summary: QI Residential - FY24-25

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Miami Youth Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider )
10855 Southwest 84th Street
Miami, Florida 33173
Review Date(s): December 3-6, 2024
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:
Sharon Wong, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Christine Calvert, Office of Accountability and Program Support, Regional Supervisor (Standard
3)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 1 and
Interviews)
Program Name: Miami Youth Academy
MQI Program Code: 1289
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10000
Location: Miami-Dade County / Circuit 11 Number of Beds: 28
Review Date(s): December 03-06, 2024 Lead Reviewer Code: 181
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 70 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 70 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 70 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 70 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 70 (Revised September 2022)
Standard 6: Education Servieces
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (Revised September 2022)
Program Overview
Miami Youth Academy is a twenty-eight-bed program for fourteen to eighteen-year-old males,
located in Miami, Florida. The program is operated by TrueCore Behavioral Solutions, LLC,
through a contract with the Department. The program provides Substance Abuse Treatment
Overlay Services (SAOS), which include substance abuse assessments, treatment, and relapse
prevention. In addition, the program fosters each youth by providing services to include Impact
of Crime (IOC), Cannabis Youth Treatment (CYT), and Living in Balance. The program provides
recreation, individual, group, and family therapy. Program administration is comprised of a
facility administrator (FA), an assistant facility administrator (AFA), a designated mental health
clinician authority (DMHCA), and a health services administrator (HSA). Two case management
staff and one director of case management/transition services manager provide case
management services. Mental health staff at the program include the director of clinical
services/DMHCA, one full-time licensed therapist, one part-time licensed therapist, two non-
licensed therapists, and one recreation therapist. Medical services are offered seven days a
week and are provided by one registered nurse (RN) and one licensed practical nurse (LPN).
One RN serves as the HSA. The program contracts with a licensed medical doctor (MD) who
serves as the designated health authority (DHA). The DHA is on-site once a week for four
hours. Florida Virtual School provides educational services on a year-round basis. The
program's layout includes one main building, consisting of a dormitory area, kitchen, two
classrooms, and a living and dining area. The program has forty-five security cameras providing
coverage, and all were operational during the annual compliance review. At the time of the
annual compliance review, the program had nine full-time and one part-time vacancy, which
included two staff mentors, two youth specialist Is, three youth specialist IIs, one RN position
which became vacant October 31, 2024, one part-time dietician, and one full-time dietician
manager.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
Strengths and Innovative Approaches
• The program partners with the University of Miami. Youth are transported to participate
in the sociology course utilizing a mix of theory, research, and interaction with the
university. Youth address many of the difficult questions concerning juvenile
delinquency, while taking a critical view of the policies developed to control such
behavior.
• The program conducts quarterly family fun days, providing creative concepts for
planning and designing themed events, as well as photos and useful resources to
promote healthy families.
• The program has increased youth participation in community church events and
baptisms with community partners at a local church in Kendall.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a written policy and procedures requiring all staff, volunteers, and
contracted staff to be background screened prior to contact with youth and youth records. All
newly hired staff and volunteers receive an initial background screening. The program has a
policy and procedures for volunteers, mentors, and interns who work with youth less than ten
hours a month requiring sight and sound supervision from a background screened staff. The
Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the
Department’s Background Screening Unit (BSU) on December 4, 2023, meeting the annual
requirement. The program hired fifteen new staff, three contracted staff, and four volunteers
since the last annual compliance review. A review of each record verified the program
completed a background screening prior to contact with youth and confidential youth records.
Each staff, contracted staff, and volunteers' criminal history report was reviewed. There were no
staff applicable for an exemption prior to working with youth. The documentation confirmed the
program reviewed the Staff Verification System (SVS) and criminal history report results for
each new staff before hire. There were no staff applicable for a break in service. Reviewed
records documented all fifteen staff, three contracted staff, and four volunteers had a
background screening completed prior to contact with the youth and confidential youth records.
None of the staff required an exemption prior to working with youth. A pre-employment
assessment tool was administered to the hired direct care staff, and each received a passing
score. A passing score for the pre-employment assessment was documented in each staff’s
record. The program added each staff, volunteer, and contract worker to their Clearinghouse
Roster, and each staff completed a background screening when a provider hired a Department
staff or when a provider was hired by another contracted provider company.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program maintains a written policy and procedures to ensure all staff and volunteers
receive a background rescreening every five years from their initial date of employment. The
program had one contracted staff applicable for a five-year rescreening since the last annual
compliance review. The five-year rescreening was submitted to the Department’s Background
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 70 (Revised September 2022)
Screening Unit (BSU)/Clearinghouse at least ten business days prior to the five-year
anniversary date.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures requiring promotion of an environment
of physical, psychological, and emotional safety, without threat by any form of abuse or
harassment. There were two incidents reported to the Department’s Central Communications
Center (CCC) since the last annual compliance review. There was one incident related to
physical abuse and one complaint against staff. Both were found unsubstantiated. The staff
involved was no longer employed at the program during the annual compliance review
week. There were no applicable cases for any potential human trafficking victims, children of
sexual exploitation, or labor trafficking reported. A formal interview was conducted with the
facility administrator (FA) who reported everyone has access to report abuse and contact the
Florida Abuse Hotline or the CCC for youth eighteen years of age and older. When reporting
general incidents, the facility administrator (FA), assistant facility administrator (AFA), unit
manager, or lead nurse is approved to call in CCC reportable incidents. Each staff is provided
with pre-service and annual training on abuse and CCC reporting. During the all-staff meetings,
all major incidents are reviewed. In the morning management meetings, all incidents are
reviewed by the management team, including the FA, AFA, clinical director (CD), health
services administrator (HSA), food service manager, transition services manager (TSM), and
physical plant manager. The FA further reported all staff are trained in trauma-responsive
practices during pre-service training, which is reinforced monthly during all staff meetings by the
clinical department. Safety plans identifying each youth’s personalized triggers, warning signs,
and preferred intervention strategies are reviewed by all staff. Each staff is trained to recognize
and respond to youth in the context of trauma-responsive care. The program completed a
Trauma Responsive and Caring Environment (TRACE) self-assessment on March 14, 2024.
Five reviewed staff records showed a code of conduct was reviewed and signed by each staff.
Five youth were interviewed, and each reported feeling safe in the program. Four reported
never being stopped from reporting abuse to the Florida Abuse Hotline or the CCC if eighteen
years or older, and one youth reported a complaint was filed last month and they are waiting for
follow-up; however, all reported knowing the location where the telephone number for the
Florida Abuse Hotline is posted. Two youth reported the staff are respectful, and three stated
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 70 (Revised September 2022)
staff are respectful most of the time. Three youth reported occasionally the staff used profanity
when the youth are disrespectful, one reported never, and one reported often for not following
instructions. This information was brought to the AFA’s attention. Each youth reported never
exchanging emails, telephone numbers, or social media contact information with staff. Five staff
were interviewed, and each reported having never observed another staff telling a youth they
could not call the Florida Abuse Hotline. Four reported never observing another staff using
profanity when speaking to youth, using threats, intimidation, or humiliation when interacting
with youth, and one reported occasionally.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a written policy and procedures to ensure the program takes immediate
action to address incidents of physical, psychological, and emotional abuse. The program had
two incident reports alleging physical abuse toward youth and a complaint against a staff since
the last annual compliance review. A review of the incident reports indicated the facility
administrator (FA) immediately addressed the concerns by removing the staff from youth
contact until further notice. One staff involved was no longer employed at the program. An
interview with the FA indicated the program did not have any substantiated incidents.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures requiring the program to notify the
Department 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 twelve reportable incidents during the annual compliance review period. A review
of five incidents found all five of the incidents were reported to the Department’s Central
Communications Center (CCC) within two hours of the incident or within two hours of any staff,
contracted staff, or volunteer becoming aware of the incident. Each of the reviewed CCC
incidents documented the type of incident and were documented in the program’s logbook, as
required. There were no additional internal incidents or grievances which should have been
reported to the CCC noted during the annual compliance review week. The program did not
have an increase in the number of reportable incidents to the CCC since the last annual
compliance review.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 70 (Revised September 2022)
The program maintains a written policy and procedures pertaining to Right Interactions (RI). The
program uses physical intervention techniques in accordance with Florida Administrative Code.
Any time staff use a physical intervention technique, such as countermoves, control techniques,
takedowns, or application of mechanical restraints, except for regular transports, a RI Report is
completed and filed in accordance with Florida Administrative Code. The program documented
fifty-three RI incidents during the annual compliance review period. A review of the program RI
binder documented monthly summaries were maintained of all RI incidents submitted to the
Department’s regional office by the fifteenth of each month, during the annual compliance
review period. The program’s RI Plan was updated and approved by the Department’s Office of
Talent, Leadership, and Culture on May 3, 2024. The program’s RI rate during the previous
quarter was 4.09, which was above the statewide Residential RI rate of 1.81. An informal
interview with the facility administrator (FA) reported there has been an increase in aggressive
youth in the program, which is why there was an increase in RI use. Additionally, the FA
indicated all RI Reports and incidents are reviewed during the morning management meeting.
The RI incident reports and videos are reviewed by the RI instructor, assistant facility
administrator (AFA), and/ or FA. A review of five RI Reports indicated all were completed by the
end of the staff’s workday and included statements from all staff involved. No mechanical
restraints were used, and none required the Department’s Central Communications or Florida
Abuse Hotline to be contacted. Each reviewed report had a supervisory review. Two youth were
applicable for an RI medical review, which was completed, and there was no further action
required. The reviewed documentation confirmed the administration conducted a RI interview
within thirty minutes and each report was reviewed by the facility administrator (FA) within
seventy-two hours. Five staff were interviewed, and each reported not using RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program maintains a written policy and procedures to ensure all newly hired staff receive
the training necessary to fulfill assigned duties and requirements to meet the needs of the
program and youth in care. The program's pre-service training plan was approved by the
Department's Office of Talent, Leadership, and Culture on March 18, 2024. The plan outlines
the program's required training hours, training objectives, course names, and descriptions for
any instructor-led training. Pre-service training is provided through a combination of instructor-
led and web-based courses. All full-time staff, part-time staff, and volunteers shall receive a
minimum of 120 hours of pre-service training during their first 180 days of employment. Five
staff training records were reviewed for pre-service certification, including successful completion
of first-aid, abuse recognition reporting and prevention, cardiopulmonary resuscitation (CPR),
automated external defibrillator (AED), emergency procedures, the program’s operating
procedures, Prison Rape Elimination Act (PREA), professionalism, interpersonal communication
and ethics, including standards of conduct, Right Interactions (RI), and suicide awareness and
prevention training. All five reviewed training records documented each staff completed the
certification process within 180 days of hire. Reviewed documentation confirmed each staff
completed additional pre-service trainings including active shooter preparedness, adolescent
development and behavior, balanced and restorative justice, the Department’s Central
Communications Center (CCC) reporting, civil rights, communication, Health Insurance
Portability and Accountability Act (HIPAA), Department of Juvenile Justice legacy/history, Equal
Employment Opportunity (EEO), gang awareness, human trafficking intervention, infection
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 70 (Revised September 2022)
control, information security awareness, effective and respectful treatment of youth, mental
health and substance abuse, motivational interviewing (MI), quality report writing, safety,
security, and supervision of youth, sexual harassment, and trauma-responsive practices. There
are specific trainings for key positions at the program, which were completed as required. All
five staff completed training for the grievance process, infection control, the Exposure Control
Plan, the behavior management system (BMS), and the intended and safe use of tools. All
applicable staff received training in Mental Health Overlay Services, Substance Abuse
Treatment Overlay Services, Comprehensive Services for Major Disorders and Developmental
Disabilities, and Intensive Mental Health Treatment Services. Two hired supervisory staff
completed training in the areas of coaching, leadership, and personal accountability.
Documentation confirmed all training was delivered by qualified trainers and documented in the
Department's Learning Management System (SkillPro).
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a written policy and procedures to ensure all staff receive the training
necessary to fulfill assigned duties and requirements to meet the needs of the program and
youth in care. Direct care staff shall complete at least twenty-four hours of in-service training
each calendar year. A review of five staff training records indicated each exceeded the twenty-
four-hour requirement. Each staff completed active shooter, cardiopulmonary resuscitation
(CPR), first-aid, automated external defibrillator (AED), human trafficking intervention,
information security awareness, mental health, substance abuse, Prison Rape Elimination Act
(PREA), Right Interactions (RI), professionalism, interpersonal communication, and ethics,
sexual harassment, suicide awareness and prevention, trauma-responsive practices,
emergency response and emergency drills, infection control, blood-borne pathogens, the
Exposure Control Plan, Mental Health Overlay Services, and Substance Abuse Treatment
Overlay Services. Each staff carried an active CPR and RI certification. One staff had additional
training in the Cannabis Youth Treatment curriculum and TrueCore licensed practical nurse
(LPN) training. In addition to the required twenty-four hours of in-service training, supervisory
staff shall complete, at a minimum, an additional eight hours of training in the areas of coaching,
leadership, or personal accountability each calendar year. Three staff were applicable for
supervisory training and trainings were completed as required. All reviewed trainings were
entered into the Department’s Learning Management System (SkillPro). A review of instructor
credentials verified all were qualified to deliver the provided trainings. The program has a
training calendar, which is updated as necessary. The program maintains a written in-service
training plan, which was submitted and approved prior to implementation. The highest-ranking
official at the program, the assistant secretary for residential services, and the director of Talent,
Leadership, and Culture approved the training plan.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
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The program maintains a written policy and procedures regarding the grievance process. The
program shall ensure staff are trained and the process is explained to youth during orientation.
The program’s grievance process includes informal, formal, and appeal phases. The
interviewed facility administrator (FA) reported the informal phase is when a youth should
informally discuss with the staff the grievance. Stage two is the formal phase in which the
assistant facility administrator (AFA) responds. The final phase is the appeal stage, during
which the FA conducts a meeting with the youth. A review of five grievances revealed four
youth’s grievances were resolved at the formal phase and one at the appeal phase. Each
grievance was maintained by the program for a minimum of twelve months. A review of twelve
months of documentation confirmed the program’s practice correlated with their process. Five
youth were formally interviewed and reported if assistance is needed in completing a grievance
form, the staff would help. Five staff were interviewed and reported grievance forms are placed
in the box and reviewed by a supervisor, and the grievance process has three phases.
Grievance forms were available to youth as observed during the program tour.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures to address life skills training for youth.
The program provides life skills training through Skillstreaming the Adolescent. The life skills
groups specifically address communication, interpersonal relationships and interactions, non-
violent conflict resolution, anger management, and critical thinking. A review of the program’s
activity schedule and sign-in sheets confirmed the therapist and case manager provide life skills
training groups to the youth once a week. All staff conducting groups received formal training
and on-the-job training by a certified trainer to deliver the curricula. In addition to the groups, the
program incorporated additional life skills for the youth through heating, ventilation, and air
conditioning (HVAC) courses and human immunodeficiency virus (HIV) awareness training.
Additionally, every month, youth discuss different types of diseases. Five youth were
interviewed and reported certifications and training were completed. An interview with the facility
administrator (FA) stated, within this reporting period, youth were provided with groups using the
Young Men's Work and Talks with Young Men curricula, although these have been
discontinued. Additionally, youth participate in recreation activities. An interview with the
designated mental health clinician authority (DMHCA) stated the youth are allowed to practice
skills through their daily use of the positive performance system and how they navigate
advancement through the level system. Youth participate in daily meetings where they are
provided an opportunity to air their grievances and issues appropriately, demonstrate their
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leadership skills, and present their levels where they are encouraged to recognize and address
their strengths and weaknesses, or areas in need of improvement.
1.12 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated a Standardized Program Evaluation Protocol (SPEP)
primary service at Miami Youth Academy. For details specific to IOC service delivery, please
refer to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures addressing alerts, including the
program’s internal alert system being updated on a continual basis and all staff having access to
alerts. The program maintains an ongoing alert system to ensure information pertaining to youth
special conditions, suicide risks, safety, and/or security risks are effectively communicated to
staff in a manner which protects the youth’s privacy. Five youth identified with alerts were
reviewed during the annual compliance review week. Documentation confirmed all youth were
placed on the alert system with the name and title of staff entering or removing an alert.
Documentation of alerts and dates were entered in the program’s logbook. All alerts were
entered into the internal alert system and the Department’s Juvenile Justice Information System
(JJIS) on the same date. An interview with the facility administrator (FA) stated the important
medical issues concerning the youth are discussed during daily morning and medication
management meetings. Furthermore, the alert board is located in the conference room, and the
information is written in the logbook and discussed during shift briefing. An interview with the
nurse stated the registered nurse (RN) and licensed practical nurse (LPN) update the alert
system and verify the alerts are correct. Five interviewed staff reported being notified of alerts
through daily debriefings, the alert board in the break room, and by the nursing staff.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
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The program maintains a written policy and procedures to ensure youth records are labeled
“Confidential” for each youth. The program records consist of two separate records, to include
an Individual Healthcare Record (IHCR) and an individual case management record. A review of
five youth healthcare, mental health and substance abuse, and case management records
showed each was marked “Confidential.” Each record documented the youth’s name,
Department identification number (DJJID), the youth’s date of birth, county of youth’s residence,
date of admission, and committing offense. Observations during the annual compliance review
week confirmed all IHCRs, mental health and substance abuse records, and case management
records were secured in a locked room, which was not accessible to youth.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board (CAB), which meets at least every ninety to 120
days. Reviewed documentation verified meeting dates of February 23, May 31, August 30, and
November 26, 2024. The facility administrator (FA) solicits active involvement from a law
enforcement representative, judiciary community, business community, school board, faith
community, a victim services agency, and the LGBTQIA+ community. There was no
documentation the FA recruited a parent/guardian whose child was previously involved in the
juvenile justice system. During the annual compliance review week, a review of the program’s
advisory board binder and sign-in sheets confirmed meetings were being conducted at least
every 120 days. A review of the sign-in sheets from quarterly advisory board meetings
confirmed the program’s practice. During the annual compliance review week, a board member
was interviewed and confirmed program involvement. An interview with the FA confirmed the
CAB meets quarterly and includes church members, local mentors, education, victim advocates,
and others.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a system for evaluating staff annually based on established
performance standards. The program’s policy and procedures were reviewed to determine the
program’s system for evaluating staff performance standards, which are conducted annually.
Five staff records indicated job/position descriptions were reviewed to ensure each staff’s
performance standards were identified. A sample of performance evaluations was reviewed to
ensure evaluations were completed as outlined in policy at least annually with no discrepancies.
The performance standards matched the job description for each staff. A review of five staff
positions whose job functions included implementing the program’s behavior management
system (BMS) had the BMS listed on their job descriptions. The program’s contract was
reviewed to ensure all specific contractually required positions were maintained and performed
as outlined in the contract. The assistant facility administrator (AFA) was interviewed and
revealed the program has monthly job fairs, open-door interviews, and a corporate recruiting
team. The program has a morale committee, which includes employee of the month lunches
during staff meetings, gift cards, and gas cards. The staff evaluations are conducted ninety-days
after hire and annually, thereafter. Five staff were interviewed in reference to formal
performance-based evaluations. Two staff reported receiving performance-based evaluations
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annually, and three received performance-based evaluations monthly. One of five staff reported
receiving weekly performance-based standards as of late to ensure the shift ran smoothly.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program implements special contract conditions as outlined in the program’s contract. The
program’s contract had a Memorandum of Negotiation (MON) during the procurement process.
The special contract conditions include the program having at least one pet, which will teach
responsibility and encourage the adoption of healthier behaviors. The program has a glass
aquarium tank with fish. Feeding the fish and cleaning the aquarium tank are completed by the
youth in conjunction with the behavior management system. The transition services manager
(TSM) shall organize a transition portfolio appropriate to the youth's needs. A review of five
youth transition exit portfolios and the staff roster confirmed the TSM organizes a transition
portfolio. The provider shall provide tuition reimbursement of up to three thousand dollars for the
youth specialists or staff mentors interested in pursuing a bachelor's or master’s degree.
Documentation was provided to confirm the reimbursement process. The provider shall contract
with a psychologist for up to four hours each week, and the provider shall contract a certified
behavior analyst for up to four hours a week. Reviewed documentation verified the agreements
were in place. The provider shall utilize the Ergometrics Pre-Hire Assessment to screen
applicants before they are hired. Documentation was provided to confirm the program uses the
assessment to screen applicants before they are hired. The program has one health service
administrator (HSA), two registered nurses (RNs), and one licensed practical nurse (LPN). One
RN is designated as a value-added service, and the program’s roster confirmed all positions
were filled. The program’s MON requirements were reviewed during the annual compliance
review week. It was confirmed all staff were trained in first-aid and cardiopulmonary
resuscitation (CPR) through pre-service and in-service trainings. An interview with the facility
administrator (FA) reported the value-added items were conducted, and all staff were trained in
first-aid/CPR. Each youth is provided a polo shirt and khaki pants. Additional provided services
include several selections of hairstyles, bus tickets, transportation for families, and hotel rates
for families. Post-secondary career and technical training, financial assistance, parent/guardian
support groups, a transition portfolio, and the pre-hire assessment were all implemented.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program utilizes data trend analysis to review and analyze data in decision-making
practices. The program uses a number of tools for data collection and analysis. Data is
accumulated through program dashboards, electronic records system, survey completion, and
the Department's Juvenile Justice Information System (JJIS). The information is shared with
staff and administration monthly. Data flows from the program level to the senior leadership
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level and back on an ongoing basis. The totals are displayed in interactive dashboards specific
to each program and provided back to corporate and program management to track trends and
inform risk management. The dashboards are updated every Monday with the previous week's
data. Additionally, regional compliance managers are responsible for ensuring data integrity by
conducting on-site checks to ensure the uploaded data matches program records and
documentation. Corrections can be made anytime by the director of internet technology. The
reviewed documentation supported this practice. The program’s practice of sharing information
with providers and stakeholders quarterly is through quarterly advisory board meetings,
residential meetings, and reports sent monthly to contract managers. Data flows from the
program level to the senior leadership level and back continuously. The movement of data
vacillates freely through multiple management levels. Data is evaluated for risk and protective
trends and forecasting trends which can impact compliance or programming. Determinations
are made and reviewed with staff during daily management meetings and monthly all-staff
meetings. Additionally, trends are reviewed for possible policy changes or, if necessary ancillary
training. Revised policies are discussed with facility administrators during their monthly one to
one meeting with senior leadership and then with all staff during monthly all staff meetings. A
review of dashboard surveys and additional documentation confirmed the program’s practice.
The program implements collected data to improve its processes through reports, which
immediately impact training and reinforce practices.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a written policy and procedures ensuring initial contacts to
parents/guardians and court notification. Five reviewed youth case management records
confirmed the program notified the parent/guardian by telephone within twenty-four hours of
admission. Each reviewed record confirmed the program notified the parent/guardian in writing
within forty-eight hours of the youth’s admission. Each record confirmed the court, juvenile
probation officer (JPO), and applicable post residential counselor were notified within five
working days of the youth’s 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 maintains a written policy and procedures regarding youth orientation. The
programs orientation included services available, daily schedule, expectations, and
responsibilities of the youth. The written behavioral management system was conspicuously
posted and provided in a handbook to allow easy access for youth. The orientation included
rules governing conduct and positive and negative consequences for behavior, availability of
and access to medical and mental health and substance abuse services, and access to the
Florida Abuse Hotline or if the youth is eighteen years of age or older, the Department’s Central
Communications Center. The youth orientation services include the program’s zero-tolerance
policy regarding sexual misconduct, including how to report incidents or suspicions of sexual
misconduct, special accommodations which are available to ensure all written information about
sexual misconduct policies, including how to report sexual misconduct, right to be free from
sexual misconduct, right to be free from retaliation for reporting such misconduct, the agency’s
sexual misconduct response policies and procedures, items considered contraband, including
illegal prohibited items, possession of which may result in the youth being prosecuted,
performance planning process involving the development of goals for each youth to achieve,
dress code, and hygiene practices. Additional orientation services include procedures on
visitation, mail and use of the telephone, expectations for release from the program, including
the youth’s successful completion of Individualized Performance Plan goals, recommendations
to the court for release based on the youth’s performance in the program, the court’s decision to
release, community access, grievance procedures, emergency procedures, including
procedures for fire drills and building evacuation, program tour, and assignment to a living unit
and room, treatment team, and if applicable, a staff advisor or youth group. Information is
conveyed verbally to youth with limited reading skills or who are visually impaired, deaf, or
otherwise disabled. During the time of the annual compliance review week, the program had no
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youth admitted into the program; therefore, there were no youth observations conducted. Five
youth were interviewed and reported their orientation to the program included program rules,
procedures, and schedules. Each youth could explain the orientation process and reported their
orientation to the program was conducted within twenty-four hours of admission.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures regarding obtaining written consent of
youth who are eighteen years of age or older. Five reviewed youth case management records
confirmed there were no applicable youth who were eighteen years of age or older. Three
additional youth case management records were requested to meet the sample size. Each
reviewed youth case management record confirmed a written consent was obtained before
release of information related to the youth’s physical or mental health screenings, assessments,
or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program maintains a written policy and procedures regarding the classification process for
youth upon admission to the program and completion of reassessments as warranted. A review
of the program’s classification form confirmed the form included physical characteristics of the
youth, age and maturity level, identified special needs, history of violence, gang affiliation,
criminal behavior, sexual aggression or vulnerability to victimization, youth’s perception of
vulnerability, youth’s history of potential or verified human trafficking, suicide risk, medical risk,
escape risk, and security risk. Five reviewed youth case management records confirmed each
contained an admission classification form including all required elements outlined by the
Department’s policy. A review of the Department’s Juvenile Justice Information System (JJIS)
alerts and the programs internal alerts confirmed there were no issues affecting each youth’s
classification. Each youth was classified for the purposes of assignment to a living area,
sleeping room and youth group or staff advisor. Each reviewed record confirmed medical,
mental health, substance abuse, security risk factors, and/or special needs identified during or
subsequent to the classification process are immediately entered into the program’s internal
alert system and JJIS. Five reviewed youth case management records confirmed each had
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reclassifications completed prior considering an increase in the youth’s 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, and participation in off-campus
activities. A review of the program’s policy and procedures confirmed they clearly outline the
classification process and include a classification system which promotes safety and security,
as well as effective delivery of treatment services, based on determination of each youth’s
individual needs and risk factors, which addresses, at a minimum, items outlined in Florida
Administrative Code. An interview with the facility administrator (FA) reported factors such as
mental health status, cognitive performance, age, and prior victimization are considered when
assigning youth to a living unit/room. The FA reported youth with higher behavior problems are
typically placed in rooms together. The youth’s prior victimization is assessed using the
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening, and youth
identified as having prior victimization are placed strategically away from peers identified as
aggressive on the VSAB.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program maintains a written policy and procedures regarding gang identification including
notification to law enforcement. One of five reviewed youth case management records
confirmed the youth was applicable for notification to law enforcement of suspected gang
association. Two additional youth case management records were requested to meet the
sample size. Each applicable record documented local law enforcement was notified of
suspected gang activity. Each record confirmed, prior to the Monitoring and Quality
Improvement seven-day notice, local law enforcement was notified by either the program,
detention staff, or the youth’s juvenile probation officer (JPO) of the youth’s gang involvement.
Reviewed documentation confirmed each youth’s home county law enforcement was notified of
the youth’s gang affiliation. Reviewed documentation confirmed gang alerts were entered in the
internal alert system and in the Department’s Juvenile Justice Information System (JJIS) upon
identification. Each reviewed record confirmed gang status was shared with the educational
provider at the program and the youth’s assigned JPO. None of the three youth were applicable
for having a post-residential services 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 maintains a written policy and procedures regarding youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. The
program utilizes the GRADE: Fifty Plus Stories of Fractured Lives curriculum and Impact of
Crime (IOC) intervention groups as part of the gang prevention and intervention curricula. One
of five reviewed youth case management records confirmed the youth was applicable for youth
identified as a gang member or affiliated gang member. Two additional youth case management
records were requested to meet the sample size. Reviewed documentation confirmed each
youth participated in gang prevention and intervention strategies for the youth to complete prior
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to release from the program. The program maintains sign-in sheets to document youth
participation in gang prevention and intervention activities. An interview with the facility
administrator (FA) reported as part of the program’s gang intervention and prevention
strategies, the program designates a member of the case management team to be a gang
liaison. The liaison is trained to identify youth who may be affiliated with an antisocial peer
group/gang. The gang liaison maintains documentation identifying these youth and conducts
gang prevention groups monthly.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program maintains a written policy and procedures requiring the Residential Assessment
for Youth (RAY) to be completed for each youth within thirty days of admission. Five reviewed
youth case management records confirmed each record contained a RAY completed within
thirty days of admission. Each initial RAY was maintained in the Department’s Juvenile Justice
Information System (JJIS). Three of five reviewed records confirmed RAY Reassessments were
completed at least every ninety-days after the completion of the initial RAY. Two were not
applicable. All other updates or reassessments were completed, when deemed necessary, by
the intervention and treatment team to effectively manage the youth’s case. All reassessment
documentation was maintained in the youth’s official case 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 maintains a written policy and procedures regarding the completion of the Youth
Needs Assessment Summary (YNAS). Five reviewed youth case management records
confirmed the YNAS was completed within thirty days of admission. Each YNAS was
documented in the Department’s Juvenile Justice Information System (JJIS). Each reviewed
YNAS documented the youth’s top three criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
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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 maintains a written policy and procedures outlining performance plan
development, goals, and transmittal. Four of five reviewed youth case management records
confirmed each youth’s Individualized Performance Plan (IPP) was developed within thirty days
of the youth’s admission. One confirmed the IPP was thirty-five calendar days late. Each IPP
was developed after the initial Residential Assessment for Youth (RAY) and Youth Needs
Assessment (YNAS). Each reviewed IPP was developed and signed by the treatment team
leader, youth, administrative representatives, living unit representatives, treatment staff, and all
parties who had significant responsibility in goal completion. Each reviewed IPP confirmed
educational staff signatures. Documentation confirmed each completed IPP included the
individualized goals which were based upon the prioritized needs reflecting the risk and
protective factors identified during the initial assessment process. Each plan included the
youth’s top three criminogenic needs and delinquency interventions. Target court-ordered
sanctions which could be reasonably initiated/completed while in the program, transition
activities targeted for the last sixty days of the youth’s anticipated stay, youth’s responsibilities to
accomplish goals, program staff responsibilities to enable youth to complete goals, and target
dates for goal completions were all listed on the IPP. Reviewed documentation confirmed 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), and parent/guardian. Signature sheets
were sent to each parent/guardian; however, none were returned to the program at the time of
the annual compliance review. Five interviewed youth reported they participated in the
development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program maintains a written policy and procedures regarding revisions to a youth’s
performance plan. Five reviewed youth case management records confirmed each were
applicable for Individualized Performance Plan (IPP) revisions. Each IPP revision was
completed when the Residential Assessment for Youth (RAY) Reassessment results warranted,
and/or when the youth demonstrated progress toward completing a goal. Four of five records
were applicable for the youth demonstrating lack of progress toward completing a goal and
revisions were made. Two of the five reviewed IPPs had revisions made when needed to
facilitate transition activities during the last sixty days of a youth’s stay. Each youth was
applicable for education and mental health plans which were incorporated into the IPP.
Reviewed documentation confirmed each youth had no current behavior support plan or case
plan through the Department of Children and Families (DCF) and/or Agency for Persons with
Disabilities (APD).
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety-day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program maintains a written policy and procedures outlining the completion of Performance
Summaries and transmittals. Five reviewed youth case management records confirmed
Individualized Performance Plans (IPPs) were completed with documented completion dates.
Three of five reviewed records were applicable for Performance Summaries. Two youth were
still within their ninety calendar days. Nine summaries were applicable for the three youth
reviewed. Seven Performance Summaries were completed every ninety calendar days following
the signing of the performance plan, or at shorter intervals. One summary was twenty-six
calendar days late and one summary was fifty-nine calendar days late. None were applicable for
a Performance Summary preparation prior to the youth’s release, discharge, or transfer from the
program. Each Performance Summary included the youth’s status on each performance plan
goal, youth’s overall treatment progress, youth’s academic status, youth’s behavior, level of
motivation/readiness to change, interaction with peers, interaction with staff, overall behavior
adjustment to the program, and significant positive and negative events. Each youth’s
Performance Summary included documentation confirming the youth was allowed to read and
add comments prior to signing, was provided a copy of the summary, and the original summary
was filed in the youth’s case management record. Each reviewed summary was signed and
dated by the treatment team leader, staff preparing the summary, facility administrator (FA) or
designee, and youth. Each summary was sent within ten working days to the committing court,
youth’s assigned juvenile probation officer (JPO), and parent/guardian. Three closed case
management records confirmed release summaries included a copy of the youth’s original
summary, along with justification for release, sent with the Pre-Release Notification (PRN) to the
JPO at least forty-five days prior to the youth’s planned release date. A signed copy was
retained in each of the youth’s case management records. None of the three youth were
applicable for the court objecting to the youth’s release. Reviewed documentation confirmed,
once approved, the program provided written notification to the youth’s parent/guardian
regarding the planned release and completion of an exit Residential Assessment for Youth
(RAY). None of the youth were applicable for the Sexually Violent Predator Program (SVPP) or
notification to a victim.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures regarding parental/guardian
involvement in case management services. Documentation supported the program makes
efforts to include the parent/guardian in the assessment process, participation in the
development of the youth’s performance plan, progress reviews, and transition planning. The
program provided the advanced notice of formal treatment team meeting’s dates and times. If
parents/guardians are unable to attend, they are given the opportunity to participate by
telephone/video conferencing or provide verbal/written input to the meetings. During the week of
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the annual compliance review, observations of a treatment team meeting confirmed the
program’s practice to have the parent/guardian participate by telephone. An interview with the
facility administrator reported the program encourages parental/guardian involvement through
monthly invites to formal treatment team meetings, transition and exit conferences, and family
days. Five youth were interviewed and asked if their parent/guardian was involved in their case
management. Two youth reported through participation in treatment team meetings, one youth
reported through telephone calls, and two reported their parent/guardian was involved.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program maintains a written policy and procedures regarding treatment team meetings.
Five reviewed youth case management records confirmed formal treatment team meetings were
held every thirty days for each youth and informal meetings were held bi-weekly, as required.
Reviewed documentation for each of the formal treatment team review meetings included the
youth’s name, date of review, required attendees, any comments from treatment team members
or others, a brief synopsis of the youth’s progress in the program, performance plan revisions,
progress on performance plan goals, positive and negative behaviors, behaviors resulting in
physical interventions, and treatment progress. Reviewed documentation confirmed three
youth’s formal treatment review meetings included the Residential Assessment for Youth (RAY)
Reassessment results, and two records were not applicable. Reviewed documentation for each
of the informal treatment team meetings confirmed reviews were held bi-weekly each month. Bi-
weekly informal meetings were alternating with the formal treatment team meetings. Reviewed
documentation for each of the informal treatment team review meetings included the youth’s
name, date of review, required attendees, any comments from treatment team members or
others, brief synopsis of the youth’s progress in the program, performance plan revisions,
progress on performance plan goals, positive and negative behaviors, behaviors resulting in
physical interventions, and treatment progress. All informal treatment team meeting
documentation was contained in each youth’s record. The youth’s assigned juvenile probation
officer (JPO), parent/guardian, and other pertinent parties were invited and encouraged through
advance notification to participate and if participation could not be arranged, the opportunity to
provide input was provided. During the week of the annual compliance review, an observation of
a treatment team meeting confirmed all required staff were present. Five youth were
interviewed, and each youth reported staff talk about their performance plan goals, positive and
negative behavior, and treatment progress. Each youth reported they are given an opportunity
during treatment team meetings to demonstrate any skills learned in the program.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
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transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program maintains a written policy and procedures regarding the transition planning
conference and Community Re-Entry Team (CRT) meetings. Three closed youth case
management records confirmed a transition conference was held at least sixty days prior to the
youth’s targeted release date. Reviewed documentation confirmed the youth, treatment team
leader, facility administrator or designee, and other team members attended the transition
conference. Reviewed documentation confirmed the treatment team leader invited and
encouraged participation from the youth’s juvenile probation officer (JPO), parent/guardian,
education staff, and any other pertinent parties through advanced notification. Reviewed
documentation confirmed during the transition conference, the participants reviewed transition
activities on the youth’s performance plan, revised performance plans, if necessary, identified
additional transition activities as needed, identified target completion dates, identified persons
responsible for completion, and the treatment team leader obtained attendees’ dated signatures
representing their acknowledgment of the transition goals and accountability for completion.
Reviewed documentation confirmed a copy of the plan was sent with a request for return with
signature to anyone not in attendance who had a responsibility for completion of transition goals
and if the plan was transmitted electronically to the juvenile probation officer (JPO), the return
email acknowledgment receipt was printed and filed with the plan. Reviewed documentation
confirmed a CRT meeting was conducted prior to the youth’s release with youth’s and case
manager’s participation and evidence of an invitation to participate in the CRT meeting.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures regarding the requirements for each
youth’s exit portfolio. Three closed youth case management records confirmed the exit portfolio
was discussed and initiated for the youth during the transition conference. Three reviewed exit
portfolios contained the youth’s transition plans, calendar with all dates, times, and locations of
upcoming community appointments, educational and/or vocational certificates earned in the
program, all educational records/documents, school transcripts, and résumés. Each youth’s exit
portfolio was discussed during the exit conference and documentation indicated the exit portfolio
was completed and given to the youth upon release. One of three closed youth case
management records confirmed documentation of the youth’s Social Security card, birth
certificate, and sample employment application. None of the three reviewed exit portfolios
contained a state-issued identification card, however, documentation confirmed this information
was requested from the parent/guardian. Reviewed documentation reflected the program staff
forwarded the exit portfolio information to the youth’s assigned juvenile probation officer (JPO).
The program’s contract does not include any additional requirements for the exit portfolio.
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2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program maintains a written policy and procedures regarding completion of an exit
conference. Three reviewed closed youth case management records confirmed an exit
conference was conducted after the program notified the juvenile probation officer (JPO) of the
release. Each conference was conducted at least fourteen days prior to release. Reviewed
documentation indicated the date of the conference, signatures, and a summary of pending
transition goals were documented. Reviewed documentation confirmed the youth’s date of
admission and date of termination correlated with the Department’s Juvenile Justice Information
System (JJIS). The status of transition activities established at the transition conference and
plans were finalized for each youth’s release. Reviewed documentation confirmed provisions for
continuation of education and/or employment, documentation the youth, the youth’s
parent/guardian, case manager, and JPO were aware of the vocational plan for the youth,
documents, and post-release discharge plans were all included. Reviewed documentation
confirmed the intervention and treatment team leader, parent/guardian, education
representative, JPO, youth, and other pertinent parties all participated in the exit conference.
Reviewed documentation confirmed the exit conference was held separately from the transition
conference and the Community Re-Entry Team meeting.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a written policy and procedures regarding written provisions for youth
input. The program has a youth advisory council and utilizes town hall meetings to promote a
formal process for youth to have constructive input regarding issues, problems, or concerns in
the program. The program’s youth advisory council binder was reviewed, and documentation
confirmed during the annual compliance review period, the program solicited input from youth
through avenues such as the youth advisory council and program surveys. The program’s
advisory council meetings are held monthly. A review of the program’s sign-in sheets, agendas,
and meeting minutes confirmed the meetings were being held as required. Five youth were
interviewed and asked how they can provide input about what happens at the program. One
youth reported by speaking to staff, one reported by talking to the therapist, one reported they
keep concerns to themselves, and two reported they cannot provide input. The interview results
were shared with the program’s administration. An interview with the facility administrator (FA)
reported the program solicits input from youth on systemic issues impacting the program,
seeking recommendations to improve conditions and enhance the quality of life for staff and
youth. The solicitation is through the youth advisory council, Let’s Talk forms, grievance forms,
youth surveys, and youth meetings with the FA and assistant facility administrator (AFA).
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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 written policy and procedures and a Coordination of Mental Health
and Substance Abuse Services Plan which dictates the role of the clinical director. The director
of clinical services or designated mental health clinician authority (DMHCA) is responsible for
the coordination and oversight of all mental health and substance abuse services at the
program. A review of the job description indicated the DMHCA shall provide at least one hour of
clinical supervision each week for non-licensed therapists, ensure compliance with contract
requirements, ensure the completion of documentation, and to ensure the program’s mental
health and substance abuse services follow federal guidelines. The program’s DMHCA is a
licensed clinical social worker (LCSW). A review of the license indicated it was free and clear in
the State of Florida with an expiration date of March 31, 2025. The same DMHCA was at the
program since the last annual compliance review. The DMHCA is on-site forty hours each week
and works Monday through Friday. The interviewed DMHCA and the job description review
verified the DMHCA is on-call for consultation and emergencies twenty-four hours each day,
seven days a week. The back-up DMHCA is a LCSW with a free and clear license in the State
of Florida which expires March 31, 2025. The interviewed DMHCA reported they are responsible
for the implementation of mental health and substance abuse services, for ensuring
documentation is completed timely and accurately meeting the requirements within outlined
systems, and for reviewing the comprehensive mental health and substance abuse
assessments, individualized treatment plans, treatment plan reviews, suicide risk assessments,
Crisis Assessments, and Mental Status Examinations. Additionally, the DMHCA provides
coverage for individual and group therapy, and other assessments, as needed. The DMHCA co-
completes and co-signs all documentation requiring substance abuse service provisions, and
the DMHCA or licensed clinician facilitates all substance abuse group interventions.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written plan for mental health services and substance abuse services.
The program has one designated mental health clinician authority (DMHCA), one additional
licensed therapist, and two non-licensed therapists. The clinical staffing is in accordance with
contract. The DMHCA is responsible for ensuring the clinical staff are qualified to provide
services based on education, training, and experience. Copies of licenses were displayed at the
program as required. The program is licensed under Chapter 397 with the Department of
Children and Families to provide substance abuse services to adolescents. A review of licenses
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indicated the DMHCA and assistant clinical director are both licensed clinical social workers with
free and clear licenses in the State of Florida with expiration dates of March 31, 2025. The
program maintains a contract with a licensed psychologist who provides services as needed.
The psychologist’s license was free and clear in the State of Florida with an expiration date of
May 31, 2026.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written plan for mental health services and substance abuse services.
The program has one licensed designated mental health clinician authority (DMHCA), one
additional licensed therapist, and two non-licensed therapists. The DMHCA ensures the non-
licensed clinical staff working under their supervision are performing services they are qualified
to provide based on education, training, and experience. A review of the non-licensed
therapists’ documentation reflected both were approved by the Department’s Office of Health
Services to provide services at the program. One held a bachelor’s-level degree in forensic
psychology and the second held a master’s-level degree in psychology. A review of direct
supervision logs for the past twelve months reflected the face-to-face clinical supervision
occurred each week through group supervision. Each supervision log was completed on the
program’s form and included a case load review, clinical services, documentation,
miscellaneous, and evidence-based services. The program is licensed under Chapter 397
through the Department of Children and Families to provide substance abuse services to
adolescents. The non-licensed staffing was in accordance with contract and aligned with the
program’s organizational chart. There were no vacancies at the time of the annual compliance
review. The bachelor's-level degree staff received fifty-two hours of pre-service training to
include sixteen hours training in their duties and responsibilities. One of the non-licensed staff
received at least twenty hours of training in the Assessment of Suicide Risk (ASR) or Crisis
Assessments and the second wasn’t yet trained; however, was not administering those
assessments. Documentation verified the untrained staff was not administering the ASR and/or
Crisis Assessments.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written plan for mental health services and substance abuse services.
All youth who present with clinical concerns during the initial mental health or substance abuse
screening, or while in the program, shall be referred for a comprehensive mental health and/or
substance abuse evaluation. A review of five records indicated each was screened utilizing the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) on the day of
admission in the Department’s Juvenile Justice Information System. Documentation supported
the program used a records review form to document the review of available information to
include the commitment packet, reports, and/or records for existing documentation of mental
health or substance abuse problems or history of human trafficking. Each of the five reviewed
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MAYSI-2s documented completion by a licensed staff who were trained in the screening
facilitation. Each MAYSI-2 was completed in full and indicated the need for a comprehensive
assessment. The program utilizes a referral form documenting the findings of the screening and
a need for the completion of a comprehensive assessment. No youth were applicable for
indications of suicide risk or crisis. The reviewed policy and procedures verified the facility
administrator is responsible for developing a written policy and procedures for the
implementation of a standardized admission screening process. The reviewed procedures
verified the process included the completion of a MAYSI-2, staff training, and a referral and
emergency response process. The interviewed facility administrator (FA) reported each youth is
screened using the MAYSI-2 by a master’s-level therapist to identify potential needs for further
assessment. Screening domains include suicide, substance use, and other mental health
related areas. Additionally, an Assessment of Suicide Risk is completed for each youth. During
the first thirty days in the program, youth are administered standardized assessments including
the Substance Abuse Subtle Screening Inventories (SASSI-A2) to assess for likelihood of a
substance use disorder, the Trauma Symptom Checklist for Children™(TSCC/TSI) for
symptomology related to traumatic experiences, the Structured Assessment of Violence Risk in
Youth (SAVRY) for psychosocial risk factors, and the Reynolds Adolescent Depression Scale,
2nd Edition: Short Form (RADS-2 SF) to assess for depression.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written plan for mental health services and substance abuse services
to ensure all youth who present with clinical concerns during the initial mental health or
substance abused screening, or while in the program, shall be referred for a comprehensive
mental health and/or substance abuse evaluation. The designated mental health clinician
authority (DMHCA) reported the therapist completes a referral for a comprehensive mental
health and substance abuse evaluation and psychiatric evaluation upon admission. A review of
five records indicated the program completes a combined mental health and substance abuse
evaluation for youth within thirty days of admission. The program’s practice is to complete a new
evaluation and youth records confirmed this practice. Each combined evaluation was completed
within thirty days and after the youth signed a consent for substance abuse treatment services.
Two evaluations were completed by the DMHCA and three were completed by a non-licensed
staff and signed by the DMHCA the same day. The program is licensed under Chapter 397 with
the Department of Children and Families to provide substance abuse treatment services to
adolescents. Each of the five reviewed evaluations documented the youth’s identifying
information, relevant background information, behavioral observations, a Mental Status
Examination, interview procedures, findings, Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnoses, patterns of alcohol and other drug abuse, impact of
alcohol and drugs on major life areas, risk factors of continued alcohol and other drug abuse,
and recommendations.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written plan for the coordination of mental health and substance abuse
services for all youth. A review of five records showed each had an initial mental health and
substance abuse treatment plan completed on the day of admission. The plans were completed
on the program’s form and contained all elements of the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. One youth was applicable for taking
psychotropic medications and the medication details and monitoring frequency were included on
the plan. The other four youth were referred for an Initial Diagnostic Psychiatric Interview which
was pending for all four youth. Each of the five initial plans were signed by the mental health
staff completing the plan. Three were completed by licensed staff and two were completed by a
non-licensed staff and then signed by the licensed staff on the same day. Each initial plan was
signed by the youth, parent/guardian, treatment team leader, program management, a living unit
representative, and other applicable members as needed. A review of five records indicated
each youth had an individualized plan completed within thirty days of admission. Two were
applicable for ongoing psychiatric services and the plans indicated the medication details and
medication management requirements. The five reviewed youth were applicable for thirty-five
treatment plan reviews to be completed every thirty days and all were completed within the
required time frames. Each of the reviews included the signature of the youth, parent/guardian,
juvenile probation officer (JPO), treatment team leader, program management, a living unit
representative, education staff, and other applicable team members as needed. A review of
prescribed services for the reviewed youth records indicated each youth was prescribed
individual, group, family, psychiatric, and comprehensive evaluation goals. Prescribed services
were specific to individualized needs of each youth. A review of three randomly selected groups
indicated the sign-in sheets coincided with the video reviewed.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program maintains a written plan for mental health services and substance abuse services
to establish the method in which mental health services and substance abuse services will be
provided to all youth. The plan requires the completion of a mental health and substance abuse
discharge summary for all youth upon completion of the program. A review of five youth records
determined each youth was assigned to a treatment team upon arrival. Each team included the
youth, program administration, a member of the residential living unit, education staff, applicable
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vocational staff, medical staff, mental health and substance abuse staff, and the
parent/guardian. The program is licensed under Chapter 397 through the Department of
Children and Families to provide substance abuse treatment to adolescents. Each youth
required substance abuse services and were receiving services as determined by their
individualized substance abuse and mental health treatment plan. Each youth had a properly
executed Authority for Evaluation and Treatment, in addition to a completed Youth Consent for
Substance Abuse Treatment form. The program maintains progress notes on a weekly form
which contains all elements of the Department’s Counseling/Therapy Progress Notes form.
Each of the program’s forms documented the date, start and stop times, type of service, who
provided the service, number of participants, topic, clinical intervention, and youth response.
Each of the five reviewed records documented youth were receiving individual psychotherapy
and psychosocial skills training. Progress notes were compared to prescribed services for each
youth and all weekly and/or monthly services were received except for one youth missing one
family session. The designated mental health clinician authority (DMHCA) reported the youth’s
individualized plan had not yet been developed and the therapist should have documented any
explanations for missed sessions. A review of three closed records showed a discharge
summary was applicable for each youth. All three records contained a discharge summary
completed on the program’s form which contained all elements of the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary. Each summary documented
applicable future services needed. None of the youth were applicable for being released while
on suicide precautions. Each record documented the discharge summary was discussed with
the youth, parent/guardian and assigned juvenile probation officer (JPO). The program’s
practice is to provide the youth and parent/guardian a copy of the plan upon release and to mail
the plan to the JPO. Reviewed documentation supported the program’s practice.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a written plan for mental health services and substance abuse services
to establish the method in which mental health services and substance abuse services will be
provided to all youth. Additionally, the program has a Comprehensive Mental Health and
Substance Abuse Services Plan. The services plan, contract, and policies identify Substance
Abuse Treatment Overlay Services (SAOS) as the program’s specialty. The program is licensed
with the Department of Children and Families (DCF) to provide substance abuse treatment to
adolescents. The program’s designated mental health clinician authority (DMHCA) is tasked
with ensuring SAOS services are in accordance with policy, contract, and DCF guidelines. The
program’s required clinical group Cannabis Youth Treatment is a primary service. The program
provides Living in Balance, Seeking Safety, Anger Management, and a substance abuse
process group. All groups are led by trained clinical staff. Five interviewed youth reported they
were participating in individual, family, and group counseling at the program. Five interviewed
staff reported the mental health staff facilitate groups. An interview with the DMHCA confirmed
the program provides SAOS services in accordance with contract requirements. Additionally, the
interviewed facility administrator (FA) confirmed the program’s specialty services. The program
has a recreation therapist, a pro re nata (PRN) psychologist, and a contract with a certified
behavior analyst. Reviewed documentation verified the DMHCA was on-site at least forty hours
each week and clinical staff were on site seven days each week. The counselor to youth ratio
was between five to nine youth to each counselor. The program was providing individual therapy
at least every two weeks, applicable family therapy at least monthly, and the psychiatrist was
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on-site bi-weekly as required. A review of the group therapy schedule and sign-in sheets
confirmed groups were occurring as scheduled five days a week.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program shall maintain an independent contractor agreement with a licensed psychiatrist to
provide on-site services bi-weekly. The program has had two psychiatrists providing services
since the last annual compliance review. The existing psychiatrist stopped providing on-site
services at the center two weeks prior to the annual compliance review. The program received
special permissions from the Department’s Office of Health Services to conduct tele-psychiatry
appointments while acquiring a new psychiatrist. The new psychiatrist was pending confirmation
of liability insurance and was slated to start a couple of weeks after the annual compliance
review week. A review of the new and previous psychiatrist’s licensure information was
completed and reflected both licenses were clear in active in the State of Florida with January
31, 2025, and January 31, 2026, expiration dates. The program does not use a psychiatric
advanced practice registered nurse (APRN). A review of psychiatric treatment team and sign-in
and sign-out log documentation verified psychiatric services were occurring bi-weekly since the
last annual compliance review. There was no back-up psychiatrist needed for scheduled
vacations since the last annual compliance review. The interviewed psychiatrist reported their
role at the program included evaluations and monthly medication management. The interviewed
psychiatrist confirmed they were on-site twice each month. The designated mental health
clinician authority (DMHCA) reported they meet with the psychiatrist bi-weekly for a psychiatric
treatment team meeting. During this time, youth are discussed, and mental health/substance
abuse referrals are reviewed. The psychiatrist provides psychiatric/psychotropic interventions,
as needed, and completes a psychiatric evaluation on youth admitted to the program within
fourteen days. A review of five youth records showed no youth were admitted on psychotropic
medications; however, the program’s practice is to refer all newly admitted youth for an initial
psychiatric evaluation. Each youth completed an evaluation within fourteen days of admission.
Each Initial Diagnostic Psychiatric Interview included the youth’s history, a Mental Status
Examination, the youth’s diagnosis, and treatment recommendations. Two youth were
applicable for the prescription of medication as a result of the initial evaluation and both
evaluations documented applicable prescribed medications, target symptoms, initial goals, the
medication’s potential side effects, risks and benefits of taking the medication, and frequency of
medication monitoring. Each evaluation was completed on the Department’s Clinical
Psychotropic Progress Note (CPPN) form and was clearly identified as the Initial Diagnostic
Psychiatric Interview. One youth was applicable for an additional referral to the psychiatrist
where they were prescribed medication, making it a total of three youth prescribed medications
after admission. All three of the youth were applicable for fourteen medication reviews to occur
at least every thirty days. All reviews were completed within the required time frame. All
medications were documented on page three of the CPPN regardless of medication changes for
all reviews. Each page three documented the identifying data, diagnosis, target symptoms for
each medication, the medications desired effect on target symptoms, and the name dosage,
quantity, dosage range, frequency, and route of administration. Additionally, each CPPN
documented the side effects, youth’s adherence to the regime, applicable labs, whether there
was telephone contact with the youth’s parent/guardian, the signature of the practitioner, and
the date. None of the youth were applicable for the monitoring of Tardive Dyskinesia. When
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tele-psychiatry was provided, it was delivered to the same standard of care as if rendered in-
person, and each youth agreed to participate in tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a written Suicide Prevention Plan to establish the method in which
suicide prevention services shall be provided to all youth. All youth admitted to the program shall
be screened for suicide risk factors as a part of the initial intake and admission classification
meeting process. Multidisciplinary intervention and treatment team staff shall complete
screenings immediately upon intake and ensure the constant supervision of the newly admitted
youth throughout the intake screening process. Anytime following admission, a youth may be
referred for an Assessment of Suicide Risk based upon observation or self-reporting of suicide
thoughts or ideations. If the youth is an imminent threat of suicide, the youth must be
transported for emergency mental health services as set forth in Florida Administrative Code. All
youth shall be afforded protection, to the degree reasonably possible, against self-inflicted injury
or death. A review of the program’s Suicide Prevention Plan indicated it was last signed by the
designated mental health clinician authority (DMHCA) on August 25, 2023. The reviewed plan
included all required elements.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan to establish the method in which
suicide prevention services shall be provided to all youth. All youth admitted to the program
shall be screened for suicide risk factors as a part of the initial intake and admission
classification meeting process. Multidisciplinary intervention and treatment team staff shall
complete screenings immediately upon intake and ensure the constant supervision of the newly
admitted youth throughout the intake screening process. Anytime following admission, a youth
may be referred for an Assessment of Suicide Risk (ASR) based upon observations or self-
reporting of suicidal thoughts or ideations. If the youth is an imminent threat of suicide, the youth
must be transported for emergency mental health services as set forth in Florida Administrative
Code. All youth shall be afforded protection, to the degree reasonably possible, against self-
inflicted injury or death. A review of five youth records indicated each was determined to be at
risk during the admission screening process and was subsequently assessed using the
Department’s ASR. Each youth was transitioned to standard supervision following the ASR. It’s
the program’s practice to complete an ASR for all newly admitted youth. The program only had
two youth applicable for suicide risk interventions since the last annual compliance review. A
review of the records indicated both youth were referred for an ASR based on staff
observations, were assessed, and remained on constant supervision. Both ASRs were
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completed within twenty-four hours by a trained staff. One was completed by a non-licensed
staff and was reviewed by the designated mental health clinician authority (DMHCA) within
twenty-four hours. Each discontinuation was only completed after the documented conference
between the assessor, licensed clinician, and the facility administrator (FA). Two records were
applicable for a Follow-Up ASR completed on the Department’s form and indicated the youth
could be stepped to close supervision. Each youth was maintained on close supervision until a
Mental Status Examination and the documented conference between the assessor, licensed
clinical staff, and FA regarding the concurrence of placement on standard supervision occurred.
Both youth had alerts entered and appropriately closed in the Department’s Juvenile Justice
Information System (JJIS). A review of logbooks verified the placement, removal, and special
instructions regarding potentially suicidal youth were documented as required. All at-risk youth
are permitted to participate in program activities. A review of video regarding youth placed on
suicide precautions verified staff maintained constant sight and sound supervision.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written Suicide Prevention Plan to establish the method in which
suicide prevention services shall be provided to all youth. The program only had two youth
applicable for placement on suicide precautions since the last annual compliance review. A
review of Suicide Precautions Observation Logs verified logs were maintained for the duration
youth were on increased supervision. Observations of youth behavior were documented in real
time and did not exceed thirty minutes. The program’s practice is for all logs to be copied in
bright colors for easy identification. Both youth were applicable for displaying warning signs and
the warning signs were documented as required; however, one form did not clearly document
the notification to mental health staff. The designated mental health clinician authority (DMHCA)
reported it is the program’s practice to call them when youth display warning signs and they
attested they remembered this occurring. Each reviewed log was signed by mental health staff
and the shift supervisor. Each reviewed log documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan to establish the method in which
suicide prevention services shall be provided. All staff who work with youth shall receive six
hours of annual training on suicide prevention and implementation of suicide precautions.
Suicide prevention trainings completed on the Department’s Learning Management System
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(SkillPro) are included in the six hours of annual suicide prevention training. All staff who work
with youth must be trained in suicide precautions and emergency response procedures and
participate in mock suicide drills quarterly on each of the three shifts. The drills are designed to
practice responses to a suicide attempt or incident of serious self-injury and include methods for
contacting medical personnel and emergency medical services. Drills shall include the provision
of life saving measures such as cardiopulmonary resuscitation (CPR) and the use of a suicide
response kit. A review of five staff training records verified each received the required six hours
of training. The program has six suicide response kits which are co-located with first-aid kits in
maintenance, the kitchen, the conference room, the laundry room, school, and in medical. A
review of mock suicide drills indicated the program completed at least one drill on each shift
quarterly. Drills included the provision of life-saving measures for acutely suicidal youth or youth
in crisis. A review of a mock suicide drill video confirmed drills were simulated and staff acted
out scenarios. Reviewed drill documentation indicated the staff listed on the sign-in sheets were
clearly identified in the drill narrative explaining their role in the scenario. Drills were thorough,
timely, and detailed. The program does not use program youth in drill simulations and staff who
are not present for a drill receive a verbal review during the debriefings and the program’s
mandatory monthly all-staff meeting. The interviewed facility administrator (FA) reported every
staff member participates in mock suicide and self-harm drills quarterly. The clinical director
reviews the procedures for responding to these situations and provides re-training for any
deficiencies noted. Five interviewed staff were knowledgeable about the location of the suicide
response kits.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written Crisis Intervention Plan indicating crisis intervention services
shall be provided to respond to youth in crisis in the least restrictive method possible, and to
protect the personal safety of the youth and others while maintaining control and safety of the
program. All youth are afforded protection, to the degree reasonably possible, against self-
inflicted injury or death, and youth in crisis shall be afforded assistance. A review of the
program’s Crisis Intervention Plan indicated it contained all required elements.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
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The program maintains a written Crisis Intervention Plan to establish the method of crisis
intervention services to be provided to all youth. A review of five youth records indicated none
were applicable for a Crisis Assessment. The designated mental health clinician authority
(DMHCA) reported there were only three Crisis Assessments completed since the last annual
compliance review. A review of the three assessments was completed and indicated each youth
was assessed within two hours on the same day they were determined to be in crisis. Each
assessment documented the reason for the assessment, a Mental Status Examination,
determination of danger, initial clinical impressions, supervision recommendations, treatment
recommendations, recommendations for follow-up, and notification to the parent/guardian. Each
assessment was completed by the DMHCA, and all youth were deemed appropriate for
standard supervision and did not require an alert in the Department’s Juvenile Justice
Information System. No youth were applicable for a follow-up assessment.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written Emergency Care Plan to establish the method in which
emergency mental health and substance abuse services will be provided to all youth. The
reviewed plan included services for immediate staff response, notification, communication,
supervision, transport for emergency services, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures for identifying stimuli which have both
positive and negative effects on the youth. The program recognizes when youth do not feel safe
and/or are triggered, they need to learn how to effectively communicate in a proactive manner to
ensure the physical and emotional safety of themselves and their community. The safety plans
are utilized to assist youth in regulating their emotions and to develop healthy coping strategies
which will assist them in day-to-day programming and their community upon discharge from the
program. The safety plans shall be jointly prepared by the youth, parent/guardian or family
member, program clinical staff, and applicable behavioral specialist. A review of five youth
records indicated each had a safety plan created within fourteen days of admission and
reviewed every thirty days. Each plan documented warning signs, youth baseline behavior,
crisis recognition, jointly developed coping strategies, preferred intervention strategies, and a
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debriefing process. Each plan was jointly prepared with the youth, parent/guardian, and mental
health staff. Each plan incorporated information from previous assessments and interviews. The
program’s practice is to store the safety plans in the administration area which is accessible to
all staff. Additionally, the plans are discussed and revised during each staff meeting and each
treatment team meeting to ensure the youth and supervisory staff are aware of the plan details.
Each plan clearly documented regular revisions and updates. The five reviewed records
contained forty-four safety plan reviews. Five interviewed youth reported they contributed to the
development of their safety plans. Five interviewed staff reported they have reviewed youth
safety plans. The facility administrator (FA) stated safety plans are updated at a minimum every
thirty days and correspond with treatment plan reviews and formal treatment team meetings.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program maintains a written policy and procedures which require a contracted health
authority to provide on-site medical services to youth in the program. The program maintains a
contract with a State of Florida licensed and board-certified medical doctor (MD) who serves as
the designated health authority (DHA). The DHA has a clear and active license in the State of
Florida, expiring on January 31, 2024, with specialty training in pediatrics. A review of the
Florida Department of Health records supported the DHA had no current disciplinary cases,
emergency actions, and/or public complaints on record. The program does not utilize an
advanced practice registered nurse (APRN) or physician’s assistant (PA). The DHA is available
twenty-four hours a day, seven days a week for acute medical concerns, emergency care, and
coordination of off-site care. The DHA is contracted to be on-site for a minimum of two hours
each week with no more than nine days passing between on-site visits. A review of DHA sign-in
sheets for the previous twelve months found the DHA was on-site for a minimum of two hours
each week without exception. The program has a back-up DHA who is a licensed physician with
a clear and active license in the State of Florida expiring on January 31, 2025; however, the
back-up DHA was not utilized during the annual compliance review period. The program did not
utilize either telemedicine or telehealth services since the last annual compliance review. The
DHA reported their role in the program is to be on-site once a week, see newly admitted youth
within seven days of admission, see chronic condition youth every two months, see any youth
who went off-site for medical care, and see any youth the nurses feel should be seen.
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’s contract with the Department outlines the requirements for a health service
administrator (HSA) and one additional full-time registered nurse (RN). At the time of the annual
compliance review, the program had one full-time registered nurse serving as the program’s
HSA who works weekdays from 7:00 a.m. to 3:30 p.m. and one full-time licensed practical nurse
(LPN) whose schedule varies. The program has another full-time nursing position which had
been vacant since October 31, 2024, which was previously scheduled to work from 7:00 a.m. to
7:30 p.m. Mondays through Wednesdays and Saturdays. A review of licenses for the HSA and
the LPN at the program showed each had a clear and active license in the State of Florida,
which expire respectively on April 30, 2025 and July 31, 2025. Reviewed documentation found
both nurses held current cardiopulmonary resuscitation (CPR) certifications.
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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 facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) is solely responsible for
an annual review of all health-related policies, procedures, and protocols. The reviewed policy
and procedures validated they were reviewed and signed by the DHA on August 29, 2023. The
nursing staff signed a cover page acknowledging their last review of all FOPs and treatment
protocols on March 12, 2024. The psychiatrist reviewed applicable FOPs on August 26, 2023.
There were no noted applicable policy changes during the annual compliance review period.
The program’s practice is to provide newly hired healthcare staff a comprehensive clinical
orientation to healthcare services, which is provided by the health service administrator (HSA).
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program maintains a written policy and procedures to ensure the completion of the
Authorization for Evaluation and Treatment (AET) for all youth admitted into the program. The
program utilizes a separate form for youth eighteen years of age or older providing consent for
release of specific information as noted on the Release of Information Authorization for Youth
Eighteen Years of Age and Older form and to whom the information can be released and
shared. A review of five youth Individual Healthcare Records (IHCRs) found four contained a
valid and legible copy of an AET and the word, “Copy” was clearly stamped on each AET. One
youth’s IHCR was applicable for the youth being eighteen years of age or older. Documentation
supported the youth signed a Release of Information Authorization for Youth Eighteen Years of
Age or Older form. The nurse reported if there is not a current AET on file, the juvenile probation
officer (JPO) will be contacted to obtain a current AET.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program maintains a written policy and procedures to address the requirement of
notification to the parent/guardian of significant changes in the youth’s condition and obtain
consent when new medications and treatments are prescribed. Five youth Individual Healthcare
Records (IHCRs) were reviewed for parental/guardian notifications. Three youth were applicable
for consent from the youth’s parent/guardian for over-the-counter medications beyond those
covered by the Authority for Evaluation and Treatment (AET) and all five were applicable for a
new medication having been ordered. Each youth had written notifications sent utilizing the
Department’s Parental Notification of Health-Related Care form in each instance. None of the
five youth were admitted to the program while taking psychotropic medications; however, four of
the five youth were prescribed a new psychotropic medication while in the program and three of
the four applicable records documented the staff witnessed the telephone conversation with the
parent/guardian about the psychotropic medications. Verbal consent for psychotropic
medication from the parent/guardian was documented for the fourth youth; however, there was
no documentation of a witness being present during the conversation. Each of the five reviewed
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IHCRs documented the program received and verified the youth’s vaccination records on the
date of admission. None of the youth were applicable for requiring new vaccinations or
requesting religious exemption. An interview with the nurse confirmed immunization records are
obtained from the Florida Shots website within the required time frame by the nurse. The nurse
confirmed the parents/guardians are informed in writing about significant healthcare decisions,
such as new medications, treatments, or changes in care, with documented attempts to contact
them by telephone or in person.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program maintains a written policy and procedures requiring a healthcare screening for
each youth upon admission into the program. The program’s practice is to complete a
rescreening and complete the Department’s Facility Entry Physical Health Screening (FEPHS)
form anytime a youth is admitted into the program or each time the physical custody of the
youth changes with subsequent return or readmission to the program. Five youth Individual
Healthcare Records (IHCRs) were reviewed, and each contained a FEPHS form completed by a
registered nurse (RN) on the day of the youth’s admission. None of the FEPHS forms were
completed by a direct care staff. None of the youth were applicable for a change in custody. The
nurse confirmed the admission screening is completed by the nurse, and if there is a change in
custody a new FEPHS form is completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a written policy and procedures to ensure each youth admitted into the
program receives a healthcare orientation. Five youth Individual Healthcare Records (IHCRs)
were reviewed, and each contained documentation the youth was oriented to healthcare
services at the program upon admission. Each youth’s orientation included all required topics
which were documented on the Health Education form and each youth signed and dated the
Healthcare Services Orientation form to acknowledge completion of the required orientation
topics. The program holds monthly health education groups which cover all topics required by
Florida Administrative Code.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a written policy and procedures requiring the designated health authority
(DHA) to be notified by telephone, text message, or verbally, if on-site, of all youth admitted into
the program identified with chronic health conditions or youth in need of emergency care. Five
youth Individual Healthcare Records (IHCRs) were reviewed, and none were applicable for a
documented chronic condition upon admission; however, reviewed documentation found the
DHA was notified upon admission for each of the five youth regardless of the youth’s status.
Notification of the required parties was documented in each youth’s IHCR in the chronological
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progress notes. The nurse confirmed the DHA is notified of each youth’s admission by the
registered nurse (RN) and an admission progress note is completed
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a written policy and procedures requiring the completion of the Health-
Related History (HRH) form upon each youth’s admission to the program and prior to the
completion of the Comprehensive Physical Assessment (CPA). Five youth Individual Healthcare
Records (IHCRs) were reviewed, and each contained a HRH completed by a registered nurse
(RN) on the day of admission. Each reviewed HRH was completed prior to the completion of the
CPA as evidenced by the date and signatures on both the HRH and CPA. Each HRH was
reviewed by the designated health authority (DHA) as indicated by a checkbox on the CPA. An
interview with the nurse confirmed the practice of licensed healthcare staff completing the HRH
upon admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a written policy and procedures to address the completion of the
Department’s standardized Comprehensive Physical Assessment (CPA) form for all youth
admitted into the program. Five youth Individual Healthcare Records (IHCRs) were reviewed. All
five IHCRs contained a new CPA completed by the designated health authority (DHA) within
seven days of admission on the Department’s form. Each of the CPAs documented the
appropriate Medical Grade for the reviewed youth. There was no indication of any missing or
incomplete elements on any of the reviewed CPAs. All five youth refused part of the
examination, and each IHCR contained a refusal form signed by the youth which reflected the
refused portion on the CPA exam and matched the date of the exam. All sections of the CPA
were completed in full utilizing an “O” and/or applicable “X” markings except for sections
numbered nineteen through twenty-two, as those sections were not applicable to the male
program. The results of each youth’s Tuberculosis Skin Test (TST) were documented on the
CPA, and on the Department’s Infectious and Communicable Disease (ICD) form. Reviewed
documentation confirmed the Department’s Problem List was updated as needed. An interview
with the program’s nurse confirmed a CPA is completed annually by the DHA during admission
and updated as needed if there is any significant change in the youth’s condition.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program maintains a written policy and procedures requiring all admitted youth to be
clinically screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). The policy stipulates HIV test results may only be disclosed to
the youth and entities approved by Florida Administrative Code. Five youth Individual
Healthcare Records (IHCRs) were reviewed, and each documented the youth was clinically
screened for STIs. Each of the youth were applicable for further evaluation and were referred to
the DHA. The five IHCRs documented testing had been ordered and performed. Testing,
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screening, clinical evaluations, and diagnoses were documented accordingly on the
Department’s Infectious and Communicable Diseases (ICD) form, excluding HIV results, and
filed within the lab section of the IHCR, for all five youth. There were no applicable youth who
were out of the Department’s custody for over thirty days or required a rescreening due to
presenting symptoms. The program maintains a written policy and procedures ensuring all
youth at risk for HIV infection are offered counseling, testing, education, prevention counseling,
and a referral for medical treatment. A review of five youth IHCRs found each youth was offered
the opportunity to receive counseling and testing for HIV. All five youth declined consent by
checking or initialing the “I do not consent” box on the Department’s HIV Antibody Test Youth
Consent form; therefore, none of the youth received pre-counseling, testing, or post-counseling
services. All youth who consent to testing are tracked on the program’s HIV Testing Tracking
Log maintained by the nursing staff. The health service administrator (HSA) reported the
program’s DHA provides the pre and post-test counseling and testing. Five interviewed youth
reported they can request a HIV test if needed. The nurse reported all youth are routinely
offered HIV testing and each youth will be tested upon request at any time.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a written policy and procedures requiring all youth to be able to make
sick call requests and have their complaints treated appropriately through the sick call system.
Sick call care is provided by licensed healthcare professionals pursuant to their scope of
practice and according to protocols approved by the designated health authority (DHA).
Observations made during the program tour validated Sick Call Request forms were located in
the main hall where the youth are housed with a corresponding wall-mounted lock box where
the youth are to submit their sick call request. The program’s practice is to check the boxes
randomly throughout each day. Sick call is provided daily by the registered nurse (RN) on
weekdays from 9:10 to 9:40 a.m. and 5:00 to 5:30 p.m. and on weekends from 8:30 to 9:30 a.m.
and 3:00 to 5:00 p.m. A review of the program’s contract and the activity schedule found the
program provides sick call hours as required. The program maintains a written Non-Healthcare
Medical and Emergency Protocol Guide for staff to utilize when healthcare staff are not on-site.
The DHA is on-call seven days a week, twenty-four hours a day for consultation. All staff have
access to call 9-1-1 if they feel a youth requires emergency care. Five youth Individual
Healthcare Records (IHCRs) were reviewed, and all were applicable for having submitted a Sick
Call Request. A Sick Call Request form was completed for each of the sick call requests
reviewed. Each of the reviewed Sick Call Request forms were completed by a registered nurse
(RN). All sick calls were documented on the Department’s Sick Call Index, Sick Call Referral
Log, and filed within each youth’s IHCR in reverse chronological order. None of the reviewed
records indicated the youth presented with a similar sick call complaint three or more times
within a two-week period. None of the reviewed sick call instances were for youth in restricted
housing, as the program does not utilize restricted housing. During the annual compliance
review week there were no sick call requests made by any youth; therefore, observations of a
sick call was not able to be completed. Five interviewed staff reported sick calls are reviewed
and conducted by the nurse. Five youth were interviewed about the sick call process. Four
youth reported being seen within one day of submitting a sick call request and one youth
reported being seen within three days.
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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 maintains a written policy and procedures to address the provision of episodic and
emergency care. Five youth Individual Healthcare Records (IHCRs) were reviewed and all five
were found to be applicable for episodic care encounters. Each of the reviewed episodic care
events were rendered by a registered nurse (RN) and documented in subjective, objective,
assessment, and plan (SOAP) format. None of the episodic or first-aid care was provided by
non-healthcare staff; however, the program maintains a written Non-Healthcare Medical and
Emergency Protocol Guide which is readily available to non-licensed staff. Each applicable
youth’s episodic care event was documented in the chronological progress notes and tracked
on the Episodic Care Log. The log documented the date and time of the treatment, nature of the
complaint, person rendering aid, treatment, and whether off-site care was needed. The program
has eight first-aid kits which are stored in the medical office, conference room, the kitchen, the
school classroom office, the laundry room, the maintenance shed, and two are stored in the
front administration office for use in each of the two program transport vans. The program has a
content list for each first-aid kit which was approved by the designated health authority (DHA).
The first-aid kits were checked weekly by the healthcare staff to ensure each was secure and
properly stocked. One first-aid kit was observed and confirmed to contain the required approved
items. The program has one automated external defibrillator (AED) which is maintained in an
alarmed, wall mounted AED cabinet in an open hallway adjacent to the day room. The AED
provides audio step-by-step instructions and written AED procedures are attached to the AED.
Reviewed documentation showed the AED battery was last changed on August 28, 2022 and
had an expiration date of October 31, 2027. The installed AED pads expire on June 9, 2025.
The RN conducted a self-test of the AED during the week of the annual compliance review and
there were no issues during the AED test. A review of the program’s inspection logs since the
last annual compliance review validated the nurses checked each first-aid kit weekly and
inspected all emergency equipment, including the AED, monthly. A review of five pre-service
and five in-service staff training records found each met staff training requirements for episodic,
first-aid, and emergency care, and each staff maintained current certification in first-aid and
cardiopulmonary resuscitation (CPR) with AED. Reviewed documentation indicated select direct
care staff were appropriately trained on the administration of the epinephrine auto-injector. The
program currently has three daily operational shifts. A review of the program’s emergency
medical drills for the previous twelve months reflected thirty-six drills were conducted, with a drill
conducted on each shift monthly. Twenty-two of the program’s emergency medical drills
included the demonstration of CPR and AED, which exceeds the minimum requirement of at
least once annually on each shift. The emergency medical drills consisted of both announced
and unannounced type drills and were conducted monthly on each shift. Each drill replicated a
medical scenario, and the drill forms documented all required elements. Emergency contact
telephone numbers were located in areas which are not accessible to youth. Observations
made during the program tour confirmed the program posted information informing staff of their
right and responsibility to call 9-1-1. The program had no episodic care events to observe during
the week of the annual compliance review. The program maintains a written policy and
procedures for the use, access, and inventory of NARCAN® by licensed healthcare staff and
non-healthcare staff trained by the RN to administer medication. The program secures
NARCAN® in the locked medical cart with a back-up supply stored in the locked medical
cabinet in the medical clinic. The nurse reported NARCAN® is inventoried weekly by the RN on
Sundays. The nurse reported all RNs are trained and identified program staff who have been
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trained on how and when to use NARCAN®. Five staff were interviewed, and four reported they
are allowed to call 9-1-1, while one reported the medical staff call 9-1-1. Five youth were
interviewed, and each reported they are able to see a doctor if needed.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a written policy and procedures requiring timely referrals, coordination,
and documentation of medical services to off-site healthcare providers for youth with emergent
or non-emergent needs. A review of five youth Individual Healthcare Records (IHCRs) found
two were applicable for off-site care for dental services. One additional record was requested.
The program provided the record for one additional youth who was taken off-site for a surgery
consultation. Reviewed documentation supported each parent/guardian was notified of the off-
site care. The program reported not having any emergency off-site care events since the last
annual compliance review. Each of the three applicable IHCRs had a Summary of Off-Site Care
Consultation Report which was filed in the IHCR with additional documents when applicable.
The designated health authority (DHA) reviewed, signed, and dated the off-site care documents,
as required. Two of the three applicable youth required follow-up care, and each was scheduled
for follow-up care to occur on a date after the week of the annual compliance review. The
interviewed nurse indicated the program utilizes logs to track youth who are sent off-site for
emergency care. The nurse reported all documentation related to off-site care findings,
instructions, and information are placed in the DHA's folder for review and youth are placed on
the referral list to see the DHA at the next scheduled clinic day.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a written policy and procedures requiring youth who have chronic
illnesses to receive regularly scheduled evaluations with the required follow-up. A review of five
youth Individual Healthcare Records (IHCRs) indicated only one youth was identified with a
chronic condition after being admitted into the program; therefore, four records provided by the
program which were applicable for chronic conditions were reviewed. None of the youth were
identified as having a communicable disease. One youth was taking medication on an on-going
basis. Three youth were undergoing treatment for a physical health condition which included a
body mass index greater than thirty and one had a dermatological condition. Each applicable
youth was placed on the chronic illness list and periodic evaluations were conducted when
applicable every ninety days. The program maintains a tracking log for youth with chronic
conditions which tracks periodic evaluation dates. The tracking log indicated each youth’s next
scheduled appointment. None of the youth were applicable for taking anti-tuberculosis
medications. One youth was applicable for and had an evaluation completed prior to a
prescription renewal, change, or expiration. None of the reviewed youth were applicable for an
off-site evaluation. There was no indication of lapses in care or missed periodic evaluations in
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each of the reviewed records. The Department’s Problem List for each youth was updated in
accordance with policy. The facility administrator (FA) was interviewed and reported
administration meets daily with the medical department in the daily morning meeting and
medication management meetings to review any youth medical issues. The designated health
authority (DHA) confirmed the process for the completion of periodic evaluations.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures which detail the process for the receipt,
storage, inventory and administration of medication in a safe and effective manner. Five youth
Individual Healthcare Records (IHCRs) were reviewed and all five were applicable for taking
medication during the annual compliance review period. None of the youth were applicable for
having been admitted to the program with medication; however, the designated health authority
(DHA) was notified of each youth’s admission to the program. Two youth had medication
prescribed by the DHA after their admission date. All five youth had the psychiatrist conduct an
Initial Diagnostic Psychiatric Interview within fourteen days of admission and three were
prescribed new psychotropic medication subsequent to their program admission. Reviewed
documentation supported all medications had a current, valid order, and were given pursuant to
a current practitioner’s order. The program utilizes a pre-printed Medication Administration
Record (MAR) to document all medication and treatment. Each of the reviewed MARs met all
requirements outlined within Florida Administrative Code. The nursing staff documented side-
effect monitoring typically at each medication administration, but at least weekly, on each MAR,
as required. There were no instances where trained non-healthcare staff assisted in the delivery
of medications. There were no undocumented explanations for a lapse or errors in medication
administration. None of the five youth were applicable for having refused medication at some
point during the annual compliance review period. There were no instances of youth refusing
medication on each applicable MAR. Each reviewed MAR documented all required elements.
When applicable, youth received medication monitoring every thirty days as required. There
was no indication of any type of standing orders for psychotropic medications, any emergency
treatment orders for psychotropic medication, or indication of any pro re nata (PRN) orders for
psychotropic medications. One medication pass involving eight youth was observed during the
annual compliance review week with no noted issues. The youth was escorted to medical by
direct care staff. The Six Rights of Medication Administration were verified by the RN. The RN
administered the medication as required and did not pre-pour any of the medications. Five youth
were interviewed, and four youth reported medication is provided by the nurse and one
indicated medication was provided by the doctor. During an interview, the nurse explained the
program’s process and reported the program has identified and trained staff to provide
medication in the event the nurse is not on-site; however, it is the program’s practice for nursing
staff to provide all medication.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program maintains a written policy and procedures stipulating the requirements for the
storage and inventory of medication and sharps, and ensuring all medication is inaccessible to
youth at the program. Observations of the program’s medical cart found all medications were
stored in the locked cart, which was neat, organized, and kept in the locked medical office. All
non-controlled medications were stored in the secure, locked medication cart. Narcotics and
other controlled medications are securely stored and double locked within a locked box within
the locked medication cart. The medication cart had stock items separated from youth specific
medication. Observations found all medications were securely stored in the medical clinic
inaccessible to youth. The program’s practice is for over-the-counter (OTC) medications to be
inventoried using a perpetual inventory daily and verified weekly, and reviewed documentation
confirmed the practice. Perpetual inventories with running balances were maintained on all
controlled substances with a shift-to-shift inventory conducted by the registered nurses.
Syringes and sharps are counted through a perpetual inventory and are verified weekly. During
the week of the annual compliance review a count of three OTC medications was observed, and
the inventories were found to be accurate. A count of three sharps was observed, and
inventories were accurate. One youth was prescribed narcotic or controlled medications, and
the reviewed inventory was accurate. The program did not have any additional controlled
medications or narcotics on-site. An interview with the nurse confirmed the process for inventory
and disposal of unused medication, which is to work with the consultant pharmacist to oversee
the destruction of the medication using a chemical drug destruction solution. The nurse
indicated the program has not had any medication inventory discrepancies since the last annual
compliance review.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according 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 maintains a written policy and procedures for infection control which includes an
Exposure Control Plan written in accordance with Occupational Safety and Health
Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) guidelines.
The infection control policy was last reviewed and signed by the designated health authority
(DHA) on August 5, 2021, and the facility administrator (FA) on July 17, 2023. The plan
addressed common infectious diseases of childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), infectious diseases caused by blood-borne pathogens, other
outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant micro-
organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. The program
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maintains procedures for staff to adhere to universal precautions and the program provides staff
with the opportunity for Hepatitis B immunizations and access to protective equipment. The
Exposure Control Plan was written in accordance with OSHA standards and was last reviewed
and signed by the DHA and the FA on July 17, 2023. The plan includes a process for needle
stick post-exposure evaluation. In the event of an incident, the FA has a process in place to
establish a separate file containing all documents for youth and staff who experienced a facility
or occupational exposure. The nurse reported a copy of the program’s Exposure Control and
Infection Control Plans are maintained in the break room. The nurse reported the program has
not had any instances which required notification to the local county health department, CDC,
and/or the Department’s Central Communications Center (CCC). In addition, the nurse reported
the licensed healthcare staff conduct infection control training for program staff and youth. The
program has not had any reportable infectious diseases since the last annual compliance
review. The program has not had any instances involving the quarantine or hospitalization of at
least ten percent of the total population since the last annual compliance review.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a written policy and procedures requiring all program staff to promote
safety and security by maintaining active supervision of youth to include interacting positively
with youth, engaging youth in a full schedule of constructive activities, closely observing
behavior of youth, and consistently applying the program’s behavior management system
(BMS). The program’s contract requires staff-to-youth ratios to be one-to-eight during awake
hours and one-to-twelve during sleep hours. The program staff are required to account for the
whereabouts of youth under their supervision and ensure staff-to-youth ratios are in compliance
with contract requirements. Program observations verified the daily youth activity schedule was
posted throughout the program and is designed to keep youth engaged in a full schedule of
activities daily. There were staff observations conducted Tuesday through Friday during the
annual compliance review week for daily activities which included school, line movement,
meals, youth searches, and youth head counts. Positive interactions were observed between
youth and staff, and they were consistent with the program’s BMS. Three staff were informally
interviewed and asked how many youth they were currently supervising. Each staff immediately
knew the number of youth they were supervising. Video observations of youth were conducted
during sleep hours. Video observations verified the youth-to-staff ratios were in compliance,
staff were awake and alert, and staff observed youth while they were in their sleeping rooms.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures addressing the implementation and
training of the program’s behavior management system (BMS) which has not changed since the
last annual compliance review. The program uses the Positive Performance System (PPS) for
the BMS. A review of documentation revealed the appropriate parties are involved in the
development and on-going maintenance of the BMS. The program’s policy and procedures
include a protocol where staff are provided feedback regarding the implementation of the BMS.
Five youth records were reviewed and confirmed youth orientation included a review of the
program’s BMS. A review of five staff records indicated each staff position description included
implementation of the BMS. A review of five staff training records confirmed staff were trained in
the program’s BMS. A program tour was conducted, and observations verified the BMS was
posted in areas accessible to youth which included the rules governing conduct and positive
and negative consequences. A review of the policy and youth handbook confirmed the BMS
was documented in the youth handbook which included the rules governing conduct and
positive and negative consequences. The BMS includes promoting safety, respect, fairness,
promoting and protecting youth rights, positive and negative consequences, constructive
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disciplinary actions/non-punitive, opportunities for positive reinforcement, recognition of
accomplishments and positive behaviors at a four to one ratio, and promoting socially
acceptable means for youth to meet their needs. The BMS has a process for explaining to youth
the reasons sanctions are being imposed, youth have the opportunity to explain their behaviors,
provides reasonable reparations for harm caused to others, discussions of alternative
behaviors, promoting positive dialogue, and separation of youth from the population is
minimized. The BMS does not include an increased length of stay, denial of basic rights or
services, promotion of group discipline, punishment by other youth, and disciplinary
confinement. There is a variety of rewards and incentives for the program’s BMS which includes
movie nights, game time, open microphone night, special meals, and extra canteen. An
interview with five staff indicated each staff was aware of the program’s BMS. Each staff stated
youth can receive daily, weekly, and monthly incentives, canteen privileges, movie nights, and
off-site outings as rewards as part of the BMS. Interviewed staff stated rights can’t be taken
away from youth consequently. Additionally, each staff stated youth are informed of
consequences verbally, through written referrals, and during treatment team meetings. Five
youth were interviewed regarding the consequences the program utilizes for negative behaviors.
The youth stated the program uses level freeze, referrals, and youth may lose incentives. All
five youth stated the program rewards youth for positive behaviors by providing canteen, daily
incentives, and off-site outings. Three youth stated staff are consistent when giving rewards and
consequences. Two youth stated staff are not consistent when giving rewards and
consequences. Each youth was able to explain the BMS, describe the levels, and knew how to
move from level to level. All five youth verified youth are not allowed to punish other youth. The
interviewed facility administrator (FA) indicated an understanding of the program’s BMS. The FA
stated the program utilizes daily point cards and the youth have opportunities to earn daily,
weekly, and monthly incentives. The youth can earn weekly canteen. Additionally, the program
utilizes incentive freeze and level freeze for inappropriate behaviors using the special treatment
team form. According to the FA, rewards are monitored by the recreation therapist. Daily point
cards are reviewed as well as positive behavior reports in morning management meetings with
input from each department. An interview with the FA indicated to ensure consistency of staff
implementation of the BMS, staff have annual evaluations for PPS management, and they
attend PPS training annually.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
This program does not use room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures for conducting and documenting ten-
minute checks during sleep hours or at other times, such as during an illness. The program has
a total of forty-five cameras and all cameras were operational during the annual compliance
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review week. The program’s video recording has a thirty-day storage capacity. Staff are
required to conduct room checks every ten-minutes and document the time of the check on the
Ten-Minute Check Log during sleeping hours. Checks are documented on the program’s Ten-
Minute Check Logs with the time of each check noted in real time along with the initials of the
staff conducting each check. A review of nine separate video footage samples which included
two shifts and the program’s one living unit of ten-minute checks and Ten-Minute Check Logs,
documented by staff, reflected no discrepancies. Staff were completing five-minute checks as
best practice. In addition, a sample of ten-minute logs were reviewed to verify ten-minute
checks throughout the annual compliance review period which included one sample of thirty-
minute increments from each shift from each month. The reviewed ten-minute check logs were
documented correctly. An interview with the facility administrator (FA) and observations
confirmed all the cameras were functional during the week of the annual compliance review and
maintained thirty days of video. Five staff were interviewed, and all indicated room checks are
completed every five minutes when the youth are sleeping in their rooms.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a written policy and procedures to ensure youth are always accounted
for through a system of physically counting youth at various times throughout each day. The
program’s policy is to conduct at least six formal counts within each twenty-four-hour period.
Staff are to document the results of all formal counts in the shift logbook to include the time the
count was called, location and number of all youth, and time count was cleared. In addition, staff
are to document all emergency counts in the shift logbook to include the reason why the
emergency count was called, time count was called, location and number of all youth, and time
count was cleared. Staff are to document informal counts in the shift logbook to include the time
the count was called, location and number of all youth, and the time count was cleared. Staff are
to document a running count in the shift logbook, noting admissions, discharges and releases,
transfers, youth temporarily away from the program such as court, appointments,
hospitalizations, and escape status. A review of the Continuity of Operations Plan (COOP)
verified program staff must always account for the whereabouts of the youth in the care and
custody of the program. This includes the need for continual head counts to be conducted
minimally, at the beginning of each shift, and during any emergency, and at regular intervals.
Twelve randomly selected dates and times in the program’s logbook were reviewed for census
counts during the annual compliance review period. Documentation validated head counts and
movements were conducted at the beginning of each shift, after outdoor activities, and during
actual and/or simulated drills. In addition, the program logbooks included documentation of new
admissions, releases, daily census counts, emergency situations, youth movements, and youth
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temporarily away from the program. Observations made during the annual compliance review
week verified staff conducted youth counts. Five interviewed staff verified formal counts are
conducted every thirty minutes and before every movement. Each staff stated the procedures
when a youth count cannot be reconciled included stopping all movement. Interviewed staff
stated an emergency headcount will be conducted during security checks when the count is off.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures to ensure the maintenance of a
chronological record of events, incidents, and activities in a central logbook. The program
maintains a bound logbook with numbered pages for each month. A review of program logbooks
confirmed the program’s logbooks were bound with numbered pages, and all entries were made
in ink with no erasures or white-out areas. There were no logbook entries destroyed or
removed, all errors were struck through with a single line and initialed by the staff correcting the
error. Reviewed documentation of twelve randomly selected days within the logbooks reflected
all entries included the dates and times of the events, the names of the staff and youth involved,
brief descriptions of the events, and the names and signatures of the staff making the entries in
the logbook. Internal incidents reported to the Florida Abuse Hotline and/or the Department’s
Central Communications Center (CCC) was documented in the logbook. The program does not
utilize a living unit logbook. The program utilizes a shift report to summarize events, incidents,
and activities documented in the program’s central logbook. The logbook included
documentation of incidents, counts, perimeter checks, youth transports, emergency situations,
admissions, releases, and calls to the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC). A copy of the shift report was available for staff to review for at
least forty-eight hours.
5.07 Key Control (CRITICAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures for assignment, inventory, tracking, and
storage of program keys. A review of the program’s policy and procedures on key control
determined it includes key assignment and usage, 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 distribution of keys was observed during the
annual compliance review week. The program’s staff turn in their personal keys and receive a
program key. This key is updated in the logbook to reflect the key with the tag number given to
staff. The key inventory log was reviewed to ensure the inventory matched the actual key rings
in use, with no discrepancies noted. There was an observation of the key storage area and the
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program’s keys were kept in a secure storage box with a secured lock. An observation of secure
storage of keys when not in use indicated keys are always secured when not in use. The
program has a process for permanent key assignment. Staff sign a permanent key assignment
acknowledgment form to receive the keys and verify the number of keys on the ring. The facility
administrator’s (FA) permanent keys matched up with the permanent key log during the annual
compliance review week. Observations revealed the restricted keys are stored and secured in
the restricted key box located in the administration hallway, personal keys were collected, and
program keys were signed out. The FA stated the process for reporting and the replacement of
keys is for a work order to be completed and maintenance to replace the keys no later than the
next day. Observations found the key box was not easily accessible while it was locked. The
key box housed active keys and the restricted medical keys were stored in a secured locked
box in the medical clinic. A review of the Department’s Central Communications Center (CCC)
reports and an informal interview with the assistant facility administrator (AFA) verified there
were no instances of lost/missing keys in the last twelve months. The program’s method for the
daily tracking and reconciliation of keys consists of staff turning in personal keys and signing out
program keys on the key log, if the key count is not accurate or lost keys are recounted, all
movement is stopped, and staff search for the missing key. If the key count is not reconciled it is
reported to the CCC. An observation of key rings of three randomly selected staff were
compared to the inventory and key log, showing there were no discrepancies noted. An
interview with five staff indicated each staff confirmed there aren’t any youth at the program with
access to the program keys, personal keys are securely stored, there is a key log for daily
tracking of keys, and any missing keys are reported to the FA.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program’s youth handbook and policy include a
list of contraband items and inform youth of the consequences if found with contraband. Each
youth is provided with a written copy of the youth handbook upon admission into the program
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and all are oriented to the program rules including the list of items considered to be contraband.
The program’s policy and youth handbook included all items considered contraband. The list of
contraband items included sharps, escape paraphernalia, tobacco products, lighters or
matches, electronic or vaporless cigarettes, unauthorized food or clothing, any intoxicating
beverages, any controlled substance, any prescription or non-prescription drug, any firearm or
weapon, any explosive substance, non-program issued keys, unauthorized currency, non-
program issued cellular telephones and/or equipment or electronic devices capable of taking
pictures or video recordings, as well as smart watches. In addition, the program’s policy and
youth handbook include search procedures of the physical plant, searching the program
grounds, youth searches, and searches of incoming and outgoing mail. The program’s visitor
log contains a contraband attestation statement. A review of twenty-nine newly hired staff since
the last annual compliance review confirmed each staff signed an attestation form. The
program’s policy and procedures, with orientation training provided to all new staff, stipulate
staff, including supervisors and administrators, found in possession of contraband will be
subject to disciplinary action up to, and including, dismissal. The program’s policy specifies the
way any unauthorized or contraband item is to be disposed, to include return to the sender,
mailed to the youth’s home, returned to the youth upon release, or in the case of illegal
contraband, turned over to law enforcement. A review of the Department’s Central
Communications Center (CCC) reports indicated there were no instances of contraband found
at the program which was turned over to law enforcement. A review of facility logbooks and
search reports confirmed unannounced room searches and common area searches are
conducted daily on each shift at random times. A review of the central logbook, visitation forms,
and incident reports validated the program’s practice of monitoring areas of the program,
grounds, and youth rooms for contraband. The program documents the confiscation and
disposal of contraband. All instances involving confiscation of illegal contraband require the
program to turn the item over to local law enforcement authorities and file a criminal report. In
an interview, the facility administrator (FA) verified the program follows the policy and
procedures regarding contraband. Five staff were interviewed, and each stated room searches
are conducted daily on each shift.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures to ensure searches and full body visual
searches are conducted according to Florida Administrative Code at the time of admission, after
off-campus activities, and visitation. Youth are searched before all movement, during a new
admission, during readmission, after returning from visitation, when returning from off-campus
activities and/or appointments, when suspected of having contraband, or when a youth is
determined to be a security risk. The program conducts searches as a method to prevent the
introduction of contraband and unauthorized items into the program. The policy indicates
searches of youth are conducted after off-site transports, after visitation, before moving youth
from an outside area into the building, and prior to moving youth from the building to an outside
area. During the annual compliance review week, the program did not have any visitations;
therefore, an observation of a search was not conducted. There were observations of searches
made during line movements, and before and after youth used Class B tools during the annual
compliance review week. Observations made throughout the annual compliance review week
validated youth are provided instructions regarding the search, searches were conducted by
staff of the same gender as the youth, were conducted with dignity and respect to minimize the
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youth’s stress and embarrassment in a manner as to not degrade the youth, and were based on
the Right Interactions (RI) training manual. In person observations for staff searches were
conducted during the annual compliance review week. The program staff used the wand,
conducted pat down searches with permission, had staff remove their shoes and checked for
contraband, and checked all bags coming into the program. In addition, a video review of staff
entering the program was conducted and verified the search protocol was followed. Five
interviewed staff stated youth are searched before and after all movements. Five interviewed
youth stated searches occur before and after every movement daily.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures for transportation, operation, and
maintenance of each vehicle used to transport youth. The program has two vans which are
used to transport youth. The program ensures any vehicle used by the program to transport
youth is properly maintained and documentation regarding the use and maintenance of each
vehicle is maintained. Each vehicle used for transporting youth shall pass an annual safety
inspection. Each vehicle used to transport youth is to be equipped with the appropriate number
of seatbelts, a seatbelt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Both transportation vans were equipped with fire extinguishers, approved first-aid kits, a seatbelt
cutter, window punch, and the appropriate number of seatbelts. Neither vehicle required a
safety screen between the driver and passengers. Both vans passed inspections during the
annual compliance review period. The program maintains a log which had documentation of
completed weekly vehicle inspections. The results of the vehicle inspections are documented
and stored in the program’s vehicle maintenance log/binder. A review of the weekly inspections
showed all were completed, as required. A random check of ten personal vehicles and the
program’s transportation vehicles was conducted during the annual compliance review. The
staff vehicles and both of the transportation vehicles were found to be locked. There was no
transportation available for observation during the annual compliance review.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures to ensure the safety and security of
youth and the community when youth are transported outside of the program. The program has
a written policy and procedures to ensure the safety and security of youth and the community
during transportation of youth, and to ensure the appropriate staff-to-youth ratio is maintained
while youth are transported off program grounds. The program has an approved transport list
which is updated monthly to ensure staff driver’s licenses are valid. Reviewed documentation
verified all approved drivers had a valid driver’s license. An informal interview with the assistant
facility administrator (AFA) indicated a cellular telephone is issued to the staff who is conducting
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the transport of the youth. The one-to-five staff-to-youth ratio is used during all transports. No
transport observation was conducted during the annual compliance review week. An interview
with the AFA and the program’s policy verified youth are not allowed to drive program or staff
vehicles. Five staff were interviewed, and each staff indicated youth are secured within the
vehicle with shackles, handcuffs, and seatbelts, and one staff sits in the back with the youth.
Each staff stated a cellular telephone is provided to staff during transport. Five staff were
interviewed, and each indicated the safety equipment in the transport vehicles include a fire
extinguisher and first-aid kit. All staff reported they are not allowed to use personal vehicles to
transport youth. Four staff reported transport vehicles are searched for contraband prior to and
after each use. One staff reported transport vehicles are not searched for contraband prior to
and after each use; however, the staff member was a new hire and had never conducted a
transport. Five staff were interviewed regarding the staff-to-youth ratios maintained during
transport, and each staff stated the correct ratio. Each staff indicated the emergency response
process consists of notifying the program’s administration, making sure all youth are safe, and
calling emergency services/9-1-1. A safety screen is not required in the transportation vehicles
for this moderate risk program. Five interviewed youth verified they have never been handcuffed
to any part of the vehicle. Each of the five youth stated they have never seen anyone place
contraband in the transportation vehicles.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures to ensure a safe and secure physical
plant, grounds, and perimeter are maintained, and for weekly safety and security audits to be
conducted. The program has designated the assistant facility administrator (AFA) and/or
designee as the person responsible for conducting the weekly safety and security audits. The
weekly safety and security audits include the inspection of the program’s cameras, radios,
communication devices, keys, locks and doors, vehicles, and living areas to include youth
rooms and bathrooms. A review of the program’s Facility Security Audit and Safety Inspection
forms during the annual compliance review period confirmed the AFA conducts weekly
safety/security inspections. All deficiencies are tracked, and efforts are made to correct any
deficiencies noted. During the annual compliance review period, there were no inspections
missing or any discrepancies. The forms documented safety and maintenance repairs needed
and the date and time the repairs were completed, or due to be completed. All inspection forms
were reviewed and signed by the facility administrator (FA). The program’s Preventative
Maintenance Checklist was reviewed to ensure maintenance schedules and repairs were
conducted in accordance with contract language, with no exceptions. An interview with the FA
confirmed the process in identifying and tracking safety and security deficiencies, by addressing
them in management meetings, and conducting audits on a weekly basis.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures for a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. All tools are inventoried
prior to being issued for work and following work activities. A review of the tool inventory log
indicated all tools are inventoried daily such as sharp-edged and pointed tools, except on days
they are not used. The policy prohibits specific tools including machetes, bowie knives, and long
blade knives. The program has identified the physical plant manager as the program’s tool
control manager. The policy classifies tools into two categories, Class A tools and Class B tools.
Class A tools are hazardous with sharp edges or points with a high potential to be used as a
weapon to inflict serious bodily harm. Class B tools do not have sharp edges or points. A review
of inventory logs and the tool storage room verified tools are securely stored when not in use
and easily marked for identification. Class A tools are secured in the maintenance shed and are
inventoried daily when in use. Observations found the maintenance shed to be organized, neat,
and clean. All tools were observed and maintained in a secured location behind lock and key.
All Class A tools were stored on the maintenance shed shelves with a corresponding label of
the tool and number to identify the tool was stored in the proper place. Class B tools are
inventoried daily by program staff and stored in a secured laundry room. The assistant facility
administrator (AFA) reviews the inventories monthly. A review of the inventory sheets validated
this practice. The program has a sign-in and sign-out log for Class A and Class B tools. All tools
were properly identified and inventoried during the annual compliance review period. The
program has a policy and procedures for missing/lost tools and for tools requiring disposal.
During an informal interview, the facility administrator (FA) stated if a tool is missing staff will
immediately notify the FA and the assistant facility administrator (AFA). Staff will then search for
the tool, ensure all youth movement is stopped, and complete an emergency head count. If the
tool is not found staff will report it to the Department’s Central Communication Center and
replace the tool. Staff are to document the incident on an internal incident report and in the
logbook. No tools were disposed of during the annual compliance review period.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures include
supervision requirements when youth are using tools, the issuing of tools to youth and staff, a
youth assessment to determine the youth’s risk, and established ratios, which include one staff
to five youth during work detail or vocational training. The program’s policy and procedures
included supervision requirements, issuing tools to youth and staff, an assessment to determine
a youth’s risk to self and others, established ratios, tool distribution and collection, and search
criteria during work projects and activities involving tools. During activities which require a youth
to use a tool, the ratio of supervision is one staff to five youth. In addition, the ratio is one staff to
five youth during vocational training. A video observation confirmed one staff to four youth while
Class B tools were in use. Each youth was searched before and after using Class B tools. Use
of Class B tools and participation in work projects is based upon each youth’s level within the
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program’s behavior management system (BMS). Five youth case management records were
reviewed, and all indicated youth have been trained on the proper usage of tools. In addition, a
review of five youth records verified each youth had a risk assessment completed prior to the
use of tools. Five youth were interviewed and three stated they are allowed to use mops and
brooms. Two youth stated the use of tools depends on the level you are on the BMS. Five staff
were interviewed, and each confirmed youth are allowed 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 maintains a written policy and procedures establishing guidelines for outside
contractors who come on-site to complete repairs. When a contractor or vendor enters the
program, they sign the Written Notification and Guidelines for Outside Contractors form which
lists contraband and unauthorized items. The program’s guidelines for external workers include
checking of tools upon arrival and departure, searching of all vendors prior to entering the
program, tool restriction while in the program, missing tool follow-up, and restriction of youth
from the work area. The outside contractor completes the program’s Vendor/Outside Contractor
Tool Inventory List upon entrance to the program, where they list what tools are needed to
complete the work order. Maintenance will review the form and sign once the tools are
inventoried and approved. Upon exiting the program, the Vendor/Outside Contractor Tool
Inventory List is reviewed, all tools are verified, then the form is signed. Any tools required to be
used within the program are inventoried and recorded on the contractor’s agreement form
before and after the repair is completed. Reviewed documentation for three project invoices
showed the vendors signed contractor agreements and an inventory of tools was completed and
documented. Documentation for the outside contractor forms verified the forms were completed
and all requirements were met. A review of three project invoices during the annual compliance
review period verified the contractors signed the Written Notification and Guidelines for Outside
Contractors form confirming notification of what items are considered unauthorized. A review of
the program’s policy verified personal cellular telephones and/or equipment/electronic devices
capable of taking pictures and/or audio/video recordings including smart watches are prohibited
in the secure area. If any unauthorized items are needed by the contractor while in the program,
approval is obtained by the facility administrator (FA) or designee.
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’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes and the frequency of conducting drills at random times, and under varied
conditions. The program has a written policy and procedures to ensure fire safety and
evacuation drills are conducted, and youth and staff are prepared for immediate implementation
or mobilization in the event of an emergency or disaster. A review of the program’s COOP
revealed the program conducts monthly fire drills and COOP drills on each shift. A tour of the
program during the annual compliance review week found fire evacuation routes and egress
plans were posted throughout the program. The program has sixteen fire extinguishers and
reviewed documentation reflected all were inspected annually. A review of drill documentation
for the annual compliance review period indicated the program conducted one monthly fire drill
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and one COOP drill on each shift. The program conducted COOP drills which included riots,
disturbances, active shooter, chemical spills, medical situations, and severe weather. Reviewed
documentation for all drills contained the type of drill, date and time, participants, brief scenario,
findings, and recommendations. Five youth were interviewed, and each reported being
instructed on what to do in case of a fire and drills are conducted once each month. Five
interviewed staff said they have participated in COOP drills, fire drills, escape drills, and medical
drills. An interview with the facility administrator (FA) confirmed the program conducted fire
drills, medical drills, and COOP drills on a monthly basis.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a written policy and procedures requiring the development of a
Continuity of Operations Plan (COOP) which is updated as necessary and maintained for the
continuity of mission essential functions of the provider in the event an emergency prevents
occupancy of the primary program location, in compliance with state law and the Department’s
policy. The COOP addresses phases of a disaster plan as well as emergency management
including preparedness, response, and recovery. The COOP is located in the lobby of the
administration area, and the plan was readily available to program staff. The COOP was
reviewed by the program on April 15, 2024, and was approved by the Department on May 22,
2024. The plan addresses alternative relocation sites approved by the Department’s residential
regional director. The COOP addressed emergencies including fire prevention and evacuation,
severe weather, major disturbances, bomb threats, hostage situations, chemical spills, flooding,
terrorist threats or acts, staff roles and responsibilities, any equipment and supplies needed,
information about youth which may be needed, alternative housing arrangements, provisions for
continuity of care and custody of youth, and provisions for public protection. The program has
the necessary supplies readily available in case of an emergency evacuation maintained within
the storage room, kitchen closet, and facility administrator’s (FA’s) office. Supplies included
batteries, flashlights, water, canned goods, and dry foods. The program’s hard copy records are
easily accessible in a binder and mobile in the event of an emergency resulting in the program
relocating quickly or in the event needed information cannot be accessed electronically for all
youth in the program. The interviewed FA and observations verified the COOP was located in
the lobby area of administration and in the FA’s office and all staff have access to view the plan.
The program maintains an administrative hard copy record for each youth, in case of an
emergency, in the administration area. A review of five youth case management records
confirmed each contained the youth’s name, a photograph, Department identification number,
admission date, date of birth, gender and race, overall health status, address, and
parent/guardian contact information which included name, address, telephone number of the
person with whom the youth resides and their relationship to the youth, and person(s) to notify
in case of an emergency. In addition, the records contained the youth’s assigned juvenile
probation officer (JPO), committing judge, state attorney, public defender, victim notification
contact information, if required, and personal physician.
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5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a written policy and procedures addressing storage and inventory of
flammable, poisonous, toxic, and caustic materials, to ensure all youth and staff are safe from
the effects of the unauthorized use of such items. The program’s physical plant manager
maintains a monitoring system to ensure compliance with flammable, poisonous, and toxic
items. The chemical inventory is completed daily and documented on the Chemical Inventory
Sheet. A tour of the program and observations found the program stored the flammable
materials in a flame-resistant locked cabinet located outside of the program’s maintenance
shed. Cleaning toxic items and materials are located in the secure maintenance shed and
secured laundry room cabinet which was inaccessible to youth. Copies of each current Safety
Data Sheet (SDS) are maintained with the chemicals. The program has an approved list of staff
authorized to handle flammable, poisonous, and toxic items which include the facility
administrator (FA), the assistant facility administrator (AFA), staff mentors, the physical plant
manager, youth specialists, the recreation therapist, medical staff, and therapists. The
program’s policy and procedures on the disposal of flammable, toxic, caustic, and poisonous
items state at no time toxic or caustic substances are to be disposed of by pouring on the
ground, flushing into sewers, or any other unsafe method. Proper disposal according to
biohazard guidelines is required. The program does not ever mix hazardous chemicals, except
as directed by the SDS, ensures all hazardous materials needing to be disposed of are
prepared for proper disposal according to the Occupational Safety and Health Administration
(OSHA) guidelines, ensures caustic acids or explosives are not utilized or stored at the
program, and chemicals are to be taken to a waste disposal site for disposal. A formal interview
the FA stated all chemicals are disposed of according to the SDS. There have been no
chemicals which required disposal during the annual compliance review period. All liquid waste
from work details is disposed of in the plumbing drains. The program disposes of grease in the
grease trap which is located in the back of the program and serviced by an outside contractor.
The program’s policy states upon becoming aware of a chemical spill, staff will notify the FA or
designee of the location. The shift supervisor directs the shut-down of all air handlers and
ventilation systems and assistance from outside the program will be contacted, as necessary,
consistent with emergency procedures. A review of ten unique chemical items verified all ten
matched the inventory sheets and the SDS was present with each item.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
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schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Program youth are strictly prohibited to
use, handle or clean dangerous or hazardous chemicals, respond to chemical spills or clean,
handle or dispose of any other person’s biohazardous material, bodily fluids, or human waste.
An observation confirmed all chemicals were maintained behind locked doors and youth do not
have access to areas where items are being stored. Youth do not have access to these items
and are supervised by staff during daily cleaning. During the annual compliance review, video
footage was observed which involved youth and the use of tools and chemicals. One youth was
observed mopping using a mop and mop bucket in the living unit hallway. During the work
detail, youth did not handle any chemicals. Five youth were interviewed, and each stated they
do not use chemicals/cleaning products.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
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5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures to allow youth to have visitation and
communication with family members while in the program. The program assists youth and
families in maintaining connections in a visitation environment which provides monitoring,
control of movement, and security practices to ensure visitor, youth, staff, and program safety.
The program’s visitation schedule is posted in the cafeteria and lobby area of the program. The
program’s policy and procedures related to visitation, youth mail correspondence, and use of
telephone ensure youth can maintain constant communication with their family members to
discuss the youth’s transition. All outgoing mail is searched by the case manager before being
processed. Youth may receive incoming calls from officials as needed. The program maintains a
list of approved visitors; however, attorneys, representatives of the court, juvenile probation
officers (JPOs), other agency representatives, and clergy are authorized to visit at any time.
Searches of visitors will be conducted upon entry and all youth are to be searched following
visitation sessions. A review of the visitation log and schedule confirmed adherence to the
program’s visitation schedule. Visitation is held two days a week on Saturdays and Sundays
from 1:00 p.m. to 3:00 p.m. Youth are given opportunities to communicate with their families in
person, by telephone, and by mail. A review of the program’s telephone log and mail log
confirmed the program’s practice. Each youth is provided an opportunity on a regular basis to
correspond with identified individuals specified on their Approved Correspondence List and legal
representatives. Alternative arrangements with parents/guardians are available for
parents/guardians who are not able to appear in person. Additionally, video conferencing is an
option. Youth are given an opportunity to communicate with family members by mail. The
program provides postage for two letters a week for each youth within the program and does not
limit the number of letters a youth is able to mail each week. Youth are permitted weekly
telephone calls. Each youth’s use of the telephone is documented in each youth’s case
management chronological documentation. A review of the telephone chronological notes
verified youth have consistent telephone communication with family members. It is the
program’s practice for the assigned case manager to follow-up with the JPO regarding human
trafficking victims to determine whether the parent/guardian should be permitted to
communicate with the youth; however, there were no youth applicable with a history of human
trafficking during the annual compliance review period. Five youth were interviewed, and each
stated they can call or send their parent/guardian a letter. During an informal interview with the
assistant facility administrator (AFA) it was confirmed, for youth who do not speak English as
their primary language, the program’s bilingual staff may translate and help youth communicate
effectively and understand important information. An interview with the facility administrator
(FA)indicated the facility maintains a list of staff members who are fluent in foreign languages.
Upon admission, the treatment team considers the needs of the families in regard to barriers in
communication and appropriately places youth with an appropriate therapist. The program
utilizes a language translation company to meet the needs of youth who speak a language
which is not represented in the staff population.
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5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. A review of the staff roster confirmed the program has a
recreation therapist, who met all requirements for the position holding a bachelor’s-level degree
in sports management and a national council for therapeutic recreation certification. The
program’s recreation calendar designates an activity for the youth to participate in during
outdoor recreation each day, as well as a calendar of alternative activities if recreation is
indoors. The program’s activity schedule is posted throughout the living units and common
areas of the program. All activities promote social and cognitive skill development, creativity,
teamwork, healthy competition, mental stimulation, and physical fitness. Youth are provided with
at least one hour of large muscle activity daily. Reviewed documentation of the logbook and
daily activity schedule confirmed the program has a range of supervised and structured indoor
and outdoor recreation and leisure activities for the youth, for at least one hour daily.
Observations made throughout the annual compliance review week validated youth are
provided with at least one hour of indoor or outdoor recreation and leisure time. Reviewed
documentation confirmed recreational therapy was included in each youth’s Individualized
Performance Plan and/or treatment plan. Five staff were interviewed regarding the type of
recreation activities the program provided and how long the activities are. Staff indicated the
program provides youth with at least one hour each day. Each staff indicated the outdoor
activities consist of basketball, football, volleyball, and soccer. Five youth were interviewed, and
each youth indicated physical activities are provided for at least one hour.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
According to the program's contract, the career and technical education (CTE) services which
are required to be provided to all youth include Occupational Safety and Health Administration
(OSHA)-10, and Florida Ready to Work Soft Skills and Digital Skills. An informal interview was
conducted with the facility administrator (FA), who reported twenty-one youth are receiving
technical and career services, and forty-one youth received a certification. Ten youth received
OSHA-10, fourteen youth received cardiopulmonary resuscitation (CPR)/first-aid, and
seventeen youth received Florida Ready to Work Soft Skills and Digital Skills. A review of the
program schedule confirmed each youth is receiving CTE services Monday through Friday from
7:30 a.m. through 8:30 a.m., which is after breakfast and before school begins. The FA reported
CTE services are being provided as required according to the program's schedule, contract, and
CTE requirements. Documentation was provided confirming two case managers are qualified
instructors who provide CTE services. The FA reported the program does not have any industry
certifications. Five youth case management records were reviewed, and all youth completed the
Florida Ready to Work Soft Skills, OSHA-10, and CPR/first-aid within the required time frame.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program provides education services through the Florida Virtual School (FLVS). The
program has an activity schedule reflecting an education schedule and times. A review of the
schedule found the activity schedule coincides with the education contract provider's schedule
time and there were no discrepancies. A review of three random days of video and logbook
confirmed youth were escorted to and from education classes as scheduled. Five youth were
interviewed and four stated the program was helping them create coping skills and address
mental health awareness skills. One youth reported the program was not helpful and they
wanted to complete the program successfully and return home. A review of twelve random
dates from each month from the program's logbooks showed all youth were in class as
scheduled.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 70 (Revised September 2022)
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. A review of the
education contract provider’s schedule confirmed it included, at a minimum, 250 days of
education programming, twenty-five hours of education access weekly, and twenty days for
teachers' planning and/or training. The schedule was approved and submitted to the
Department on April 27, 2024. An interview was conducted with the lead instructor, who stated
each youth can receive credits for the educational and training experience. A review of three
random days of video and the logbook confirmed education classes were facilitated as
scheduled. The interviewed lead teacher reported the program's educational schedule was met.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. A review of the
education provider’s contract reflected the career education program is appropriate for the
educational abilities, goals, length of stay, and classification of the youth in the program. The
residential juvenile justice education program includes a contracted minimum length of stay of
nine months and provides Career and Professional Education (CAPE) courses leading to pre-
apprentice certifications and industry certifications. The career education program provides
Type 2 vocational competency development programming, which provides program content and
an orientation to the broad scope of career choices based upon personal abilities, aptitudes,
interests, exploring and gaining knowledge of occupation options, and the level of effort required
to achieve the essential prerequisites to skill training. Additionally, the program does include
Type 1 programming, which includes personal accountability skills and behaviors leading to
appropriate work habits for employment and living standards. Furthermore, the career education
programming includes communication, interpersonal, and decision-making skills.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
Education services are provided by Florida Scholars Academy/Florida Virtual School
(FSA/FLVS). This indicator was reviewed; however, will not be rated until the 25/26 review
cycle. The contracted educational provider is required to develop an educational transition plan
for each youth. Three closed case management records were reviewed, and none included an
education transition plan. This is due to youth entering the program prior to July 1, 2024. The
new education provider, FLVS, did not create the transition plans for the youth already placed in
the program. The education provider, FLVS, has recently developed an education transition
plan template and trained the education staff on the transition plan creation and its
implementation for each youth moving forward.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 70 (Revised September 2022)
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The contracted
educational provider has procedures in place to provide qualified instructional personnel. A
review of sixteen flex teachers and two instructional personnel staff showed each had a valid
Florida educator's certificate with the appropriate coverage as provided for in the course code
directory, have completed a minor in the field of study in the subject area being taught, and
demonstrated sufficient subject matter expertise through the passage of a standardized
examination or comparable method. All instructional personnel credentials were active and
current, according to the Department of Education's website. All instructional personnel were
teaching in their qualified field. None of the sixteen flex teachers were teaching any out-of-field
courses; however, the two in-house personnel were teaching the out-of-field subjects of science
and English. No approval was obtained by the school board for out-of-field teaching. Three case
management records were reviewed, and each youth received education from out-of-field
personnel. Notification letters were sent to parents/guardians informing them out-of-field
teaching was occurring; however, the letters did not identify the specific out-of-field classes
being taught.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle. The education
contract provider is responsible for referring all youth who receive their high school diploma or
equivalent to Florida Youth College. Three closed youth case management records were
reviewed, and all youth had a referral for Florida Youth College.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each youth referral received by Florida Youth College (FYC) from the education contract
provider is assigned a career navigator. The career navigator then connects with youth through
the residential contract provider to schedule an orientation session. During orientation, the youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 70 (Revised September 2022)
and career navigator develop a career pathway plan to include postsecondary education and/or
enrollment in a state or technical college. Three closed youth case management records were
reviewed, and all youth were referred to FYC and assigned a career navigator. There was
documentation to support the day, date, and time of their FYC orientation. Each youth record
included a career plan based on the youth’s interests and aptitude, and follow-up documentation
to support a thirty-day and sixty-day follow-up. The youth's ninety-day and 180-day follow-ups
were not documented. There was a copy of the youth's admission and registration to a
postsecondary program included in each youth's record.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

report_type: QI Residential

program_name_raw: Miami Youth Academy