certificate with appropriate coverage as provided for in the Course Code Directory. A
review of the Florida Department of Education’s website confirmed both staff had active
credentials. Both teachers were teaching courses out-of-field, and notification letters were sent
out to the parent/guardian by email. The letters addressed the teachers were out-of-field;
however, they did not state which out-of-field subjects were being taught.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The education contract provider is responsible for referring all youth who receive their high
school diploma or equivalent to Florida Youth College so they can work with a career navigator
on postsecondary courses and/or enrollment in a state or technical college. Three applicable
records were reviewed for youth who met the eligibility criteria for a referral to Florida Youth
College, and each was referred as required. The lead teacher was interviewed regarding which
post-secondary pathways are available to youth participating in Florida Scholar’s Academy. The
lead teacher indicated a survey is completed for graduates and youth close to graduating either
through the academic or GED track. Additionally, youth names are placed on a spreadsheet to
Florida Youth College for career navigators to follow-upon.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each referral received by Florida Youth College from the education contract provider is
assigned a career navigator. The career navigator connects with the youth through the
residential contract provider to schedule an orientation session. During orientation, the youth
and career navigator develop a career pathway plan to include postsecondary courses and/or
enrollment in a state or technical college. The career navigator continues to assist youth on their
career pathway plan and have incremental follow up sessions scheduled through the residential
contract provider. For the three applicable reviewed records the Career Navigator continues to
assist the youth on their career pathway plan and have incremental follow up sessions
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 71 (Revised September 2022)
scheduled through the residential provider. Documentation was included in the youth’s records
for the ninety-day follow-up, but not the 180-day follow-up.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 71 (Revised September 2022)

report_type: QI Residential

program_name_raw: DOVE Academy

rule: Indicator 3.14

excerpt: Suicide Prevention Training (Critical)

rating: Failed Compliance

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)

rating: Limited Compliance