state: FL

facility_name: Kissimmee Youth Academy

summary: QI Residential - FY25-26 - 4 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Kissimmee Youth Academy High/Max
Youth Opportunity Investments, LLC
(Contract Provider)
2330 New Beginnings Road
Kissimmee, Florida 34744
Review Date(s): September 9-12, 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:
Tamara Mahl-Adkins, Office of Accountability and Program Support, Lead Reviewer (Standard
1)
Belinda Alexander, Office of Education, Central Education Coordinator (Standard 2)
Teresa Andersen, Office of Accountability and Program Support, Regional Deputy Supervisor
(Interviews, Video Observation, Standard 5)
Kara Brown, Office of Accountability and Program Support, Regional Deputy Supervisor
(Interviews)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jamie Franz, Florida Youth College, Deputy Director of Postsecondary and Workforce
Education (Standard 2)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 2
and Standard 5)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Kissimmee Youth Academy MQI Program Code: 1426
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10287
Location: Osceola County / Circuit 9 Number of Beds: 63
Review Date(s): September 9-12, 2025 Lead Reviewer Code: 156
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 66 (Revised August 2025)
5.09 S
T h e fo llo w in g lim ite d
Lim ited R atings
earches and Full B ody V isual S earches
a n d /o r fa ile d in d ic a to rs re q u
5.18 S
ire im m e d ia te c o rre c tiv e a c tio n .
Failed R atings
5.04 Ten M inute C hecks *
5.13 Tool Inventory and M anagem ent
torage, Inventory, and D isposal of Flam m able, P oisonous, and Toxic Item s and M aterials
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 66 (Revised August 2025)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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N o n -A p p lic a
S a tis fa c to
S a tis fa c to
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N o n -A p p lic a
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S a tis fa c to
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tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 66 (Revised August 2025)
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
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S a tis fa c to
S a tis fa c to
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r) S a tis fa c to
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 66 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
le
le
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff * Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education 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 66 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 66 (Revised August 2025)
5555555555555555555555555 .0 1
C .0 2
.0 3
.0 4
.0 5
.0 6
.0 7
.0 8
.0 9
.1 0
.1 1
.1 2
.1 3
.1 4
.1 5
.1 6
.1 7
.1 8
.1 9
.2 0
.2 1
.2 2
.2 3
.2 4
.2 5
* T h e D e
p ro g ra m o
in d ic a to
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l *
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
F a ile d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
F a ile d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
F a ile d
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
m a re a (d e te n tio n ,
Program Overview
The Kissimmee Youth Academy is a sixty-three bed program, for ages fourteen to twenty-one
year old males, located in Kissimmee, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides the following
services: Mental Health Overlay Services (MHOS) or Substance Abuse Treatment Overlay
Services (SAOS). In addition, the program fosters each youth by providing Skillstreaming the
Adolescent, Seven Challenges, Impact of Crime (IOC), Life Skills Training, Trauma Focused-
Cognitive Behavioral Therapy, and the Teen Relationships Workbook. Additional treatment
services provided include family/individual therapy, Daniel Memorial Life Skills, and recreational
therapy. Program administration is comprised of a facility administrator, three assistant facility
administrators, one administrative assistant, one business manager, and one human resources
manager. Case management services are provided by the director of case management, six
case managers, and two transition managers. Mental health staff at the program include the
clinical director, a contracted psychiatrist, two licensed therapists, seven mental health and
substance abuse clinicians, and one recreational therapist. Medical services are offered twenty-
four hours a day seven days a week and are provided by the designated health authority, a
health service administrator, and four registered nurses. Educational services are provided by
the Florida Scholars Academy, and post-secondary services are provided by Florida Youth
College. The layout of the program includes administration, case management, medical, mental
health and substance abuse departments, as well as classrooms, modules, and a kitchen within
one building. The program has 148 operating security cameras providing coverage. At the time
of the annual compliance review, the program had eleven vacant positions: seven safety and
security specialists, two food services workers, one master control operator, and one night
nurse.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 66 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures to address the initial background screening
requirements for volunteers, mentors, and interns who work with youth less than ten hours a
month requiring sight and sound supervision. An Annual Affidavit of Compliance with Level 2
Screening Standards was completed and sent to the Department’s Background Screening Unit
(BSU) on January 14, 2025, prior to the January 31st deadline. Twenty-three new staff were
hired since the last annual compliance review. The program did not have any volunteers,
mentors, or interns. All twenty-three staff had a background screening completed prior to
contact with youth and confidential youth records, including review of a criminal history report.
None of the staff required an exemption prior to working with youth. Two of the twenty-three
staff had a break in service as indicated in the Department’s Staff Verification System (SVS)
and a new background screening was completed. All twenty-three staff required and had a pre-
employment assessment tool administered and a passing score was documented in each staff’s
record. All the staff were added to the program’s Clearinghouse employee roster, and each had
signed a contraband attestation form.
1.02 Five-Year Rescreening Non-Applicable
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
There have been no eligible staff to receive a five-year rescreening during the annual
compliance review period; therefore, this indicator is rated non-applicable.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 66 (Revised August 2025)
▪ 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 address child abuse reporting guidelines.
The program had no incidents involving staff physically, emotionally, or psychologically abusing
or neglecting youth during the annual compliance review period. A review of ten staff personnel
records showed all reviewed and signed the code of conduct. The program had the Florida
Abuse Hotline and the Department’s Central Communications Center (CCC) numbers posted
throughout the facility, including in each youth module for youth and staff access. The program
completed a Trauma Responsive and Caring Environment (TRACE) self-assessment on March
12, 2025. The facility administrator (FA) was interviewed and stated the staff code of conduct
includes but is not limited to theft, violence in the workplace, improper conduct, dress code,
attendance, insubordination, and unethical or abusive behaviors. The program uses progressive
discipline starting with coaching and verbal warning, up to termination of staff. Depending on the
severity of the incident staff can be terminated on the first offense. The program uses the
TRACE assessment and provides trauma training to all staff, including crisis response and
mental health emergency procedures, as well as Prison Rape Elimination Act (PREA), and child
abuse reporting; all staff are mandatory reporters. The staff also receive the youth handbook,
staff handbook, and are required to complete human trafficking training annually in the
Department’s Learning and Management System (SkillPro). Staff know the reporting
requirements based on their training, as well as postings throughout the program. Youth are
made aware of the reporting guidelines in the intake orientation, youth handbook, and the
postings on the modules. The FA stated there were no staff in need of disciplinary actions due
to allegations of abuse towards youth since the last annual compliance review. If the program
must take action, the area in which the alleged abuse has occurred is secured, youth are
secured and protected from retaliation, the Florida Abuse Hotline, the CCC, law enforcement,
and a victim service advocate are contacted, and the staff is terminated. Five staff were
interviewed, and all stated they allow youth to make a call to the Florida Abuse Hotline or the
CCC to report suspected abuse, as well as notifying the supervisor, and staff are allowed to call
as well. All five indicated they had never observed another staff telling a youth they could not
call the Florida Abuse Hotline or CCC. Three stated they had never heard another staff using
profanity while speaking with youth. Two stated they occasionally had but reiterated not at the
youth. Five youth were interviewed and stated they feel safe at the program, mentioning staff
are respectful, treat them well and do what they are supposed to do. All five youth said they had
never been stopped from reporting abuse to the Florida Abuse Hotline or the CCC and they
were aware of where to locate the Florida Abuse Hotline telephone number. All five said the
staff treat them respectful when talking with them and other youth. None of the youth have ever
heard staff use curse words when speaking to them or other youth or exchanged emails,
telephone numbers, or social media contact information with staff.
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1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had twenty-two incidents reported to the Department’s Central Communications
Center (CCC) during the annual compliance review period. A review of five CCC reports
indicated four were reported to the CCC within the required two-hour time frame. The remaining
one incident was reported thirty-two hours and twenty-eight minutes late. The program provided
disciplinary action taken against the staff causing the report to be late. The program had no
additional internal incidents/grievances, which should have been reported to the CCC. The
program experienced a decrease in the number of reportable incidents to the CCC in the current
annual compliance review period. The facility administrator (FA) was interviewed and stated
CCC reports are required to be made within two hours of an incident. All staff at the program
have access to make a report to the CCC, law enforcement, and the Florida Abuse Hotline. The
program’s practice is when a reportable incident occurs the staff advises the unit manager/shift
supervisor, then the incident is reported to administration to call the CCC. If administration is
unavailable, the unit manager/shift supervisor is authorized to make the report themselves. All
staff know they are mandatory reporters.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had twenty-three Right Interactions (RI) incidents during the annual compliance
review period. The program maintained and submitted monthly RI incident summaries to the
Department by the fifteenth of each month during the annual compliance review period. The RI
plan was updated on December 10, 2024 and approved by the Department on December 13,
2024. The program’s RI rate during the previous quarter was .86, which is below the statewide
residential RI rate of 2.57. A review of five RI incident reports showed all were completed by the
end of the staff’s workday and included statements from all staff involved. None required the
Mechanical Restraint Supervision Log, none resulted in injury to the youth or staff, none of the
youth alleged abuse, and none required a RI medical review. All five RI reports were reviewed
by a supervisor, and by a RI instructor. An administrator/designee also reviewed the RI reports
within seventy-two hours of the incident. The FA was interviewed and stated following the use of
physical intervention, a mediation is completed between the youth and staff, the staff complete a
RI report and turn it into the assistant facility administrator (AFA) for review. The AFA reviews
the RI report the following business day in the morning meeting. Five staff were interviewed and
stated they knew the RI process and were able to explain it, which included completing an RI
report. The staff also mentioned de-escalation, and using verbal intervention.
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1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program considers all staff to be direct-care staff and are counted in the staff-to-youth ratio
other than the maintenance or kitchen staff, nurses, and master control operator. The master
control operators are cross-trained and can take on a shift but are not allowed to work master
control and count in ratio at the same time. A review of training documentation showed all
instructors qualified are to deliver the provided training. The program submitted a pre-service
training plan/calendar prior to implementation, and the training plan/calendar was approved by
the highest ranking official at the location, the Department’s assistant secretary for residential
services, and the director of the Department’s Office of Talent, Leadership, and Culture (TLC).
A review of seven staff training records showed all completed a minimum of 120 hours of pre-
service training within 180 days of hire. All seven completed essential skills prior to any contact
with youth, which included child abuse recognition, reporting, and prevention, first-aid,
automated external defibrillator (AED), cardi-pulmonary resuscitation (CPR), emergency
procedures, program operating procedures, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, and ethics, including standards of conduct, Right
Interactions (RI), and suicide awareness and prevention. Additional training was completed and
included Active Shooter Preparedness, adolescent development and behavior, balanced
approach to rehabilitative justice, the Department’s Central Communications Center (CCC)
incident reporting, civil rights, communication, Confidentiality/Health Insurance Portability and
Accountability Act (HIPAA), Department legacy/history, and equal employment opportunity
(EEO). The staff also completed gang awareness, human trafficking intervention, infection
control/bloodborne pathogens, Information Security Awareness, the Department’s Juvenile
Justice Information System (JJIS), mental health and substance abuse, motivational
interviewing (MI), quality report writing, safety, security, and supervision of youth, sexual
harassment, effective and respectful treatment of youth, trauma responsive practices, grievance
process, infection control, exposure control plan, behavior management system, and the
intended and safe use of tools. Specialized and other trainings included mental health and
substance abuse overlay services, developmental disabilities treatment services, epinephrin-
auto injector, Narcan, and Massachusetts Youth Screening Instrument-Second Version (MAYSI-
2). None of the staff were supervisory staff. Three more staff were reviewed within their first 180
days of hire. All three staff completed the required training prior to being in the presence of any
youth, which included child abuse recognition, reporting, and prevention, first-aid, AED, CPR,
emergency procedures, program operating procedures, PREA, professionalism, interpersonal
communication, and ethics, including standards of conduct, RI, and suicide awareness and
prevention.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures to address in-service training requirements.
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In-service training for calendar year 2024 was reviewed during the last annual compliance
review; therefore, in-service training was not reviewed during this annual compliance review. A
review of training documentation showed all instructors were qualified to deliver training. The
program submitted an in-service training plan/calendar prior to implementation, and the training
plan/calendar was approved by the highest ranking official at the location, the Department’s
assistant secretary for residential services, and the director of the department’s office of talent,
leadership, and culture (TLC).
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures to address the grievance process, including training
requirements. The program’s grievance process included informal phase, formal phase, and an
appeal phase. The program did not have any grievances during the annual compliance review
period. The facility administrator (FA) was interviewed and stated the youth have a right to
grieve and have access to the grievance forms on the modules. Once the form has been
completed the youth will place the form in the grievance box in the hallway, which is checked
daily, and all forms are reviewed. The grievance is given to the appropriate staff to meet with the
youth within forty-eight hours. During the informal phase the assistant FA will review the
grievances and get back to the youth with a written response within forty-eight hours. In the
formal phase the FA will review grievance, get back to the youth with a written response within
twenty-four hours or no more than five business days from the day the grievance was originally
completed. Five staff were interviewed, and all stated youth can request assistance in
completing the grievance form and the supervisor reviews the form. Three also stated the FA
reviews the form. The five staff were also able to explain the grievance process, such as the
youth are able to ask for the form anytime, they can place the form in the grievance box, and
administration collects it. One staff was able to provide different stages and time frames
attached to the grievance process.
Five youth were interviewed and stated they can ask for assistance in completing a grievance
form. Four also stated they can request a grievance form, one said the forms are placed
throughout the program, one indicated the form is to explain any issues with the program, two
said the form goes to the supervisor, and one said they are able to place it in the grievance box.
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
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1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing life and social skills activities offered to
youth. The program uses mainly primary groups; however, provides the Daniel Memorial Life
Skills program, which is an online assessment, with individual sessions provided by the
transition services manager. The life and social skills address communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, critical
thinking, including problem-solving and decision-making, as well as addressing the needs of the
program’s targeted population. The facility administrator was interviewed and stated youth
participate in daily group sessions facilitated by trained mental health professionals using
evidenced-based curricula including Seven Challenges, Teen Relationship, Trauma-Focused
Cognitive Behavioral Treatment, Skillstreaming the Adolescent, and life skills training. Youth
also complete a cycle of Impact of Crime (IOC) facilitated by a trained case manager. Five youth
were interviewed and stated they receive different types of groups. They mentioned respectively
they have groups every day, talk about life and mental health, drug abuse, things to better
themselves, self-control, communication, and how to express themselves. The clinical director
(CD) was interviewed and stated licensed and non-licensed mental health professionals provide
group services at the program. During the intake process, the licensed staff gather current
information from the youth and refer to collateral information obtained in youth's Department
records to complete the brief behavioral health status exam. Each youth receives a
comprehensive assessment within twenty-one days of intake based on their current and past
behavior which is conducted by a licensed/non-licensed mental health professional and
reviewed by the CD/designee. Based on the information gathered, evidenced-based
interventions are implemented to meet the youth's needs through individual, family, and group
counseling as a part of the youth's treatment. All youth are presented and encouraged daily
during group activities to practice the skills they have learned, as well as use and practice them
outside of the group environment.
1.11 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at this program. For details related specific to IOC service delivery, please refer
to the annual SPEP report. The program’s contractual requirement indicates IOC shall be
provided; however, states other services shall teach youth accountability, discipline, reinforce
lawful behavior, develop their competency, self-discipline, respect for authority, understanding
consequences to their actions, and promote responsibility. A review of documentation showed
youth had participated in a legal studies lecture, created a vision board, painted the facility,
made hygiene bags for the homeless, as well as wrote thank you cards to the local fire fighters.
The facility administrator was interviewed and stated all youth participate in daily group sessions
facilitated by a trained mental health professional using evidenced-based curricula, like Teen
Relationships addressing the need of the targeted gender group. Youth are required to
complete service projects like spot painting doors, walls, and living quarters, Hopes of Hands
projects, get well letters for sick youth, inspirational cards for cancer patients, hygiene bags for
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the homeless, and a vision board for Nemours Hospital. Five youth were interviewed and two
stated they had not yet participated in restorative justice groups/activities while at the program.
The remaining three stated they have participated in IOC, where they talk about crime and laws,
watch videos, and prepare them for the life ahead. One also mentioned cleaning as an activity.
One youth stated they had not practiced a new skill yet and the remaining four stated they had
practiced coping skills, communication, talking to peers, self-control, controlling anger, and
better decision-making skills.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures addressing the internal alert system and alerts. When
risk factors or special needs are identified during or following the classification process, staff
shall immediately update the internal program alert information and shall enter this information
into the Department’s Juvenile Justice Information System (JJIS). Only appropriate staff may
recommend downgrading or discontinuing a youth’s internal alert status. The policy states the
program alerts staff utilizing the JJIS alert list, the dietary alert list, and the alert communication
board. The mental health staff, as well as medical, case management, and operations input
alerts based upon type, and update the information when needed. During shift briefings alerts
are provided to the staff. The medical team also has an alert log specific to medical conditions
and the kitchen staff has the alerts specific to food allergies. A review of seven youth confirmed
each youth was identified with alerts totaling thirty alerts, and all were entered on the program’s
alert system, as specified in the program’s written procedures. Four of the thirty alerts were
entered or closed wrong. One of the four alerts was entered by mistake and was closed when
the mistake was realized. Two of the remaining three alerts were entered into JJIS thirty-five
days late and one was closed thirty days late. The facility administrator (FA) was interviewed
and stated they discuss important medical issues pertaining to the youth at the program during
morning meetings and during shift briefings, which are conducted daily. The medical team, the
assistant clinical director (CD), and the director of case management (DCM) are responsible for
entering and closing alerts pertaining to their areas of expertise. Changes in the medical alerts
are emailed to the staff.
Five staff were interviewed and four stated they are informed of alerts by looking at the alert
board in the conference room and all five stated there is also an alert book. One staff mentioned
they are informed during shift briefing. A nurse was interviewed and stated the registered nurses
(RN) update the medical alert binder daily.
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1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program divides the youth records into two separate records: an Individual Healthcare
Record (IHCR) and an individual management record. The individual management records
contained the required elements of youth’s name, the Department identification number (DJJID),
date of birth, county of residence, and committing offense. The individual management records
contained legal information, demographics and chronological information, correspondence, case
management and treatment team activities, and a miscellaneous section. All youth records were
labeled “Confidential”, were secured in a locked file cabinet or a locked room, and each file
cabinet or room was also labeled “Confidential”.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program conducted community advisory board (CAB) meetings at least every ninety to 120
days, as indicated by a review of the agendas, meeting minutes, and video conference invites.
The facility administrator (FA) actively solicited involvement or recruited the following community
partners: law enforcement representative, judiciary community, other community partners,
business community, Florida Scholar’s Academy, faith community, victim/victim advocate/or
other victim services community representative, and a parent/guardian whose child was
previously, rather than currently involved with the Department. A CAB member was interviewed
and stated she is very new to the board and just attended her first meeting in August 2025. The
services the program is providing were discussed during the meeting. She is a community
mental health provider, who already works with the Department, and her goal is to work with the
youth during the transition phase and provide outpatient services when the youth have returned
to the community. The FA was interviewed and stated the CAB meets on a quarterly basis. The
invitations are sent to the CAB by mail and email with a calendar invite. A follow-up telephone
call for confirmation is also done if a response has not been received through the invitations.
The program recruits CAB members through invitations, referrals, mentors, guest speakers, and
staff recommendations.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures addressing staff performance standards and
frequency of evaluations. Three job/position descriptions were reviewed, and each staff’s
performance standards were clearly identified. Six performance evaluations were reviewed, and
all were completed as outlined in the program’s policy at least annually. The performance
standards matched the job descriptions for each staff. The program’s contractually required
positions were maintained, other than one night nurse, who resigned on July 13, 2025. The
program provided documentation they have been recruiting for the position since it has become
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vacant. A review of the staffing roster, schedule, and credentials for the recreational therapist
showed the program employed the one contractually required recreational therapist. The facility
administrator (FA) was interviewed and stated the program has partnered with Career Source
for staff referrals, utilizes staff referrals, and conducts daily interviews to hire new staff. The
program conducts meet and greets, bowling events, breakfast for staff, three-on-three
basketball games, waffle day, potlucks, and Christmas parties to boost morale and minimize
staff turnover. All staff have monthly coaching meetings with their supervisor, assisting staff to
know what needs improvement, and be acknowledged for a job well done. Each staff has an
annual evaluation, and new hires receive a ninety-day evaluation. Five staff were interviewed
and four stated they received formal evaluations of their performance based on performance
standards annually, one had not been at the program for a year at the time of the annual
compliance review. Two also mentioned they received an evaluation 190 days after hire and
then annually, and another stated 290 days after hire.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
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 had two special contract conditions. One was the designated health authority
(DHA) shall be available twenty-four hours a day seven days a week, which was corroborated
with the DHA interview. The master control operators shall not fall under the staff to youth ratio
as they do not provide direct care and supervision to youth. An informal interview with the
assistant facility administrator (AFA) corroborated the program does cross train the master
control operators as safety and security specialist; however, when these staff work master
control they are not included in the youth and staff ratio and do not supervise youth.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
A review of documentation indicated the provider utilizes satisfaction surveys in their monitoring
and verification activities as a part of the program's quality assurance. Satisfaction surveys are
provided at least quarterly and include youth surveys, family surveys, and staff surveys. The
surveys target admission activities, topic-specific assessments, and discharge satisfaction. The
survey data is reviewed and evaluated monthly on a program-level and during corporate
leadership meetings. Survey outcomes are collected and communicated as part of ongoing
program communication and quality improvement activities. Annual grievance and incident
analysis are completed and provided to the Commission on Accreditation of Rehabilitation
Facilities (CARF). The program staff and corporate leadership meetings include monthly quality
assurance review processes, which incorporate review of facility data, surveys, and findings of
formal monitoring and verification activities. Each meeting discusses progress to date, program
strengths, improvement needs, and corrective action. Recommendations are made by the team
with ongoing review and follow-up, and technical assistance is provided as applicable. Data
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gathered by the program and the Department is used for long-term planning, provisions for
staffing, and a system of communication to keep staff informed. The program indicated during
the current annual compliance review period they have not utilized any data trend analysis to
make any changes within the program.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures in place to address initial contact with the youth’s
parent/guardian as well as the committing court. The program’s policy states case management
staff will contact the parent/guardian by telephone to notify them of placement, within twenty-
four hours of the youth’s admission to the program. Within forty-eight hours, the case manager
will send written notification of the youth’s placement to the parent/guardian. The assigned case
manager will notify the committing court, assigned juvenile probation officer (JPO), and post
residential services case manager, as applicable, within five working days. Seven youth case
management records were reviewed, and all records contained documentation the
parent/guardian was contacted by telephone on the day of admission. All records indicated
parents/guardians were mailed an admission letter on the day of admission which spoke about
length of stay, visitation, and the performance planning process. Each record contained a copy
of the notification letter sent to the committing court informing them of each youth’s placement,
which was mailed on the day of admission. Each record further indicated the assigned JPO was
copied on the notification and the youth’s post release counselor, if known at the time of
admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to provide youth orientation to the program’s rules,
expectations, goals, and services applicable to the youth on the day of youth’s admission or
prior to admission into the program. The program uses an orientation checklist during the
process to ensure all required elements are addressed. Additionally, they provide a youth
handbook detailing all required elements. During the annual compliance review week, the
program did not have any admissions; therefore, an observation of orientation could not be
observed. Seven youth case management records were reviewed and each record verified each
youth received an orientation to the program on the day of admission. Orientation contained all
required elements. Five youth were interviewed and each youth confirmed they received an
orientation within twenty-four hours of their admission and each were able to describe the
orientation process.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to obtain written consent of any youth eighteen years
of age or older for release of their confidential information to their parent/guardian. Seven youth
case management records were reviewed. One youth was applicable for requiring written
consent. Two additional applicable case management records were requested for a minimum
sample of three. All three applicable youth case management records contained written consent
signed by each youth.
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 to utilize a classification system, in accordance with
Florida Administrative Code, promoting safety and security, as well as effective delivery of
treatment services. The program utilizes a classification system for which a youth’s classification
is determined by their individual needs and identified risk factors. A review of the program’s
classification form validated the form included all required elements. A review of seven youth
case management records found documentation indicating each record contained an admission
classification form including all required elements outlined by the Department’s policy. Each
youth was classified for the purpose of assignment to a living area, sleeping room, and group. A
review of the Department’s Juvenile Justice Information System (JJIS) alert list for any issues
affecting classification was completed for each youth and any identified risk was entered into
JJIS. The program’s policy and procedures also address reassessment and reclassification of
youth prior to an increase of a youth’s privileges or freedom of movement, participation on work
projects or other activities which involve the use of tools, or a youth’s participation in any off-
campus activities. Each youth record contained a reassessment prior to consideration for
participation in any off-campus activities or work projects. Reassessments are also warranted
based on new/updated alerts, behavioral concerns, or any relevant information affecting the
safety or security of the youth at the program. An interview with the facility administrator
confirmed the program’s practice.
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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 for gathering information on gangs or youth involved
in a gang and sharing this information with law enforcement. Seven youth case management
records were reviewed. One of the seven reviewed youth were applicable for gang involvement.
Two additional records were provided for a minimum sample of three. Each applicable record
indicated upon identification, local law enforcement and the youth’s home county law
enforcement were notified of each youth’s suspected gang activity, and this was completed prior
to the seven-day notification from the Department. Each record contained notifications to their
juvenile probation officer and education provider. None of the reviewed youth were applicable
for the program needing to enter an alert into the Department’s Juvenile Justice System (JJIS)
as each youth was identified as a gang member prior to admission and the alert had already
been entered into JJIS. Each record reflected a gang alert was entered into the program’s
internal alert system. None of the youth were applicable for requiring notification to a post-
residential counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to ensure the implementation and provision of gang
prevention and intervention strategies. The policy also includes providing youth the opportunity
to disaffiliate with a criminal street gang, if desired. Seven youth case management records
were reviewed. One youth was applicable for gang prevention and intervention services. Two
additional records were provided for review for a minimum sample of three. Each applicable
youth record reflected the program incorporated a gang goal in each youth’s Individual
Performance Plan addressing the need for gang awareness and intervention services. The
program has a gang binder which maintains all documented information and program activities
completed with gang identified youth. The program utilizes the 50+ Stories of Fractured Lives
curriculum as the selected gang prevention and intervention curriculum. All program youth
participate in Impact of Crime (IOC) which also has a gang prevention and awareness
component. The gang binder included all packets completed by the identified youth and the
sign-in sheets reflecting each youth completed the gang prevention segment of IOC and
attended group monthly to complete the 50+ Stories of Fractured Lives curriculum. The facility
administrator was interviewed and confirmed the program’s practice.
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.
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The program has a policy and procedures ensuring each youth receives a Residential
Assessment for Youth (RAY) within thirty days of admission. The program maintains all
documentation of the initial RAY in the Department’s Juvenile Justice Information System
(JJIS). The program also maintains documentation of RAY Reassessments in the youth’s
record. The program’s policy also requires each youth to receive a RAY Reassessment within
ninety days of the initial RAY, or when deemed necessary by the intervention and
multidisciplinary treatment team. Seven youth case management records were reviewed, and
each youth had a RAY completed within thirty days of admission. Each youth’s RAY was
entered into JJIS. None of the youth were applicable for other updates or reassessments
needed to be completed by the intervention and treatment team to effectively manage the
youth’s case. Four of seven reviewed youth were applicable for a ninety-day RAY
Reassessment. The remaining three youth have not been in the program long enough to require
a RAY Reassessment. Three out of four applicable youth had a RAY Reassessment completed
within ninety days of the initial RAY. The remaining one youth had their RAY Reassessment
completed one day late. All RAY Reassessments were maintained in each youth’s case
management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to ensure a Youth Needs Assessment Summary
(YNAS) for each youth is completed within thirty days of admission and maintains all
documentation of the initial assessment process in the Department’s Juvenile Justice
Information System (JJIS). Seven youth case management records were reviewed and five had
a YNAS completed within thirty days of admission. The remaining two youth were transferred
from another residential program and services were continued from the original YNAS. Each
applicable youth had their YNAS documented in JJIS, as required.
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 regarding the development of the Individualized
Performance Plan (IPP) within thirty days of a youth’s admission. Seven youth case
management records were reviewed for the development of the IPP within thirty days of
admission. Five of the seven youth records indicated each youth had an IPP developed within
thirty days of the youth’s admission, the remaining two youth’s IPP were developed one day
late. Each youth had their IPP developed after the completion of a Residential Assessment of
Youth (RAY) and Youth Needs Assessment Summary (YNAS). All required members of the
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treatment team were involved in the development of each youth’s IPP, and all required
signatures were documented in each record. A review of documentation confirmed each youth
had individualized goals based upon the prioritized needs identified during the assessment
process. Each IPP included the youth’s top three criminogenic risk factors, delinquency
interventions, and court-ordered sanctions. Each plan contained transition activities targeted for
the last sixty days of each youth’s anticipated stay. Each plan included youth and program staff
responsibilities and target dates for completion and reflected within ten working days of
completing the plan, a transmittal letter and copy of the plan were sent to the committing court,
juvenile probation officer (JPO), parent/guardian, and the Department of Children and Families
(DCF), where applicable. Five youth were interviewed and each youth stated they were involved
in the development of their IPP.
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 the completion of performance plan
reviews and the incorporation of other plans. Seven youth case management records were
reviewed and four youth were applicable for plan revisions. The remaining three youth had not
been in the program long enough to require a review or revision. Revisions were completed
based on Residential Assessment for Youth (RAY) Reassessment results and progress youth
made toward completing goals for three of the four youth. One of the four youth was applicable
for a plan revision to facilitate transition activities during the last sixty days of the youth’s stay at
the program, one of four demonstrated lack of progress toward goal completion, and one of four
youth was due to newly acquired/revealed information warranting a revision. All seven youth
were applicable for the incorporation of treatment and academic plans. Documentation
confirmed each youth had treatment and academic goals incorporated into their performance
plan. One of the seven reviewed youth was applicable for the incorporation of a Department of
Children and Families (DCF) plan and a DCF plan goal was incorporated into their performance
plan. The program did not have any youth applicable for Agency for Persons with Disabilities
plan during the annual compliance review period.
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 to ensure the completion of Performance Summaries
and transmittals. The policy states a Performance Summary will be completed at minimum
every ninety days, or sooner if requested by the committing court, and prior to a youth’s release,
discharge, or transfer from the program. Seven youth case management records were
reviewed, and four of seven youth were applicable for the completion of a Performance
Summary. The remaining three youth have not been in the program for ninety days. Each
applicable youth had a Performance Summary completed within ninety days of the signing of
the initial performance plan. None of the applicable youth required a Performance Summary
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prepared prior to the youth’s discharge. A review of documentation confirmed the Performance
Summaries contained all required elements. Each applicable youth was afforded the opportunity
to read and add comments prior to signing the summary. Each record contained documentation
reflecting the youth were provided with a copy of their performance summary and the original
performance summary was filed in each youth’s record. Documentation confirmed each
Performance Summary was signed and dated by the youth, facility administrator (FA) or
designee, treatment team leader, and staff member preparing the summary. Each youth record
contained a copy of the Performance Summary which was sent within ten working days to the
committing court, juvenile probation officer (JPO), parent/guardian, and Department of Children
and Families (DCF) case manager, if applicable.
A review of three closed youth case management records found release summaries were
completed, as required. Each record contained a release summary, justification for release, and
Pre-Release Notification (PRN) sent at least forty-five days prior to the youth’s planned release.
One youth was applicable for direct discharge, and the record contained a discharge summary,
which was sent, as required. A signed copy of the PRN was maintained in each record. Each
record contained a notification letter to youth parent/guardian upon approval of the PRN
regarding each youth’s planned release. Each youth record contained a completed exit
Residential Assessment for Youth (RAY). None of the reviewed youth were applicable for the
court objecting to the youth’s release. None of the youth were applicable for being a non-
sexually violent predator program sexual offender (SVPP) or SVPP sexual offender. One of the
three closed records was applicable for requiring a Victim Notification of Release. The
remaining two youth’s charges did not require victim notification. The program mailed a Victim
Notification of Release at least ten days prior to the youth’s release in the applicable record.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to address parent/guardian involvement in the case
management process. Upon admission, each youth’s parent/guardian is mailed a letter which
includes information about the services offered at the program. Included in the letter are the
dates and times of the youth’s treatment team meetings. The parent/guardian is encouraged to
participate in person; however, if this cannot be arranged, parents/guardians may participate by
telephone. Seven youth case management records were reviewed, and each record confirmed
the program mailed the parent/guardian letters with program services and dates and times of
each youth’s treatment team meeting on the day of admission. A review of documentation
confirmed each record contained a letter to the parent/guardian inviting them to quarterly Family
Day, participation in the development of the youth’s performance plan, transitional planning, and
progress reviews. Each record reflected parent/guardian was provided the opportunity to attend
all meetings by telephone, if unable to participate in person, or was able to provide input prior to
the meeting. A treatment team meeting was observed during the annual compliance review
week. The parent/guardian participated by telephone and was an active participant in the
treatment team meeting. The parent/guardian was also made aware of the date and time of the
next treatment team meeting. An interview with the facility administrator confirmed
parent/guardian involvement is encouraged throughout the youth’s stay at the program. Five
youth were interviewed and reported their parent/guardian were involved in telephone calls,
treatment team meetings, family therapy, and Family Day.
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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 addressing treatment team members and meetings.
Seven youth case management records were reviewed, and documentation confirmed each
youth had a formal treatment team meeting held at least every thirty days, except one youth had
one treatment meeting which was five days late. Documentation confirmed attendance of all
required treatment team members including youth, case manager, a representative from
education, a mental health therapist, the youth’s parent/guardian, assigned juvenile probation
officer (JPO), medical staff, a representative from the living unit, and a representative from the
program’s administration. One youth was applicable for the Department of Children and
Families’ (DCF) case manager to participate and documentation confirmed the DCF case
manager participated in the youth’s treatment team meetings. If staff from education or the
medical department were unable to attend, they provided a written progress report to be shared
with the treatment team. Documentation for each of the formal treatment team review meetings
included youth’s name, date of review, comments from treatment team members, a brief
synopsis of the youth’s progress, progress on performance plan goals, positive and negative
behaviors, behaviors resulting in physical interventions, treatment progress, Residential
Assessment for Youth (RAY) Reassessment results, an opportunity for youth to demonstrate
skills learned, and performance plan revisions. Documentation of all formal treatment team
meetings was contained in each youth’s record. Each record confirmed formal and informal
treatment team meetings were held bi-weekly, except for two youth, one youth who was
maximum risk and did not have informal treatment team meetings, and one youth who missed
one month’s treatment team. An informal interview with the director of case management stated
the youth missed their treatment team meeting due to being in state education testing.
Documentation for each of the informal treatment team review meetings included youth’s name,
date of review, comments from treatment team members, a brief synopsis of the youth’s
progress, positive and negative behaviors, behaviors resulting in physical interventions, an
opportunity for youth to demonstrate skills learned, and treatment progress. Documentation for
each of the informal treatment team reviews included RAY Reassessment results and
performance plan revisions for applicable youth. Documentation confirmed each youth’s JPO,
and parent/guardian were invited and encouraged to participate in treatment team meetings. A
treatment team meeting was observed during the annual compliance review week, and all
required members were in attendance. Five youth were interviewed, and four confirmed the
program discusses youth’s performance to include progress on performance plan goals, positive
and negative behavior, and treatment progress, the remaining youth stated staff does not
discuss youth’s positive or negative behaviors. Each youth confirmed the program gives youth
the opportunity to demonstrate the skills they have learned in the program during their treatment
team meetings.
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2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures to ensure the intervention and treatment team is
planning for the youth’s successful transition to the community upon release from the program.
Three closed youth case management records were reviewed for transition planning, transition
conferences, and Community Re-Entry Team (CRT) meetings. Each youth’s transition
conference was held at least sixty days prior to youth’s targeted release date. Each transition
conference included a review of transition activities on each youth’s performance plan, targeted
completion dates, persons responsible for completion, and other pertinent transition activities, if
applicable. Documentation reflected all required transition conference attendees were
invited/encouraged to participate, except for one youth’s parent/guardian. Each record
confirmed all required treatment team members attended/participated in the transition
conference and signed/dated the transition conference forms, except for one youth’s
parent/guardian where the record reflects the program mailed a copy of the transition plan with
request for signature to parent/guardian. Documentation was found in each record confirming a
return email acknowledgement receipt for plans transmitted electronically to juvenile probation
officer and/or the Department of Children’s and Families counselor. Each of the three youth
records confirmed CRT meetings were conducted prior to each youth’s release from the
program with invitations for participation being sent out by the juvenile probation officer (JPO).
Chronological notes reflected two out of three youth and case manager participated in the CRT
meeting as well as education, mental health staff, parent/guardian, and program administration.
The remaining youth’s record did not contain documentation confirming attendance by the youth
and case manager; however, chronological note did include what was discussed during the
CRT meeting.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to ensure the program assembles an exit portfolio for
each youth prior to their release from the program. Three closed youth case management
records were reviewed. A review of each record confirmed the exit portfolio was discussed and
initiated for each youth during the transition conference. Each exit portfolio contained the
required items to include state-issued identification card, social security card, copy of youth’s
transition plan, calendar with all dates, times, and locations of upcoming community
appointments, birth certificate, education/vocational certificates earned in the program,
education records, school transcripts, résumé, and sample employment application. Each
record confirmed the exit portfolio was verified during the exit conference and a copy of the exit
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portfolio was given to each youth upon release and forwarded to each youth’s juvenile probation
officer (JPO). One of the three reviewed youth was a maximum-risk youth. Documentation
confirmed the applicable youth’s exit portfolio contained forms and clear instructions to youth on
how to obtain employment and this plan was put in place during the transition conference
designating who was responsible for working with youth to obtain these items. The program’s
contract does not include any special conditions for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure a meeting is conducted to review the status
of goals developed at the transition conference and finalize release plans. Three closed youth
case management records were reviewed. Documentation confirmed the exit conference was
conducted for each youth after the program notified the juvenile probation officer (JPO) of the
release and at least fourteen days prior to youth’s release. Each record contained the date of
the exit conference, signatures of all required parties, and a summary of pending transition
goals. The admission and release dates in the Department’s Juvenile Justice Information
System (JJIS) matched the dates in each youth record. The exit conference form for each youth
reflected the status of transition activities established at the transition conference and plans
finalized for each youth’s release were reviewed, provisions for continued education and/or
employment, review of the exit portfolio, and documentation the parent/guardian and JPO are
aware of each youth’s vocational plan. Documentation in each youth record confirmed the case
manager and parent/guardian were aware of the plan, documents, and post-release discharge
plans. All required individuals participated in the exit conference for each youth. Two of three
records documented the exit conference was conducted separately from the transition
conference and Community Re-Entry Team (CRT) meetings. The remaining youth’s CRT
meeting was conducted during the exit conference due to the JPO originally thinking the youth
did not require a CRT meeting due to the youth being a direct discharge. Electronic mail
documentation confirmed the program’s efforts to have the JPO schedule a CRT meeting prior
to the exit conference.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to ensure there is a process to allow youth to provide
input to the program. Youth input is provided through twice monthly student council meetings,
“Request to Speak” forms, and town hall meetings. A review of documentation to include sign-in
sheets confirmed the program’s practice. Five youth were interviewed and confirmed they can
talk with staff or complete a “Request to Speak” form if they want to provide input to the
program. An interview with the facility administrator confirmed youth can provide input to the
program through student council, town hall meetings, youth surveys, and open dialogue with
program staff.
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2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide for educational access. The program
integrates education into the daily schedule. A sample of three days of videos and coordinating
logbook reviews showed youth missed the required amount of daily education times: thirty-nine
minutes, thirty-two minutes, and nineteen minutes, respectively. In addition, logbook reviews for
one random day a month for the annual compliance review period were reviewed, and youth
were moved accordingly with little deviation. Five youth were interviewed and one said there are
interruptions during the school day. The remaining four stated there were none. One youth also
stated sometimes other youth are too loud and they could use more headphones.
2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program’s contractually required career and technical education (CTE) services include soft
skill credentials in Florida Ready to Work, Occupational Safety and Health Administration
(OSHA) 10-hour training course, and first-aid/cardiopulmonary resuscitation (CPR) training. The
program shall serve as a collaborative partner who provides CTE services which lead to career
pathways with student outcomes which must include industry certifications earned from the
master credentials list and may include articulation agreements providing enrollment
opportunities into in-demand CTE programs at a local technical college. Fourteen youth
received certifications in Florida Ready to Work, and fifty-one in OSHA-10, as well as three in
CPR/first-aid. CTE services are scheduled and provided on Wednesdays and Fridays from
12:05 p.m. to 1:05 p.m. weekly. The program has five staff who provide CTE services; all had
their certifications to facilitate the services they are providing. At the time of the annual
compliance review week the program had forty-six youth enrolled in coursework towards
earning an industry certification. A review of seven youth case management records indicated
none of the youth had received any of the CTE services at the time of the annual compliance
review week. Three of five interviewed youth stated they receive career and technical education
services, mentioning OSHA and SafeServ. The remaining two stated they do not receive CTE
services. The facility administrator was interviewed and stated youth receive OSHA-10, OSHA-
30, first-aid, and CPR certifications as part of the career and technical education services
offered at the program.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program maintains a policy and procedures addressing the requirement for a designated
mental health clinician authority (DMHCA). The program has a clinical director (CD) who serves
as the DMHCA. The CD is a full-time position and on-site forty hours weekly as required by the
program’s contract to ensure appropriate coordination and implementation of mental health and
substance abuse services. The CD ensures consistent and appropriate services in addition to
being on-call twenty-four hours a day seven days a week for emergency consultation. The CD is
a licensed mental health counselor (LMHC). The license was reviewed and was free and clear
in the State of Florida with an expiration date of March 31, 2027. The program’s back-up CD
has a free and clear license in the State of Florida with an expiration date of March 31, 2027.
The previous CD had a clear and valid license in the State of Florida which expires on March
31, 2027. The interviewed CD stated their role in the coordination and implementation of mental
health and substance abuse services include conducting clinical supervision for non-licensed
mental health professionals, providing weekly group schedules, as well as monthly fidelity
monitoring to the mental health professionals who submit monthly service calendars of
scheduled individual and family sessions to the CD or designee. The program provides
individual, family, and group therapy services. The clinical staff and the CD communicate daily.
Formal meetings include weekly supervision, and informal methods to ensure good morale and
open dialog fostering the effective functioning of the clinical department. Mental health
professionals are notified when staff complete a mental health substance abuse referral, which
is provided to clinical staff. The CD is on-call and can be reached twenty-four hours a day seven
days a week.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures ensuring established requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
licensed clinical director (CD) serves as the program’s supervisor for on-site clinical staff. The
program’s staff roster was reviewed, and confirmed there is one contractually required licensed
clinical staff, the assistant clinical director (ACD). The ACD is a licensed mental health
counselor with a free and clear license in the State of Florida, which expires March 31, 2027.
Additionally, the regional clinical manager is a licensed mental health counselor. The reviewed
license confirmed it was free and clear in the State of Florida with an expiration date of March
31, 2027. The regional clinical manager provides support and supervisory services to ensure
the licensed clinical staff working under their supervision are performing services they are
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qualified to provide based on education, training, and experience based on a review of job
description and an informal interview with the CD. The licensed mental health and substance
abuse clinical staffing is in accordance with the current contract and Florida Administrative
Code. Copies of all licenses were available on site; furthermore, the program maintains a binder
with licenses, training, policies, and procedures. All licensed mental health professionals were
reviewed and were clear and valid.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures regarding non-licensed clinical staff. The
clinical director (CD) confirmed their responsibility for ensuring non-licensed clinical staff are
working under their supervision and performing services they are qualified based on education,
training, and experience. Reviewed documentation for the annual compliance review period
reflected each non-licensed mental health clinical staff received a minimum of one hour a week
on-site direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the program. The program’s practice is to
complete group and/or individual clinical supervision for the non-licensed clinicians and the
recreation therapist. The clinical supervision was documented on the program’s form and
included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. The program is
licensed under Chapter 397 by the Department of Children and Families (DCF) to provide
substance abuse services to adolescents. The Chapter 397 license expires October 15, 2025.
The license was displayed in the lobby with the program’s physical address listed. The
program’s non-licensed clinical staffing, based on the contract, requires one recreation
therapist, and seven non-licensed mental health clinicians. Documentation supported education
and service requirements were in accordance with the contractual requirements. The program
had no clinical staff vacancies since the last annual compliance review. The program had seven
non-licensed mental health clinicians providing therapeutic services during the annual
compliance review period. A review of the seven non-licensed staff’s education documentation
reflected each held a master’s-level degree from an accredited university or college in the field
of counseling, social work, psychology, or a related human services field. Each non-licensed
staff was providing clinical services was employed by a service provider which was licensed
under the program’s Chapter 397. Each of the seven non-licensed clinical staff who conducted
Assessments of Suicide Risks (ASR) completed twenty hours of training and were supervised in
assessing suicide risk, mental health crisis intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a policy and procedures ensuring staff complete a mental health,
substance abuse, and suicide risk screening upon a youth’s admission to the program. The
clinical director (CD) confirmed the program’s practice, indicating during admission a
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Massachusetts Youth Screening Instrument, Second Version (MAYSI-2), a referral for clinical
services, an Assessment of Suicide Risk (ASR), and a comprehensive assessment evaluation
for each youth is conducted. Reviewed documentation confirmed the facility administrator (FA)
is responsible for developing a written policy and procedures for the implementation of a
standardized admission and intake mental health and substance abuse screening process,
including the review of the commitment packet information, reports, records, administration of
the MAYSI-2 on the Department’s Juvenile Justice Information System (JJIS) ,and referral for
youth identified by screenings as in need of further evaluation or immediate attention, staff
training in mental health and substance abuse issues and administration of the MAYSI-2, and a
standardized process for referral of youth identified as in need of further mental health and/or
substance abuse evaluation to an appropriate service provider/professional or, when immediate
attention is needed, to a hospital or Baker Act or Marchman Act receiving program. A review of
seven mental health and substance abuse records confirmed the program completed a MAYSI-
2 on the day of admission for each youth. Each reviewed record confirmed the screener
reviewed available information to include the commitment packet, reports, and records for
existing documentation of mental health or substance abuse problems and/or history of human
trafficking information. Each reviewed MAYSI-2 included the date of completion, the name of the
trained staff who completed the screening and was completed in the JJIS in full. Each reviewed
MAYSI-2 confirmed further assessment was required and a referral was made for further
evaluation and/or immediate attention. Each reviewed MAYSI-2 confirmed the need for an
assessment. The FA was notified and a referral was made to alert the designated CD. Seven
reviewed MAYSI-2 screenings confirmed the FA ensured an ASR was conducted within twenty-
four hours when the MAYSI-2 category “suicide ideation” indicated further assessment was
needed or other information obtained at intake suggested potential risk. One youth record was
applicable for youth being referred for an immediate assessment or emergency services due to
being in crisis. The one youth was placed on Precautionary Observation (PO). All seven
reviewed youth records confirmed each youth was referred for an ASR, comprehensive
evaluation, and each referral documented the reason for referral. The interviewed FA reported
the program has a contracted board-certified behavior analyst who provides additional services
for referred youth who are identified as at-risk for mental health, substance abuse, and suicide.
An interview with the CD confirmed the MAYSI-2 is conducted by the case manager. Once the
MAYSI-2 is completed, a referral form is completed and given to the mental health professional
during the intake process. An ASR is completed for all youth at the time of intake, regardless of
the MAYSI-2 results.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a policy and procedures to establish an evaluation process to assist in
the development of each youth’s individualized treatment plan. The program ensures the mental
health and substance abuse needs of the youth are identified through a comprehensive mental
health and substance abuse evaluation process. Seven reviewed youth mental health and
substance abuse records confirmed the program completed a combined mental health and
substance abuse evaluation for each youth. A new evaluation was completed for each youth
within thirty calendar days of admission. Reviewed documentation confirmed consent was
obtained for substance abuse services for each youth. Each reviewed evaluation was
completed by a non-licensed staff and reviewed and signed by a licensed mental health
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professional within ten calendar days after the evaluation was conducted. Each evaluation
included identifying information/demographics, the reason for evaluation, relevant background
information including home environment and family functioning, history of physical abuse,
sexual abuse, neglect, witnessing violence and other forms of trauma, behavioral functioning,
physical health, mental health and substance abuse history, and education functioning. Each
evaluation also included behavioral observations, a Mental Status Examination, interview or
procedures administered, discussion of findings, diagnostic impression/formulation including
Diagnostic and Statistical Manual, Fifth Edition (DSM-5) diagnosis, patterns of alcohol and other
drug abuse, impact of alcohol and other drug abuse on major life areas, risk factors of continued
alcohol and other drug abuse, and recommendations. The CD was interviewed and reported the
mental health department provides individualized treatment through individual, family, and group
therapy services to address mental health and substance abuse concerns of the youth. When
youth complete the intake process it includes classification and problem areas are discussed
with the youth and parent/guardian. Staff are notified of a potentially suicidal youth after the
assessment, and the youth is placed on an internal alert system for Precautionary Observation
(PO). A new PO log is initiated for every shift. During the shift briefing all staff are notified of
youth on PO and the level of supervision. The CD confirmed when a youth appears to be
suicidal staff complete a mental health substance abuse referral, a licensed mental health
professional is contacted, the youth is assessed using the Assessment of Suicide Risk (ASR),
an involuntary commitment is completed, and law enforcement is called for a secure transport to
local facility. Upon arrival, the youth is accompanied by staff, and the intake is completed at the
local provider. Prior to revising a youth’s supervision level, the licensed mental health
professional meets with the facility administrator (FA) and it is documented in the master control
logbook, and ASR.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a policy and procedures addressing the program’s mental health and
substance abuse treatment services. Seven reviewed youth records confirmed each had an
initial mental health and substance abuse treatment plan developed within seven days of
initiation of treatment, or for youth prescribed psychotropic medication, within seven days of the
initial psychiatric interview. Each initial mental health and substance abuse treatment plan was
documented on the Department’s Initial Mental Health/Substance Abuse Treatment Plan form.
Two of the seven youth Initial Mental Health/Substance Abuse Treatment Plans required and
documented each youth’s psychiatric needs including medication and frequency of monitoring
by the psychiatrist. Each of the seven initial plans were signed by the mental health clinical staff
completing the form, and if the initial treatment plan was completed by a non-licensed mental
health clinical staff, the plan was signed by a licensed clinical supervisor within ten days of
completion. Each plan was signed by the youth, parent/guardian, juvenile probation officer
(JPO), treatment team leader, program management, living unit, education, and other applicable
treatment team members. Each plan confirmed the participation of the JPO, and
parent/guardian by telephone. Two of seven Individualized Treatment Plans required and
included psychiatric services, including psychotropic medication and frequency of monitoring by
the psychiatrist. Each individualized treatment plan review was completed on the Department’s
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Individualized Mental Health/Substance Abuse Treatment Plan Review form. Each treatment
plan review was completed every thirty days. Each individualized treatment plan and review
included signatures from the clinical director (CD) on the day of completion, youth,
parent/guardian, JPO, treatment team leader, program management, living unit, education, and
all other applicable treatment team members. Each treatment plan prescribed individual, group,
and family services. Two youth treatment plans required and noted psychiatric services. Each
treatment plan was individualized with goals and objectives. A review of video compared to
sign-in sheets for groups confirmed groups were being conducted as required. The CD was
interviewed and confirmed during the intake process, licensed or non-licensed mental health
and substance abuse clinical staff gather current information from youth, and the therapist
confirms youth reports by referring to collateral information obtained in youth records to
complete the Brief Behavioral Health Status Exam. Furthermore, each youth receives a
comprehensive assessment within twenty-one days of intake based on their current and past
behavior by a licensed or non-licensed mental health professional, which is reviewed by the CD.
This process ensures services are provided. Licensed or non-licensed mental health and
substance abuse clinical staff provide weekly groups which guide the implementation and
execution of group therapy. Monthly fidelity monitoring is conducted to ensure service fidelity;
mental health professionals submit a monthly service calendar of scheduled individual or family
therapy sessions to the CD. Mental health professionals utilize internal forms to track services
provided. The CD meets with facility administration daily.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program maintains a policy and procedures ensuring treatment and discharge planning are
provided to youth. Seven reviewed youth records confirmed each youth was assigned to a
treatment team upon arrival to the program. Reviewed documentation confirmed the treatment
team members for each youth were comprised of youth, program administration, living unit,
education, medical staff, mental health staff, parent/guardian, and substance abuse staff.
Reviewed documentation confirmed each youth who received mental health treatment had a
properly executed Authority for Evaluation and Treatment (AET) form, unless the youth was
eighteen years of age or older or had a court order. Reviewed documentation confirmed each
record contained consent for substance abuse treatment through a signed Youth Consent for
Substance Abuse Treatment form. All mental health treatment notes or substance abuse
treatment notes were documented on the Department’s Counseling/Therapy Progress Notes
form. Reviewed documentation confirmed mental health and substance abuse therapy included
individual psychotherapy or counseling, and psychosocial skills training. Progress notes
determined youth received services as stipulated on the treatment plans. Three closed youth
records were reviewed for discharge plans. Each reviewed discharge summary was
documented on the Department’s Mental Health and Substance Abuse Treatment Discharge
Summary form. None of the reviewed closed records were applicable for the youth being
released while on suicide alert/precautions. Each reviewed summary documented the future
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services needed. Reviewed documentation reflected the discharge plan was discussed with
each youth, parent/guardian, and juvenile probation officer (JPO) during the exit conference. A
copy of the Mental Health/Substance Abuse Treatment Discharge Summary form was provided
to each youth, assigned JPO, and parent/guardian.
The clinical director (CD) interview confirmed mental health and substance abuse clinical staff
complete master treatment team plans which are created within twenty-five days of admission.
After completing the comprehensive assessment, mental health professionals assist youth with
identifying problem areas, and an individualized treatment plan is created. Treatment plan
reviews are created monthly, which are reviewed by the CD. Updates are made using a
treatment addendum if treatment adjustments are needed.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a policy and procedures ensuring a delivery protocol for mental health
overlay services (MHOS), and substance abuse overlay services (SAOS). Required program
clinical treatment groups include Skillstreaming the Adolescent, Seven Challenges, Trauma
Focused Cognitive Behavioral Therapy, and Life Skills Training. Five interviewed youth reported
they are participating in family and/or individual counseling. Five interviewed staff reported direct
care staff do not facilitate any mental health or substance abuse groups. An interview with the
clinical director (CD) reported, the program provides group, individual, and family counseling
services to address mental health and substance abuse concerns of the youth. The interviewed
facility administrator (FA) reported the program provides contractually required specialized
treatment services and mental health and substance abuse services for the youth.
Documentation confirmed the CD was onsite for forty hours each week and licensed mental
health staff were on-site at least five days each week. Reviewed documentation confirmed the
required counselor to youth ratio of one counselor to sixteen youth was met. Additionally, each
non-licensed staff holds a master’s-level degree. The program met requirements to include
individual therapy provided at least once every two weeks, family therapy provided at a
minimum of monthly, and psychiatric services at least once every two weeks. Group therapy
documentation was reviewed and indicated four mental health and/or substance abuse groups
were conducted each week for all youth. No youth missed services due to being on medical
quarantine.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures ensuring the implementation of a Suicide
Prevention Plan. The plan included identification and assessment of youth at risk of suicide,
staff training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and review process. The review process for suicide
attempts and mortality review included circumstances surrounding the event, procedures
relevant to the incident, all relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, and recommendations,
if any, for changes in policy, training, physical plant, medical or mental health services, and/or
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operational procedures. The Suicide Prevention Plan was reviewed on August 1, 2025, by the
facility administrator (FA) and the clinical director (CD). The (CD) meets with the psychiatrist to
discuss youth receiving psychiatric services bi-weekly by telehealth.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program maintains a Suicide Prevention Plan outlining the program’s suicide prevention
procedures. The Suicide Prevention Plan addresses the program’s suicide prevention services,
suicide precautions and observation logs, as well as suicide prevention training. The program
had a deficiency which was closed on June 12, 2025; therefore, documentation was reviewed
from the day of the closure until the week of the annual compliance review. Seven reviewed
youth records confirmed none were applicable for precautionary observation (PO). A sample of
three applicable records was requested. The program only had two samples for the applicable
period. A review of the two applicable records indicated both youth were referred due to staff
observation and an Assessment of Suicide Risk (ASR) determined each youth to be at risk.
Reviewed documentation confirmed each ASR contained the PO start date, referral date, level
of supervision and was completed on the Department’s ASR form. Reviewed documentation
confirmed each youth’s parent/guardian was notified of each youth’s potential suicide risk, as
indicated by the ASR. Each parent/guardian and juvenile probation officer (JPO) notification was
documented on the ASR. Reviewed documentation confirmed mental health staff provided
supportive services, the assessment was completed by the clinical director (CD) and
documented the result of the assessment in each record. The ASR was completed within
twenty-four hours of the screening by a licensed staff. Reviewed documentation confirmed the
facility administrator (FA) documented discontinuation of supervision in the program’s logbook.
Documentation of the actual date/time the clinician conferred with the FA was recorded on each
ASR in the date/time sections. Reviewed documentation confirmed a Follow-Up ASR was
completed prior to the removal for each youth from PO. Each Follow-Up ASR was documented
on the Department’s Follow-Up Assessment of Suicide Risk form. Each youth was maintained
on suicide precautions and constant supervision until the Follow-Up ASR indicated suicide
precautions could be discontinued. Reviewed documentation confirmed each youth’s Follow-Up
ASR indicated suicide precautions could be discontinued, and the youth was stepped down to
close supervision prior to transition to normal routine and standard supervision. Reviewed
documentation confirmed close supervision was maintained for each youth until it was
determined no longer necessary by the CD. Reviewed documentation confirmed a conference
was held by the FA and CD to reduce level of supervision for each youth. The discontinuation of
close supervision for each youth was documented in accordance with the program’s Suicide
Prevention Plan. Reviewed documentation confirmed there was a suicide alert initiated in the
Department’s Juvenile Justice Information System (JJIS) for each youth placed on suicide
precautions and each was accurately closed following the recommendations of the ASR.
Reviewed documentation confirmed there was evidence in the program’s logbook indicating
administration or supervisory staff provided instructions related to the suicide risk assessment
findings and suicide precaution decisions. While on PO, each “at-risk” youth was allowed to
participate in select activities with other youth in designated safe housing/observation areas of
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the program. A video review was unable to be conducted for one youth because it was over
thirty days. A video review of the other youth was conducted and verified the PO.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “non-
applicable.”
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a policy and procedures ensuring staff always maintain at least constant
supervision of the youth on precautionary observation (PO) and document their observations of
the youth on the Suicide Precautions-Observation Log in intervals which do not exceed thirty
minutes. Seven reviewed youth records confirmed one was applicable for being placed on PO.
Two more examples were requested. In the three applicable records the Suicide Precaution
Observation Logs were maintained for the duration each youth was under suicide precautions.
Reviewed documentation confirmed the appropriate level of supervision and observations of
each youth’s behavior was documented in real time and not exceeding thirty-minute intervals.
One of three youth presented warning signs. Reviewed documentation confirmed when warning
signs were observed, the notification to the facility administrator (FA) and mental health clinical
staff was documented on the Suicide Precautions Observation Log. Each Suicide Precautions
Observation log was reviewed and signed by the shift supervisor and mental health clinical staff.
Each Suicide Precautions Observation Logs documented safe housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures which ensure 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. Eight pre-service staff training records were reviewed for
suicide prevention training. There was no in-service training records reviewed because the 2024
training was already reviewed during the prior annual compliance review. Documentation
supports completion of suicide prevention training for the eight applicable staff. The program
maintains two suicide response kits, including a knife-for-life, wire cutters, and needle nose
pliers, which were all observed during the annual compliance review week. One kit is located in
the East Wing sub-control and the other kit is in the West Wing sub-control, both of which were
co-located with the first-aid kits. Training records indicated mock suicide drills were held no less
than quarterly on each shift. There was one mental health drill conducted within the last thirty
days; however, video review was unable to be completed because the drill was conducted in an
area with no camera coverage. Additionally, the program staff completing the video review
indicated the drill was not simulated for the third shift. The program’s suicide trainings included
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mock drills for all staff who encounter youth, including kitchen and maintenance staff. All mock
mental health drills were in response to a suicide attempt and/or incident of serious self-injury.
No youth were used in drill simulation related to mental health or substance abuse care. The
program conducted semi-annual training on emergency response procedures which included
mock training in emergency response to a suicide attempt or incident of serious self-inflicted
injury. Staff who were not present during any quarterly drill had the opportunity to review the drill
scenario and procedures to understand the process and receive necessary training to respond.
The interview with the facility administrator (FA) indicated the program conducts mock drills
monthly on all three shifts and the mental health drills are reviewed in the monthly All-Team
Meeting. Five interviewed staff indicated if a youth expresses suicidal thoughts, they are
responsible for calling a code, notifying mental health, keeping each youth under constant sight
and sound supervision, and informing their supervisor. Four of the five staff indicated suicide
response kits are located in sub control, one staff stated master control, and one staff added
medical. Three of five staff confirmed medical emergency and suicide drills are conducted on
their shift monthly, while the remaining two staff indicated often; however, were not sure of the
exact frequency of the drills.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to outline operating procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan confirmed it included a notification and
alert system, means of referral, as well as youth self-referral, communication, supervision,
documentation, and review. The facility administrator (FA) interview confirmed mock drills are
conducted monthly for all three shifts. Mental health drills are reviewed in the All-team meeting.
Five staff were interviewed and stated medical emergency and suicide drills are conducted on a
shift at least monthly or twice a month.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. Seven reviewed youth records confirmed only one was applicable for a
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Crisis Assessment. Two more examples were requested; however, the clinical director (CD)
stated the program had only had two youth who have experienced a crisis since the last annual
compliance review. Each youth Crisis Assessments documented the date each youth was
determined to be in a crisis and the date of the Crisis Assessment. The Crisis Assessment was
conducted immediately, or within two hours for emergencies, or within twenty-four hours based
on the needs of each youth. Each Crisis Assessment included the following: reason for the
assessment, mental status examination and interview, determination of danger to self/or others
(including imminence of behavior, clarity of danger, lethality of behavior), initial clinical
impressions, supervision recommendations, treatment recommendations, recommendations for
follow-up or further evaluation, and notification to the parent/guardian of follow-up treatment.
Each Crisis Assessment was conducted by a licensed mental health professional, or by a non-
licensed mental health clinical staff working under the direct supervision of a licensed mental
health professional. A mental health alert was entered into the Department’s Juvenile Justice
Information System (JJIS) foreach youth placed on precautions after completion of a Crisis
Assessment. Both youth records were reviewed and documented the Crisis Assessment
determined each youth posed a safety and security risk and each youth remained on alert until
a follow-up Crisis Assessment and/or follow-up Mental Status Examination was completed.
One-to-one supervision or constant supervision of each youth while on the mental health alert
was documented on the Department’s Mental Health Alert-Observation Log, or a form
developed by the program, which contained all the information required. Neither youth received
an off-site Crisis Assessment or Follow-Up Crisis Assessment. One youth was an alleged victim
in a Prison Rape Elimination Act (PREA) event, and a Mental Health and Substance Abuse
Referral Summary was submitted immediately for a Crisis Assessment. The one youth was
offered ongoing mental health and substance abuse treatment services.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a policy and procedures outlining the mental health and substance
abuse procedures for youth who are believed to be in imminent danger to themselves or others
because of mental illness or substance abuse impairment. The Emergency Mental Health and
Substance Abuse Services Plan includes immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for emergency mental health evaluation and treatment for
Baker Act and Marchman Act, documentation, training, and review. The procedures for
notification of the facility administrator (FA), parent/guardian or other agencies regarding a
potentially suicidal youth or youth who has committed suicide involves the licensed professional
conferring with the FA, parent/guardian by telephone, and the juvenile probation officer (JPO) by
telephone or email. In the last six months, no youth have attempted to self-injure themselves.
3.17 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 or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated, “non-applicable.”
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3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a policy and procedures ensuring an ongoing safety planning process
for each admitted youth. Safety planning is designed to identify stimuli which has both positive
and negative effects on the youth. Seven reviewed youth records confirmed each Safety Plan
was completed within fourteen days upon admission, and was jointly prepared by each youth,
parent/guardian or family members, the program’s clinical staff, and behavioral specialist, if
applicable. Each plan incorporated any recommendations from previous or current clinical
assessments or screening instruments, incorporated trauma responsive practices, was
reviewed and updated as necessary at least every thirty days and/or following any significant
behavioral or mental health event identified by each youth’s intervention and treatment team.
Reviewed documentation confirmed the Safety Plan included warning signs identified by youth
or collateral contacts, parent/guardian which indicate a youth is escalating in their behavior(s).
Each youth’s baseline behavior(s) was gathered from collateral contacts, parent/guardian,
youth’s history, and evaluations, if applicable. Each safety plan also had crisis recognition,
jointly developed coping strategies, to include people and healthy environments as defined by
each youth, intervention strategies preferred by youth, and a debriefing process. The reviewed
documentation confirmed the Safety Plans were reviewed by staff who have contact with youth
and plans are kept in both sub controls and in each youth’s record. Seven youth were
interviewed and reported they contributed to their Safety Plan. The facility administrator (FA)
was interviewed and reported the Safety Plans and results are updated monthly at treatment
team reviews.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures addressing the responsibilities of the designated
health authority (DHA). The program has a board-certified physician who is an osteopathic
physician (DO) who meets all requirements for independent and unsupervised practice in
Florida to serve as the DHA. The DHA holds an unrestricted license which expires on March 31,
2026. The DHA is responsible for performing evaluations, sick call, reviewing the nursing
protocols, as well as establishing policies for providing medical care for the youth in the center.
The DHA did not have any disciplinary cases/public complaints on record. The program did not
have an advanced practice registered nurse (APRN) or a physician assistant (PA) providing
services during the annual compliance review period. A review of the sign-in and out logbook
confirmed the DHA was on-site as required by contract to meet with youth as needed. The
program has a back-up DHA who holds an unrestricted license which expires January 31, 2028;
however, the back-up DHA was not utilized during the annual compliance review period. The
program did not utilize tele-medicine/tele-health during the annual compliance review period;
however, each youth and parent/guardian signed a consent to participate in tele-health while in
the program. The DHA interview reported the role of the DHA is to conduct sick call, periodic
evaluations, review off-site visits, and policy and procedures development. The DHA is on-site
weekly and communicates with direct care staff through alerts and shift reports, and with
healthcare staff through weekly meetings to discuss youth records. The DHA is available by
telephone when not on-site. The DHA confirmed the process of off-site visits and follow-ups.
The DHA reported when on vacation another physician provides coverage.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures addressing the responsibility of licensed medical
staff. The program has one licensed practical nurse (LPN). The designated health authority
(DHA) provides direction to the LPN and reviews all medical cases daily with the LPN including
on-call consultation. The program had four registered nurses (RNs) and one licensed practical
nurse (LPN) who provided services during the annual compliance review period. Each of the
nursing staff had current cardiopulmonary resuscitation (CPR) and first-aid certifications. The
program’s contract stipulates nursing staff are on-site twenty-four hours a day seven days a
week.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures, and treatment protocols, which were written and
authorized by the DHA. A review of the FOPs/treatment protocols confirmed the facility
administrator (FA) and designated health authority (DHA) signed and dated them all on July 5,
2025. The FOPs were signed each year, and as a result of a review or changes in policies were
signed on January 1, 2025, and on July 5, 2025. Each nurse reviewed, signed, and dated the
cover page on which all FOPs, healthcare protocols, and other procedures were listed. The
program did not have any newly hired nurses during the annual compliance review period.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of seven youth Individual Healthcare Records (IHCR) found five included a valid
original or legible copy of the Department’s Authority for Evaluation and Treatment (AET) form.
One of the remaining two IHCRs included a signed court order due to the youth being in the
Department of Children and Families (DCF) custody and the other youth was eighteen years of
age and did not require an AET; the eighteen-year-old youth is responsible for authorizing their
treatment and releasing of health care information. Each AET was obtained prior to providing
medical services and signed by a Department representative and parent/guardian. The nurse
interview reported the staff will call the youth’s parent/guardian to obtain a new or current AET if
needed. Youth who are eighteen years of age do not require an AET; however, would sign a
different consent 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.
A review of seven youth Individual Healthcare Records indicated four were applicable for
parental notification. All four included documentation of parental notification for over-the-counter
(OTC) medication beyond those covered by the Authority for Evaluation and Treatment (AET).
Each of the four parents/guardians provided consent which was documented on both the
Department’s parental notification form and progress notes for new medications. The remaining
three youth did not require parental notification. One of the seven youth was prescribed a new
medication, and attempted parental contact was documented in the youth’s progress notes. Two
of the seven applicable youth were taking psychotropic medications at admission, and there
was documentation a staff witnessed all telephone call attempts and conversations for
psychotropic medications. None of the youth were prescribed new psychotropic medications,
discontinued, or the drug dosage was significantly changed. One of the seven youth was in the
care of the Department of Children and Families (DCF) and the court authorized all treatment
and procedures. The medical staff verified each of the seven youth vaccinations within thirty
days of admission. None of the youth required vaccinations nor did any youth refuse. The nurse
interview reported parental notifications are completed verbally and in writing for all medications,
activity restriction, or medical procedures. The parent/guardian notifications are made by
telephone at the time the medical doctor’s order is received and a written notification is mailed
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within twenty-four hours of the verbal notification. The nurse reported, when youth require
emergency medical services the facility administrator, designated health authority (DHA) and
parent/guardian are notified and updated on the incident. The nurse reported, vaccines are
provided on-site when needed and immunizations are verified on Florida Shots website at the
time of admission. The nurse reported a parent/guardian can sign an exemption form and it is
kept 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.
Seven Individual Healthcare Records (IHCRs) were reviewed and each included a Facility Entry
Physical Health Screening (FEPHS) form completed on the date of admission. Each screening
was completed by a registered nurse (RN). None of the youth were out of the program’s custody
greater than twenty-four hours. Each IHCR included documentation of the designated health
authority (DHA) notification. The nurse interview reported youth are seen by medical upon
arrival and medical is notified of new admissions through email. Admission screenings are
completed by the RN and if the admission is completed by a direct care staff the RN documents
a review of the form. The nurse reported if a change of physical custody occurs, a FEPHS is
completed by the RN when the youth returns to the program.
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.
Seven reviewed Individual Healthcare Records (IHCRs) included documentation each youth
received a general healthcare admission orientation. The orientation review was documented on
the Department’s Health Education Form. The orientation included all required elements. The
program’s contract was reviewed for topics and frequency of health education. The program’s
health education contained, at a minimum, the required topics: seatbelt use, substance abuse
problems, sexually transmitted diseases, tobacco use, dental care, basic hygiene,
immunizations, infection control, violence prevention, nutrition, physical fitness, self-
examination, parenting/pregnancy skills/education, and chronic conditions.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
A review of seven Individual Healthcare Records (IHCRs) indicated five youth were applicable
for chronic conditions. None of the youth were in need of emergency care upon admission. A
review of Chronological Progress Notes confirmed the designated health authority (DHA) was
notified the day of admission and within twelve hours. It should be noted the DHA is notified for
every youth admitted into the program. Two of the seven youth were taking psychotropic
medication upon admission and the psychiatrist was notified. The nurse interview reported
knowledge of the DHA notification process when a youth enters the program with a chronic
condition.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of seven Individual Healthcare Records (IHCRs) confirmed a completed Health-
Related-History (HRH) form was completed for each youth on the day of admission. Each HRH
was updated or completed prior to the Comprehensive Physical Assessment (CPA) as evident
by signatures and date. The physician reviewed each HRH form, as evident of documentation
on the CPA. The nurse interview reported the HRH is completed at the time of admission by the
admitting registered nurse (RN).
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
A review of seven Individual Healthcare Records (IHCR) included a current Comprehensive
Physical Assessment (CPA) upon admission for each youth. It is the program’s practice to
complete a new CPA upon admission for each youth; therefore, each of the seven youth had a
new CPA completed within seven calendar days of admission. There was documentation of the
Medical Grade on each youth’s CPA. Each youth had a current CPA at the time of admission.
Each CPA was completed by the physician and each CPA had all sections marked with an “O”
or an “X”. Each youth refused part of the CPA and the physician documented “Youth Refused”
on the CPA. Each youth signed a refusal form which reflected the refused portion on the CPA
exam and matched the date of the exam. The Problem List was updated, as required, for four of
the seven youth. The remaining three youth did not require an update to the Problem List. The
CPA for each youth had documentation of at least one verified Tuberculosis Skin Test (TST)
documented in the IHCR within the last year. A review of the CPA and Infectious and
Communicable Disease (ICD) forms confirmed the result of the TST was documented on both
forms. The nurse interview reported the DHA completes the CPA within seven days of youth
admission and yearly. The TST is administered yearly.
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 outlining the process of evaluation and treatment of
sexually transmitted infections (STI) and human immunodeficiency virus (HIV). The policy and
procedures include all of the required entities. A review of seven Individual Healthcare Records
(IHCRs) confirmed the screening and evaluation for STIs for each youth. Five of the seven
youth needed further evaluation and were referred to the physician. The referral was
documented on the Department’s STI screening tool for each of the applicable youth. The
physician ordered testing for the five applicable youth and each test was within a reasonable
time frame. The testing, screening results, clinical evaluations, and diagnosis for each of the five
youth were documented on the Infectious and Communicable Diseases (ICD) form. None of the
applicable youth were out of the Department’s physical custody nor were symptoms present. All
seven youth were offered counseling, testing, and if indicated treatment/referral for human
immunodeficiency virus (HIV). Four of the seven youth signed a consent form advising consent
for testing. The HIV results for each applicable youth were filed confidentially in a sealed
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envelope marked “Confidential” and the physician signed the envelope documenting review on
the sealed envelope. There was documentation in each applicable IHCR of pre/post-test
counseling. Each youth confidentiality was protected by not including the HIV status and any
other STI diagnosis on the program’s internal alert. The designated health authority (DHA)
and/or a local certified health department staff provide HIV pre- and post-test counseling. The
nurse interview reported youth are screened at admission. The nurse reported during admission
youth either consent or do not consent to testing. The STI screenings, evaluations, referrals,
and testing are documented in each youth IHCR on the ICD. The policy and procedures reflect
HIV results are only disclosed to the youth and entities outline in Florida Statute. The nurse
reported testing will be completed on-site. The nurse reported HIV results are kept in a closed
envelope with “confidential” stamped on it, in the IHCR. The nurse confirmed HIV pre-
counseling, testing, and post-counseling is conducted by a local agency and documented in an
HIV logbook. Five interviewed youth reported being able to ask for an HIV/AIDS test.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
A review of seven Individual Healthcare Records (IHCRs) found four youth were applicable for
sick call process. The remaining three youth did not have any sick call requests. None of the
youth presented with similar sick call complaints three or more times within a two-week period.
Each appliable youth submitted a completed Sick Call Request form. A registered nurse (RN)
completed the appropriate section of each Sick Call Request form. Each Sick Call Request form
was located in each youth’s IHCR and file in reverse chronological order. None of the youth
were placed in restricted housing of any kind. The progress notes/Sick Call forms were
documented according to Health Service Rule. Each sick call was documented on the Sick Call
Index and Sick Call Referral Log which matched for each youth. Sick call is conducted twice
Monday through Friday, at 8:00 a.m. and 2:45 p.m. and Saturday and Sunday at 8:00 a.m. The
program has the sick call hours posted on the modules and outside the medical office. Only the
licensed healthcare staff conduct sick call; however, when a licensed nurse is not on-site, the
program has a policy and procedures addressing trained non-healthcare staff administering
medication. The staff keeps the Sick Call Request forms in a binder and provides them to the
youth when asked. The exam table and medical equipment is used when a sick call is
performed. Five youth were interviewed and reported they are able to see the nurse within one
day after submitting a Sick Call Request. During the interview with the nurse, it was reported
RNs routinely conduct sick calls Monday through Friday twice a day and once on weekend
days. The nurse reported the designated health authority (DHA) does not conduct sick calls and
sick calls are conducted in the medical exam room. Youth are referred to the physician by being
placed on the DHA weekly logbook. The nurse confirmed the DHA approves the treatment
protocols. When a youth is placed in restricted housing and healthcare staff are not available
the supervisors are to assess the youth. One sick call was observed during the annual
compliance review week. The youth was escorted to the medical office by direct care staff and
the staff remained at an appropriate distance as well as kept supervising the youth. The youth
identified himself to the nurse and the purpose of the sick call. The youth was in a private area
with no other youth present to hear or see the examination. The youth was examined by the
licensed healthcare staff and privacy was maintained. The direct care staff was near the door of
the medical office.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures outlining the episodic and emergency care process,
and the use and access of Narcan. Four of seven reviewed Individual Healthcare Records
(IHCRs) were applicable for episodic/first-aid/emergency care. Each of the four applicable youth
required on-site first-aid or episodic care. The licensed healthcare staff provided on-site care,
and it was documented in problem-oriented format, in the IHCRs, for each applicable youth.
First-aid kits are located in sub control rooms and the kitchen. The first-aid kits for transportation
are stored in master control. The registered nurse (RN) conducts monthly checks for each first-
aid kit; during the checks the RN collects and opens all kits to review the contents to ensure
they are meeting requirements. Documentation was reviewed and confirmed the RN conducted
monthly checks. The program has one automated external defibrillator (AED) and it is located in
the break room, a central location in the facility. The AED procedures are located with the AED.
The licensed healthcare staff check the batteries and pads. The program staff conducted a self-
test of the AED in front of the annual compliance review team and there were no issues with the
test. The batteries and pads were last changed in March of 2024 and current batteries expire
December 26, 2025. The pads expiration date is October 31, 2025. The list of emergency
numbers was posted and accessible for non-licensed and licensed staff but not accessible to
youth. Each of the ten pre-service staff were appropriately trained on the administration of the
epinephrine auto-injector, episodic, first-aid, Narcan, and emergency care. The program had no
episodic care incidents to observe during the annual compliance review week. The program
stores Narcan in the locked medical cart and in a locked cabinet only accessible by the facility
administrator (FA), assistant facility administrators (AFA), nurses and supervisors. The nursing
staff conduct a weekly medical supply inventory which includes Narcan. Staff are trained by a
registered nurse (RN) on recognizing and treating symptoms of overdose. The training includes
risk factors for overdose, strategies to prevent overdose deaths, and response. Eight
supervisory staff have documented Narcan training. A review of medical drills was conducted
and found the program conducted seven medical drills on each of the three shifts during the
annual compliance review period: twenty-one in total. Drills were announced and unannounced,
conducted at least quarterly. Documentation confirmed direct care staff participated in at least
one drill which included cardiopulmonary resuscitation (CPR) and a “man-down” drill; however,
video review was not available as none of the drills had been conducted within the last thirty
days. The program stated the staff simulate each drill. The nurse interview confirmed the
location of the first-aid kits and the process of documenting on-site episodic care. The nurse
confirmed the program’s location of their one AED with the procedures. The nurse confirmed the
AED batteries and pads expiration dates. The nurse reported CPR drills are conducted quarterly
on every shift. The nurse confirmed the emergency numbers are in the medical office and
master control and they are not accessible to youth. Five youth were interviewed and three
reported being able to see the dentist if needed and the remaining two youth reported not being
able to. Each of the youth reported being able to see the doctor if needed. Five staff were
interviewed and reported medical emergency and suicide drills are conducted at least once a
month. Three of the five staff reported they are personally allowed to call 9-1-1 in a medical
emergency. The remaining two youth reported there is no telephone on the module and they
notify the supervisor to call 9-1-1.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
A review of seven Individual Healthcare Records (IHCRs) found three were applicable for off-
site care/referrals. A review of the three applicable youth confirmed the Summary of Off-Site
Care Consultation Report form was utilized and filled in each IHCR. Each off-site emergency
care was documented on the Episodic Care Log. Parental notification efforts were documented
in each applicable incident. The discharge and other applicable documents were filed in each
youth IHCR. The designated health authority (DHA) reviewed and signed all off-site findings,
instructions, and information for each youth. Each applicable youth required follow-up testing,
referrals, and appointments and each IHCR had documentation referrals were tracked and
youth received appropriate and timely follow-up care, as needed. The nurse interview reported
off-site care is documented on the DHA log, calendar, and the DHA is notified in regard to the
hospital orders. To ensure the DHA is reviewing all off-site care documents, the nurse flag and
mark all Summary of Off-site Care Consultation Reports.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of seven Individual Healthcare Records (IHCRs) found five had chronic conditions.
Each of the applicable youth Facility Entry Physical Health Screening (FEPHS) had
documentation of youth having a chronic condition. Three of the five youth were taking
prescribed medication on an on-going basis. Two of the five youth were undergoing treatment
for physical health condition. Each youth had a Medical Grade between two and five and were
placed on the chronic illness list. Four of the five applicable youth had periodic evaluations as
required, the remaining youth’s periodic evaluation was not due at the time of the annual
compliance review week. None of the youth had an evaluation conducted off-site, had a
communicable disease, were pregnant, were taking anti-tuberculosis medication, or needed an
evaluation prior to renewing a prescription. In all five applicable IHCRs the Department’s
Problem List was updated as required and each youth was placed on the program’s chronic
condition list. The nurse interview reported chronic conditions are monitored through internal
alerts. The facility administrator (FA) interview reported healthcare staff are present for daily
morning meetings to discuss medical issues. The healthcare staff send out daily emails with
updated alerts and the staff have access to the alert board and alert binder. The designated
health authority (DHA) interview reported periodic evaluations for chronic conditions are
conducted every ninety days or less and youth needing a periodic evaluation are placed on a
tracking system.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of seven Individual Healthcare Records (IHCRs) for medication management indicated
four youth were admitted with medication according to the Facility Entry Physical Health
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Screening (FEPHS). Each of the four youth IHCRs included documentation the medication was
verified prior to being admitted into the program. The prescription verification was documented
in the Chronological Progress Note and on the Prescription Medication Verification Checklist
form for each youth. The designated health authority (DHA) and psychiatrist were contacted to
obtain an order to resume the specified medications prescribed prior to admission for each of
the four youth.
A review of seven IHCRs indicated each youth was taking medication at some time during their
stay in the program and each medication had a current, valid order, and was administered
pursuant to a current prescription. The DHA placed an order on the Practitioner Order Form for
medications which were continued, discontinued, changed, or new ones were ordered. None of
the youth were placed in restricted housing. Over-the counter (OTC) medications not listed on
the Authority for Evaluation and Treatment (AET) form were administered according to
approved protocols for six of the seven youth; the one youth did not have any OTC medication
not listed on the AET. The Department Medication Administration Record (MAR) was used to
document all medication and treatment for all seven youth. The MARs clearly indicated
medication start and stop dates. Non-healthcare staff did not administer medication for any of
the seven youth. None of the MARS reviewed had any undocumented explanations for lapses
or errors in medication administration. The nursing staff documented weekly side-effect
monitoring on each reviewed MAR. None of the youth refused medication. Each MAR included
all required elements, and each youth initialed every medication administration entry. None of
the youth required parenteral medication. There were no standing orders, emergency treatment
orders or any pro-re-nata (PRN) orders for psychotropic medications. Staff are not allowed to
administer medication and conduct or supervise any other center activities, and medication
delivery is the sole responsibility of the nurse during the time of administration. One observation
of medication administration was conducted during the annual compliance review week. The
youth was escorted to medical by direct care staff. The youth approached the nurse
administering medication individually. The nurse identified themselves and stated why the youth
was there and verified the youth’s allergy and alert status. The Six Rights of Medication
Delivery/Administration was verified. The nurse and youth initialed the MAR. The medication
was not pre-poured from the original packaging nor placed in another container for subsequent
administration. The staff observed the youth to make sure medication was swallowed. Three of
the five interviewed youth reported the nurse gives them their medication and two reported not
taking medication. The three youth who reported taking medication were able to explain the
process of medication administration. The nurse interview reported the program uses the
standard Department MAR. The nurse reported trained non-healthcare staff can administer
OTC medications. The nurse reported the program has a psychiatrist who provides psychiatry
services. The nurse interview reported when youth are admitted with medication, only the
registered nurses (RNs) admit the youth and the prescription verification form is completed. The
nurse interview confirmed medication pass times/days. The nurse interview reported the
program has a pharmacy where they submit prescriptions. There is not a separate fee
generated for each youth, according to the nurse.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures to ensure psychiatric services are available for youth
with diagnosed mental disorders and youth receiving psychotropic medications. The program
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has a psychiatrist with a clear and active license who is available, as required, twenty-four hours
a day, seven days a week. For each youth receiving psychiatric services, the psychiatrist
provides briefing of status and services rendered to the youth’s treatment team. The evaluation
and recommendation from the psychiatrist are utilized by the clinical mental health staff when
formulating and reviewing the youth’s treatment plan. The program utilizes a psychiatric
advanced practice registered nurse (APRN) with a clear and active license, and the required
education, experience, and certification, as a back-up. The APRN works under a Collaborative
Practice Protocol with the psychiatrist, and a copy is maintained on-site at the program. During
the annual compliance review period, the program has utilized two other psychiatrists, both with
clear and active licenses. A review of the sign-in/sign-out log for the annual compliance review
period and
confirmed psychiatric services were rendered in accordance with the contractual requirements.
The review of the documentation confirmed the psychiatrist is actively involved in the
management and supervision of the psychotropic medication services. The psychiatrist does
provide bi-weekly supervision of the APRN and is available by telephone and email when not
physically on-site. The contract was reviewed for tele-psychiatry requirements. The contract
does not include tele-psychiatry; however, the program did receive written approval from the
Department’s Office of Health Services to utilize tele-psychiatry services in lieu of on-site
psychiatry services. A review of seven Individual Healthcare Records (IHCRs) indicated all
youth are referred to receive an initial psychiatric interview. Two of the seven were applicable
for taking psychotropic medication upon admission; therefore, the program provided one
additional record for review. All youth were referred for a psychiatric interview and as a result of
the psychiatric interview three youth were continued on psychotropic medications. Each youth
received a diagnostic interview within fourteen days of their admission. Each Initial Diagnostic
Psychiatric Interview included all required elements and was documented on the Department’s
Clinical Psychotropic Progress (CPPN) form and was clearly identified as the “Initial Diagnostic
Psychiatric Interview”. In three IHCRs the interview resulted in the prescription of psychotropic
medications or changes to each youth’s existing psychotropic medication regimen and the page
three of the CPPN was completed. All three applicable youth had a medication review at least
every thirty days. Each of the three appliable CPPNs had the required elements and was filled
out completely. The parent/guardian was contacted by telephone for two of the three youth, the
remaining youth was eighteen years of age. The psychiatrist and the nursing staff documented
monitoring for Tardive Dyskinesia monthly as indicated on the CPPN for each of the three
applicable youth. The psychiatrist dated and signed each CPPN. Tele-psychiatry was available
for each of the applicable youth who agreed to participate. The three applicable IHCRs received
the standard of psychiatric care delivered through tele-psychiatry the same as rendered in-
person, and it was only utilized for youth who agreed to participate in the tele-psychiatry session
and the parent/guardian provided consent. The psychiatrist interview reported meeting with the
clinical director (CD) and facility administrator (FA) at least once every thirty days, conducting
psychiatric evaluations, and being on-call twenty-four hours a day, seven days a week. The
psychiatrist confirmed providing tele-health services. The CD interview reported licensed and
non-licensed clinicians provide services seven days a week. The CD confirmed the intake
process and gathering of information during the first twenty-one days. The CD confirmed
meeting with the psychiatrist bi-weekly through tele-health.
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4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure all medical sharps equipment and
medications are stored securely, correct inventory is maintained, and disposal is handled
properly. The program’s medications and sharps were observed to be secured in a designated
locked area, inaccessible to youth. Each medication and piece of equipment has a perpetual
and a weekly maintenance inventory. Medications were stored separately by delivery type. The
medication cart was observed to be clean and well organized by youth-specific medications.
The program had one controlled medication on-site, and this medication was stored separately
behind two locks and had a perpetual inventory. The controlled medication had a shift-to-shift
inventory maintained on the youth’s Individualized Controlled Medication Inventory Record as
required. The program did not have any refrigerated medication during the annual compliance
review week; however, a locked refrigerator designated for medication was observed. The
program utilizes medication destroying liquid for non-controlled medication which have expired
or were not returned to the pharmacist, which is stored in the locked medical closet. Controlled
medication is returned to the pharmacist for destruction. A review of training documentation
confirmed the program has seven supervisory-level, non-healthcare staff who received the
required training, by a registered nurse (RN), in delivery and oversight of medication self-
administration. A review of three over-the-counter medications, three sharps, and the one
available controlled medication was conducted. Each medication and sharp had documentation
to confirm the on-site inventory matched the inventory logs. An informal interview with the RN
manager confirmed any discrepancies located during inventory of medication or sharps will
prompt a recount for verification, and if the discrepancy is confirmed the program administration
and the Department’s Central Communications Center (CCC) are notified. The nursing staff
interview confirmed two RNs, or a RN and the pharmacist, sign off on all medication disposal
incidents; and controlled medications are delivered by the pharmacist, stored behind two locks,
and have a shift-to-shift inventory conducted by two RNs. The program has a current
agreement/contract with a local pharmacy, who maintains a properly licensed pharmacy
consultant, to ensure all medications are verified.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according to 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 detailing the infection control plan which includes
prevention, containment, treatment, and reporting requirements related to infectious diseases
and is in accordance with the Occupational Safety and Health Administration (OSHA) federal
regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
designated health authority (DHA) reviewed and signed the plan on January 1, 2025, and the
facility administrator (FA) reviewed and signed the plan on January 2, 2025. The infection
control and the exposure control plans are reviewed annually and were available for staff. The
infection control procedures included all required elements. Hepatitis B immunization is
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available for staff and staff have access to protective equipment. The program did not have any
incidents in which the local health department, CDC and/or Department’s Central
Communications Center (CCC) should have been notified. There is a separate file maintained
for youth and staff who have experienced a facility/occupational exposure; however, the
program did not have any applicable. The program has a process for needle stick post-exposure
which includes documentation, collection/testing, counseling, communication and evaluations.
The nurse interview reported the Exposure Control Plan is available to the healthcare staff. The
infection control training is facilitated by the registered nurse (RN) or health service
administrator (HSA). The nurse reported youth at admission receive infection control training.
4.20 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.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures addressing how they will maintain active supervision
of youth by closely observing youth behavior and changes in behavior, as well as knowing the
whereabouts of youth at all times, interact positively with youth, engage in constructive activities
and provide thorough observation of youth behavior while consistently applying the program’s
behavior management system. The program’s contracted supervision ratio is one staff to eight
youth for Mental Health Overlay Services/Substance Abuse Treatment Overlay Services
(MHOS/SAOS) services during the day hours, and one staff to ten youth during sleep hours.
Each day of the annual compliance review week, program staff were observed to be actively
supervising youth during classroom activities, school breaks, head counts, movements, and
outdoor recreation activities. Staff were always positioned properly in a manner to supervise and
interact with all youth they were supervising and within the contractually required ratio.
Interactions were observed to be positive. Three staff were informally interviewed during these
observations, and all staff immediately knew the number of youth they were supervising. The
program has a daily youth activity schedule which was posted on all living units and throughout
the program. During the annual compliance review week, youth were observed to be engaged in
a full schedule of activities. Video camera observation revealed during three ten-minute checks
youth windows were covered with white paper affecting the direct line of sight of youth and on
six ten-minute checks staff members did not properly conduct room checks. The program did
not have any escapes during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the development, implementation, and
on-going maintenance of the behavior management system (BMS) by all appropriate parties,
including education. The policy also includes procedures where staff are provided with feedback
regarding the implementation of the BMS and wherein staff explain to the youth the reason for
any sanction imposed prior to the end of the staff’s work day, the youth is given an opportunity
to explain his or her behavior, and staff and the youth discuss the behavior’s impact on others,
reasonable reparations for harm caused to others, and alternative acceptable behavior. A
review of the program’s contract, policies, and BMS confirmed all appropriate parties, to include
education, were involved in the development, implementation, and on-going maintenance of the
BMS. The program and education provider have a joint plan related to the utilization of the BMS
in the classroom. Documentation and an informal interview with the facility administrator (FA)
confirmed the FA trained education staff on the combined BMS plan. A review of seven youth
case management records confirmed each youth’s orientation included a review of the BMS. All
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requirements of the BMS are also included in the youth handbook. Eighteen staff position
descriptions were reviewed for staff whose job functions include implementation of the BMS,
and all position descriptions included a requirement for the implementation of the BMS. Seven
pre-service staff training records were reviewed which confirmed each staff member received
training in the BMS. Observations during the week of the annual compliance review confirmed
the BMS was seen posted in all modules and in the multi-purpose room which is accessible to
youth and included the rules governing conduct and positive and negative consequences. The
program’s BMS has not been changed or was in the process of being changed during the
annual compliance review period. The program’s written BMS includes four levels and
contained all required elements. The program has no contractually required special BMS
provisions. Observations made during the annual compliance review week confirmed positive
interactions between staff and youth and adherence to the requirements of the BMS. The
program provides a variety of rewards/incentives to include nightly privileges, “Super Monday,”
“Phat Friday,” and “Gotchas”. The BMS does not include an increased length of stay, denial of
youth’s basic rights or services, promotion of group discipline, punishment of youth by other
youth, or disciplinary confinement. Four of five interviewed youth were able to articulate the
consequences for bad behaviors and provide examples. The remaining youth indicated youth
really do not get consequences and stated youth can curse staff out and still make their day. All
five interviewed youth were able to provide examples of rewards they can earn while at the
program. Four of five interviewed youth stated staff are consistent in their implementation of the
BMS. The remaining youth stated some youth will do bad and still get rewarded. Each of the five
interviewed youth were able to articulate the difference between each level and how to move
from level to level. All five youth confirmed youth are not allowed to punish other youth. Five
staff were interviewed and all were able to articulate the program’s BMS. Each of the five staff
were able to verbalize rewards which are provided as part of the BMS to include snacks, movie
nights, and “Gotchas”. All five staff confirmed basic rights cannot be taken away from youth as a
consequence. Each of the five staff described ways youth are informed of consequences and
explain their behaviors. The FA’s interview confirmed the programs practice and implementation
of the BMS.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Failed Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
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 to ensure youth are observed at a minimum of every
ten minutes when youth are in their rooms. The program has 128 video cameras, and all were
operational during the annual compliance review week. Video coverage is stored for thirty days.
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Staff are required to conduct room checks every ten minutes when youth are in their rooms and
document the check in real time along with the initials of staff conducting the check. A random
sample of ten-minute check sheets for each month of the annual compliance review period
found one check was completed five minutes late, two checks were not initialed by the staff
member completing the check as required, and all remaining checks were documented as
required. A video review of nine different dates of ten-minute checks was compared to the ten-
minute check logs. Thirteen checks were not completed as required. Two different youth rooms
contained white paper covering the window on the door, not allowing staff to observe the youth
during three of the ten-minute checks, the staff member did not pause to look into the rooms for
three other checks, and on three different dates ten-minute checks were completed five
minutes, eighteen minutes, and eleven minutes late respectively. One ten-minute check was not
completed; however, the staff documented it was completed. One ten-minute check was
documented for all youth rooms on the module; however, video review showed only a couple of
rooms were completed. The staff documented all checks were completed. The falsification was
reported to the Department’s Central Communications Center (CCC) during the week of the
annual compliance review. Two additional falsifications were reported to the CCC during the
week of the annual compliance review due to checks being noted on two days; however, were
not completed, as confirmed by video review. Five staff were interviewed and stated youth are
checked every nine minutes while in their room and the three remaining staff stated checks are
completed every ten minutes. The facility administrator was interviewed and confirmed the
program has operational security cameras and which store recordings for thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures which addresses population census, counts, and
tracking of youth. The policy requires counts to be conducted at a minimum at the beginning of
each shift and throughout the day to include after each outdoor activity and during any
emergency situations. The program tracks daily census information including at a minimum,
daily census count, new admissions, releases, transfers, and youth temporarily away from the
program. Observations during the annual compliance review week confirmed head counts were
conducted throughout the day. The program utilizes a master control logbook to document
youth counts, movements, and daily census. A review of program logbooks for one day each
month of the annual compliance review period reflected headcounts are being conducted at the
beginning of each shift, after recreation, total daily census counts, head counts, youth
movements, transfers, youth temporarily away from the program, and randomly throughout the
day. The program documented all census, counts, and tracking activities as required. Five staff
were interviewed, and all indicated how and when youth counts are conducted. Each of the five
interviewed staff were able to explain when emergency head counts are conducted and the
procedures when a youth count cannot be reconciled.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures addressing logbook entries. The program maintains
one master control logbook which documents a chronological record of events. The program
logbooks are bound with numbered pages. All reviewed entries were made in ink with no
erasures or white-out areas. None of the reviewed logbooks had any entries removed or
destroyed. All reviewed entries with errors were struck through with a single line and initialed by
staff as required. All reviewed entries included the dates and times of events, the names of staff
and youth involved, brief descriptions of the events, and the names and signatures of the staff
making the entries. Two dates had incidents reported to the Department’s Central
Communications Center (CCC), which were documented in the logbook. A review of shift
reports indicated the program maintains them in the modules for forty-eight hours, summarizes
the events, incidents, and activities documented in the program’s central logbook, and the
incoming staff sign and date the shift reports for the previous shift to document they reviewed or
were verbally briefed about its contents. Logbook entries required and documented two
emergency drills. There were no incidents including the use of mechanical restraints or escape
or escape attempts, and requests by law enforcement to access any youth. One sample
required and documented an incident of special instructions for supervision and monitoring of
youth. All reviewed samples had population counts at the beginning and end of each shift, and
any other population counts conducted during a shift, perimeter security checks and other
security checks conducted by direct care staff, three transports away from the facility, including
the names of the staff, youth involved, and the destination. The reviewed samples also included
two incidents of removal of youth from the mainstream population, and three
admission/releases, including the name, date, and time of anticipated arrival/departure and
mode of transportation were documented.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to govern the control and use of keys. The program’s
policy and procedures include key assignment and usage, restrictions on usage, inventory and
tracking, secure storage of keys when not in use, procedures for missing or lost keys, and
reporting and replacement of keys. The program’s policy lists the position titles who can be
issued permanent keys with written authorization of the facility administrator (FA). An
observation during the week of the annual compliance review verified when entering the
program, master control staff are required to sign, date, and list the program key number on a
key log and secure the personal key in a lock box. When leaving the program, master control
staff are required to sign the log and key sheet to show the program key was returned. Any staff
who are issued permanent keys must sign the Key Responsibilities form prior to being issued
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permanent keys. The policy details which staff can have access to restricted keys and which
areas those keys can access. The policy states any damaged keys should be reported to the
shift supervisor and returned to the assistant facility administrator (AFA), who will be responsible
for discarding the key, updating inventories as applicable and issuing of replacement keys.
There were no incidents reported to the Department’s Central Communications Center (CCC) or
Program Monitoring and Management (PMM) system related to key control concerns. An
informal interview with the master control operator indicated the restricted keys are only
accessible to authorized staff who are assigned to specific job functions requiring restricted key
use. The program uses a sign in/sign out log for daily tracking and reconciliation of keys. The
program’s key storage includes three gray key lock boxes, which are not accessible when
locked, with hooks and labels for each key ring which corresponds to the key inventory. The
program’s key storage area is located in master control. A review of the key inventory and a
sample of five staff key rings revealed the key inventory correctly matched the keys on the five
reviewed key rings. An informal interview of three staff revealed all three staff were able to
correctly list the number of keys they had on their key ring and know the function of each key.
All five interviewed staff were able to articulate the process for storage of personal and program
keys from the beginning of shift until end of shift, where they are stored, and how program keys
are assigned.
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 addressing program safety and security and to
control the introduction of materials considered contraband into the program. The program has
a system in place to prevent contraband from entering the facility and clearly describes those
items considered to be contraband. The program’s system and policy include all required
elements. The program’s policy specifies law enforcement will be contacted if any found item
would be considered illegal as defined by Florida Statutes or if there is any suspicion of unlawful
activity. The program’s facility visitor log contains a contraband attestation statement. All newly
hired staff are required to sign contraband attestation forms upon hire. A review of personnel
records for the twenty-four newly hired staff, since the last annual compliance review, confirmed
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each staff member signed an attestation form upon hire. The program’s policy includes staff
found in possession of contraband in the program are subject to disciplinary action up to and
including dismissal as outlined in Florida Administrative Code. A review of documentation
confirmed the program documents the confiscation and disposition of any contraband. The
program did not have any illegal contraband turned over to law enforcement during the annual
compliance review period. An informal interview with the assistant facility administrator (AFA)
indicated there was one incident during the annual compliance review period of non-illegal
contraband being discarded. The program followed all required protocols to include calling the
Department’s Central Communications Center (CCC), notifying law enforcement, and securing
the contraband; however, the AFA indicated law enforcement did not take possession of the
broken vape pen charger and it was later discarded off-site. A review of logbooks, incident
reports, and search reports confirmed the program completes searches of program areas daily.
An interview with the facility administrator (FA) confirmed the program’s practice. Five staff were
interviewed and three stated searches are conducted daily, the remaining two staff stated
searches are conducted weekly. One staff also stated searches can be done anytime for any
reason.
5.09 Searches and Full Body Visual Searches Limited Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to ensure the program performs searches and full
body visual searches. The program conducts searches as a method to prevent the introduction
of contraband and unauthorized items into the facility. The annual compliance review team
observed several youth searches during the week of the annual compliance review week
including transition to school and from school, moving from the module to treatment team
meetings, to recreation, and back to the module. The program did not have any admissions,
transports, visitations, off-campus activities, nor was there an observation of youth access or
ability to obtain tools during the annual compliance review week. Searches were conducted by
staff of the same gender as the youth, while a second staff member assisted with supervision.
Search procedures and expectations were properly explained to all youth before searches were
conducted. Searches were thorough and completed in a manner to minimize the youth’s stress
and embarrassment. Searches were conducted as required by the Right Interactions (RI)
training manual. Video review of five random days of staff and visitor searches found three days
searches were not completed as required. On two days, two staff entered the search area of the
program, and their belongings were not thoroughly searched prior to entering the secure area,
and the remaining, day a visitor’s bag was not searched prior to entering the program. Five staff
were interviewed, and all confirmed youth are searched before and after every movement. Five
youth were interviewed, and all youth confirmed youth are searched before and after every
movement.
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.
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The program has a policy and procedures to ensure any vehicle used by the program to
transport youth is properly maintained and documentation regarding the use and maintenance
of each vehicle is kept. The program utilizes one van for youth transports; however, the program
has two assigned vans. An informal interview with the assistant facility administrator (AFA)
indicated only one van has a safety screen and is the only one utilized to transport youth. A
random check of five staff vehicles and both program vans was completed to ensure vehicles
were locked when not in use. All vehicles were locked as required. Both vans passed their
annual inspections and documentation confirmed regular maintenance was completed. The
program is a high/secure program; therefore, a safety screen is required and only the youth
transport van had the safety screen. An observation during the annual compliance review week
confirmed both vans have all required equipment, which included the appropriate number of
seat belts, a seat belt cutter, window punch, and fire extinguisher. The AFA stated both first-aid
kits are maintained at master control to preserve the integrity of the supplies, and an
observation confirmed this practice. All seatbelts in the van were in proper working condition.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to ensure the 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’s policy includes all requirements outlined
by the Department relating to transportation of youth and driver eligibility. A review of the
program’s policy and procedures, and interviews completed during the annual compliance
review week, confirmed the program provides a program issued cellular telephone for all
transports. There were no scheduled transports during the week of the annual compliance
review; therefore, an observation was not completed. The program’s practice is human
resources (HR) completes driver’s license checks from the Department of Highway Safety and
Motor Vehicles (DMV) on all newly hired staff and subsequently obtain monthly driving record
information to ensure all staff operating a program vehicle have a current driver’s license and
reviewed documentation confirmed this practice. The policy states HR shall notate all staff
within the Department’s Staff Verification System as designated transportation staff. The policy
further states youth are not permitted to drive program or staff vehicles. Five youth were
interviewed, and each youth confirmed they have never been handcuffed to any part of the
vehicle during transport, nor have they seen anyone place contraband in a transport vehicle.
Five staff were interviewed and two had never completed a youth transport; therefore, they
could not articulate the procedures relating to youth transport. The remaining three staff stated
youth are secured within the vehicle by seatbelts and are handcuffed during transport, and the
program provides radios and cellular telephones for all transport. Additionally, the remaining
three staff stated emergency equipment to include first-aid kit, window punch, fire extinguisher,
and seat belt cutter are in the transport vehicles. All five interviewed staff stated staff cannot use
their personal vehicles to transport youth and all transport vehicles are searched for contraband
prior to and after each use. The three staff who had participated in transports were able to detail
the emergency response and the required staff to youth ratio during a vehicle transport. An
interview with the facility administrator confirms the program’s transportation practice.
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures requiring the program maintain a safe and secure
physical plant, grounds, and perimeter. The programs assistant facility administrator (AFA) is
responsible for conducting weekly safety and security audits and the implementation of any
corrective action warranted as a result of any deficiencies found during the weekly audits. The
weekly safety audits are kept in a binder in the AFA’s office. Findings are discussed and a
corrective action plan is implemented to fix any deficiency noted and submitted to the
Department. The program’s policy meets the requirements outlined in Florida Administrative
Code. During the annual compliance review week reviewed documentation confirmed weekly
safety and security audits were conducted during the annual compliance review period and any
identified deficiencies were documented on the reports including the status and due date of any
needed corrective action. All forms were reviewed and signed by the AFA. A review of the
program’s Preventative Maintenance Checklist forms for the annual compliance review period
indicated inspections were completed, as required, and documented deficiencies and repair
updates were conducted. The interview with the facility administrator (FA) indicated the program
completes a key performance indicator report based on the reported information from each
morning meeting report, and this information is totaled each month and compared to the
previous month. A meeting of the management team is conducted to plan how to reduce
deficiencies. The program also uses internal interviews completed by corporate staff to verify
deficiencies are being reduced.
5.13 Tool Inventory and Management Failed 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, missing/lost tools, and dysfunctional tools and their disposal. The policy
confirms machetes, bowie knives, or other long blade knives are prohibited. The maintenance
supervisor indicated when a tool is dysfunctional, it is disposed of according to policy. He further
stated they have not had any lost or missing tools since the last annual compliance review. A
review of tool inventory for the program’s maintenance shed since the last annual compliance
review confirmed a perpetual inventory is kept anytime a tool is used and a daily inventory is
maintained. Ten tools were compared to the tool inventory and two were not able to be located
in the maintenance shed. Two screwdrivers in the toolbox drawer had no identification markings
and were not on the tool inventory. There were also multiple tools in the maintenance shed not
found on the tool inventory; specifically, two shovels, a drill bit set, and an Allen-wrench T-
handled set. Multiple tools had no label/inventory number or any identification markings on the
items and were not located on the inventory list. The current inventory was not completed on
Class A tools for two days of the annual compliance review week. An observation of
tools/kitchen utensils was completed. Multiple items in the kitchen had no label/inventory
number or any identification markings on the items. The program maintains an inventory of
knives, cooking spoons, spatulas, whisks, and pizza cutters; however, not all cooking spoons,
ladles, and whisks are documented on the inventory, despite they are the same utensil type.
Five kitchen tools were compared to inventory and found one of two spatulas were not on hand.
The kitchen’s perpetual inventory indicates only one utensil is used daily, making it unclear if all
items utilized each day are documented on the inventory as they are utilized. The daily kitchen
tool inventory did not contain all items which were on-site, specifically, three large knives, one
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small knife, and two metal peelers were not on the inventory list; however, were securely
maintained. The kitchen inventory was not completed on one day during the annual compliance
review week.
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 including the issuance of tools, staff to youth ratios,
tool distribution, and search criteria involving work projects. The policy states the ratio is one
staff to five youth during a work project involving youth; however, the assistant facility
administrator (AFA) indicated the program does not utilize youth for any work projects involving
class A tools. A review of seven youth case management records confirmed each youth
received training in the intended and safe use of tools. Five staff were interviewed, and four
stated youth are only permitted to use scrub brushes, mops and brooms. One staff further
stated these tools can only be used under supervision. The remaining staff stated youth are not
permitted to use any tools. Five youth were interviewed, and each stated they are permitted to
use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors
regarding tool control and restrictions. The physical plant manager is responsible for monitoring
all tools and sensitive items at the facility. The policy states outside contractor tools are limited
to only those necessary, all tools are checked upon and prior to exiting the program, youth
access to work areas must be restricted, and all contractors must sign a written notification and
attestation form and tool inventory list upon arrival. The policy also includes a follow-up if any
tools are missing and restrictions on personal cellular telephones and/or equipment capable of
taking pictures or video recording. Contractors are escorted and supervised by the physical
plant manager or designee any time they are within the facility. A review of three project
invoices showed the vendors signed contractor agreements and an inventory of tools was
completed and documented. Reviewed outside contractor logs confirmed the program reviewed
the inventory or equipment when the vendor arrived and left. The program's policy states the
facility administrator is responsible for providing approval and permissions for personal cellular
telephone and/or equipment/electronic devices capable of taking pictures and audio or video
recordings, including smartwatches.
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 addressing fire, safety, and evacuation drills. A
review of the Continuity of Operations Plan (COOP) drills revealed the program was conducting
monthly drills on a rotating basis as required on each shift during the annual compliance review
period. Each reviewed drill included the type of drill, date and time, participants, a brief scenario,
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and recommendations. The program had twenty-four fire extinguishers. All fire extinguishers
had been inspected in the last six months and were valid, with another inspection due by the
end of September 2025. All inspections are conducted every six months, rather than annually.
Five of the twenty-four extinguishers observed had monthly checks missing. One fire
extinguisher located in a utility room outside, and the spare reserve fire extinguisher did not
have any monthly checks conducted. In another outside utility room and the two vehicles fire
extinguishers were missing two monthly checks each. Fire evacuation routes and egress plans
were posted throughout the facility. There were three identified locations which did not have
evacuation routes which were in two modules and the multi-purpose room. The program was
notified during the annual compliance review week of the issue and took corrective action
posting evacuation routes in all three locations which was observed and verified by the annual
compliance review team. An interview conducted with the facility administrator (FA) indicated
the program conducts monthly fire/medical/suicide drills on all three shifts, COOP and
operations drills monthly, and quarterly mental health drills on all three shifts. Five youth were
interviewed, and each confirmed they had been instructed on what to do in case of a fire and
had participated in fire drills. Four youth stated they participate in drills monthly and the
remaining youth stated a lot of drills are conducted. Five staff were interviewed, and all five
stated they had participated in drills to include fire, weather, escape, medical and mental health
drills.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a policy and procedures addressing the Continuity of Operations Plan
(COOP). The program maintains a combined COOP and Emergency Disaster Preparedness
Plan. An informal interview with the assistant facility administrator (AFA) indicated the COOP is
readily available to all staff in master control, the facility administrator’s (FA) office, and
conference room, and observations during the annual compliance review week confirmed this
statement as well as confirming it is readily available to staff. The plan addressed alternative
relocation sites approved by the applicable Department regional director/designee. The COOP
was last approved on January 10, 2025, and submitted for approval to the Department on
March 20, 2025. The COOP addressed the following: fire prevention and evacuation, severe
weather, disturbances or riots, bomb threats, hostage situations, chemical spills, flooding,
terrorist threats or acts, staff roles and responsibilities, any equipment and supplies needed,
information about youth which may be needed, alternative housing arrangements, provisions for
continuity of care and custody of youth, and provisions for public protection.
An informal interview with the AFA indicated the emergency supplies consist of batteries,
flashlights, radios, canned food, and gloves. The equipment and supplies required for
continuous operation and services during emergencies or disasters were also observed in
designated areas including in the administration office, medical office, and kitchen. The program
maintains identifying information on each youth in the program in the facility administrator (FA)
office and if the program must evacuate the youth record accompanies the youth to the
temporary location, or in the event needed information cannot be accessed electronically.
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Reviewed documentation confirmed the program maintains critical identifying information in
hard copy binders including case management, and medical information. Seven youth
administrative hard copy records were reviewed which contained the youth’s name, a
photograph, Department identification number (DJJID), admission date, date of birth, gender
and race, overall health status and physician information, address, and parent/guardian contact
information which included name, address, telephone number of the person with whom each
youth resides and their relationship to each youth, and person(s) to notify in case of an
emergency. In addition, the hard copy records contained the youth’s assigned juvenile probation
officer (JPO), committing judge, state attorney, and public defender. Each record contained the
committing offense and judicial circuit where offense occurred, notation of whether or not the
judge retains jurisdiction, victim notification contact information, physical description of youth to
include height, weight, eyes and hair color, and any identifying marks. An interview with the FA
confirmed a copy of the COOP is in the FA’s office, and in master control.
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous,
Failed Compliance
and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures addressing the process for chemical spills, disposal,
storage, and inventory of flammable, poisonous, and toxic items and materials. The program
maintains a list of staff who are authorized to dispose of chemicals and who have access to
chemicals. The program’s policy and procedures related to the disposal of chemicals was in
accordance with the Occupational Health and Safety Act (OHSA) Standards. An interview with
the facility administrator (FA) confirmed the program uses all of the chemicals/cleaning products
in their entirety, requiring no unused chemicals to be disposed of by the program. As a result,
the program does not maintain a disposal log. The FA explained a local company disposes of all
kitchen grease, which is stored in a grease trap until the company arrives for pickup. All liquid
waste, such as dirty mop water, unused beverages and kitchen liquid waste are disposed of in
the program’s drains. The program did not have any chemical spills requiring them to activate
the program’s procedures regarding chemical spills. A review of all chemicals during the week
of the annual compliance review confirmed each was secure and inaccessible to youth. A
comparison of chemicals in the kitchen’s chemical cabinet to the kitchen’s chemical inventory
confirmed there were only four chemicals on the inventory list; however, there were nine
additional chemicals in the cabinet. The inventory form is pre-printed and a review of all
inventories, since the last annual compliance review, confirmed none of the nine additional
items were on any of the kitchen’s chemical inventory list. Only one of the four observed
chemicals was documented accurately on the corresponding inventory. A binder was in the
same cabinet containing a Safety Data Sheet (SDS) for three of the four reviewed chemicals
located on the inventory. A review of the inside chemical closet confirmed there were six small
caddies, one for each module, containing three bottles of chemicals in each caddy. A review of
the chemical’s perpetual inventory confirmed the inventories were maintained for each bottle of
chemical since the last annual compliance review. A binder was in the inside chemical closet
containing a SDS sheet for each of the three chemicals. There were also nine large bottles of
chemicals, two different types, not listed on the inventory located in the chemical closet. An SDS
sheet was in the SDS binder for both types of chemicals. A comparison of ten different
chemicals in the maintenance shed to the maintenance shed chemical inventory confirmed each
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 66 (Revised August 2025)
was listed: however, only two matched. The inventory is not documented when items are used;
therefore, the amount on the inventory was not accurate. According to the maintenance
supervisor, inventory is captured at the end of each month and then the following month any
new deliveries which arrive in the current month are captured; then all chemicals are counted
again at the end of the month. There is no way to tell how many chemicals are on-site at any
given time throughout the month, except for the last day of each month, when the inventory is
completed. Two of the ten reviewed chemicals did not have a SDS sheet. Further observation of
the maintenance shed found multiple chemicals in the drawer cabinet, where tools are kept,
which were not on the inventory.
5.19 Youth Handling and Supervision for Flammable, Satisfactory
Poisonous, and Toxic Items and Materials Compliance
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures to ensure strict control of flammable, poisonous, toxic
items and materials. The program’s policy prohibits youth handling, using, or disposing of any
dangerous/hazardous chemicals, bio-hazardous material, bodily fluids, or human waste. All
chemicals are stored in a locked storage closet inaccessible to youth. The annual compliance
review team was unable to observe youth during cleaning activities involving chemicals due to
youth not being allowed access to any chemicals. The facility administrator (FA) was
interviewed and was able to explain the program’s disposal practice and indicated the program
only purchases what is used and has not disposed of any items. Five youth were interviewed,
and each confirmed they do not handle any chemicals to include cleaning supplies.
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.
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Office of Accountability and Program Support Page 63 of 66 (Revised August 2025)
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to ensure the program allows visitation and
communication for youth while in the program. The program’s visitation schedule is posted in
the lobby of the program and in each module. The program’s policy and procedures are
reviewed during orientation and are communicated to youth and parent/guardian within forty-
eight hours of youth’s admission to the program. A review of the logbooks and visitation sign-in
sheets confirmed the program allows visitation for approved family members. Visitation occurs
two days a week on Saturdays and Sundays from 1:00 p.m. to 4:00 p.m. The program’s
visitation policy indicated consideration for requests of alternative visitation arrangements with
parent/guardian, if needed. The program policy states any visitors or communication with youth
must be on the youth’s approved correspondence list which is maintained by the case manager.
The program’s policy also states mail is opened in front of youth and outgoing mail is searched
prior to leaving the facility. Youth can send letters or make a telephone call at least once a week
to approved family members. A review of the program’s telephone log reflected youth have
consistent telephone communication with approved family members. None of the reviewed
youth had a history of human trafficking. The program has an agreement with a third-party
language service to provide translation services. An interview with facility administrator (FA)
indicated the program does have a third-party translation agreement. Five youth were
interviewed, and each youth confirmed they can call and/or send a letter to their
parent/guardian.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures to ensure the program provides a variety of
recreational and leisure activities to youth. The program’s policy requires recreation activities to
be provided for a minimum of one hour a day. The youth have a variety of recreation and leisure
activities posted on a recreation calendar which promotes creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. The program’s schedule has structured
indoor and outdoor recreation and leisure activities which include large muscle activity for a
minimum of one hour each day. A review of the master control logbook during the annual
compliance review period indicated recreation was conducted as scheduled. The program’s
contract requires a recreation therapist. A review of documentation confirmed the recreation
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Office of Accountability and Program Support Page 64 of 66 (Revised August 2025)
therapist has the required credentials and is providing services as stipulated in the program’s
contract. A review of seven youth mental health and substance abuse records confirmed each
youth record contained a wellness plan, which was incorporated into their individualized
treatment plan. Recreation was observed during the annual compliance review week, which
confirmed the program takes precautionary measures to prevent overexertion, heat stress,
dehydration, frostbite, hypothermia, and exacerbation of existing illness or physical injury. Five
youth were interviewed and four indicated physical activity is provided for at least one hour a
day, and the remaining one youth denied physical activity being conducted. All five youth
indicated they play basketball or work out. Five staff were interviewed, and all confirmed
recreation occurs for a minimum of an hour a day and includes activities such as football,
basketball, kickball, and board games.
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 to ensure youth searches and room inspections are
conducted prior to placing a youth in on controlled observation. Each room was a minimum of
thirty-five unencumbered square feet, had a metal door with a shatter resistant observation
window, had properly covered vents and lighting, and no electrical outlets or switches inside the
room. Mattresses in the program are fire retardant. Five controlled observation reports were
reviewed and found staff documented an inspection of the room and a search of each youth
before each youth was placed in the room, as required. Staff of the same gender searched each
youth before each 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 to ensure youth are only placed on secure
observation when non-physical interventions would not be effective. The program had forty-
seven youth on 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 with
suicidal ideations. 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. All
five youth were advised for the reason of placement in controlled observation and the expected
behavior for removal. All five had a healthcare professional or staff of the same gender as youth
complete the health status checklist. There was one youth who complained about injuries and
staff reported to the medical staff for assessment and treatment. Times of controlled observation
ranged from one to nine hours and forty-five minutes, in which the three applicable reports
included the facility administrator (FA) or designee granting approval for the extension of the
two-hour window and approval for continued placement at least every two hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 66 (Revised August 2025)
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a policy and procedures for controlled observation safety checks and release
procedures, based on the youth’s behavior, as well as staff designations for controlled
observation. A sample of five youth records was reviewed. All five reports confirmed the staff
making placement completed the first page of the Controlled Observation Report, submitted the
form to a supervisor, documented the safety checks at least every fifteen minutes, and observed
youth’s behavior. The facility administrator (FA) or designated supervisory staff who had the
delegated authority gave written approval before a youth was released from controlled
observation, which was based on whether the youth was no longer an imminent threat to self or
others. It was determined an internal alert was warranted for each reviewed youth. The
Controlled Observation Report, Health Status Checklist, and Controlled Observation Safety
Check forms were maintained in an administrative record and individual case management
record for each youth. The FA or designated supervisory staff, approved each youth’s
Controlled Observation Report within fourteen days of the youth’s release from controlled
observation to determine if the placement was appropriate. In all five records reviewed, staff
decided whether an in-house alert was warranted when each youth was released from
controlled observation.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 66 (Revised August 2025)

source: DJJ

program_name_raw: Kissimmee Youth Academy - MHOS