state: FL

facility_name: Cypress Creek

summary: QI Residential - FY24-25 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Cypress Creek Treatment Center
TrueCore Behavioral Solutions LLC
(Contract Provider)
2856 West Woodland Ridge Drive
Lecanto, Florida 33461
Review Date(s): January 14-17, 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:
Jeremy Curvan, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (co-lead)
Jeff Campbell, Office of Education, Education Coordinator (Standard 6)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Carlametress Harrell, Office of Education, Workforce Education Coordinator (Standard 6)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 4)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Sandra Thompson, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Cypress Creek Treatment Center MQI Program Code: 1055
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10207
Location: Citrus County / Circuit 5 Number of Beds: 32
Review Date(s): January 14-17, 2025 Lead Reviewer Code: 213
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
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 70 (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 * Satisfactory
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 Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 70 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 70 (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 * Limited
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 70 (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 70 (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 * Satisfactory
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 Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 70 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Indicator Ratings
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Non-Applicable
6.02 Educational Access (Residential Contract) * Non-Applicable
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) 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 9 of 70 (Revised September 2022)
Program Overview
The Cypress Creek Treatment Center is a thirty-two-bed program, for fifteen to twenty-one year
old males, located in Lecanto, Florida. The program is operated by TrueCore Behavioral
Solutions LLC, through a contract with the Department. The program provides mental health
and substance abuse services. In addition, the program fosters each youth by providing
Aggression Replacement Training (ART), Skillstreaming the Adolescent, the Passport Program,
the Bullying Workbook for Teens, Social Perception Training, the Stress Reduction Workbook
for Teens, Problem Solving Training, Empathy and Social Competence Training, Living in
Balance, Resilience Builder Program for Children and Adolescents, and Impact of Crime.
Additional treatment services provided includes family and individual counseling. Program
administration is comprised of a facility administrator, assistant facility administrator of
operations, assistant facility administrator of support services, and a chief of security. Case
management services are provided by one director of case management, six case managers,
one intake specialist and two transition services managers. Mental health staff at the program
includes one contracted psychiatrist, one clinical director, one assistant clinical director, seven
therapists, two recreational therapists, and one file technician. Medical services are offered 6:30
a.m. to 7 p.m. daily and are provided by one contracted designated health authority, one health
services administrator, and four registered nurses. Educational services are provided by the
programs educational staff. The layout of the program includes: one large building which houses
all dormitories, kitchen, classrooms, administration, clinic, offices, controlled observation rooms,
maintenance, mental health, case management, and master control. The program has 121
operating security cameras providing coverage. At the time of the annual compliance review,
the program had twenty-nine vacant positions: twenty-four youth care workers, one dietary
associate, one master control operator, one file clerk, and two unlicensed therapists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures addressing pre-employment background screenings.
An informal interview with the facility administrator (FA) confirmed the program had one new
volunteer who assisted or interacted with youth on an intermittent basis for less than ten hours a
month and did not need to be background screened. The program’s policy requires a staff, who
is background screened, to always be present within the line of sight and sound of the volunteer
who is not background screened. An Annual Affidavit of Compliance with Level 2 Screening
Standards was completed and submitted to the Department’s Background Screening Unit (BSU)
on December 9, 2024, meeting the annual requirement. An annual Affidavit of Compliance with
Level 2 Screening Standards for teachers who are paid by the school board, or funding provided
by the school board or Department of Education, was completed, and submitted to the BSU on
December 12, 2024, meeting the annual requirement. A review of program staff, volunteer, and
contractor rosters found thirty staff were applicable for an initial background screening during
the annual compliance review period. No volunteers were applicable for an initial background
screening during the annual compliance review period. Each of the thirty applicable staff had a
completed and eligible background screening, as required, prior to contact with youth and
confidential youth records. Reviewed documentation validated a criminal history report was
reviewed for each staff. A pre-employment assessment tool was administered for each direct
care staff and a pre-employment assessment passing score was documented in each reviewed
direct care staff record. All thirty staff were added to the program’s roster in the Agency for
Healthcare Administration’s Clearinghouse system, as required. None of the thirty staff reviewed
had a break in service.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures addressing five-year background rescreenings for
staff. The program had six staff and two contracted staff applicable for a five-year rescreening
during the annual compliance review period. All eight applicable staff received a five-year
rescreening within the required time frame and the rescreenings were submitted to the
Department’s Background Screening Unit (BSU) at least ten business days prior to the five-year
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 70 (Revised September 2022)
anniversary date, as required. There were no volunteers applicable for a five-year background
rescreening during the annual compliance review period.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure program-related incidents which place at
risk or have the potential to place at risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. The program has a zero-tolerance policy
regarding any abuse. All staff shall immediately report any knowledge or suspicion regarding an
incident of abuse which occurred in the program by calling the Florida Child Abuse Hotline, and
additionally the notification is made to the Department’s Central Communications Center (CCC)
and their regional director. The program had three incident reports of claims against staff for
physical abuse or emotional. The program conducted the Trauma Response and Caring
Environment self-assessment (TRACE) on February 13, 2024. Staff adhere to the program’s
code of conduct, as acknowledged by the review and signing of a Code of Conduct form during
their orientation and are contained in the staff personnel records. Seven staff Code of Conduct
forms were reviewed, and all seven forms were signed by staff. Seven reviewed pre-service and
seven in-service training records reflected staff received training on child abuse reporting.
During the facility tour, the Florida Abuse Hotline and CCC telephone numbers were posted
throughout the facility. All seven interviewed youth reported they feel safe in the program. All
seven youth reported they have never been prevented from making a call to the Florida Abuse
Hotline. All seven youth reported either knowing the telephone number for the Florida Abuse
Hotline or knowing where it was posted. All seven youth reported staff are respectful when
talking with youth. None of the seven youth reported hearing staff curse around youth, nor have
they ever exchanged emails, telephone numbers, or social media contact information with staff.
Each of the seven interviewed staff were familiar with the program’s abuse reporting
procedures. All seven interviewed staff reported they have never observed a co-worker denying
a youth the right to report an abuse incident, and all seven reported they have not witnessed
their coworker’s using profanity, using threats, intimidation, or humiliation when interacting with
youth. The facility administrator (FA) reported the program’s code of ethics directs staff to
provide youth with quality care and promotes excellent customer service and states the abuse
of youth (verbal or physical) will not be tolerated. Staff are provided new hire training and
discussions take place in all staff meetings to ensure staff are knowledgeable in contacting the
Florida Abuse Hotline and CCC. The youth handbooks and youth information boards contain
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 70 (Revised September 2022)
contact information as well. All calls at the program are tracked in the master control logbook
and are discussed in the daily management meetings. The program incorporates trauma-
responsive practices by utilizing the champion team, to develop a plan based on surveys, can
we discuss forms, and additionally, they utilize community meetings and educational handouts
monthly for staff and youth.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures addressing management’s response to allegations.
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. There were three separate
incidents during the annual compliance review period involving management response to
allegations. Documentation was reviewed and there is evidence management took immediate
action to address allegations of physical, psychological, and emotional abuse. The facility
administrator (FA) explained the management response to allegations of abuse involves
suspending the staff pending the investigation, notifying the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC), an internal investigation is conducted,
and if applicable, the staff will be terminated.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures addressing the process for contacting the
Department’s Central Communications Center (CCC). The program reported sixteen incidents
to the CCC during the annual compliance review period. A review of five reportable CCC
incidents during the annual compliance review period revealed all five incidents were reported to
the CCC within the required time frame, and each incident was documented in the center’s
logbook. There were no additional internal incidents or grievances during the annual compliance
review period which should have been reported to the CCC and were not. An interview with the
facility administrator (FA) indicated when a youth requests to make a call to the Florida Abuse
Hotline, the youth is taken to the telephone to call and any reportable incident must be reported
to the CCC within two hours. To ensure staff and youth are knowledgeable in contacting the
Florida Abuse Hotline/CCC staff are trained during new hire training, all-staff meetings, and are
provided the abuse reporting policy. Youth are provided with a handbook and youth information
boards have information as well. Calls are tracked in the master control logbook and are
discussed in the daily management meetings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 70 (Revised September 2022)
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 has a policy and procedures requiring a Right Interactions (RI) Incident Report be
completed and filed in accordance with the Florida Administrative Code, any time staff uses a
physical intervention technique, such as countermoves, control techniques, takedowns, or
application of mechanical restraints (other than for regular transports). The program had a total
of fifty-nine RI incidents during the annual compliance review period. A sample of five RI reports
were reviewed. All five reports were completed by the end of the staff’s workday and included
statements from all staff involved. None of the RI incidents required the use of mechanical
restraints; therefore, the Mechanical Restraint Supervision Log was not required. One of the RI
incidents resulted in injuries to staff; therefore, staff did contact the Department’s Central
Communications Center (CCC). All the RI reports were reviewed by a supervisor, a RI
instructor, and the facility administrator (FA) within seventy-two hours of the incident. None of
the RI incidents required a medical review for youth. Copies of the RI reports were placed in a
centralized file within forty-eight hours of approval/signature by the FA. Monthly summaries of all
RI incidents were submitted to the Department’s regional office by the fifth of each month and
are maintained by the program. The program last updated the RI plan on April 29, 2024, and the
plan was approved by the Department on May 1, 2024. The program had a total of ten RI
incidents during the previous annual compliance review period. The program experienced an
increase in RI incidents from the time of the previous annual compliance review. The program’s
response regarding the increase involved more training and more staff meetings to discuss the
increase. The program’s RI rate during the annual compliance review period was 2.38, which is
above the statewide Residential RI rate of 1.71. The FA was interviewed and advised RI
incidents are reviewed daily during the management meetings. Seven staff were interviewed
and two stated they had never used RI, while five staff were able to explain, in detail,4 the
proper techniques and procedures when RI is used.
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.
The program has a policy and procedures outlining the training and certification requirements
for all new staff. The following staff are direct care staff and are counted in the staff to youth
ratio; youth care worker I, youth care worker II, master control technician, shift supervisor,
kitchen personnel, recreation therapist, career, and technical education (CTE), case managers
and medical staff. The program has an instructor who is qualified to deliver the following
trainings, Right Interactions (RI), first-aid, and cardiopulmonary resuscitation (CPR). The
program does have a pre-service training plan/calendar which outlines the program’s training.
Furthermore, the training plan/calendar was approved by the facility administrator (FA),
assistant secretary of residential services, and the director of the Department’s Talent,
Leadership and Culture by evidence of their signatures. Seven staff training records were
reviewed for pre-service/certification requirements. All seven staff completed all required pre-
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 70 (Revised September 2022)
service trainings and essential skills prior to contact with any youth. One exception was a
registered nurse who is not required to complete the forty-hour RI training, which if completed
would have given him 130.5 hours. All seven staff completed trainings which are required by
Florida Administrative Code. Two supervisory staff completed an additional forty hours of
training in coaching, leadership, and personal accountability. All completed trainings were
documented in the Department’s Learning Management System (SkillPro), as required.
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.
The program has a policy and procedures outlining the in-service training requirements for staff.
Seven staff training records were reviewed for in-service trainings including five direct care staff
and two supervisory staff. All five direct care staff completed all required in-service trainings.
Each of the two supervisory staff training records included all required in-service trainings and
meet the required eight hours of supervisor trainings in the areas of coaching, leadership, and
personal accountability. All seven staff completed trainings as required by Florida Administrative
Code. All completed trainings were entered into the Department’s Learning Management
System (SkillPro). The program maintains an annual in-service training calendar which is
updated as changes occur. The program utilizes one instructor, who is qualified to deliver the
trainings provided. The program did submit an in-service training plan/calendar prior to
implementation which was approved by the facility administrator (FA), assistant secretary for
residential services, and director of the Department’s Talent, Leadership and Culture.
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 which includes training requirements for the
grievance process, as well as the informal, formal, and appeal phase. Youth are encouraged to
resolve questions, disputes, and complaints through informal communication with program staff.
Staff are directed to use active listening skills, respectful conversation, and give youth the
opportunity for full expression of feelings regarding the conflict, with the goal of encouraging and
promoting open communication, and to assist the youth in the development of improved
problem resolution skills. Informal complaints should be handled within twenty-four hours. The
program maintained grievance logs for each month of the annual compliance review period.
Eight grievances were reviewed, and seven were resolved during the informal phase by the
program. One reviewed grievance was resolved during the formal phase with the supervisor. All
seven youth interviews indicated they knew where to find a grievance form and six of seven
youth knew what to do with the form upon completion. One youth indicated he does not know
the process because he never submitted one. All seven youth stated they could ask for
assistance in completing a grievance form. All seven staff interviews indicated the grievance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 70 (Revised September 2022)
forms are placed throughout the program; two staff stated youth can request assistance in
completing the forms; five staff stated the supervisor reviews the grievances and four staff
indicated the facility administrator (FA) reviews them as well. Six of seven staff were able to
describe the grievance review process and the remaining staff was new and stated they did not
know about the grievance process. To ensure understanding, the program reviewed the
grievance process with staff during the all-staff meeting, during the week of the annual
compliance review. The FA provided written documentation of the all-staff meeting. The FA
interview indicated the program's informal grievance process is resolved by using the “Can We
Discuss” forms. Youth place the completed grievance in the box, it is collected, and then
reviewed in the management meeting. The forms are logged and resolved with the youth. I If not
resolved, the FA will review the complaint.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures to ensure youth are provided with instruction for the
development of life and social skills. The review of the curriculum, Life Skills streaming the
adolescent and activities confirmed the life skills group being utilized addresses communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
critical thinking skills, and needs of the targeted gender group of the program. A review of the
group sign-in sheets, for the annual compliance review period, was conducted and confirmed
the services were delivered as required. The services were provided in a weekly groups.The
sign-in sheets included the topic, date of service, instructor/therapist delivering the service, each
youth’s signature in attendance, and each youth’s level of participation. In addition to the
groups, the program ensures the youth receive instruction on resume building, personal
finances and budgeting, and career selection and development. Additional activities provided for
life skills development are guest speakers and mentorship opportunities. The guest speakers
have provided information on human trafficking, hate crimes awareness, child welfare, and
bullying at monthly community meetings. Seven youth were interviewed and each youth was
able to provide at least one example of life and social skill activities provided by the program.
The facility administrator’s (FA) interview confirmed the program provided targeted gender
related instruction through the monthly community meetings. The program’s designated mental
health clinician authority (DMHCA) was able to confirm all services provided to the youth during
the annual compliance review period; along with the qualified instructor/therapist, method of
delivery, and discipline. The DMHCA also confirmed how the youth can demonstrate the newly
acquired skills while in the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 70 (Revised September 2022)
1.12 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at the program. For details related specific to IOC service delivery, please refer
to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to address the internal alerts system and the
Department’s Juvenile Justice Information System (JJIS), including how new alerts are
identified, documented, updated, and communicated to staff. All seven youth were identified
with alert risks, for a total of forty-three alerts and each youth was placed on the alert system, as
specified in the program’s policy and procedures. Each applicable alert was documented in the
logbook. All applicable alerts matched JJIS and the internal alert system. The facility
administrator (FA) interview indicated the medical department meets with the designated health
authority (DHA) and the FA weekly to discuss important medical issues pertaining to youth at
the program. The program’s internal alert system process includes an internal alert form, as well
as a youth alert board. The different departments, case management, medical, and mental
health are responsible for entering and closing out alerts in JJIS. Management conducts alert
reviews during morning management meetings. The nursing staff interview indicated licensed
nurses update the medical alert system daily and master control confirms youth on security.
All seven staff interviews indicated they are informed of youth alerts during shift briefing. Five
staff also stated they can review the alert binder/log located in the staff break room, and one
said the alerts are also located on the alert board in the break room and master control room.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 70 (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 has a policy and procedures to ensure all youth records are maintained properly to
include healthcare and case management in a secure and confidential manner. All records
observed during the annual compliance review week were found to be maintained securely
within a locked room and/or cabinet marked as confidential along with each physical record
marked as confidential. All required information was documented on the record labels and each
record had information which was maintained in the required five sections.
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.
A review of sign-in sheets and agenda/meeting minutes for the annual compliance review period
indicated the program conducted community advisory board (CAB) meetings at least every
ninety to 120 days. The facility administrator (FA) actively solicits or recruits involvement from
law enforcement, judiciary community, other community partners, business community, school
board or district, faith community, LGBTQIA+ community, victim advocate, and a
parent/guardian whose child was previously involved in the juvenile justice system. The FA
interview indicated the CAB meets quarterly at the facility. Prior to Florida Virtual School (FLVS)
providing education services, the CAB approved the education calendar. The CAB meetings
give input on the school schedule, creative suggestions to keep youth occupied, and provides
suggestions on community contacts. A CAB member interview confirmed they participate in
quarterly meetings with the program. The board member indicated they had been chair of the
CAB for over a year. It was stated the CAB is effective and important to the community and to
the youth being served in the program.
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 for evaluating staff, performance standards, and the
frequency of evaluations. The program’s policy and procedures indicate evaluations are to be
completed after a ninety-day introductory period and annually and are to be completed by
supervision and management staff. A review of three position descriptions was conducted and
determined each staff member’s performance standards were clearly identified. A review of
seven performance evaluations confirmed annual evaluations have taken place consistent with
the program’s policy. Staff are evaluated on their established performance standards at the
ninety-day mark for first year employees and annually for all additional staff. The performance
standards matched position descriptions for each staff position reviewed. The program’s
contract requires the following positions to be maintained and performed: one facility
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 70 (Revised September 2022)
administrator (FA), one assistant facility administrator (AFA), five registered nurses (RN), one
designated health authority (DHA), one designated mental health clinician authority (DMHCA),
one licensed therapist, two transitional case managers, and two recreational therapists. An
interview was conducted with the FA who stated staff turnover has been a consistent issue.
Staff have cited their reasons for leaving as the demands/hours of the job and the pay for direct
care staff. The program has a staff morale committee which meets monthly and plans activities
for staff to participate and monitors an employee suggestion box. The program conducts hiring
events to hire new staff and reduce burnout. The FA additionally indicated staff evaluations are
completed after the first ninety days and then yearly thereafter. Seven staff were interviewed
and asked how often a formal evaluation of performance is completed, all seven staff stated
yearly.
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.
The program’s contract with the Department includes four special contract conditions not
covered by the Monitoring and Quality Improvement indicators.
The first special contract condition requires either the president or the chief operating officer to
make a visit to the program at least once a quarter. A review of the facility visitor sign-in log
confirmed visits were made as required during the annual compliance review period (January
2024, April 2024, July 2024, October 2024).
The second special contract condition requires eighty percent of eligible youth work part-time or
full-time within thirty days of exiting the program. The transition specialist will keep track of
employment of youth for thirty days following their exit. The transition specialist confirmed forty-
one youth were released from the program since the last annual compliance review. Twelve of
the released youth were currently working part time. The remaining twenty-nine youth were
unable to be contacted by the program and did not return their telephone calls.
The third special contract condition requires 100 percent of youth to complete, on average,
eighty percent of their community service hours prior to their release. Two youth from the
program had court ordered community service which was completed prior to their release. This
was evidence by documentation from the court.
The final special contract condition requires an additional forty-five vocational slots will be made
available beyond those mentioned in the contract, covering computer programming in the future,
twenty driving certifications in commercial driver license (CDL) of forklift, five food service
manager certifications, and twenty Microsoft Office certifications. The program currently offers
agriculture services, where the youth receive high school credits. Food Handling and Food
Management are both offered, affording the youth certificates after completion. The program
has a Home Builders Institute (HBI) program on-site for youth to participate in, after vetted, and
accepted, where youth can receive a myriad of certificates. The vocational program offers basic
computer literacy programs such as Microsoft Word, PowerPoint, and Excel, where youth can
receive a certificate after completion. The program also offers Commercial Driver License (CDL)
courses, including opportunities in semi-truck, and forklift training, carpentry, electrical,
landscape, and painting. During the annual compliance review period, twenty youth were
enrolled in forklift Safety & Health Administration (OSHA); however, none had completed
because they haven’t been in the program long enough. Additionally, the program will offer
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 70 (Revised September 2022)
Microsoft slots once the forklift certification is completed. Youth are informally asked at the
beginning of each semester to gauge interest. The facility administrator (FA) explained
education staff previously provided food management and Microsoft trainings; however, the new
Career and Technical Education (CTE) Coordinator recently passed the course for SERV Safe
and is currently offering it to youth. The facility administrator interview indicated the program
currently does not have a Memorandum of Negotiation.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The provider uses several systems for the purposes of tracking data
and outcome measures. The provider has implemented an internal database and dashboard
system which allows for daily data entry by every program. This daily process and outcome
information is aggregated into weekly and monthly totals, displayed in interactive dashboards
specific to each program, and provided back to corporate as well as program management for
the purposes of tracking trends and informing risk management. The dashboards are updated
every Monday with the previous week's data. Additionally, the program compiles information
obtained from youth surveys and parent surveys completed upon exit from the program.
Information is shared with staff and administration during staff meetings, morning meetings, shift
briefings, and during advisory board meetings. A review of staff meetings, morning meetings,
and shift briefings confirmed the information is shared with staff and administration. A review of
the quarterly community advisory board agendas, meeting minutes, and sign-in sheets
confirmed the information sharing with providers and stakeholders. The program also takes
information received during supplemental and annual compliance reviews and shares the
outcome with staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 70 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures outlining the process to ensure parents/guardians,
juvenile probation officer, and the court are notified upon the youth’s admission. Seven youth
case management records were reviewed. In all seven records the parents/guardians were
notified by telephone and in writing within twenty-four hours of admission. All seven youth
records indicated the parent/guardian was mailed a parent admission letter on the day of
admission which spoke about length of stay, visitation, and the performance planning process.
All seven youth records contained a copy of the Judge Notification of Admission Letter sent to
the committing court informing them of the youth placement, which was mailed on the day of
admission. The court, and Juvenile Probation Officer (JPO) were notified within five working
days for each youth admission to the program.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures regarding the orientation process. Seven youth case
management records were reviewed. All seven youth received an orientation within twenty-four
hours of being admitted to the program. All seven records contained a signed orientation
brochure addressing: services available, daily schedule, expectations and responsibilities of
youth, access to medical, mental health and substance abuse services, grievance procedures,
community access, visitation, telephone calls, access to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC), behavior expectations and related
consequences, emergency procedures, the program’s zero-tolerance policy regarding sexual
misconduct, including how to report incidents or suspicions of sexual misconduct, items
considered to be contraband, the performance planning process, dress code and hygiene
practices, a program tour, assignment to living unit, and Prison Rape Elimination Act (PREA)
related information. A youth orientation was observed on January 16, 2025, during the week of
the annual compliance review, which confirmed all elements of the orientation process were
discussed with the youth on his day of admission. Seven youth were interviewed and all youth
confirmed they received orientation to the program within twenty-four hours of arrival. All seven
youth were able to articulate information provided during the orientation process and each
orientation was provided by the case manager.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 70 (Revised September 2022)
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to address written consent of any youth eighteen
years of age or older before providing or discussing any of the youth’s information with the
parent/guardian, which is contained within the orientation policy. Seven youth records were
reviewed to determine if the program obtained written consent for providing youth information
with the parent/guardian, Department of Children and Families (DCF), or other applicable
agencies. Five youth records reviewed were applicable and two youth records were not
applicable. Five youth records contained the Authorization to Release Information Form which
was signed by each youth on their eighteenth birthday or upon admission to the program for
those youth who were already eighteen years of age at the time of admission.
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 which ensure a classification system is implemented
in accordance with Florida Administrative Code and promotes safety and security as well as the
effective delivery of treatment services. The system is designed to ensure the safest room and
dorm assignment for the arriving youth. Seven youth case management records were reviewed,
and each contained a classification form completed upon admission. The classification process
included information from the admission documents, which reflected the youth’s gender, height,
weight, age, level of aggressiveness, mental illness, intellectual disabilities, physical disabilities,
history of violent behavior, history of human trafficking, gang affiliation, criminal behavior, history
of sexual offenses, the results of the Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB), medical needs, suicide, escape, and security risks. All reviewed youth room
assignments were based on the youth classification procedures, which may be re-classified if
there are any changes in behavior or status and youth with a history of committing sexual
offenses were placed in a room alone. Two of the seven youth were re-classified due to a
restructuring due to contractual changes regarding the youth population at the program. One of
the seven youth were identified with a suicide risk. All seven youth were identified with a
medical risk. Six of the seven youth were identified as being an escape risk, and one youth was
not applicable. Two of the seven youth records had other alerts noted; the remaining five did
not . A review of the Department’s Juvenile Justice Information System (JJIS) Alert List for any
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 70 (Revised September 2022)
issues affecting classification was completed for all seven youth and each youth was classified
for purposes of assigning to a living area, sleeping room, and youth group or staff advisor. The
medical, mental health, substance abuse, security risk factors, and/or special needs identified
during or after the classification process were immediately entered into the program’s internal
alert system and JJIS for all seven youth. Three of the seven reviewed youth case
management records were applicable for reclassification; the remaining four records were not
applicable. None of the three applicable reclassifications resulted in increased privileges or
freedom of movement. Two of the three applicable reclassifications confirmed the youth's ability
to participated in work projects and off-campus activities; the remaining reclassification did not.
The program’s policy and procedures promote safety and security of both youth and staff and
clearly outline the process of classification/reclassification in accordance with Administrative
Rule. The program director was interviewed and indicated factors such as mental health status,
physical health status and cognitive performance, age, and prior victimization are all factors
reviewed and considered during the assessment classification process, including the
vulnerability, victimization, and sexually aggressive behavior.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures outlining the process to notify law enforcement when
a youth is identified with gang affiliation. Seven youth case management records were
reviewed. Three of the seven records indicated the youth were applicable for suspected gang
affiliation. All three identified youth were confirmed in the Department’s Juvenile Justice
Information System (JJIS) with gang alerts, as well as the program’s internal alert system. A
review of the three youth records established each contained a security threat questionnaire
which was completed at the time of admission to the program to gauge the level of gang
involvement. Documentation demonstrated the program ensured timely notification to local law
enforcement, law enforcement in the county of the program, the educational provider, the
youth’s juvenile probation officer, and the youth’s post-residential counselor, if applicable, for all
three reviewed youth. All documentation was maintained in the youth’s individual case
management record as well as in the gang binder. Each of the three applicable youth were
identified prior to admission by law enforcement and placed outside of their committing counties.
Documentation of each youth’s gang involvement was shared with the assigned juvenile
probation officer (JPO), and education provider.
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 which address the implementation of gang prevention
and intervention strategies. Youth identified as being criminal street gang members, are
affiliated with any criminal street gang, or who are at a high risk of gang involvement are
required to participate in gang prevention and intervention activities. During an interview with the
facility administrator, it was stated the program uses Gang Resistance and Drug Education and
Achieve Realistic Impact to Sustainable Enhancement (ARISE) as part of their gang prevention
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 70 (Revised September 2022)
and intervention strategies. Three of the seven reviewed case management records were
applicable with gang affiliation. A review of the three records confirmed each youth was
identified as a gang member or affiliated gang member. All three youth had a gang goal listed
on their Individualized Performance Plan (IPP). A review of the program’s gang binder found the
three applicable youth participated in monthly gang intervention sessions with their assigned
case manager as evidenced by observed sign-in sheets. The program’s gang prevention and
intervention policy indicate a youth will be provided the opportunity to “dis-affiliate” from their
identified criminal street gang should they choose to. There was documentation in all three
applicable records each youth participated in gang resistance and drug education and the
ARISE curriculum.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure an initial Residential Assessments for
Youth (RAY) are completed within thirty days of admission to the program and RAY
reassessments are completed within ninety days after completion of the initial RAY assessment.
Seven youth case management records were reviewed. All seven reviewed records included
the RAY assessments, and each were completed within thirty days of admission. All
assessments were maintained in the Department’s Juvenile Justice Information System (JJIS).
Four of the seven youth were applicable for RAY reassessments which were conducted before
the ninety days and maintained in each youth’s record. Three youth were not applicable for the
ninety-day reassessment. Each youth also had a copy of their RAY Overview Report filed within
their individual case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures ensuring the completion of the Youth Needs
Assessment Summary (YNAS) is conducted within thirty days of admission to the program. The
assigned case manager is responsible for gathering information from all members of the
treatment team as well as collateral documents and incorporating this information into the YNAS
report. Seven case management records were reviewed. All reviewed youth records had a
YNAS completed, with the top three criminogenic needs documented within thirty days of
admission. All YNAS reports were documented in the Department’s Juvenile Justice Information
System (JJIS).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 24 of 70 (Revised September 2022)
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.
The program has a policy and procedures to ensure all members of the treatment team, youth,
juvenile probation officer (JPO), and parent/guardian are involved in the development of the
youth’s Individualized Performance Plan (IPP) within thirty days of admission to the program.
The findings of the initial assessment completed on each youth, along with information from the
intervention and treatment team, are utilized by the assigned case manager to create the
performance plan. In addition, information provided by the parent/guardian on the Parent Input
form sent at admission, is incorporated into the performance plan. Seven youth case
management records were reviewed. Six of the seven youth IPPs were developed within thirty
days of admission and one IPP was developed six days late. The intervention and treatment
team were present during the development of each performance plan and included participation
from the following parties: treatment team leader, youth, program administration, living unit
representative, mental health treatment staff, education staff, and medical staff. All seven
reviewed records contained documentation of each parent/guardian provided a copy of the IPP
through the postal service. One of the seven youth records documented a copy of the IPPs as
provided to the Department of Children and Families caseworker; the remaining six were not
applicable. All seven IPPs addressed goals based on prioritized needs reflecting the risk and
protective factors identified during the initial assessment process. All seven youth performance
plans addressed the youth’s three top criminogenic needs and targeted court-ordered sanctions
which could be reasonably initiated and completed while in the program. Each IPP identified
program staff responsibilities and target dates for goal completion. Within ten working days of
completing the plan, a transmittal letter and copy of the IPP was sent to the committing court,
juvenile probation officer, the parent/guardian, and DCF caseworker, where applicable, for each
of the seven reviewed youth. During an interview with seven youth, six of the youth stated they
had participated in the development of their performance plan, and one youth stated he had not
participated, with no additional comment as to why.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures to ensure performance plan reviews will result in
revisions when determined necessary by the intervention and treatment team. The youth’s
Individualized Performance Plan (IPP) shall reference or incorporate the youth’s treatment or
care plan. Seven youth case management records were reviewed. Five performance plans were
revised based on the Residential Assessment for Youth (RAY) reassessment results. Four
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 25 of 70 (Revised September 2022)
youth required updates due to newly acquired information. Five youth demonstrated progress
toward completing a goal. No revisions to IPPs were needed to facilitate transition activities
during the last sixty days, for any of the seven reviewed youth. Five of the seven reviewed youth
confirmed the incorporation of treatment and academic plans. The remaining two youth records
did not have additional plans. One of the reviewed youth was applicable for the incorporation of
a Department of Children and Families (DCF) plan.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures outlining the completion of performance summaries
and transmittals, every ninety days, or sooner, if requested by the committing court, prior to
youth’s release. Three of the seven reviewed case management records for performance
summaries and transmittals were applicable. The remaining four were not applicable due to the
youth being in the program less than ninety-days. The three applicable youth records contained
documentation to support the performance summaries were completed in ninety-day intervals.
Each of the three applicable records documented the youth’s status, performance plan goals,
overall treatment progress, academic status, behavior, motivation and readiness for change,
interactions with peers and staff, overall progress, and any significant positive and negative
events. Each of the three youth were permitted to read and add any comments prior to signing
their performance summaries. Each applicable youth was provided a copy of the summary and
the original summary was placed in each youth’s case management record. Each performance
summary was signed and dated by all required parties and sent to the committing court, the
juvenile probation officer (JPO), the parents/guardians, and the Department of Children and
Families caseworker for one youth.
Three closed case management records were reviewed and the original summary and
justification for release for all three youth were sent with the Pre-Release Notification to the
juvenile probation officer (JPO) at least forty-five days prior to release. In all three of the closed
case management records, a signed copy was retained in the youth’s record. Documentation
showed the program provided written notification to each youth’s parent/guardian regarding the
planned release. Each record had a completed Residential Assessment for Youth (RAY) exit
assessment. None of the three reviewed closed records were applicable for victim notification.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has policy and procedures outlining the process to encourage parent/guardian
involvement in case management services. Seven case management records were reviewed for
parent/guardian involvement and each record contained documentation reflecting the
encouragement of each parent/guardian in the assessment process, the development of the
performance plans, and the progress reviews. Each record reflected documentation the
parent/guardian participated in the case management process and was provided advance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 70 (Revised September 2022)
notification of formal treatment team meetings, dates and times, and were permitted to
participate by telephone when applicable. A treatment team meeting was observed during the
annual compliance review week, and for each youth observed, a parent was asked to
participate by telephone. Seven youth were interviewed and all seven youth reported their
parent/guardian was involved in their case management. The facility administrator was
interviewed and reported the program encourages parental involvement through the intake
process, needs assessment, individual performance plan, weekly telephone calls, family
sessions, treatment team, parent surveys, and family days.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures outlining the required treatment team members and
ensuring the times for both formal and informal meetings. Seven youth case management
records were reviewed. All seven records contained documentation each youth’s treatment
team consisted of the youth, the treatment team leader, an administrative representative, a
living unit representative, educational staff, mental health staff, and if applicable, medical staff,
gang liaison, human trafficking liaison, and transitional staff. One record documented a juvenile
probation officer was not in attendance; however, the program made attempts to communicate
by telephone and sent an email. Documentation in all seven records reflected the treatment
teams met on a bi-weekly basis and each document was clearly marked as being a formal or
informal meeting type. Documentation for each formal and informal treatment team meeting
included the youth’s name, date of the review, comments from the treatment team members, a
brief synopsis of the youth’s progress, performance plan revisions, positive and negative
behaviors, behaviors resulting in physical interventions, treatment progress, and Residential
Assessment for Youth (RAY) reassessment results. All documentation for each reviewed youth
was placed in the youth’s permanent record. Documentation confirmed each youth’s
parent/guardian, and juvenile probation officer was invited and encouraged to participate in
treatment team meetings.
Seven youth were interviewed and reported they were provided an opportunity to discuss what
they had learned through active listening, showing respect to others and consistent positive
behavior.
A treatment team meeting was observed. All required staff members were present for the
treatment team meeting. Case management, mental health, medical, juvenile probation officer,
director of case management the parent, and community-based program representative were
present on the telephone. Educational information was presented in writing.
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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 70 (Revised September 2022)
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures to ensure the intervention and treatment team is
planning for successful transition to the community upon release from the program when
developing the transition plan. Seven youth case management records were selected for
review. None of the seven were applicable for transition planning, transition conference, and the
Community Re-Entry Team Meeting. Three closed youth case management records were
selected for review. All three records documented a transition conference was conducted at
least sixty days prior to the youth’s targeted release date. All required treatment team members
were present, except in two of the three records, the education staff was not present; however,
presented information in writing to the team. All three records revealed a review of the transition
activities on the youth’s revised performance plan: identifying target dates for completion, and
persons responsible for the completion. All applicable signatures for each youth were obtained
on the treatment plan and a copy the transition plan was electronically sent to each youth’s
juvenile probation officer (JPO) and Department of Children and Families (DCF) case worker, if
applicable. Documentation revealed a Community Re-Entry Team (CRT) meeting was
conducted prior to release for all three youth with the youth and case manager present. There
was evidence in each of the three records confirming an invitation to participate in the CRT
meeting was sent.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures outlining requirements in assembling the Exit
Portfolio for each youth prior to release. Three closed case management records were
reviewed. All three records contained documentation of an Exit Portfolio which was discussed
during the transition conference, including a calendar with dates, times, and location of all
upcoming appointments. A state-issued identification, social security card, and birth certificate
was not found in two of the three records reviewed. All three records included documentation of
educational certificates, educational records, a resume, a sample employment application, and
school transcripts. All three records were verified to contain the Exit Portfolio and documentation
of the youth’s receipt of the portfolio upon release. All three records reflected the program staff
forwarded the Exit Portfolio information to the JPO. All three records included documentation
the youth were provided with instructions to complete forms and instructions on how to obtain
documents for employment. During the Transition Conference for each reviewed youth, there
was a plan put in place as to who will be responsible for working with each youth to obtain
specific items.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has policy and procedures outlining the requirements of the Exit Conference.
Three closed youth case management records were reviewed. All three records contained
documentation the Exit Conference was conducted at least fourteen days prior to the youth’s
release and after the program was notified by the juvenile probation officer (JPO) of the youth’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 28 of 70 (Revised September 2022)
approved release. Each reviewed youth’s date of admission and date of termination
documented in the case record correlated with the Department’s Juvenile Justice Information
System (JJIS). All three records contained documentation of the date of the exit conference,
signatures, status of established transition activities, provisions for continuation of education
and/or employment, and a finalized plan. Each reviewed record contained documentation each
youth’s parent/guardian and JPO are aware of the vocational plan. Each reviewed record
contained documentation each youth’s case manager and parent/guardian were aware of the
plan, documents, and post-release discharge plans. All three records documented evidence of
the participating parties: including the parent/guardian, treatment team leader, education
representative, the JPO, and the youth. In all three records it was documented the Exit
Conference was held separately from the transition conference and Community ReEentry Team
meeting.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures outlining the requirements for a formal youth input
process to promote constructive input by youth. Monthly community meetings and resident
council meetings were held on the dorms allowing an opportunity for youth to provide input on
community matters. Interviews were then conducted with selected youth to determine the
program’s formal process. Minutes and attendance sheets were provided and confirmed youth
participation in both resident council meetings and monthly community meetings. The council
consists of members from each of the dorms to represent the community meetings. Seven
interviewed youth stated they can discuss any issue they may be having with staff. There are
forms on each dorm the youth can complete and submit. Any issue the youth may have is
discussed during dorm meetings. In an interview, the facility administrator (FA) stated the forms
are where the youth can propose questions or issues they want to discuss with staff. Each week
youth are interviewed during resident council meetings and selected randomly to attend a daily
management meeting to discuss any issues they may have.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 70 (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 policy and procedures which provides for a single licensed mental health
professional to be designated as the designated mental health clinician authority (DMHCA). The
DMHCA is responsible for the coordination and implementation of mental health and substance
abuse services in the program. The DMHCA is a licensed mental health counselor (LMHC) with
a clear and active license which expires on March 31, 2025. There have been no other
DMHCAs during the annual compliance review period. The back-up DMHCA is a LMHC with a
clear and active license which expires on March 31, 2025. The DMHCA is on-site forty hours a
week and on-call twenty-four hours a day for emergencies. A review of the DMHCA’s position
description confirms required hours for DMHCA. An interview with the DMHCA confirmed they
are responsible for coordination, implementation, and oversight of mental health and substance
abuse services in the program. The DMHCA provides weekly supervision for non-licensed
clinical staff.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The program has a contract
agreement with a certified behavior analyst to provide services to youth as needed. The
designated mental health clinician authority (DMHCA) ensures the licensed clinical staff working
under their supervision are performing services they are qualified to provide based on
education, training, and experience. The certified behavior analyst has an active certification
which expires on August 25, 2026. The program had two licensed clinical social workers
(LCSW) who provided services during the annual compliance review period. Both LCSWs had
clear and active licenses which expire on March 31, 2025. One of the LCSWs is no longer
employed with the program and the other is a regional clinical staff member who provides
services on pro re nata basis.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 70 (Revised September 2022)
The program has six non-licensed mental health and substance abuse clinical staff. There were
two vacant positions for non-licensed clinical staff at the time of the annual compliance review,
one has been vacant since January 2025 and the other since December 2024. Each of the six
non-licensed clinical staff hold a master’s-level degree. The designated mental health clinician
authority (DMHCA) assures the non-licensed clinical staff are performing services they are
qualified to provide based on education, training, and experience. A review of weekly clinical
supervision confirmed each non-licensed clinical staff received one hour a week of on-site, face-
to-face direct supervision by a licensed mental health professional. Each clinical supervision
was documented on a form similar to the Department’s supervision log, which included all
required elements. The program does have a Chapter 397 license which expires September 6,
2025. The non-licensed clinical staff are on-site forty hours a week. Four of the six non-licensed
clinical staff completed twenty hours of Assessment of Suicide Risk (ASR) training. The
remaining two non-licensed clinical staff were newly hired and pending completion of ASR
training at the time of the annual compliance review.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures to ensure mental health and substance abuse needs
of youth are identified through a comprehensive screening process ensuring referrals are made
when youth have identified mental health and/or substance abuse needs or are identified as a
possible suicide risk. The program screens all youth utilizing the Massachusetts Youth
Screening Instrument-Second Version (MAYSI-2) in the Department’s Juvenile Justice
Information System (JJIS). Seven youth mental health and substance abuse records were
reviewed. All seven records reflected a full MAYSI-2 was completed for each youth on the day
of admission by a staff member qualified to complete the screening. Documentation confirmed
staff reviewed all available information for each youth to include commitment packets, reports,
and records for existing documentation of mental health or substance abuse problems or history
of human trafficking. All seven reviewed records were completed in JJIS on the day of
admission. Five out of seven reviewed MAYSI-2 reports indicated further assessment was
needed; however, all seven youth were referred for an Assessment of Suicide Risk (ASR) and a
comprehensive evaluation as program policy requires all youth have an ASR and a
comprehensive evaluation completed upon admission to the program. The facility administrator
(FA) and designated mental health clinician authority (DMHCA) were notified of the need for an
assessment as documented on the mental health and substance abuse referral form. An ASR
was completed on the day of admission for each youth. None of the seven reviewed youth were
applicable for needing to be placed on precautionary observation. An interview with the FA
confirmed the program utilizes the MAYSI-2 and ASR to screen youth for mental health and
substance abuse needs.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 70 (Revised September 2022)
The program has a policy and procedures to ensure youth identified by screenings, staff
observations, or behaviors observed post-admission and need further evaluation will be referred
for a combined comprehensive mental health and substance abuse evaluation. Seven youth
mental health and substance abuse records were reviewed. All seven youth had a new
combined comprehensive evaluation completed within thirty calendar days of admission. Each
record contained a substance abuse consent for services signed by the youth. Six out of seven
reviewed youth were applicable for completion of their comprehensive evaluation by non-
licensed clinical staff. In all six records, the licensed clinical staff reviewed and signed the
comprehensive evaluation within ten calendar days. The remaining youth’s comprehensive
evaluation was completed by a licensed clinical staff member. Each youth’s comprehensive
evaluation contained all required elements. None of the reviewed youth were applicable for
needing an updated comprehensive evaluation. An interview with the designated mental health
clinician authority (DMHCA) confirmed the program’s practice.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures to ensure youth determined to have a 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 (ITP). Seven youth mental health and substance abuse records were reviewed.
Each record had an Initial ITP completed on a program form which contained all required
elements within seven days of the initiation of treatment. The Initial ITP was signed by the
mental health clinical or substance abuse clinical staff completing the form. All seven Initial ITPs
were signed by all members of the treatment team who participated in the development of the
plan, except for the parents/guardians who participated on the telephone, and this was noted on
the Initial ITP. One youth’s ITP review was missing the program management/designee
signature for the December 2024 ITP review. All seven ITPs were completed by non-licensed
mental health clinical staff and each was signed by the licensed clinical supervisor within ten
days of completion. Two of the seven reviewed youth were foster care youth. One youth had
their dependency case manager participate in the development and reviews of the ITP. The
remaining youth was eighteen, so the dependency case manager involvement in treatment was
not required. Three of seven Initial ITPs included the youth’s psychiatric needs, including
medication and frequency of monitoring by the psychiatrist; the remaining four were not
applicable for psychiatric services. One youth did have psychiatric goals listed on two out of six
months of ITP’s; however, this youth was not receiving psychiatric services. The program noted
this was a typo and the ITP was corrected during the annual compliance review. Each youth
had an Individualized ITP completed on a program form which contained all required elements.
Individualized ITP reviews were completed for each youth at minimum every thirty days, except
for one youth who had one ITP review completed five days late. All seven youth had
Individualized ITPs signed by all required parties, except for parents/guardians who participated
by telephone, and this was documented on the ITP. During the annual compliance review
period, the program had an open deficiency related to groups not being held for the required
amount of time. A review of video camera observations of three groups compared to logbooks
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 70 (Revised September 2022)
and sign-in sheets confirmed groups are being held as scheduled. This deficiency is being
recommended for closure.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a policy and procedures which directs treatment and discharge planning.
Seven youth mental health and substance abuse records were reviewed. Each youth was
assigned to a treatment team upon admission to the program. Three out of seven reviewed
youth had a properly executed Authority for Evaluation and Treatment (AET) in their records.
One youth’s AET was invalid due to a previous loss of custody by the Department.
Documentation reflected the program contacted youth’s juvenile probation officer (JPO)
requesting a new AET. A valid AET was obtained from youth’s JPO during the annual
compliance review. Two of the remaining youth were foster care youth with court orders and
limited AET’s in their record, and the remaining youth was eighteen and did not require an AET.
Each record contained a signed consent for substance abuse treatment services. All seven
records contained treatment progress notes which contained all elements of the Department’s
form. Documentation confirmed each youth was receiving individual therapy and psychosocial
skills training. Each reviewed youth received all services as stipulated on their treatment plan.
Three closed youth mental health and substance abuse records were reviewed for discharge
planning. Each record included a discharge plan on the Department’s Mental Health/Substance
Abuse Treatment Discharge Summary form which documented future services needed. None of
the reviewed youth were released while on suicide precautions or a mental health alert.
Documentation confirmed the discharge plan was discussed with each youth, parent/guardian,
and JPO during the Exit Conference. A copy of the Mental Health/Substance Abuse Treatment
Discharge Summary was provided to each youth, parent/guardian, and JPO.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures which require specialized mental health overlay
services to be provided to youth. The program’s required clinical groups according to the
contract are Aggression Replacement Therapy, Skillstreaming the Adolescent, The Passport
Program, and Living in Balance. Seven youth were interviewed. Six of seven youth confirmed
they participate in individual and family therapy. The remaining youth was new to the program
and was going to be starting individual and family therapy the month of the annual compliance
review. Seven staff were interviewed. All seven staff confirmed only clinical staff facilitate mental
health and substance abuse groups. An interview with the designated mental health clinician
authority (DMHCA) confirmed all youth receive intensive mental health treatment services and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 70 (Revised September 2022)
substance abuse services according to their Individualized Treatment Plan. An interview with
the facility administrator confirmed youth receive mental health overlay services to include
weekly mental health groups, career counseling, individual therapy, and family therapy. The
DMHCA is on-site forty hours a week and clinical staff are on-site at least five days a week. A
review of clinical staff caseloads confirmed clinical staff have no more than sixteen youth to one
therapist. The program has contracted with a certified behavior analyst to provides services as
needed. Documentation confirmed program’s mental health and substance abuse groups are
held at least four times a week, individual therapy is provided at a minimum of biweekly, family
therapy is provided monthly, and a psychiatrist is on-site biweekly. The program did not have
any youth applicable for needing services during medical quarantine.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures to ensure the provision of psychiatric services which
include psychiatric evaluation, psychiatric consultation, medication management, and medical
supportive counseling provided to youth with a diagnosis from the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) and each youth receiving psychotropic
medication in the program. The program employs a psychiatrist through an independent
contractor agreement. The psychiatrist is scheduled to be on-site every two weeks, for a
minimum of two hours, and on-call for emergencies during the evening and on weekends and
holidays. The psychiatrist has a clear and active license which expires on January 31, 2026.
The psychiatrist briefs a representative of the treatment team regarding the psychiatric status of
each youth receiving psychiatric services who is scheduled for treatment team review. The
psychiatrist’s evaluation and recommendations for each youth are also incorporated into the
mental health clinical staff’s evaluations of the youth and the youth’s Individualized Mental
Health or Substance Abuse Treatment Plan (ITP). The program does not use a psychiatric
advanced practice registered nurse (APRN). A review was conducted of the sign-in/out logs for
the psychiatrist’s bi-weekly visits, which confirmed the psychiatrist was at the program as
required by the agreement with the program and the program’s contract with the Department.
Documentation confirmed the psychiatrist actively participates in, manages, and supervises
psychotropic medication services at the program. The program does not have a back-up
psychiatrist and is not required by contract; the program did not utilize a back-up psychiatrist
during the annual compliance review period. The program does not utilize tele-psychiatry;
however, the program did get permission from the Department’s Office of Health Services
(OHS) to utilize tele-psychiatry for one day during the annual compliance review period. An
interview with the psychiatrist confirms the psychiatrist oversees psychiatric interventions,
medication management, and completes psychiatric evaluations for youth. The psychiatrist
states he is on-site bi-weekly and meets with medical and mental health staff to discuss youth
receiving services prior to seeing youth. The psychiatrist has no concerns with the mental health
and substance abuse services at the program. An interview with the designated mental health
clinician authority (DMHCA) confirms the program’s practice. Seven youth mental health and
substance abuse records were reviewed. Three of the seven youth were applicable for entering
the program on psychotropic medication and received a psychiatric interview within fourteen
days of admission; however, it is the program’s practice to refer all newly admitted youth for a
psychiatric interview. Documentation confirmed all seven youth had a psychiatric interview
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 70 (Revised September 2022)
conducted within fourteen days of admission. The initial diagnostic psychiatric interviews
included history of the youth, mental status examination, diagnoses, and ensuring each
diagnosis is consistent with the treatment plan, treatment recommendations, prescribed
medications, explanation of the need for psychotropic medication, target symptoms, initial
treatment goals, potential side effects, risks, and benefits of taking the medication, and
frequency of medication monitoring. The initial psychiatric evaluations were completed on a
form developed by the program which contains all required elements of the Department’s
Clinical Psychotropic Progress Note (CPPN). The form was clearly identified as an initial
psychiatric interview. Three of the seven youth entered the program on the psychotropic
medication which required psychiatric medication management. The three applicable youth
records for medication management confirmed each youth received the prescribed psychotropic
medications and included documentation of face-to-face medication monitoring reviews being
conducted every thirty days for two of the three applicable youth. The remaining applicable
youth had one medication review out of four reviews completed twelve days late. All other
medication monitoring reviews were completed at minimum every thirty days. The psychiatric
evaluations were documented on a form developed by the program which contained all the
required elements within the CPPN. The reviews were completed, signed, and dated by the
psychiatrist; and included identifying youth information, diagnosis, target symptoms of each
medication, evaluation, and description of effects of prescribed medication on target symptoms,
the name, dosage and quantity of the medication, side effects, youth’s adherence to the
medication regimen, height, weight, blood pressure, and most recent serum drug levels or
laboratory findings. Two of the three applicable youth records with prescribed psychotropic
medications required monthly monitoring of Tardive Dyskinesia; and reviewed documentation
supported the monitoring was conducted monthly.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a suicide prevention plan in place, which received an annual review by the
designated mental health clinician authority (DMHCA) on February 26, 2024. The plan included
procedures for identification and assessment of youth at risk of suicide, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and a review process. The review process included all required
elements.
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.
The program has a policy and procedures which governs suicide prevention services. This
policy defines suicide precautions as methods utilized for supervising, observing, monitoring,
and housing youth identified through screenings, available information, or staff observations as
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 70 (Revised September 2022)
having suicide risk factors. It requires any youth exhibiting suicide risk behaviors to be placed on
suicide precautions at a minimum of constant supervision. Seven youth mental health and
substance abuse records were reviewed. One of the seven reviewed youth were applicable for
suicide prevention services. Additional records were requested for youth applicable for suicide
prevention services. The program only had one additional record applicable for suicide
prevention services during the annual compliance review period, which was provided for a
sample of two records. One youth was determined to be at risk through staff observations and
the remaining youth self-reported suicidal ideation. Each youth had an Assessment of Suicide
Risk (ASR) completed on the Department’s form within twenty-four hours of youth being
determined to be at risk. Each youth was maintained on constant supervision. Each record
reflected the youth’s parent/guardian and juvenile probation officer (JPO) were notified about
the youth’s potential suicide risk as indicated on the ASR. Documentation confirmed each youth
was provided supportive services by mental health clinical staff and each ASR was completed
by a licensed clinical staff member, or by clinical staff under the supervision of a licensed mental
health professional. One of the two reviewed youth had an ASR completed by a non-licensed
therapist which was reviewed by the designated mental health clinician authority (DMHCA)
within twenty-four hours. The remaining youth’s ASRs was completed by the backup DMHCA.
Both youth were continued on constant supervision after the completion of the ASR.
Documentation confirmed each record contained the actual date and time recorded on the ASR
in the date/time sections, confirming the clinician conferred with facility administrator or
designee and the licensed mental health professional (LMHP). Each record contained a Follow-
Up ASR on the Department’s form completed prior to the removal of the youth from
precautionary observation. Each youth was maintained on constant supervision until the
completion of a Follow-Up ASR and was stepped down to close supervision once it was
determined the youth could be discontinued from suicide precautions. Each youth was
maintained on close supervision until it was determined no longer necessary by the DMHCA,
and a conference was held between DMHCA and facility administrator. Discontinuation was
documented in accordance with the program’s suicide prevention plan. A review of the
Department’s Juvenile Justice Information System (JJIS) reflected a suicide alert was initiated
for each youth and closed upon the recommendation of the Follow-Up ASR. A review of the
program logbooks confirmed administration or supervisory staff provided instructions related to
the suicide risk assessment findings and suicide precaution decisions for each youth. While on
precautionary observation, each at-risk” youth was allowed to participate in select activities with
other youth in designated safe housing/observation areas of the program. A review of video
footage for one of the applicable reviewed youth placed on precautionary observation was
unable to be completed due to video footage being maintained a maximum of thirty days;
however, a review of video camera observation for the remaining youth on precautionary
observation confirmed staff were always with the youth while the youth was on precautionary
observation.
3.12 Secure Observation (Critical) Satisfactory Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program has a policy and procedures to ensure youth placed on suicide precautions may
be maintained on secure observation when less restrictive means is not effective. Seven youth
mental health and substance abuse records were reviewed. One of the seven reviewed youth
was applicable for being placed on secure observations; therefore, additional records were
requested. The program only had one additional record applicable for secure observation during
the annual compliance review period, which was provided for a sample of two records. Each
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 70 (Revised September 2022)
youth’s placement in secure observation was approved by the designated mental health
clinician authority (DMHCA) and facility administrator/designee. Each youth had secure housing
designated in writing, had a Health Status Checklist form completed, and had Suicide
Precautions Observation Logs completed in their entirety. Both applicable youth had their room
inspected immediately prior to the youth’s placement to ensure the room was safe and secure.
Both youth were placed in secure observation due to at-risk or suicide risk behavior and were
maintained on one-to-one supervision while in the secure observation room. Each youth had a
new Assessment of Suicide Risk (ASR) completed within eight hours of placement and
parent/guardian and juvenile probation officer was notified of each youth’s suicide risk as
indicated on the ASR. The youth had a staff member of the same gender conduct a visual check
to determine if there were any observable injuries which would make placement in the secure
observation room inappropriate. None of the reviewed youth were maintained on secure
observation beyond twenty-four hours. The youth received supportive services from mental
health clinical staff while on secure observation placement. Documentation confirmed each
youth’s supervision level was lowered upon conference with the DMHCA and facility
administrator and authorization was approved in writing. Each youth’s ASR was reviewed by a
licensed mental health staff member prior to youth’s removal from secure observation. A review
of logbooks confirmed discontinuation and step-down from secure observation placement for
each youth was documented in the logbooks and youth’s mental health and substance abuse
record. A review of video footage for one of the youth placed on secure observation was unable
to be completed due to video footage being maintained a maximum of thirty days; however, a
review of video camera observation for the remaining youth on secure observation confirmed
proper supervision was maintained while youth was on secure observation.
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.
The program’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision of youth placed on suicide precautions. Seven youth mental health and substance
abuse records were reviewed. One of the seven reviewed youth were applicable for suicide
prevention services. Additional records were requested for youth applicable for suicide
prevention services. The program only had one additional record applicable for suicide
prevention services during the annual compliance review period, which was provided for a
sample of two records. Documentation confirmed suicide precaution observation logs were
maintained for each youth for the duration the youth was on suicide precautions. Each suicide
precautionary observation log documented the appropriate level of supervision and
observations of each youth’s behavior in real time, not exceeding thirty-minute intervals, as well
as each log being reviewed and signed by each shift supervisor and mental health clinical staff.
Each log documented safe housing requirements. Both records reflected warning signs were
observed and the facility administrator/designee and mental health clinical staff were notified,
which was documented on the log. During interviews with seven staff, it was reported when a
youth expresses suicidal thoughts, direct care staff are responsible to notify mental health, place
youth on constant sight and sound, document supervision, search youth/room for sharp objects,
and place youth in a locked room. Each of the seven staff reported the suicide kits are in master
control, sub control, and medical clinic. Six staff reported the suicide kit is in the supervisor’s
office.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 70 (Revised September 2022)
3.14 Suicide Prevention Training (Critical) Limited Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures outlining suicide prevention training. A review of five
pre-service and five in-service staff training records confirmed completion of suicide prevention
training. The program has ten suicide response kits which are co-located with first-aid kits. The
suicide kits are in master control, medical, kitchen, Home Builder’s Institute, and each of the five
dorms. A review of suicide mock drills and medical drills completed during the annual
compliance review period was conducted. The mock suicide drills were held quarterly on each
shift, for all staff who encounter youth including kitchen and maintenance staff. A review of
written suicide mock drills for each shift confirmed the program provided semi-annual training on
emergency response procedures for a suicide attempt or incident of serious self-inflicted injury
using cardiopulmonary resuscitation (CPR). The mock mental health drills were in response to a
suicide attempt and/or incident of serious self-injury and were written as if simulated. The
program reviews drills during staff meetings to give staff who were not present during drills the
opportunity to review each drill scenario and procedures. The facility administrator reported
through an interview, the program conducts suicide drills, one each shift, and are reviewed
during staff monthly meetings. During interviews with the seven staff, all reported medical
emergency and suicide drills are conducted on each shift once a month.
Video observation of five suicide mock drills was conducted in the last thirty days. Two of the
drills, which were the same scenario on different shifts, showed staff entering the classroom
with the automated external defibrillator (AED) and medical bag. The staff then signed the sign-
in log and left without simulating the drill. One drill was not able to be observed due to not being
able to locate on video and having a written drill indicating the drill occurred. Two of the drills,
which were the same scenario just different shifts, and same number of staff attended both
drills. According to this drill, staff entered the room with the life saving devices, which could be
observed and applied; however, this could not be seen. This drill was not simulated accordingly.
Youth were not used in drill simulations related to mental health or substance abuse care.
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 crisis intervention plan which was reviewed annually by the facility
administrator and designated mental health clinician authority (DMHCA) on February 26, 2024.
The plan included notification, an alert system, means of referral including youth self-referral,
communication, supervision, documentation, and review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 70 (Revised September 2022)
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures ensuring the program responds to youth in crisis in
the least restrictive means possible to protect the safety of the youth and others, while
maintaining control and safety of the program. The program shall be able to differentiate a youth
who has an acute emotional problem or serious psychological distress from one who requires
emergency services. Seven youth mental health and substance abuse records were reviewed.
One of the seven reviewed youth records were applicable for requiring a Crisis Assessment.
Two additional records were requested and provided for a minimum sample of three. All three
youth had a Crisis Assessment completed on the same day the youth was identified as being in
crisis. Each Crisis Assessment included reason for the assessment, mental status examination
and interview, determination of danger to self and/or others, initial clinical impressions,
supervision and treatment recommendations, and recommendations for follow-up or further
evaluation. Each youth was applicable for parent/guardian notification of follow-up treatment
and each youth had documentation confirming their parents/guardians were notified. Each youth
had a Crisis Assessment completed by mental health clinical staff. None of the reviewed youth
were applicable for requiring a mental health alert to be placed in the Department’s Juvenile
Justice Information System (JJIS) due to being placed on precautions after completion of the
Crisis Assessment. None of the three reviewed youth were applicable for their Crisis
Assessment determining the youth posed a safety and security risk and were required to remain
on alert until a follow-up Crisis Assessment and/or follow-up Mental Status Examination was
completed. None of the three youth were applicable for returning from an off-site Crisis
Assessment. None of three reviewed youth were applicable for being the alleged victim of a
Prison Rape Elimination Act (PREA).
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 an emergency mental health and substance abuse services plan in place,
which is separate from the crisis intervention plan. The plan includes immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services including Baker Act and Marchman Act, documentation,
training (including mock drills),1 and review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 70 (Revised September 2022)
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker Act or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to 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
reviewed. All seven youth had a safety plan completed within fourteen days of admission which
contained all required elements. Each youth’s plan was jointly prepared by the youth,
parent(s)/guardian(s) or family member, and the program’s clinical staff. Documentation
confirmed each safety plan incorporated any recommendations from previous or current clinical
assessments or screening instruments and incorporated trauma responsive practices. All seven
youth had their safety plans reviewed and updated at least every thirty days. All seven youth had
safety plans which included all required elements. None of the youth reviewed were applicable
for needing their plan updated following any significant behavioral or mental health event identified
by the youth’s intervention and treatment team. Safety plans are in the staff break room for direct
care staff to review as well as in the youth’s mental health and substance abuse record. Seven
youth were interviewed. All seven youth confirmed they participated in the development of their
safety plan. An interview with the facility administrator confirmed safety plans are updated monthly
and on an as needed basis.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 70 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician (MD) who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The DHA’s license expires on January 31, 2027, and the specialty training
is in internal medicine. The DHA did not have any disciplinary cases/public complaints on record
and the program did not have a physician assistant or advanced practice registered nurse
(APRN). The back-up DHA is a MD who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida. The back-up
DHA’s license expires on January 31, 2027, and the specialty training is in family medicine. A
review of the DHA sign-in/out logs for the annual compliance review period indicated the DHA
was not utilized and the back-up DHA was on-site once a week for the required two hours. The
program does not utilize tele-medicine. The DHA interview described the DHA being clinically
responsible for the medical care of all youth at the program. The DHA performs any on-site
services needed by the program and the nurses keep a log of any youth needing to be seen, as
well as placing any documentation to be signed in the front of each youth chart. All off-site
appointments are documented in the MD logbook for DHA follow-up and the youth is also
placed on the weekly to-be-seen list. The DHA is on-site weekly on Thursdays to review any
youth being seen, conducts monthly staff meetings, and is available twenty-four hours a day
seven days a week telephonically to communicate with program staff regarding the medical
needs of the youth. The DHA reviews and signs policies and procedures when needed. The
DHA stated when unavailable the back-up DHA covers the program. The DHA voiced no
concern or issues regarding the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has one full-time health service administrator (HSA) who is a registered nurse
(RN), one pre-re nata RN, three full-time RNs, and one full-time licensed practical nurse (LPN)
providing nursing coverage on-site. The contractual requirement asks for four full-time RNs and
one RN serving as the full-time HSA. The Department’s Office of Health Services (OHS) has
given permission to substitute one full-time RN for a full-time LPN. The LPN is provided
direction by a RN. All six nurses had clear and active licenses. Two RN licenses expire on April
30, 2026, three RN licenses on July 31, 2026, and the LPNs on July 31, 2025. All nurses had
current cardiopulmonary resuscitation (CPR) certifications.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 70 (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) and the facility administrator signed and dated all
respective treatment facility operating procedures (FOP), as well as the psychiatrist signed and
dated the psychiatrist applicable FOPs on July 2, 2024, and conducted an annual review. The
nursing staff reviewed, signed, and dated a cover page on which all FOPs, healthcare protocols
and other procedures were listed. The program did not have any new or changes in policies
during the annual compliance review period. All newly employed health care personnel received
a comprehensive clinical orientation to the Department’s health care policies and procedures,
given by a registered nurse (RN). The approval of treatment protocols or standing procedures
was written and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. The
AET is required prior to providing medical services to youth except for emergency care and
routine medical/mental health intake screenings. is The AETs are valid until the youth leaves the
custody of the Department. A review of seven youth Individual Healthcare Records (IHCRs)
found four were applicable for the AET forms. Three of the four AET’s were valid and had the
word “copy” stamped on each form. The remaining one AET was not valid and the program had
to request and received an updated AET during the annual compliance review week. All four
AETs were signed by parent/guardian and a Department representative. Two of the remaining
three youth were over the age of eighteen at admission to the program. Two other youth turned
eighteen during their stay at the program. The program utilizes a separate form for youth
eighteen years of age or older. Documentation supported all four youth signed a Release of
Information Authorization Form for Youth Eighteen Years of Age or Older to provide consent for
the release of specific information. The remaining one youth was in the care of the Department
of Children and Families and had a court order filed within the youth’s IHCR. The nursing
interview confirmed the youth’s AET is documented in the Department’s Juvenile Justice
Information System (JJIS) within the electronic commitment packet. If the youth does not have a
current AET, the nursing staff will then contact the case manager who reaches out to the
juvenile probation officer (JPO) to obtain a current AET from the parent/guardian. If a youth is
over the age of eighteen, the nursing staff reported the youth would sign a release of
information form.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 70 (Revised September 2022)
The program has a policy and procedures to ensure parents/guardians are notified of any
changes in the youth’s condition and obtain consent when new medications and treatments are
prescribed. A review of seven youth Individual Healthcare Records (IHCR) found three were
non-applicable for parental notifications/consent. The remaining four were not applicable for
parental notification for over-the-counter medications beyond those covered in the Authority for
Evaluation and Treatment (AET). All four youth were ordered new medication while in the
program and each record documented parental contact in the progress notes. Each of the
IHCR’s contained written notifications documented on the Department’s Parental Notification of
Health-Related Care: General or Parental Notification of Health-Related Care: Medications
forms or the Acknowledgement of Receipt of the Department’s Clinical Psychotropic Progress
Note (CPPN). Two of the four youth were taking prescribed psychotropic medications at
admission and when a new psychotropic medication was prescribed, or discontinued, or a
significant change in dosage occurred it was documented on page three of the CPPN form. All
seven reviewed IHCR’s documented vaccinations were verified within thirty days of each youth
admission. None of the youth were applicable for requiring new vaccinations or requesting
religious exemption. The nursing interview indicated verbal and written parental notifications are
made for new medications and over-the-counter medications not covered by the AET. Written
notifications are sent to the parent/guardian for every encounter with the psychiatrist, doctor,
dentist, eye doctor, or off-site visit, including emergency medical services. The parental
consents/notifications are sent on the day of or within twenty-four hours of when the youth is
seen by the doctor or psychiatrist, medication orders, or day of admission. When a youth
receives a new psychotropic medication, has a medication discontinued or adjusted, attempts to
contact the parent/guardian are made while the psychiatrist is in the facility. If unable to contact
the parent/guardian at the time, calls are made until verbal consent is obtained prior to starting
the medication. The Acknowledgement of Receipt (AOR) of the CPPN and page three of the
CPPN are sent certified and by regular mail to the parent/guardian. Discontinued medication
and adjustments are sent on the AOR. The nursing interview indicated vaccinations are
provided on-site after a written order is received from the designated health authority and
parental consent is obtained. Immunization records are received with the youth admission
paperwork, and they are verified and downloaded from Florida Shots within twenty-four hours of
admission. A copy of the medical exemption from the parent/guardian, which is signed by the
youth’s doctor is obtained, if the parent/guardian requires exemption from immunization, and the
form is filed in the IHCR.
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.
All seven reviewed Individual Healthcare Records (IHCR) had a Facility Entry Physical Health
Screening Form (FEPHS) completed on the date of admission by a licensed medical staff. In
two of the seven records, there was a change in physical custody greater than twenty-four
hours. The program completed a new FEPHS re-screening of each youth for each returning
date. The nursing interview indicated all newly admitted youth are seen on the day of admission.
The nurses are notified through email and verbally by the intake specialist when a new youth is
being admitted to the program. The admission screening is completed by a licensed nurse.
Each youth with a change in physical custody since admission has a new FEPHS and body
chart completed by a registered nurse upon return to the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 70 (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.
The program has a policy and procedures ensuring all youth receive an orientation to the
general process of healthcare delivery of services at the program. The program contract
requires youth receive monthly Health Education. The health education provided covered
seatbelt usage, alcohol and drug related problems, sexually transmitted disease/infections,
tobacco products, dental hygiene and dental care, basic personal hygiene, immunizations,
infection control, prevention of sexual and other physical violence, nutrition, physical fitness,
breast and testicular self-examinations, parenting skills, prenatal, postpartum, and parenting
education, as applicable. A review of seven youth Individual Healthcare Records (IHCR)
confirmed each contained a completed Department of Health Education form documenting
youth orientation to the program’s healthcare services within twenty-four hours of admission to
the program. The orientation sheets included all required topics and were signed by each youth.
In addition, during the intake process the case manager reviews an orientation packet to
address access to medical services.
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.
Seven youth Individual Healthcare Records (IHCR) were reviewed for the designated health
authority (DHA) or designee admission notification. Three of the seven reviewed youth records
were applicable for suspected chronic conditions. All seven records included documentation a
referral was made to the designated health authority (DHA). None of the youth were identified
as in-need of emergency care upon admission. In all seven IHCRs, the DHA was notified within
twelve hours of admission and notification was documented. In three of the seven records each
youth was currently taking psychotropic medication upon admission and the psychiatrist was
notified. The nursing interview indicated the DHA is notified upon each youth admission who has
a chronic condition through fax or telephone by a licensed nurse and this is documented in the
chronological progress notes in each IHCR.
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.
All seven Individual Healthcare Records (IHCRs) reviewed had a Health-Related History (HRH)
form completed within seven calendar days of admission and prior to the Comprehensive
Physical Assessment (CPA) being completed, as evidenced by signature and date. The
designated health authority reviewed each of the seven HRH forms. The nursing interview
indicated the nursing staff complete a new HRH for each youth on the day of admission.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 70 (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.
In all seven Individual Healthcare Records (IHCR) each youth’s physical assessment was
completed on the Department’s Comprehensive Physical Assessment (CPA) form by the
designated health authority (DHA) within seven calendar days of admission and included the
Medical Grade. Two of the seven CPAs were missing a mark on one section each and the
program indicated human error. The remaining five CPAs had all sections marked with an “O” or
an “X”. All seven CPAs had the genital exam part marked as refused by youth and each youth
signed a refusal form which reflected the refused portion on the CPA exam and matched the
date of the exam. Six of the seven youth required the Department’s Problem List to be updated
which was completed. All seven IHCRs contained at least one verified Tuberculosis Skin Test
(TST) completed within the last year. The results of the TST were documented on the CPA and
the Infectious and Communicable Disease (ICD) forms. The nursing interview indicated the
DHA/designee completes a new CPA for all newly admitted youth within seven days of
admission and annually thereafter. All youth are screened for tuberculosis at admission and
annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures reflecting human immunodeficiency virus (HIV) test
results are only disclosed to the youth and the youth’s legally authorized representative, health
care providers during the course of consultation, diagnosis, or treatment of the individual, the
Department of Health (DOH) for purposes of reporting and control of spread of disease, health
facility staff committees conducting program monitoring, evaluation and service reviews,
medical personnel who have been subject to a significant exposure, and health care facility
personnel or agents for the healthcare provider who have a need to know in the course of
patient care activities or administrative operations. All seven reviewed youth were clinically
screened and evaluated for sexually transmitted infections (STI) on the day of admission. None
required further evaluation, testing, had been out of the Department’s physical custody, or had
present symptoms. All seven Individual Healthcare Records (IHCR) documented each youth
was offered counseling, testing, and if indicated, treatment/referral for HIV. None of the youth
provided consent for HIV testing. The designated health authority (DHA) provides the HIV pre
and post-test and counseling services, as indicated by the nursing interview. All seven youth
interviews indicated they can request and receive HIV testing. The nursing interview indicated
all youth are screened at admission for STIs through a questionnaire and the DHA; testing is
ordered as needed. STI screenings, evaluations, referrals, and tests are documented on the
Infectious Communicable Disease (ICD) form, the STI form, the HIV form, and if labs were
completed the results are in the lab section of the IHCR. If a youth has been out of the
program’s/Department’s physical custody for more than thirty days and/or symptoms present, a
new facility entry screening and STI screenings are completed. If symptoms present the DHA
will be notified verbally and testing is completed as ordered. If a youth receives an HIV test, pre
and post HIV counseling is documented on the Health Education form and the results are
placed in a sealed envelope, marked confidential and placed in the lab section of the IHCR. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 70 (Revised September 2022)
Health Department does not leave test results to maintain in the IHCR unless a youth requests.
Youth are asked at admission if they want an HIV test and counseling, and they are informed
they can request testing at any time by talking with a nurse or requesting in writing through a
sick call form.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing when there is not a licensed nurse on-site
the shift supervisor reviews all sick call requests as soon as possible and within two hours after
the request is submitted. Nurses are the only staff conducting sick call.
In six of seven reviewed Individual Healthcare Records (IHCR) each youth had a sick call event.
The remaining one youth did not. None of the six applicable youth presented with similar sick
call complaints three or more times within a two-week period. All six IHCRs documented each
youth and the nurse completed each Sick Call Request form. In five of the six records the
licensed practical nurse (LPN) conducted some of the sick calls, which were reviewed daily with
a registered nurse (RN) and documented on the form. All six IHCRs had the Sick Call Request
forms filed in reverse chronological order and each was documented in accordance with Health
Services Rule 63M-2. In five of six IHCR’s all sick calls were documented on the Sick Call
Index. In the remaining IHCR one of the sick calls was missing and the nurses indicated human
error. All sick call events for the six applicable IHCRs were documented on the Sick Call
Referral Log. None of the youth were in restricted housing. A review of the daily schedule
posted schedule, and the nurse interview confirmed sick call was conducted daily. The sick call
hours were observed to be posted in the clinic and on all dormitories, accessible to all youth.
The Sick Call Request forms were available to youth in each dormitory. Sick Call observation
during the annual compliance review week indicated sick call is conducted in the exam room
utilizing an exam table. The youth was escorted to the clinic by a youth care worker, who stayed
outside of the exam room behind a curtain to afford privacy for the nurse and youth, but able to
still observe the youth. The nurse identified herself and stated what was documented on the
Sick Call Request form. The nurse took vitals and questioned the youth about his ailments. The
sick call was concluded with a referral to the designated health authority (DHA). Two of seven
youth interviews indicated they can see the nurse immediately when requesting a sick call. The
remaining five stated it takes one day. The nursing interview indicated if youth want to see a
nurse regarding any physical complaints, they have sick call forms to complete and place in a
sick call box on the dormitory. These boxes are checked several times a day, at least once a
shift while a nurse is on-site. Youth are usually seen within twenty-four hours. Sick calls are
conducted by a RN or LPN once a day in the exam room and if an LPN completed the sick call
the RN will review it within twenty-four hours. The DHA will conduct sick call if on-site. A youth is
referred to the DHA if complaining of the same illness three or more times in a fourteen-day
period, if nursing protocols indicate, or due to a nurse’s judgement. The nursing interview stated
the program has DHA approved treatment protocols. The program does not have restricted
housing.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 70 (Revised September 2022)
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures addressing episodic and emergency care, including a
process for ensuring contents of the first-aid kits are maintained and stored in accordance with
guideless to prevent expiration or deterioration, and are replenished as needed. The program’s
policy includes the use, access, and inventory of Narcan. Four of seven reviewed Individual
Healthcare Records (IHCR) had an indication each youth required on-site first-aid or episodic
care. The remaining three were not applicable. All four applicable IHCRs had on-site care
provided by a licensed healthcare staff which was documented in problem-oriented charting.
The program had ten first-aid kits, one in the Home Builder Institute building, South sub control,
North sub control, kitchen, vocational/educational room, controlled observation, and master
control; the three vehicle kits were also located in master control. Three first-aid kits were
observed to be fully stocked with designated health authority-approved contents. One of the kits
had an expired saline solution which the nurse exchanged. The first-aid kits are monitored
weekly. A review of the first-aid kit checks for the annual compliance review period indicated
they were monitored as required and stocked with DHA approved items. The program has one
automated external defibrillator (AED) located in master control with the procedures in the same
box. The AED was found in working order during the annual compliance review week with the
pads expiring June 7, 2030, and the batteries expiring in August 2025. The pads were
exchanged last in November 2021 and the batteries June 2024. A review of the AED checks for
the annual compliance review period indicated the nurses conduct weekly AED checks as
required. The emergency numbers were posted in the nurses’ office accessible to staff and
inaccessible to youth. A review of documentation indicated the authorized direct care staff were
trained on the administration of the epinephrine auto-injector by a registered nurse. A review of
seven pre-service and seven in-service training records indicated all fourteen staff received
episodic, first-aid, and emergency care training. During the annual compliance review, the
program did not have an episodic care event while the team was on-site; therefore, were unable
to observe a first-aid event. A review of the medical drills for the annual compliance review
period indicated the program conducted emergency medical drills announced or unannounced
at least quarterly on each shift. All direct care staff participated in at least one drill annually
which included the use of cardio-pulmonary resuscitation (CPR). An effort was made to ensure
all staff with direct contact on a day-to-day basis had the opportunity to participate in at least
one emergency “man-down” drill annually or had the opportunity to review each scenario in an
effort to understand the process and respond to the specific scenario. Video observation was
conducted for two medical drills and four mental health drills which included medical responses.
The two medical drills were simulated as seen on video. A review of the medical drill
documentation indicated prior to June 2024; the drills were written as if conducted during a
training session. The Department’s Office of Health Services (OHS) conducted a deficiency
review in June 2024. After June 2024 the drills simulated an episodic care event which called for
immediate first-aid and/or administration of CPR techniques and the initiation of the emergency
procedures to follow when a life-threatening emergency does occur. Observation during the
annual compliance review week indicated the program maintains two doses of Narcan in the
medical cart, two doses each in two “jump bags”, which are first response kits used by the clinic,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 70 (Revised September 2022)
and two doses in a locked cabinet in the examination room. The program maintains a list of staff
which were trained and are allowed access to Narcan. The Narcan is inventoried perpetually
and by shift-to-shift count.
All seven staff interviews indicated they are personally allowed to call 9-1-1 if a youth has a
medical emergency. All seven youth interviews indicated they can see a doctor and a dentist if
needed. The nursing interview indicated if the non-healthcare staff provide first-aid/emergency
care to the youth, it is documented on the Non-Licensed Health Care form by the staff providing
care. Youth who receive off-site care are tracked in the off-site care logbook. The interview
indicated mock medical drills are conducted once a month on each shift. Sometimes they are
done at all staff meetings. Drills are usually conducted by having a staff member simulate the
drill and the AED and CPR drills are completed using the mannequin.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to provide timely referrals and coordination for off-site
healthcare. A review of seven Individual Healthcare Records (IHCR) found two were applicable
for off-site care; therefore, one additional IHCR was requested. In each of the three applicable
IHCRs, there was an indication the youth required off-site medical care. The Department’s
Summary of Off-Site Care Consultation Report form was utilized and filed in each youth’s IHCR.
Each off-site care was documented on the youth-out log. Two youth were eighteen years of age
and did not require the parent/guardian notification. The remaining youth was in the care of the
Department of Children and Families (DCF) and had a valid court order authorizing all
medications and treatment. Notifications were sent to DCF. The discharge and other applicable
documentation were filed in all three applicable IHCRs. All three IHCRs maintained off-site care
findings, instructions, and information reviewed and were signed by the designated health
authority (DHA). None of the three youth required follow-up testing, referrals, or appointments.
The nursing interview indicated the nurses track youth who are sent off-site for first-aid or
emergency care through the off-site log, and an off-site schedule book. Upon a youth’s return
from a hospital visit the DHA is called to confirm all off-site written orders and the youth is
logged in the DHA logbook and the paperwork is placed in the front of the IHCR for review and
initialing. The nurses have a logbook to track follow-up testing, referrals, and appointments.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Three of the seven reviewed Individual Healthcare Records (IHCR) confirmed each youth was
identified on the Facility Entry Physical Health Screening (FEPHS) form with a current chronic
condition. The four remaining youth were not applicable. None of the three applicable youth had
a communicable disease, were undergoing treatment for a physical health condition, were
pregnant, were taking anti-tuberculosis medication, had a periodic evaluation completed off-site,
or had any lapses in care or missed evaluations. All three youth were taking prescribed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 70 (Revised September 2022)
medication on an on-going basis, were placed on the chronic illness list, received periodic
evaluations at least every ninety days, and periodic evaluations were conducted prior to
renewing a prescription medication which expired. One youth was classified with Medical Grade
two to four and the other two with Medical Grade five. In two of the three records, the
Department’s Problem List was updated, as required. The facility administrator interview
indicated the medical department meets with the designated health authority (DHA) weekly. The
DHA interview indicated every sixty days youth with chronic conditions have a periodic
evaluation completed and tracked. The nurses have a chronic clinic log and youth with chronic
conditions are scheduled by the nurses every sixty days or less. The nursing interview indicated
youth with chronic conditions are monitored every sixty days by the DHA. Those youth are listed
on a chronic condition log.
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.
Seven youth Individual Healthcare Records (IHCR) were reviewed for medication management.
Three of the seven youth were applicable for medication management. In all three reviewed
IHCRs, the Facility Entry Physical Health Screening (FEPHS) form and progress notes indicated
each youth was admitted with medication and all medications were verified prior to youth
admission into the program. All three applicable IHCRs had the prescription verification
documented on the Department’s Prescription Medication Verification Checklist form and the
designated health authority (DHA)/designee, and when applicable, the psychiatrist, was
contacted to obtain the order to resume the specified medications prescribed prior to admission.
In four of seven IHCRs each youth was admitted or was prescribed a medication while at the
program and all medications had a current, valid order, and were administered pursuant to a
current prescription. In the four applicable IHCRs if a current medication was continued,
discontinued, changed, or new ones were ordered, the DHA placed an order on the Practitioner
Order Form. In one of the seven IHCRs an over the counter (OTC) medication, not listed on the
Authority for Evaluation and Treatment (AET) form, was administered according to approved
protocols or Practitioner Order. None of the youth were in restricted housing, required parenteral
medication, or were required to initial for medication administration. All seven IHCRs utilized a
pre-printed pharmacy Medication Administration Record (MAR) which included all required
information, documented all medication and treatment, and each MAR clearly indicated
medication start and stop dates. All medication entries were initialed by a nurse, and there were
no lapses or errors in medication administration. All seven IHCRs documented, at a minimum,
weekly side-effect monitoring on each MAR, which was conducted by a nurse. In two of seven
records, both youth signed a Refusal of Treatment form indicating their refusal of medication,
which was clearly documented on each MAR. Each of the MARs in all seven IHCRs contained
all required elements. Three youth were admitted with current prescribed psychotropic
medication. In all three applicable IHCRs the DHA and psychiatrist were notified upon
admission, and the psychiatrist conducted an initial diagnostic psychiatric interview within
fourteen days of admission. Two of the three applicable youth received a medication review
every thirty days as required. In the remaining IHCR the youth was off-site for multiple days and
received the medication review late upon his return to the facility. The review was twelve days
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 49 of 70 (Revised September 2022)
late due to having to wait until the psychiatrist was back on-site. The program did not have any
standing orders, emergency treatment orders, or pro re nata orders for psychotropic
medications. During the annual compliance review week an observation of medication
administration was conducted. The observation indicated medication delivery was the sole
responsibility of the nurse during the time of medication administration. Each youth was
escorted to the medical clinic by a youth care worker and each youth approached the nurse
individually. The nurse identified themselves and stated why each youth was there. The nurse
prepared and administered each medication, after each youth’s allergy and alert status was
verified. Each MAR was initialed by youth and nurse, as well as the nurse ensuring each youth
swallowed the medication. No OTC medications were administered, and no medication was pre-
poured. The Six Rights of Medication Delivery/Administration were verified.
All seven youth interviews indicated the nurse provides medication to the youth. One of the
youth stated they do not take any medication. The remaining six stated medication is provided
in the medication pass room, and four also stated the staff observe medication administration.
The nursing interview indicated MAR’s, orders, and prior facility paperwork is checked for
medication during youth admission. This is documented on the Health Related History (HRH)
form, Facility Entry Physical Health Screening, DHA notification, and nurses’ admission note.
Non-healthcare staff do not verify medication, only nurses verify medications at admission.
Trained non-healthcare staff can provide OTC medications and they are required to fill out the
Non-Licensed Healthcare form. Medications are ordered through a local pharmacy and OTC
medications and stock medications are ordered through a medication provider.
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 program has a policy and procedures addressing medication management including a
process for the destruction and disposal or return of expired or discontinued medications and a
process for inventory discrepancies and the reporting criteria. Observation of the clinic indicated
the sharps and all medications were secured when not in use and inaccessible to all youth. A
review of the medication cart indicated it was locked when not in use, clean and organized with
stock items, injectable, topical, drops, and liquids being separated from youth-specific
medications. The medication cart included a locked box for all narcotics and controlled
medications. The clinic maintains a medication-only refrigerator and a specimen-only
refrigerator. A review of the sharps and over-the-counter (OTC) medication inventory for the
annual compliance review period indicated all were inventoried perpetually and weekly as
required. The program only had one controlled medication on-site during the annual compliance
review week and the shift-to-shift inventory count was documented on the youth’s Individualized
Controlled Medication Inventory Record. Eighteen non-healthcare staff were trained in the
delivery and oversight of medication self-administration by a registered nurse. Observations of
the nurse conducting a count of three sharps indicated the ending count and the final count of
the inventory matched. A count of the only controlled medication on-site matched the count on
the inventory. A count of three OTC medications indicated one medication count matched the
inventory count. The remaining two counts were off, one documented one on the inventory and
there were two in the cabinet and the other documented two and there were six in the cabinet.
The nurses indicated they had just received a new delivery for those OTC medications and had
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 70 (Revised September 2022)
not documented them in the inventory binder. The health service administrator was able to
provide documentation for one of the medications, but unable to provide any for the other.
The nursing interview indicated all controlled substances are maintained in the medication cart
behind two locks. All medications are secured in cabinets or the medication cart. The process
for disposal of medications is to dispose of them in the approved liquid in the presence of the
pharmacist, who comes once a month.
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 has a policy and procedures addressing infection and exposure control, including
a process for needle stick post-exposure evaluation. The program’s infection control procedures
include prevention, containment, treatment, and reporting requirements related to infectious
diseases according to the Occupational Safety and Health Administration (OSHA) federal
regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
designated health authority (DHA) and the facility administrator (FA) reviewed the infection
control procedures on July 9, 2021, and the remaining medical staff reviewed them on July 1,
2021. The infection control procedures include common, infectious diseases of childhood, self-
limiting, episodic contagious illnesses, viral or bacterial infectious diseases, tuberculosis,
Hepatitis A, B, and C, and human immunodeficiency virus (HIV), infectious diseases caused by
bloodborne pathogens, other outbreaks or epidemics caused by any other infectious agent ,
spread directly or indirectly, outbreaks of pediculosis and/or scabies, Methicillin-Resistant
Staphylococcus Aureus and other emerging antibiotic-resistant micro-organisms, foodborne
illnesses, bio-terrorist agents, and chemical exposures in the workplace. The procedures
address availability of Hepatitis B immunizations and access to protective equipment for staff.
The program did not have any instances in which the local county health department, CDC,
and/or the Department’s Central Communications Center (CCC) had to be notified of an
infectious disease. The human resource department of the program will maintain a file to
contain all documents for youth and staff who have experienced a facility/occupational
exposure, if needed. The exposure control plan was written in accordance with OSHA
standards, is located in master control, administration, and the staff break room, and is available
to all staff. The plan was reviewed and signed annually by the administration of the program
and/or designees on July 2, 2024.The FA interview confirmed the location of the exposure
control and infection control plan, as well as stating the plans are reviewed during training and
bi-annually with all staff.
The nursing interview indicated infection control training is conducted during admission and
annually with youth. Infection control training and exposure control plan review is conducted by
a registered nurse or the health services administrator bi-annually with staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 70 (Revised September 2022)
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 70 (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 has a policy and procedures which requires staff to 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, and consistently
applying the programs Behavior Management System (BMS). The program adheres to a staff-
to-youth ratio of one to eight during daytime activities and one to twelve during hours of sleep.
Observations during the annual compliance review week confirmed supervision ratios were
being followed according to contractual requirements. Additionally, observations found staff were
actively supervising youth during school, recreation activities, and during breaks and were
interacting positively with youth. The program has schedules of activities posted on each living
module and observed youth were engaged in activities and following the schedule. Three staff
were interviewed and asked how many youth they are supervising. All three interviewed staff
were able to answer the number of youth they were supervising.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the Behavior Management System (BMS)
and protocols regarding feedback given to staff about their implementation of the BMS during
their annual performance evaluations. The written description of the BMS was posted on each
of the four active living modules and in the youth handbook which included the rules governing
conduct and positive and negative consequences. The program’s BMS allows for youth and
staff to discuss behavior, impact on themselves and others, discussion of alternate behaviors,
and peaceful conflict resolution. The program’s BMS includes several key components which
are designed to promote a positive and supportive environment for youth. These include
promoting safety, respect, and fairness for all participants, as well as protecting and promoting
youth rights. The system incorporates both positive and negative consequences, with an
emphasis on constructive disciplinary actions and are non-punitive in nature. It provides
opportunities for positive reinforcement, ensuring positive behaviors are recognized at a four-to-
one ratio as required by the program’s contract. The BMS also focuses on promoting socially
acceptable means for youth to meet their needs and includes a process for explaining to youth
the reasons behind any sanctions imposed. Youth are given the opportunity to explain their
behavior, and there are opportunities for both staff and youth to discuss the impact of behaviors
on others. The program encourages reasonable reparations for harm caused to others, while
also discussing alternate behaviors to prevent future issues. It emphasizes promoting positive
dialogue, peaceful conflict resolution, while minimizing the separation of youth from the general
population whenever possible. The program’s policy and procedures include a protocol for
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 53 of 70 (Revised September 2022)
providing staff with feedback on their implementation of the BMS, which is incorporated into the
annual performance evaluation process. This ensures staff members receive regular,
constructive input on how effectively they are utilizing the BMS and helping to maintain a high
standard of practice throughout the program. In addition, the program has established an
agreement with the school as it pertains to the BMS, referred to as the Cooperative Training
Joint Plan. This agreement ensures there is a consistent approach to behavior management
across both the program and the educational environment. The facility administrator plays a key
role in training the education staff in this jointly combined BMS plan, ensuring the same
strategies and techniques are used during school hours. Further training is provided by the
facility administrator and the education liaison, who offer guidance to the education staff on how
to implement the BMS effectively. To verify the program’s adherence to its procedures, seven
youth case management records were reviewed and confirmed youth orientation included a
detailed review of the BMS, ensuring all youth understand the system and its expectations.
Additionally, thirty-two position descriptions were reviewed for staff whose job functions include
the implementation of the BMS. This review confirmed staff are appropriately designated to
carry out these responsibilities. Seven staff training records were also reviewed and it was
confirmed these staff members had completed training in the program’s BMS, further ensuring
the system is consistently and effectively implemented across the program. The program’s BMS
also includes a process wherein staff explain to youth the reason for any sanction imposed,
ensuring clarity, and understanding. This explanation takes place prior to the end of the staff
member’s workday. Furthermore, the youth are given an opportunity to explain their behavior,
which promotes open communication and reflection. Staff and youth are encouraged to discuss
the impact of the behavior on others, ensuring the youth understand the broader consequences
of their actions. The process also includes discussions on reasonable reparations for any harm
caused to others and the identification of alternative, acceptable behaviors, providing youth with
the tools to make more positive choices moving forward. Seven staff members were interviewed
and asked to explain the program’s BMS. All seven staff were able to explain the program’s
BMS as a level system, which includes written behavior reports, point cards, honors, and honors
gold. All seven staff confirmed no basic rights can be taken away from youth as a consequence.
Seven youth were interviewed, and all stated staff are consistent with rewards and
consequences. Each of the seven youth were able to explain the BMS system and all confirmed
youth are not allowed to punish other youth. All interviewed youth and staff reported youth can
earn rewards such as canteen, Monday burgers, Thursday sausage, pizza parties, special
meals, and level points. All interviewed youth and staff stated consequences consists of
behavior reports, point reductions, behavior contracts, and canteen restrictions. The facility
administrator was interviewed and stated staff implementation of the BMS is monitored through
performance evaluations and annual evaluations. Additionally, positive behavior reports,
behavior reports, and incident reports are reviewed daily in management meetings, where
trends are discussed. If staff are found not adhering to the BMS process, a discussion takes
place to address the issue.
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 states the program does not use restricted housing, to include room
restriction; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 70 (Revised September 2022)
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures requiring staff to observe youth at least every ten
minutes while they are in their sleeping quarters. These observations must be conducted in a
manner which ensures the safety and security of each youth. The checks are to be documented
in real time. The program is equipped with 121 cameras, all of which were operational at the
time of the review. The program retains thirty days of video recordings. A sample of video
recordings and corresponding logs was reviewed to verify the ten-minute checks. The sample
included three thirty-minute increments from each shift, for a total of three days, using stored
video recordings from each living module. The review confirmed all checks were conducted at
eight-minute intervals, which is below the required ten-minute interval and all checks were
documented in real time. A further review of the ten-minute check sheets confirmed staff
members who completed the checks initialed the check sheets. Video recordings also confirmed
the checks were conducted as required and staff did not simply walk by the rooms. The staff
were observed to pause and thoroughly observe the youth to ensure their safety. A review of the
check sheets for the annual compliance review period showed checks were conducted as
required. Seven staff members were interviewed and confirmed checks are conducted every
four 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 has a policy and procedures addressing census, counts, and tracking. The
program’s census and counts are documented in the master control logbook with three formal
counts completed each shift. The program’s policy and procedures state there are to be six
formal counts completed every twenty-four hours. Observations during the week of annual
compliance review week found master control calling for and completing counts as required at
various times throughout the day. The program’s master control logbooks were reviewed during
the annual compliance review period confirming counts were completed three times a shift. A
review of a full day for each month, since the last annual compliance review, was conducted of
the logbooks, and each day contained documentation of total daily census counts, head counts,
youth movements, youth admissions and releases, and youth temporarily away from the
program. Seven staff were interviewed stated youth counts are conducted nine times a day, or
three times a shift.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 70 (Revised September 2022)
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has established a policy and procedures for logbook entries. Observations during
the annual compliance review week confirmed the program uses a single bound logbook with
numbered pages for each month. A review of the logbooks verified all entries were made in ink,
with no erasures or white-out areas, and no entries were destroyed or removed. The reviewed
logbook pages included entries with dates, times, brief descriptions of events, and the names of
staff making the entries. The program does not utilize living unit logbooks. A review of the
logbooks during the annual compliance review period showed minimal interference with the
educational instruction period. Youth movements to recreation were also documented. The
review of the logbooks indicated the documentation of incidents involving mechanical restraints,
population counts at the beginning and end of each shift, perimeter security checks, and
transports away from the facility, including the names of staff, youth involved, and the
destination. It also showed the removal of any youth from the mainstream population, such as
when placed on room restriction or controlled observation, along with admissions and releases,
including the name, date, and time of anticipated arrival or departure. The program utilizes shift
reports, which include the census of all living units, incidents, youth out of the facility, youth
alerts, gang members, security alerts, staffing assignments, sick calls, perimeter checks, and
their findings. Shift reports are reviewed by the supervisor from the previous shift and the
incoming shift during staff briefings at shift change. Shift reports reviewed during the annual
compliance review period included signatures from staff and supervisors, confirming their review
of the shift report. A review of the master control logbooks and shift reports confirmed internal
incidents were reported to the Department’s Central Communications Center (CCC) and/or the
Florida Abuse Hotline.
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 has an established policy and procedures to address key control, which include
key assignment and usage, restrictions on usage, inventory and tracking of keys, secure
storage of keys not in use, procedures for handling missing or lost keys, and the reporting and
replacement of damaged keys. The program’s keys are stored in a padlocked, clear-view
cabinet located in master control, under camera surveillance. This area is secured and
inaccessible to youth. Staff’s personal keys are securely stored in a locked cabinet within
master control. Keys are issued by master control based on staff position. The key box in
master control is securely locked and not easily accessible. Each set of keys is assigned a
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 70 (Revised September 2022)
specific number and corresponding key ring. A review of five sets of keys in the master control
key box was compared to the inventory which confirmed the actual key rings in use matched the
inventory records. Keys are always locked in the cabinet when not in use. During the annual
compliance review week, observations of master control issuing keys confirmed the key
inventory matched the correct number of keys assigned to each individual key set. Key sets in
the administration area were stored in a locked box on the wall. Both key storage boxes were
locked when not actively in use. The facility administrator assigns permanent and restricted
keys based on position. An acknowledgment form is completed for each permanent key
assigned, which includes the staff member’s signature, the key number, and the return date.
Restricted keys are stored separately from non-restricted keys in a locked box and only
assigned staff members have access to the restricted key box. The program has a broken key
report procedure, which is submitted to the plant manager, the only individual authorized to
replace keys. Both key storage boxes are not easily accessible to unauthorized personnel. No
incidents related to key control were reported to the Department’s Central Communications
Center (CCC), nor were there any Program Monitoring and Management (PMM) deficiencies
related to key control during the annual compliance review period. The program maintains a
twenty-four-hour key log, which is updated by the master control operator. The log includes the
keys issued, the date and time of issuance, the person receiving the key, the time the key was
returned, and the master control operator’s initials for each entry. Three random staff members
were informally interviewed and were able to identify the key set they were assigned and the
function of each key on the set. The key sets were verified against the master key inventory.
Additionally, seven staff were interviewed and asked to explain the process for handling
personal and program keys from the time they arrive to begin their shift until they leave. All
seven staff stated staff keys are given to master control upon entry, and visitor personal keys
are securely stored. They also confirmed youth do not have access to the 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 has a policy and procedures in place to prevent contraband from entering the
facility. The policy includes items and materials considered as contraband, as well as
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 70 (Revised September 2022)
exemptions, providing youth with a list of items considered as contraband, informing program
youth of the consequences if found with contraband, searching the facility and grounds, and
searching of youth, incoming mail, and outgoing mail. The policy includes the consequences if
any program staff is found in possession of contraband. The policy also includes contacting law
enforcement if any item found is considered illegal as defined in Florida Statutes, or if there is
any evidence of unlawful activities. The facility visitor log was reviewed and it included a
contraband attestation statement. A review of the Department’s Central Communications Center
(CCC) reports showed there were three reports of contraband confiscated during the annual
compliance review period. A review of the facility logbooks and youth room search reports for
the annual compliance review period showed the program conducted searches as required.
Contraband items or illegal contraband is documented on the search log and disposed of as
required. The review of thirty new staff members hired since the last annual compliance review
indicated attestation forms were signed and completed. The facility administrator’s interview
stated the policy is to turn all contraband into the facility administrator. All illegal contraband is
secured and turned over to law enforcement. Non-legal contraband is secured in the facility
administrator's office and disposed of once the CCC report closes. Seven staff interviews
confirmed the program’s process for youth room searches is conducted daily on each shift.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to address searches and full body visual searches to
ensure no contraband is introduced into the facility. During the week of the annual compliance
review, staff were observed searching youth prior to and after movement. Staff were also
observed searching a youth returning from a detention transport. The program had two
admissions and no releases during the annual compliance review week. Observed the
admission process of two youth who were transferred from the detention center to the facility.
Upon arrival, both youth were received by facility staff and escorted to the intake area. Standard
intake procedures were followed, including identity verification, a brief health screening, property
inventory, and documentation review. Staff engaged with the youth in a respectful and
professional manner, explaining each step of the process clearly. Both youth appeared calm
and cooperative during the intake. No incidents or concerns were noted during the admission
process. Visitation did not take place during week of annual compliance review nor were there
any off-campus activities scheduled. During observed searches youth were treated with dignity
and respect to minimize the youth’s stress and embarrassment. Observed searches were
conducted by the same gender as the youth and with appropriate number of staff. Youth were
given instructions and reason for search prior to search, which were in line with program policy.
Seven staff were interviewed and stated youth searches are done during every movement.
Seven youth interviews confirmed searches occur when returning from off-campus activities,
after outdoor activities, when items are missing, after visitation, after meals, and after work
detail. Video footage was reviewed and indicated youth were searched during movements
throughout the facility.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 70 (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 has established a policy and procedures to address vehicle maintenance and
usage. The program utilizes three vehicles for youth transport. Reviewed documentation
confirmed the vehicles underwent annual safety inspections, and all required maintenance
records were properly documented. During the week of the annual compliance review, fifteen
randomly selected personal vehicles and three facility vehicles were found to be securely
locked. Observations during the annual compliance review week confirmed each facility vehicle
was equipped with a seatbelt cutter, window punch, safety screen, fire extinguisher, an
appropriate number of seatbelts, and youth doors cannot be opened from the inside. First-aid
kits are issued when vehicles are checked out. A youth transport was observed during the
annual review week. During the observation, youth were secured with shackles, handcuffs, a
waist belt, and a seatbelt. During staff interviews, it was reported youth are transported in a
secure manner following facility policy and safety protocols. Staff explained youth are restrained
using handcuffs, leg shackles, and a waist belt to ensure security and reduce risk during
transport. Each transport includes a minimum of two staff members present in the vehicle.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to address transportation of youth and driver
eligibility. The review of the program’s policy and procedures states a program cellular
telephone is issued for all transports, the program’s policy states a minimum of two staff to one
youth is required, and a staff of the same gender of the youth is present during a transport. The
program provides transportation for the youth. During the week of the annual compliance
review, an observation was made of two staff members transporting two newly admitted youth.
Both staff members were of the same gender as the youth. The staff and youth were observed
removing seat belts prior to exiting the vehicle. Upon the return of the transport, the youth were
secured with shackles, handcuffs, a belt, and a seat belt. All three facility vehicles have safety
screens installed. Reviewed documentation revealed the program maintains an approved driver
list and ensures each approved driver has a valid driver license. Youth are not permitted to drive
program or staff vehicles. The interview with the facility administrator indicated each vehicle
used for youth transports is equipped with a safety screen. Five of the seven interviewed youth
reported they had never been on a transport. Two youth indicated they had been on transports
and stated they were secured with seat belts, handcuffs, waist belts, and shackles. All seven
youth indicated they had never seen anyone place contraband in a transport vehicle. Seven
staff were interviewed and asked how youth are secured during transport. Three responded
youth are secured using shackles, handcuffs, a waist belt, and a seat belt. The three staff who
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 70 (Revised September 2022)
complete transports stated they are provided a work cellular phone during a transport. Four
stated they do not complete transports.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has established a policy and procedures outlining weekly safety and security
audits. These procedures specify the program staff responsible for conducting the audits and
safety inspections, the development and implementation of corrective actions for any
deficiencies identified during inspections, an internal system to verify deficiencies are corrected,
and the improvement or introduction of systems as needed to maintain compliance. The weekly
audits are conducted by the facility administrator, assistant facility administrator, chief of
security, plant manager, and unit manager. During the annual compliance review period,
documentation confirmed weekly inspections were completed as required. No safety or security
audit related Program Monitoring and Management (PMM) deficiencies were identified during
the annual compliance review period. The program’s preventive maintenance schedule was
reviewed with the plant manager, and repairs were conducted as outlined in the policy. The
facility administrator indicated in an interview the program conducts daily walk-throughs and
utilizes a weekly safety inspection sheet, work orders, and discussions during the daily
management meeting to address safety concerns.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing the issuance, inventory, and control of
equipment and tools. The plant manager completes a monthly tool inventory which is signed off
by the facility administrator. The program’s policy prohibits machetes, bowie knives, or other
long blade knives. The program has procedures for missing/lost tools and disposal of
dysfunctional tools. The program did not have missing, lost, or damaged tools during the annual
compliance review period. A review of the program’s tool inventory records for the annual
compliance review period confirmed tools being issued were inventoried following return. Ten
tools were randomly selected, which included five from the maintenance shed and five from the
kitchen. All tools were secured, had easy identification, and accurately matched the inventory
list.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing the supervision requirements when youth
use tools including one staff to five youth ratio, issuing tools to youth and staff, assessment to
determine a youth’s risk to self and others, tool distribution, collection, and search criteria during
work projects. The program does not utilize disciplinary work projects. There were no home
builder activities observed during the annual compliance review week. Seven case management
youth records were reviewed and confirmed all seven youth were trained on the intended and
safe use of tools. All seven youth has risk assessments completed as required. Seven
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 70 (Revised September 2022)
interviewed staff reported youth are not to use any tools. Seven youth interviews reported youth
are not to use tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures to address outside contractors which includes tools
shall never be left unattended, tools should be limited to only the required tools necessary to
perform tasks, no tool shall be given to youth at any time, and youth are restricted from any
work area. The plant manager or designee inspects all tools upon arrival and departure of
outside contractors, is responsible for providing approval if such tools as personal cellular
telephone and/or equipment/electronic devices capable of taking pictures and/or audio/video
recordings
are required and is responsible for missing tool follow-up. The program has a vendor sign-in and
out sheet where the plant manager and/or designee as well as master control checks in the
vendors. Ten records of outside contractors and their tool inventory sign-in sheet were reviewed.
All contractors signed the contractor’s policies and contraband attestation form. Three project
invoices submitted to the program by the vendor were reviewed and indicated all tools were
inventoried before and after the arrival of the vendor.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to address fire, safety, and evacuation drills. It was
confirmed through drill documentation, during the annual compliance review period, the program
conducted fire drills monthly on every shift. The drills included type of drill, date and time,
participants, brief scenario, findings, and recommendations. The fire evacuation routes, and
egress plans are posted throughout the facility. The program has twenty-one fire extinguishers
which were inspected annually. The last annual fire marshal extinguisher inspection date was
August 02, 2024. Seven staff were interviewed and all reported participating in various types of
drills during the past year, including fire, weather, disturbance, hostage, chemical spill, flooding,
escape, medical, mental health, tornado, and suicide drills. Seven interviewed youth stated they
have been instructed on what to do in the event of a fire. The facility administrator (FA) was
interviewed and advised fire drills, Continuity of Operations Planning (COOP) drills, medical
drills, and mental health drills are conducted monthly on each shift.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 70 (Revised September 2022)
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 Continuity of Operations Plan (COOP) and the COOP was last
reviewed and updated on April 11, 2024, by the facility administrator, and submitted to the
Department for approval. The plan was approved by the Department on April 15, 2024. Copies
of the program COOP plan are in the facility administrator’s and assistant facility administrator’s
offices and the staff break room. The plan addresses alternative relocation sites approved by
the Department’s regional director and the COOP includes all the required and relevant
information for continuous operation during an emergency. Supplies and equipment required for
COOP are in the plant manager area and food items are stored in the kitchen. Supplies
observed during the annual compliance review week were water, dry goods, can goods, non-
perishable items, and youth related items which are stored on the mods. The program COOP
plan includes delegation of authority, new cooperative agreements, vendor contact list,
emergency, staff contact numbers, and county cooperation checklist. Seven youth records were
reviewed and confirmed the program maintains an administrative hard-copy file for each youth
which every department will take during an emergency. An interview with the facility
administrator (FA) confirmed the COOP is in the staff break room, master control, and in the
facility administrator’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures regarding the storage and inventory of flammable,
poisonous, and toxic items. Flammable, poisonous, and toxic items are secured in the locked
storage area, which is in the maintenance shop where youth do not have access. Inventories
are maintained for all flammable, poisonous, and toxic items. The program maintains a list of
positions authorized to handle flammable, poisonous, and toxic items which include the facility
administrator, assistant facility administrators, chief of security, maintenance staff, shift
supervisors, and medical staff. The program maintains Safety Data Sheets (SDS) for all
materials on-site. Ten chemicals were randomly selected, all items matched inventory, were
secured, and had SDS present, with no discrepancies noted. The maintenance manager was
interviewed and indicated the program uses the city landfill for disposal. The program did not
dispose of any hazardous materials; therefore, did not have a disposal log. The facility
administrator, in consultation with the physical plant manager, has designated the following staff
to dispose of flammable, poisonous, and toxic items and materials: assistant facility
administrator, chief of security, unit managers, maintenance staff, medical staff, shift managers,
youth care workers, and food service. All disposal procedures were in accordance with
Occupational Safety and Health Administration (OSHA) standards. Hazardous liquid waste is
disposed of in accordance with the Safety Data Sheets (SDS). Grease is placed in a separate
container for proper disposal. In line with the program’s policy and procedures, chemical spills
are cleaned up as follows: upon discovering a chemical spill, staff are required to notify master
control of the location. The shift supervisor or master control will then direct the shutdown of all
air handlers and ventilation systems, ensuring all windows and doors are closed, as instructed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 70 (Revised September 2022)
by the on-scene supervisor or facility administrator (FA). If necessary, assistance from outside
the facility is contacted in accordance with emergency procedures. The reviewed FA interview
results indicated the program utilizes the landfill for the disposal of hazardous items and obtains
a receipt for the disposal of these materials.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handling and supervision of
flammable, poisonous, and toxic items. The program maintains strict control of flammable,
poisonous, and toxic items. The policy prohibits youth to use, handle, or the clean-up of
dangerous or hazardous chemicals by youth, except for youth in the Home Builders Institute
(HBI) program. These youth have access to paint, paint thinner, and wood stain under the direct
supervision of staff and only after being trained on how to handle these items. Youth were not
observed conducting cleaning activities during the week of annual compliance review. Seven
youth were interviewed, and all said they do not handle any chemical/cleaning products.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 70 (Revised September 2022)
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation and communication, youth
correspondence, and use of the telephone by youth. The visitation schedule is posted in the
lobby and at the entrance of the facility. The program’s facility operating procedures (FOP) state
the program shall make every effort to assist youth in maintaining and strengthening positive
family and community ties in an environment which unobtrusively monitors and controls the
movement of visitors within the program. Each youth is provided an opportunity on a regular
basis to correspond with identified individuals specified on their approved correspondence list
and legal representatives. A review of the correspondence logs confirmed all incoming and
outgoing mail is searched and recorded in the correspondence logs. The facility administrator’s
interview indicated the program utilizes an interpreter service when necessary to ensure
effective communication. Seven youth were interviewed and each confirmed they can call their
parent or guardian or write letters to them as a means of communication. There was no
visitation scheduled the week of the annual compliance review; therefore, no visitation was
observed. The program’s visitation hours are Saturdays and Sundays from 1:00 p.m. to 4:00
p.m. A review of the visitation logs validated visitations were taking place as scheduled.
Telephone calls and the opening of mail are conducted by the youth with their case managers
and were documented in each youth’s case record. Telephone calls are offered weekly
according to the program’s facility operation procedures (FOP). Each youth is allowed to make
one telephone call per week to approved family members. The case manager is responsible for
scheduling these telephone calls. The program provides postage for each youth within the
program and does not limit the number of letters a youth is able to mail each week.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities for the youth. The program
activity schedule contains at least one hour of supervised and structured indoor and outdoor
recreation and leisure activities, to include large muscle activity, for youth each day. A review of
the logbook confirmed recreation and leisure activities were conducted as scheduled. The
activity schedule for the program documents a range of supervised and structured indoor and
outdoor recreation and leisure activities for the youth, ensuring at least one hour of such
activities is provided daily. The activities include large muscle activities, both indoors and
outdoors, and are designed to promote social and cognitive skill development, creativity,
teamwork, healthy competition, mental stimulation, and physical fitness. The program’s contract
requires the program to employ a recreational therapist. Seven youth case management
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 70 (Revised September 2022)
records were reviewed and confirmed recreational therapy was included in each youth's
individualized performance and treatment plan. There were no discrepancies found with the
recreational therapist's credentials. A review of the logbook confirmed recreation was conducted
as scheduled. Recreational activities were observed to ensure the program takes precautionary
measures to prevent over-exertion, heat stress, dehydration, frostbite, hypothermia, and
exacerbation of existing illness or physical injury. Seven youth were interviewed and all
confirmed physical activities are provided for at least one hour each day. Additionally, seven
staff members were interviewed and reported indoor and outdoor activities provided to the youth
include basketball, pull-up bars, four square, and indoor ping pongs, all lasting at least one hour.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a policy and procedures for the search and inspection of the controlled
observation room. The rooms used for controlled observation had a metal door with a shatter-
resistant window, was at least thirty-five unencumbered square feet, properly covered vents and
lighting, and no electrical outlets. Mattresses in the program are fire retardant. Three controlled
observation reports were reviewed, and found staff documented an inspection of the room and a
search of each youth before the youth was placed in the room, as required. Staff of the same
gender searched each youth before the youth was left alone in the controlled observation room.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a policy and procedures for controlled observation. The program had fifty-five
youth with documented controlled observations since the last annual compliance review. A
sample size of five were reviewed. None of the reports reflected youth in a mental health crisis
or suicide. Each youth met at least one of the required criteria for controlled observation. All five
contained documentation of supervisory or higher-level staff authorizing placement. There was
one youth who complained about injuries and staff reported to the medical staff and the health
status checklist was completed. Times of controlled observation ranged from one to two hours,
in which one report included facility administrator or designee approval to go over the two-hour
window.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has established a policy and procedures for controlled observation safety checks
and releases, including staff designations for controlled observation. A sample of five youth
records was reviewed since the last annual compliance review. All five reports included
documentation of staff responsible for placement, completion of the first page of the controlled
observation report, submission to the supervisor, and documentation of safety checks
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 70 (Revised September 2022)
conducted, at least, every ten minutes, observing the youth’s behavior on the controlled
observation safety check form. It was determined an internal alert was warranted for each
reviewed youth. The facility administrator or designee gave written approval before each youth
was released from controlled observation. The Controlled Observation Report, Health Status
Checklist, and Controlled Observation Safety Checks forms were maintained in both an
administrative file and the youth’s individual case management record. Each of the five reports
documented approval from the facility administrator or designee for the youth's release from
controlled observation, based on behavior. Additionally, all reports were reviewed and approved
by the facility administrator or designee within fourteen days of the youth’s release from
controlled observation. It was determined an internal alert was warranted when each youth was
released from controlled observation. Staff designations for controlled observation are included
in the program’s policies and procedures.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 70 (Revised September 2022)
Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
According to the program’s contract, the Career and Technical Education (CTE) services
required to be provided are ServSafe (Food Handlers) and Home Builder’s Institute (HBI).
These CTE services are provided Monday through Friday from 7:30am to 8:30am. The program
has two instructors who provide these services. Their qualifications include a bachelor’s degree
and CTE Associates. Currently, twenty-five youth are enrolled in coursework towards earning an
industry certification. Seventy-one youth received each of the career and technical education
services provided for the annual compliance review period. Seventy-four youth received their
cardiopulmonary resuscitation (CPR) and first-aid certificates. Forty-seven youth received an
Occupational Safety and Health Administration (OSHA)certification. 135 youth have earned the
Florida Ready to Work Soft Skills certificate. Five youth records were reviewed and all five youth
completed the following courses within the required time frame: Florida Ready to Work Soft
Skills, OSHA-10, and CPR/First-Aid. The facility administrator was interviewed and explained as
it relates to CTE, HBI, SafeServ, OSHA, Commercial driver’s licenses (CDL), Forklift, Microsoft,
Florida Ready to work, CPR/first-aid, and Career Counseling all are offered.
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 educational access. The program
provides education services through Florida Virtual School (FLVS). A review of the facilities'
activity schedule and the daily academic schedule indicated the facilities' activity schedule
incorporates the daily school schedule. No discrepancies were found. The interview with the
lead teacher indicated all youth receive credit for completing a course. He also reported the
school schedule is adhered to. Seven youths were interviewed, and six reported no interruptions
during school. One youth reported they got chatty. A review of randomly selected days in the
logbook throughout the past year indicated education classes started and ended on time or
within a few minutes of the schedule. Observations of the program video on January 7, 2025,
January 10, 2025, and January 13, 2025, indicated classes started and ended on time as
scheduled.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 70 (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 Florida Virtual School (FLVS). The 250-day calendar is
distributed over twelve months and includes twenty days for teacher training and planning. A
review of the daily school schedule revealed education provides six fifty-minute classes from
8:30 a.m. through 2:45 p.m. with a sixty-minute lunch break from 12:05 p.m. through 1:05 p.m.,
fulfilling the weekly requirement of twenty-five hours of instructional time. The interview with the
lead teacher indicated all youth receive credit for completing a course. He also reported the
school schedule is adhered to. Five youths were interviewed and reported no interruptions
during school. A review of randomly selected days in the logbook throughout the past year
indicated education instruction was provided according to the daily bell on time or within a few
minutes of the schedule. Observations of the program video on January 7, 2025, January 10,
2025, and January 13, 2025, indicated classes started and ended on time as scheduled.
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 does meet the above requirements including Type 2 and Type 3 levels, as well as
communication, interpersonal, and decision-making skills. The lead teacher was interviewed
and as it relates to Career and Technical Education Services (CTE), career education services
and assessments are provided to the youth in the program. This is documented by way of
Occupational Safety and Health Administration (OSHA), cardiopulmonary resuscitation (CPR),
Ready to Work, and Home Builder’s Institute (HBI) with various credentials.
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 maintains a policy and procedures requiring an Education Transition
Plan to be developed upon each youth’s admission. Upon entering a residential commitment
program, an Education Transition Plan must be developed for each youth. Three closed youth
records were reviewed; none contained an Education Transition Plan. Many youths entered the
program before July 1, 2024, when the new education provider, Florida Virtual School (FLVS),
started; therefore, they would not have had an Education Transition Plan developed. A request
was made for alternative student plans entered after July 1, 2024. Still, the response received
was Education Transition Plans had not been created for any youth before early December
2024; therefore, there were none available to review. FLVS has recently developed an
education plan template and trained its staff to implement an Education Transition Plan for each
youth moving forward. The interview with the instructional leader indicated an Exceptional
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 70 (Revised September 2022)
Student Education (ESE) teacher and paraprofessional are developing the Education Transition
Plan.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
In reviewing the educational instructional staff for the facility, including flex teachers who provide
virtual education at the program, it indicated all the teachers, but one, have an active
certification, according to the Florida Department of Education website. One instructor had a
statement of eligibility, which expired on December 15, 2024. Three of the five teachers were
teaching in the field, and two were teaching out of the field. The parent notification
documentation provided by Florida Virtual Schools (FLVS) didn’t match the closed youth
records provided.
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. There was one
youth referral to Florida Youth College; however, the youth declined to participate. During an
informal interview with the Florida Scholars Academy instructor, there is awareness this is now
the process and referrals to Florida Youth College are no longer optional; they are a
requirement for all youth with a high school diploma or equivalent. The lead teacher was
interviewed as it relates to Career and Technical Education (CTE), there are two CTE programs,
Digital Information Technology and Foundations of Programming.
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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 70 (Revised September 2022)
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. Two youth records were reviewed and there was no referral to Florida Youth
College; therefore, a career navigator was not assigned to either youth. An informal interview
with the Florida Scholar’s Academy (FSA) instructor explained post-secondary pathways are
individualized for each youth. Youth are offered several options during their time in FSA. Youth
are offered high school diplomas and general educational development (GED) testing while at
the facility. Students are connected to other resources by way of their juvenile probation officers
(JPO) and case managers and youth can earn certifications while at the program. FSA
instructors offer support to youth within the classroom to continue academic and credential
progress by means of referrals.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

source: DJJ

program_name_raw: Cypress Creek High Risk