state: FL

facility_name: Oak Grove Academy

summary: QI Residential - FY25-26 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Oak Grove Academy
Rite of Passage, Inc.
(Contract Provider)
11180 NE 38th Street
Jasper, Florida 32052
Review Date(s): October 7 – 10, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Ken Phillips, Office of Accountability and Program Support, Lead Reviewer (Standard
1,Interviews)
Roberta Ellis, Probation and Community Intervention, Juvenile Probation Officer Supervisor
Circuit 5 (Standard 2)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Forrest Hallam, Office of Accountability and Program Support, Regional Monitor (Standard
1,Interviews)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Oak Grove Academy MQI Program Code: 1450
Provider Name: Rite of Passage, Inc. Contract Number: 10590
Location: Hamilton County / Circuit 3 Number of Beds: 40
Review Date(s): October 7-10, 2025 Lead Reviewer Code: 145
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 63 (Revised August 2025)
T h e fo llo w in g lim ite
Lim ited R atings
1.07 In-S ervice Training
5.13 Tool Inventory and M anagem ent
d a n d /o r fa ile d in d ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n
Failed R atings
.
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 63 (Revised August 2025)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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tin g in e a c h o f th e s e
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 63 (Revised August 2025)
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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tin g in e a c h o f th e s e
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 63 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff * Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education 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 63 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 63 (Revised August 2025)
5555555555555555555555555 .0 1
C .0 2
.0 3
.0 4
.0 5
.0 6
.0 7
.0 8
.0 9
.1 0
.1 1
.1 2
.1 3
.1 4
.1 5
.1 6
.1 7
.1 8
.1 9
.2 0
.2 1
.2 2
.2 3
.2 4
.2 5
* T h e D e
p ro g ra m o
in d ic a to
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l *
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
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S a tis fa c to ry
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S a tis fa c to ry
S a tis fa c to ry
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
m a re a (d e te n tio n ,
Program Overview
Oak Grove Academy is a forty-bed program, for fourteen- to nineteen-year-old males located in
Jasper, Florida. The program is operated by Rite of Passage, Inc., through a contract with the
Department. The program provides Substance Abuse Treatment Overlay Services (SAOS).
Youth are able to receive individual and group mental health, behavioral health, substance
abuse services, and family therapy. In addition, the program fosters each youth by providing
Aggression Replacement Training (ART), Impact of Crime (IOC), Seeking Safety, Living in
Balance, and Boys Council. Program administration is comprised of the program director,
director of group living, compliance coordinator, director of student services, shift supervisors,
and designated mental health clinician authority (DMHCA). Mental health and case
management services are coordinated by the DMHCA. The program employs four therapeutic
managers, two transition services managers, and a recreation specialist. Additional services
include equine therapy, ServSafe Food handler certifications, culinary arts, and masonry.
Medical services are offered twenty-four hours and day, seven days a week, and are provided
by the medical doctor who also serves as the designated health authority (DHA). The medical
services are overseen by the health services administrator (HSA), who is also a registered
nurse (RN) and provides direct supervision to three other RNs. Educational services are
provided by Florida Scholars Academy. The layout of the program includes: two youth living
areas/cottages, the administration building, education building, kitchen/cafeteria, and
maintenance building. The program has a total of fifty-three cameras, all of which were reported
to be working during the annual compliance review week. The program administration reported
having no vacant staff positions at the time of the annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 63 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures for volunteers, mentors, and interns who work with
youth less than ten hours a month. No volunteers, mentors, or interns during the annual
compliance review period provided services for over ten hours a month. The program sent their
Annual Affidavit of Compliance to the Department’s Background Screening Unit (BSU) on
December 18, 2024. Twenty-eight new staff were hired within the annual compliance period.
Each staff member received eligible background screenings prior to contact with the youth and
records, and criminal history reports were reviewed for each applicant. No staff required an
exemption prior to working with youth. Two staff members had a break in service and new
background screenings were completed. Eighteen applicable staff completed a passing pre-
assessment tool prior to the hire date, and the documentation was present in the staff records.
All twenty-eight newly hired staff were added to the provider’s Clearinghouse employee roster
and each staff signed a contraband attestation form. All twenty-eight applicants were located in
the staff verification system.
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.)
There are no staff applicable for five-year re-screenings during the annual compliance review
period; therefore, the indicator is rated as non-applicable.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 63 (Revised August 2025)
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures which outlines the provisions of an abuse free
environment. The procedures notate all staff, volunteers, interns, or contracted staff shall
immediately report any allegations or suspicion of an incident of abuse or harassment which has
occurred in the program to the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC), for youth eighteen years of age or older. The program
completed their Trauma Responsive and Caring Environment (TRACE) self-assessment May
14, 2025. Seven staff personnel records included evidence the staff electronically signed the
required code of conduct. Observations made during the annual compliance review week found
postings of the Florida Abuse Hotline and CCC numbers in areas visible to both staff and youth.
The program’s policy includes steps to report any allegations of abuse or neglect. The program
reported having had no substantiated incidents related to physical, psychological, and emotional
abuse for the scope of this annual compliance review. A review of CCC reports found a total of
five incidents involving allegations. None were substantiated for physical, psychological, and
emotional abuse. One was noted as substantiated for failure to report by staff and one was
noted as failure to intervene by staff. Each included evidence in each of these showing
management took immediate action to address allegations of physical, psychological, and
emotional abuse. None included evidence of any potential human trafficking, child sexual
exploitation, or labor trafficking. The program director (PD) was interviewed and was able to
give the full description of the program’s code of conduct policy. The PD also described the
policy and procedures for abuse reporting, as well as was able to summarize the program’s
trauma-responsive practices. Seven staff were interviewed and reported they have never heard
of a co-worker informing a youth they could not call the Florida Abuse Hotline. Three of seven
reported they have never heard a staff using profanity when speaking with youth. The remaining
four staff reported they have heard this; however, once or on occasion, and the context was in
general conversation or repeating what a youth said. Seven interviewed youth reported feeling
safe in the program. None of the seven youth reported they have been prohibited in calling the
Florida Abuse Hotline. All confirmed they knew the number of the hotline or where in the facility
it was located. All youth confirmed staff were respectful when speaking with them. None of the
youth interviewed reported having exchanged phone, email, or social media information with a
staff.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
A review of the Department’s Central Communications Center (CCC) reports was completed
and found a total of thirty-five reports made to the CCC for the scope of the annual compliance
review. This was an increase from the previous year of thirty-two total reports. No additional
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reports indicated a need to be made tot he CCC based on grievances and incident reports
provided and reviewed. A sample size of five CCC reports were reviewed for reporting
requirements. Each of the five were found to have been reported within the required two-hour
timeframe. All five were found documented in the program’s logbook.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a Right Interactions Plan (RI) which was updated December 10, 2024, and
approved by the Department on December 13, 2024. The program provided a binder which
included all Right Interactions incidents and Protective Action Response (PAR) incidents for the
scope of the annual compliance review. The program had a total of twelve incidents
documented. The program’s PAR rate during the annual compliance review period was 1.27,
which is below the statewide Residential PAR rate of 2.57. A sample of five total RI incidents
were reviewed. Each of the five included statements from all staff involved with the incidents.
One of the five reports had statements from each staff, but no date was included on the
statement forms. None of the incidents included the usage of mechanical restraints or resulted
in injury to youth. None of the incidents included evidence the youth alleged abuse and required
contact to the Florida Abuse Hotline. Each of the five had evidence the report was reviewed by
a supervisor or acting supervising as well as an RI instructor or RI certified supervisor. Each of
the reports reviewed contained documentation the administrator, or designee, reviewed the
report within seventy-two hours of the incident. One of the five reports indicated the incident
occurred on February 1, 2025, but the administrative review was noted as December 16, 2024.
The program administration was made aware of this and reported this was the result of human
error. The program director was able to relay the PAR monitoring process. Two of seven
interviewed staff reported they are not in a direct care position and have not utilized RI. The
remaining five staff were all able to summarize the processes when needing to utilize RI. The
staff gave examples such as they are to try and deescalate the situation initially by using verbal
interventions with the youth, also to notify the supervisor on duty.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The Department’s Learning Management System (SkillPro), staff training plans, training
records, and the program’s training tracker was reviewed for pre-service training. The program’s
instructor was qualified to deliver training. The program submitted a pre-service training plan
which was approved by the program director, the Department’s regional residential director, and
director of Talent, Leadership, and Culture. Seven reviewed pre-service records found six of the
seven records had the required 120 hours of training within the first 180 days. One staff was
short four hours for the total 120 hours. The program stated the staff has been out on extended
medical leave and has since completed all required hours. All seven staff records contained all
essential skills training required prior to any contact with youth. Two staff were missing
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additional training of Motivational Interviewing (MI) and one staff was missing effective and
respectful treatment of youth training. Five of six staff had all training required by other rules and
manuals. Two staff were missing training in the intendent and safe use of tools. None of the
staff were applicable as a newly hired supervisor. No returning direct care staff records were
reviewed. Three records for newly hired staff under 180 days of hire were reviewed and none of
these staff had completed their required pre-service training. All three staff have not been in the
presence of youth.
1.07 In-Service Training Limited 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 Department’s Learning Management System (SkillPro), staff training records, training
plans, and the program’s training tracker were reviewed for in-service training. Seven staff
records were reviewed and all seven contained more than the twenty-fours of required annual
training. Three staff were missing required training; two were missing three courses and one
was missing seven courses. All three of these staff completed the missing courses in 2025 and
are now in compliance with required training. Five staff had all trainings required by other rules
and manuals; one staff was missing two courses, and the other staff was missing one course
which has been completed during the current year’s training. Three supervisory staff had over
nine hours of supervisory training for the annual compliance review period. All training required
according to the contract were Skillpro courses and were completed. All instructors were
qualified to deliver the training provided. The program had an updated annual in-service training
plan which was approved by the regional director, director of Talent, Leadership, and Culture,
and the program director.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures which addresses the grievance process and
youth right to grieve the actions of staff or peers and conditions or circumstances of care and
treatment. Youth have the right within the program to make an informal verbal grievance or to
file a formal written grievance. Grievance forms and Request to Speak forms were observed
located accessible to youth in living areas. The forms are completed and placed in a drop box
and checked daily by staff. The grievance process includes the informal, formal, and appeal
phases. A sample of five grievances were reviewed for completion and response requirements.
Each was noted as resolved within the required timeframe. None of the five required action at
the appeal phase. The program maintains all grievances in a binder for the past twelve months.
The program director was interviewed and was able to describe the program’s policy and
procedures related to grievances. Seven interviewed staff were able to summarize the
grievance process. Seven interviewed youth were also able to summarize the process. All
seven confirmed they are able to ask for assistance in completing a grievance if needed.
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1.09 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program provides groups for The Council of Boys and Young Men as a supplemental
group. Three staff records were reviewed for provided training. The staff’s education and work
experience were considered by the program when determining staff delivery of delinquency
intervention services. All three staff were trained in the groups they are facilitating. A review of
the facility’s group schedule and sign-in sheets indicated the program is providing the groups
weekly. The program’s activity schedule was reviewed and youth are provided structured,
planned programming for greater than sixty percent of their awake hours. The program director
was interviewed and confirmed trainers are selected based on education and work experience.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program’s only life skills groups are considered primary services. The program incorporates
Living in Balance for Life Skills. Life skills activities were reviewed and found topics covered
educational life skills, health, finances, independent living, and inter-personal skills. Seven
youth were interviewed and advised they participate in life skills activities through paperwork,
and roleplaying. The program director interview confirmed youth are provided with life skills
groups. The designated mental health clinician authority interview affirmed living in balance is
an evidence-based curriculum which is provided twice a week for forty-five minutes.
1.11 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardize Program Evaluation Protocol (SPEP)
primary service at Oak Grove Academy. For details related specific to IOC service delivery,
please refer to the annual SPEP report.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
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The program has a written policy and procedures for youth alerts which determine how new
alerts are identified, documented, updated, and communicated to staff. The program’s
procedure indicates any staff member, direct care staff, case manager, clinicians, and facility
nurses may place a youth on alert status if he meets the criteria for an alert. A total of seven
Department Juvenile Justice Information System (JJIS) alerts were reviewed for the seven
youth sampled for the annual compliance review. Alerts were all entered by the required
program staff. All applicable alerts reviewed matched the program’s internal alerts and
documentation required in the program logbook. Four of the seven were entered on the date the
alert was identified. For one alert, the youth was prescribed medication, and alert was noted as
beginning June 25, 2025, but was not entered until September 10, 2025; however, according to
the medical records, the youth was taking the prescribed medication since June when the initial
alert was entered. For another youth who had an alert entered for medication, the youth was
prescribed medication on June 7, 2025, but the alert note was not entered until June 11, 2025.
One youth had an alert for suicide risk which began June 16, 2025, but was entered in the JJIS
on June 17, 2025, which was one day late. The precautionary log for this youth confirmed the
youth was on precautionary observation for the period of June 16 through June 17, 2025, as
required. Seven interviewed staff all confirmed they are made aware of youth alerts in the
program. Staff gave examples of this process such as being notified through email notifications,
shift briefings, reviewing JJIS, shift bypass information exchange, and reviewing an alert book in
the administration area. The program director was interviewed and provided a detailed
description of the program’s alert process.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains youth records into three separate binders which include the youth
individual healthcare record, individual management record, and mental and substance abuse
record. Individual management records contain all required information and are divided into the
following sections: Legal, Demographics and Chronological, Correspondence, Case
Management and Treatment Team Activities, and Miscellaneous. All records observed were
labeled ‘Confidential’ and were maintained inaccessible to youth. Records were maintained in a
locked room or filing cabinet, which was also marked ‘Confidential’.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has scheduled three advisory board meetings during the annual compliance
review period within ninety to 120 days between meetings. The program director (PD) has a
mailing list of advisory board members including a law enforcement representative, a judge,
community partners, business members, Florida Scholar’s Academy, representative of a faith
community, victim services representative, and a parent/guardian of a youth previously involved
in the juvenile justice system. The program had meetings scheduled on March 21 and June 19,
2025, and provided an agenda, email notices to board members, and a sign-in roster advising
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no outside participants were available and the program staff would discuss ways to engage the
community. The meeting on September 24, 2025, had an agenda, meeting minutes, and a sign-
in roster with community stakeholder signatures. The PD was interviewed and was able to
describe the policy and procedures for the advisory board. A board member was interviewed
and confirmed her participation, she is notified of meetings, and she enjoys participating in
meetings at the program.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures which includes an established system for
evaluating staff at least annually based on established performance standards. The program
director (PD) was interviewed and reported staff receive an initial ninety-day performance
evaluation and then annually thereafter. The PD’s interview response also included a detailed
description of the program’s policy related to the performance evaluation process. Seven
performance evaluations were reviewed for the annual compliance review period which included
evidence each staff received a performance evaluation as required. The performance standards
matched job descriptions for the staff. A sample of job descriptions, which included three coach
counselors, a night shift coach counselor, and case manager positions were reviewed which
ensured each staff’s performance standards were clearly identified. Each of these position
descriptions included reference to the program’s Behavior Management System (BMS). All
contracted positions required were maintained as outlined in contract, as the program reported
having no vacancies at this time of this annual compliance review. The program employs a
recreational therapist. A review of this staff’s educational background and records found
documentation they hold a bachelor’s degree in physical education. Four of seven interviewed
staff reported they have received an evaluation. Three of the four staff reported they have
received this annually, and one stated they believe it is done every ninety days. Two of seven
interviewed staff reported they haven’t received an evaluation yet, but they also state they
haven’t been at the program a full year. One staff reported they have received
recommendations for good behavior. A follow-up with the program was made and found this
staff did receive an annual evaluation for the scope of the annual compliance review period.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of special contract conditions was completed. Program administration provided
documentation for all information related to special contract conditions. A total of twelve special
contract conditions and contractual requirements were reviewed. The numbers of youth who
received benefit from these special services were provided along with evidence of certifications
received and training documentation. Compliance was observed and maintained in eleven of
twelve of these special contract services provided, including utilizing video chat, post release
contacts, family days, ServSafe food handler, Junior Achievement, equine training, culinary arts,
therapeutic managers, food service manager, and parent teacher conference. One requirement
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indicated staff will be trained in Motivational Interviewing (MI) as part of their pre-service training
requirements. A review of seven pre-service training records revealed two of seven staff were
missing the MI training.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures regarding data trend analysis. The program
completes monthly site operations summary (SOS) reports which are accessible to staff,
educators, and stakeholders. Monthly documentation of SOS reports was reviewed since
November 2024. The program advised they review the SOS and comprehensive accountability
reports with stakeholders at their advisory board meetings. The program also reviews key
performance indicators monthly with each department where the data is used to determine if
there are concerns and look at trends which would signify areas to be addressed.
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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.
Seven youth case management records were reviewed for initial contacts to the parent/guardian
and court notification. All seven case management records indicated parent/guardians were
notified by telephone within twenty-four hours during the youth’s admission. In all seven case
management records reviewed, the parents/guardians were notified by writing within forty-eight
hours of admission, as required. Each case management record indicated the committing court,
assigned juvenile probation officer (JPO), and post-residential case manager, if applicable, were
notified in writing within five working days of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures addressing the orientation process. According to the
program’s policy, the assigned case manager is to provide each youth an orientation during the
intake and admission process. The program utilizes an orientation checklist to explain and
discuss program rules, expectations, goals of the program, and services applicable to the youth.
Each of the seven reviewed youth case management records had documentation the youth
received an orientation, and the orientation checklist was signed by each youth on the day of
admission. Orientation included all required elements such as program rules, services available,
the daily schedule, expectations and responsibilities, the written behavior management system
(BMS) conspicuously posted and provided in the youth handbook, access to medical and mental
health services, access to the Florida Abuse Hotline, zero-tolerance policy regarding sexual
misconduct, special accommodations, right to be free from sexual misconduct, and items
considered contraband. Also included in the orientation is the performance planning process
involving the development of goals for each youth to achieve, dress code and hygiene practices,
procedures on visitation, mail, use of the telephone, expectations for release from the program,
community access, grievance procedures, emergency procedures, a facility tour, living unit
assignment, treatment team, and medical topics as outlined in Administrative Rule. A youth
orientation was observed and included all required elements. Seven youth were interviewed,
and all seven reported receiving an orientation to the program within twenty-four hours including
all the required elements.
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.
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Seven youth case management records were reviewed for written consent of youth eighteen
years or older. Of the seven reviewed, one was applicable for being eighteen years or older;
therefore, the program provided two additional records for review. The three applicable records
contained documentation written consent was obtained by the youth prior to discussing any
information related to each youth’s physical or mental health screenings, assessments, or
treatments with the parent/guardian.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures regarding classification which requires the program to
conduct an initial admission classification meeting with the youth to be attended by the therapist,
case manager, nurse, living unit representative, and parent/guardian, if available. Per policy, the
classification factors shall include a review of the youth’s physical characteristics, age and
maturity level, any identified special needs, history of violence, gang affiliations, criminal
behavior, sexual aggression or vulnerability to victimization to include the youth’s perception of
vulnerability, youth’s history of potential human trafficking, any identified or suspected risk
factors such as medical, suicide and escape or security risks, and a review of the Department’s
Juvenile Justice Information System (JJIS) Alert List for any issues affecting classification. In
addition, the program policy addresses the re-classification process in which each youth is to be
re-classified at intervals throughout their length of stay to include when warranted based upon
changes in the student’s supervision status, new/updated alerts, behavioral concerns, and
relevant information to the treatment team to ensure safety and security of the student and
program. The policy indicated several examples requiring re-classification when there is a living
unit or room assignment change, assignment to work projects or activities which involve tools or
instruments which may be used as potential weapons or means of escape, prior to level change,
increase in student privileges and advancement or freedom of movement, prior to anticipated off
campus activity, or at the request of program director (PD) or designee.
Seven youth case management records were reviewed, and documentation confirmed a
classification meeting occurred for all youth reviewed. For each youth, the program utilized
classification forms which addressed the youth’s physical characteristics, age and maturity level,
any identified special needs, their history of violence, any gang affiliation, criminal behavior,
sexual aggression or their vulnerability to victimization, the youth’s history of potential or verified
human trafficking, and any suicide risk, medical risk, escape risk or security risk. All of the seven
records included documentation regarding the review of the JJIS for alerts. Three of the
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applicable seven youth were identified as having a medical risk and had an applicable alert
entered into JJIS and the program’s internal alert list. Each youth was classified for purposes of
assigning to a living area, sleeping room, and the youth group or staff advisor. Each record
contained a classification re-assessment for any increase in the youth’s privileges, freedom of
movement or participation in work projects, or participation in off-campus activities. The PD was
interviewed and confirmed the programs policies and procedures for the classification process
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures regarding youth identified as being affiliated with
gangs to include adding an alert to the internal alert system as well as the Department’s
Juvenile Justice Information System (JJIS), documenting the affiliation in the master control
logbook, and sharing the gang information with law enforcement and the youth’s juvenile
probation officer (JPO). Seven youth case management records were reviewed and none were
applicable for gang identification and notification requirements. At the time of the annual
compliance review, the program had no applicable youth within the scope of the annual
compliance review; therefore, the program was unable to provide additional records for review.
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.
Seven youth case management records were reviewed for gang identification, prevention, and
intervention strategies. Identification of youth to participate in gang prevention or intervention
activities is based on information obtained through the program’s screening, assessment, and
classification processes, as well as gang-associated behaviors exhibited or the youth’s
expressed interest or intent while in the program. Seven youth case management records were
reviewed and were not applicable for gang identification and notification requirements. At the
time of the annual compliance review the program had no applicable youth within the scope of
the annual compliance review; therefore, was unable to provide additional records for review.
Gang intervention strategies are implemented when youth are identified as being a criminal
street gang member, are affiliated with any criminal street gang, or are at high risk of gang
involvement. Identification of youth to participate in gang intervention activities is based on
information obtained through the program’s screening, assessment, and classification
processes, as well as gang-associated behaviors exhibited or the youth’s expressed interest or
intent while in the program. Services are determined by each youth's individualized treatment
team and input from the gang coordinator. Gang prevention/awareness efforts provided to youth
at the program include the Impact of Crime (IOC) curriculum, Gang Resistance and Drug
Education (GRADE) curriculum, and informational pamphlets from the National Crime
Prevention Council and the Department of Juvenile Justice. The program’s policy and
procedures also address providing youth an opportunity, if they desire, to develop a plan to
disaffiliate with a criminal street gang. An interview with the program director (PD) confirmed the
program’s policy and procedures for providing services to youth identified as gang involved or
affiliated to include intervention and prevention strategies such as IOC.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to assess each youth using the Residential
Assessment for Youth (RAY) within thirty days of admission and reassessment within ninety
days. Seven youth case management records were reviewed, and each contained a completed
RAY within thirty days of the youth’s admission date into the program. Six of seven youth
records contained RAY reassessments at least once every ninety days after the completion of
the initial RAY Assessment. The remaining youth had not been at the program for ninety days at
the time of the annual compliance review therefore not yet due for a reassessment. In all seven
records, documentation of the process was maintained in the Department’s Juvenile Justice
Information System (JJIS).
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to complete a Youth Needs Assessment Summary
(YNAS) of each youth within thirty days of admission. Seven youth case management records
were reviewed and all seven YNAS were completed within thirty days of admission. All seven of
the records had documentation of the process maintained in the Department’s Juvenile Justice
Information System (JJIS.) All seven records indicated the youth’s top three criminogenic needs
were identified and documentation was maintained in each youth’s case management record.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
Seven youth case management records were reviewed and all seven contained documentation
the development of the individual performance plan (IPP) occurred within thirty days of each
youth’s admission. All seven IPPs were completed subsequent to the initial Residential
Assessment of Youth (RAY) and Youth Needs Assessment Summary (YNAS). All seven
performance plans were developed with the intervention and treatment team members present
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to include the treatment team leader, the youth, a representative from administration, a living
unit representative, mental health/substance treatment staff, and education staff. No youth were
applicable for involvement with the Department of Children and Families (DCF). All parties
involved signed the initial plan and a copy was mailed to the youth’s parent/guardian for
signature; however, none of the signature sheets were returned to the program by the
parent/guardian. Each record contained the signature sheet attached to the original
performance plan, sans parent/guardian signature, and was filed in the youth’s official record.
Each performance plan contained the youth’s individualized goals based on the prioritized
needs reflecting the risk and protective factors during the initial assessment process to include
the top three criminogenic needs based on the RAY and/or the YNAS. Each initial performance
plan contained specific delinquency interventions based on the RAY results, with measurable
outcomes aimed at decreasing the youth’s criminogenic risk factors, and promoting strengths,
skills, and support to reduce the likelihood of the youth reoffending. Each initial performance
plan contained court-ordered sanctions which could be reasonably completed while in the
program, transition activities targeted for the last sixty days of the youth’s anticipated stay,
target dates for goal completions, and the responsibilities of the youth and program staff to
enable the youth to complete the goals. Each initial performance plan was mailed to the
committing court/judge, the juvenile probation officer (JPO), and the parent/guardian, within ten
days of completion. Seven interviewed youth confirmed they participated in the development of
their IPP and were provided a copy of their 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.
Seven youth case management records were reviewed for performance plan revisions and
incorporation of other plans. One of the seven records reviewed was applicable for revisions to
the performance plan completed with documentation of demonstrated lack of progress toward
completing goals and newly acquired information warranted the revision. All seven youth had
additional plans, including academic or treatment plans, incorporated into their performance
plan. None of the youth were applicable for having a current behavior support plan or case plan
through the Department of Children and Families (DCF) and/or the Agency for Persons with
Disabilities (APD).
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures which indicate the program's case manager is to
complete a performance summary for each youth every ninety days after the development of
the Individualized Performance Plan (IPP) unless the committing court requests a summary at a
shorter interval. Seven youth records were reviewed for performance summaries and
transmittals. Five records were applicable, as two youth have not been at the program long
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enough for a performance summary to be due. Five applicable records showed all performance
summaries were completed every ninety calendar days following the signing of the performance
plan. Each performance summary included the youth’s status for each performance plan goal,
the youth’s overall treatment progress, academic status, and grades and credits earned in the
program. Each performance summary included a review of the youth’s behavior at school, their
overall behavior in the program, and their interactions with peers and staff. One applicable
performance summary included the youth’s motivation and readiness to change, four of the
applicable performance summaries did not include the stage of change in the performance
summary. Each performance summary included a review of the youth’s overall behavior,
adjustment in the program, and any significant positive and negative events. Documentation in
all five records reflected a performance transmittal allowed for the youth to read and add
comments prior to signing and contained a separate signature page confirming the youth was
provided a copy of the performance summary. All documentation was filed in the youth’s case
management record. All five youth records contained performance summaries signed and dated
by the treatment team leader, the staff preparing the summary if not the treatment team leader,
the program director or designee, and the youth. Each record contained documentation
reflecting a copy of the performance summary was sent to the committing court/judge, the
youth’s juvenile probation officer (JPO), and parent/guardian within ten working days of its
completion in all five records. Three closed records were reviewed for discharge summaries. All
three Pre-Release Notifications (PRN) were sent within the required timeframes and contained
the original summary, along with the justification for release. Two youth were to be directly
discharged and each record contained a copy of the signed release/discharge summary. Three
records confirmed the court approved the PRN and documented the program then provided a
written notification to the youth’s parent/guardian regarding the planned release. For each youth
approved for release, the program completed an exit Residential Assessment for Youth (RAY).
None of the reviewed records were applicable for the sexually violent predator program. None of
the reviewed records required victim notification of release per Florida Statute.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate involvement of the youth’s
parent/guardian in the case management process. The program invites the youth’s
parent/guardian to participate in the assessment process, development of the youth’s
performance plan, progress reviews, advanced notice of formal treatment team meeting dates
and times, and transition planning. If unable to attend, the program gives the parent/guardian
the opportunity to participate by telephone/video conference or provide written input prior to the
meeting. There were no treatment team meetings held during the week of the annual
compliance review; therefore, observations could not be completed. An interview with the
program director (PD) indicated parent/guardian participation in case management is
encouraged and facilitated to the extent possible and reasonable, including assessment,
performance development, progress reviews and transition planning. To facilitate this
involvement, each youth’s parent/guardian are invited to participate in intervention and
treatment team meetings for the purpose of developing their individualized performance plan,
conducting formal performance reviews of their progress in the program, and planning for the
youth’s transition to the community upon release. Seven interviewed youth confirmed parental
involvement through treatment plan development and treatment team meetings over the
telephone.
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2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
Seven youth records were reviewed and each contained documentation a formal treatment
team meeting was conducted at least once every thirty days in all records. Each formal
treatment team meeting was documented in the youth’s case management record. All seven
reviewed youth records documented an informal treatment team meeting was held on a bi-
weekly basis each month alternating with formal treatment team meetings. Each formal and
informal treatment team meeting form documented the youth’s name, the date of the review,
and all required attendees, including the youth, juvenile probation. officer (JPO),
parent/guardian, treatment team leader, program management, a living unit representative, an
education representative, a mental health representative, and a medical representative. Each
treatment team meeting documented comments from treatment team members, a brief synopsis
of the youth’s progress in the program, performance plan revisions, if applicable, and progress
for each performance plan goal. Each treatment team meeting also documented any behaviors
resulting in physical interventions, if applicable, treatment progress, Residential Assessment for
Youth (RAY) reassessment results, and each youth was provided an opportunity to demonstrate
skills acquired in the program. A treatment team meeting was unable to be observed due to the
meetings not being held the week of the annual compliance review. Seven youth were
interviewed and indicated staff talk about their performance while at the program to include
performance plan goals, positive and negative behaviors, and treatment progress. All seven
youth are able to show the skills they have learned during treatment team by talking about their
goals, how they have addressed them, and reporting on the skills they have learned.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Three closed youth records were reviewed for transition planning. All three records documented
a transition conference was held at least sixty days prior to the youth’s targeted release date.
Each transition conference plan documented the participation of the intervention and treatment
team members to include the youth, treatment team leader, program director or designee, the
parent/guardian, if available, the juvenile probation officer, the case manager, and education
personnel. Each transition plan documented a review of the transition activities on the youth’s
performance plan, identified additional transition activities as needed, identified target
completion dates, and the persons responsible for completion of goals. Each transition plan
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documented signatures and dates of the treatment team participants, which represented their
acknowledgement of the transition goals and accountability for completion. A copy of the
transition plan was mailed to individuals who participated by telephone, to be returned with
signatures. All three case management records documented the youth and the case manager
participated in the Community Re-Entry Team (CRT) meeting, which was conducted prior to the
youth’s release from the program. All three records contained documentation of the invitation to
participate in the CRT meeting sent by the probation department.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management records were reviewed for an exit portfolio. Each record
documented the exit portfolio was discussed and initiated for the youth during the transition
conference. All three records contained a copy of the youth’s transition plan and a calendar with
all dates, times, and locations of upcoming community appointments. Two youth either had a
copy of or had documentation of the purchase and obtainment of a state issued identification
card. Two records contained a copy of the youth’s birth certificate and social security card, the
remaining record had documentation the parent was asked for the documentation; however,
was never received. All three records contained documentation of any educational and
vocational certificates earned while in the program, education records, and school transcripts.
Two applicable records did not contain a completed resume, the program provided copies of the
required documentation; however, there is no way to discern if it was included in the original exit
portfolio provided to the youth upon release. The remaining youth was not applicable due to
being under the age of fifteen. All three closed records contained a completed sample of
employment applications. Each record confirmed the youth’s exit portfolio was verified during
the exit conference, and contained documentation each youth was provided a copy of the exit
portfolio upon release as well as documentation the exit portfolio was sent to the juvenile
probation officer (JPO).
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth case management records were reviewed for the Exit Conference. All three
closed records included documentation the Exit Conference was conducted after the program
notified the youth’s juvenile probation officer (JPO) of the youth’s release. All three closed
records included documentation the Exit Conference was conducted at least fourteen days prior
to release. Each closed record included documentation of the date of the conference,
signatures, and a summary with pending transition goals. All three closed records included
documentation of the youth’s date of admission and date of termination correlated with the
Department’s Juvenile Justice Information System (JJIS). All three closed records included
documentation the transition activities established at the Transition Conference and plans were
finalized and reviewed for the youth’s release. All three closed records included documentation
the following participated in the Exit Conference: intervention and treatment team leader,
parent/guardian, education representative, JPO, and youth. All three closed records included
documentation the Exit Conference was held separately from the transition and Community Re-
entry Team (CRT) meetings.
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2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures addressing the formal process to promote
constructive input by youth. This includes providing opportunities for the youth to share input on
programming, concerns, improvements, systemic issues, and recommendations through the
use of youth surveys, student government, request to speak forms, contributor club, safety
meetings, treatment team meetings, town hall meetings, maintenance requests, a problem
resolution process, and grievance forms. Reviewed sign-in sheets confirmed the program
conducts student council and town hall meetings periodically. The program also provides
surveys for youth to complete regarding their time while at the program and food quantity and
quality. Youth provide written and verbal input during informal and formal treatment team
meetings as documented in each case management record for treatment team meetings. The
program also conducts Trauma Responsive and Caring Environment (TRACE) Assessments
and the most recent assessment was completed May 14, 2025. An interview with the program
director (PD) confirmed the processes with which youth are able to share input on programming.
Seven youth were interviewed and all seven youth indicated they are able to provide input about
what happens at the program through community group, talking to staff, and student council.
2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The services
are provided through Florida Scholars Academy and the 250-day calendar was reviewed, which
is distributed over twelve months, including twenty days used for teacher training and planning.
A review of six random dates in the logbook showed the program’s daily class schedule was
being followed, coinciding with the education contract provider’s schedule times. Further review
of logbook entries and video footage for three days verified the youth were attending school as
scheduled. Seven interviewed youth reported educational services are being provided. Three of
seven interviewed youth stated there are no interruptions during school, with four youth stating
there are interruptions due to misbehaving youth, staff interventions, and sometimes staff
coming into the classroom yelling.
2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
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exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
Per the executed contract, the provider must deliver career and technical education (CTE)
services leading to career pathways and industry certifications on the master credentials list
(MCL), as approved by Florida Department of Education. Youth are to be enrolled in a CTE
program within three months of admission, with those in high and max-risk settings expected to
earn an industry certification before release. All youth must also complete Florida Ready to
Work, Occupational Safety and Health Administration (OSHA) 10, and cardiopulmonary
resuscitation (CPR)/First Aid within prescribed timelines. The review verified the provider
delivers and documents Ready to Work, OSHA 10, and CPR/First Aid as required. Identified
CTE offerings include culinary arts, entrepreneurship, and equine/horse care. While the
ServSafe Food Handler credential is offered, it is not on the MCL. The MCL ServSafe Food
Protection Manager credential was not documented as earned by any youth. The provider also
did not implement the Junior Achievement program to meet entrepreneurship training
requirements. The “All-Around Cowboy” certificate was delivered through 4-H provides basic
horsemanship training but is not MCL-recognized; however, it could serve as a pathway toward
higher-level industry credentials such as the Elanco Veterinary Medical Applications or Equine
Management & Evaluation certifications. The provider’s CTE offerings are in place but not yet
fully aligned with MCL-recognized certifications or entrepreneurship requirements. Five of seven
interviewed youth stated the program is providing CTE services through OHSA 10, Serve Safe,
and CPR/First Aid. Two youth stated they have not been at the program long enough but will be
starting soon.
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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 employs a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor and holds a valid and active license in the State of Florida. The
DMHCA’s license expires on March 31, 2027. The DMHCA was on-site as contractually
required and ensured appropriate coordination and implementation of mental health and
substance abuse services were taking place as required. The program provides specialized
treatment services and the DMHCA is the single licensed health professional responsible for the
coordination and implementation of mental health and substance abuse services. The DMCHA’s
position description was reviewed and included all required information. The program has a
back-up DMHCA who has an active and valid license which expires March 31, 2027. The
DMHCA was interviewed and reported being responsible for the coordination and
implementation of mental health and substance abuse services at the facility, ensuring youth
receive timely, appropriate, and individualized care based on their clinical needs. The program
provides group, family and individual therapy. Communication between the DMHCA and the
clinical staff at the program is consistent, collaborative, and occurs daily.
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 currently employs one licensed mental health and substance abuse clinical staff
who serves as the designated mental health clinician authority (DMHCA). The DMHCA is
licensed under the appropriate Florida statutes chapter with expiration dates of March 31, 2027.
Copies of DMHCA’s license was available on-site. All licensed mental health professionals and
licensed qualified professional’s licenses were reviewed with no noted issues.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) serves as the clinical supervisor in
the program. The DMHCA assures all non-licensed staff are performing services they are
qualified to provide based on education, training, and experience. Review of provided
supervisions logs did reflect each non-licensed metal health clinical staff working under the
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direct supervision of the DMHCA received a minimum of one hour a week of on-site, face-to-
face direct supervision. Documentation review confirmed direct supervision was recorded on the
Department’s Licensed Mental Health Professionals and Licensed/Certified Substance Abuse
Professionals Direct Supervision Log form. The program maintains a Chapter 397 license which
was observed and posted in the main lobby. The Chapter 397 license was observed with an
expiration date of March 22, 2026. The program employs three non-licensed mental health and
substance abuse clinical staff which is in accordance with contractual obligations. The mental
health staff are scheduled to be on-site Sunday through Thursday from 9:00 a.m. through 6:00
p.m. and Tuesday through Saturday from 10:00 a.m. to 7:00 p.m. for a total of thirty-eight on-
site hours Monday through Friday and eight on-site hours Saturday and Sunday. The program’s
Therapeutic Manager position was vacant from August 1, 2025, to September 16, 2025. Each of
the non-licensed mental health clinical staff holds a master’s level degree from an accredited
university or college in an appropriate human services field. The program maintains a chapter
397 license and the non-licensed clinical staff are working under the direct supervision of a
qualified professional. Documentation review confirmed each of the non-licensed mental health
clinical staff conducting Assessment of Suicide Risk (ARS) completed twenty-four hours of
training and supervised experience in assessing suicide risk, mental health crisis intervention,
and emergency mental health services
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Seven youth records were reviewed for mental health and substance abuse admission
screening. Documentation review confirmed each youth was administered a Massachusetts
Youth Screening Instrument – Second Version (MAYSI-2) upon admission. Each record
included documentation confirming the screener reviewed available information including the
commitment packet and existing reports for documentation of mental health and/or substance
abuse problems. Each MAYSI-2 screening was completed by a trained clinical staff as
evidenced by review of the Department’s Learning Management System (SkillPro). Five of
seven screenings were completed timely in the Department’s Juvenile Justice Information
System (JJIS) on the day of admission. For the two late screening, one was not completed in
JJIS at the time of the annual compliance review and the remaining screening was completed
twelve days late. Of the remaining two screenings, one was not completed within JJIS and the
other was completed twelve days late. For the two late screenings, a paper MAYSI was
completed. Each of the screenings were completed in full. Four of seven screenings required
further assessment; however, the program’s practice is to refer all youth for further screening
regardless of MAYSI-2 results. All eligible screenings requiring further assessment were
referred to the DMHCA. The program director ensured an Assessment of Suicide Risk (ASR)
was completed within twenty-four hours for all seven youth. None of the youth were placed on
Precautionary Observation (PO). Each youth was referred for an ASR and comprehensive
evaluation. The program director developed a policy and procedures for the implementation of
standardized admission/intake mental health and substance abuse screening process. The
policy included the standardized screening process which also included a review of the
commitment packet information, reports, records, administration of the MAYSI-2 in JJIS,
referrals identified by screenings, staff training in mental health and substance abuse issues
and the administration of the MAYSI-2, and a standardized process for referrals of the youth
when identified as in need of further mental health and/or substance abuse evaluation to an
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appropriate service provider, or when immediate attention is needed to a hospital or Baker Act.
The program director was interviewed and was able to describe the mental health and
substance abuse screening process.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
Seven youth mental health and substance abuse records were reviewed for mental health and
substance abuse assessment and evaluation. Each record contained a completed new
combined evaluation. Each evaluation was completed within thirty days of the youth’s admission
to the program. Each record contained evidence consent was obtained for substance abuse
services. Each evaluation was completed by a non-licensed mental health clinical and
documentation review confirmed each evaluation was reviewed and signed by a licensed
qualified professional within ten calendar days. Each new evaluation contained all required
elements such as identifying information, reason for evaluation, relevant background information
including home environment and family functioning, history of physical and sexual abuse,
neglect, witnessing violence, and other forms of trauma, behavioral functioning, physical and
mental health, substance abuse history, and education functioning. Each evaluation further
contained mental health status evaluations, interview or procedures administered, discussion of
findings, diagnostic impression which included the Diagnostic and Statistical Manual of Mental
Disorders-Fifth Edition (DSM-V), patterns of alcohol and other drug abuse, risk factors of
continued alcohol and other drug use, and recommendations.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Seven youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment services. Each initial treatment plan was developed on the day of
each youth’s admission. The programs practice is for all youth to receive an initial psychiatric
evaluation. Each youth’s initial treatment plan was documented on an initial treatment plan form
which included all required elements of the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form. Two of the seven youth’s initial treatment plans included psychiatric needs
including medication and frequency of monitoring. Each reviewed initial treatment plan was
signed by the clinical staff completing the form. All initial treatment plans were completed by
non-licensed clinical staff, and all were reviewed and signed by the designated mental health
clinician authority (DMHCA) within ten days of completion. All initial treatment plans reviewed
were signed by the youth, treatment team leader, living unit representative, and program
management. No youth was involved with the Department of Children and Families. Two of
seven Individualized Treatment Plans and reviews were applicable and included psychiatric
services. All individualized treatment plan reviews were completed on a form which contained all
elements of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
Review form. Documentation review confirmed each record contained treatment plan reviews
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which were completed every thirty days as required. Each individualized treatment plan was
completed by a non-licensed clinical staff, and each was reviewed and signed by the DMHCA.
All reviewed individualized treatment plans and reviews included signatures from the youth,
treatment team leader, program management, living unit representative, education, and medical
staff. The treatment plan reviews did not contain parent/guardian signatures or signatures of
juvenile probation officers (JPO). Documentation review confirmed parents/guardians and JPOs
participated in the treatment plan reviews by telephone. All dates of the treatment teams
matched the treatment plan review dates. All individualized treatment plans included prescribed
services, goals, and objectives which were individualized for each youth. Video footage of three
groups was observed and revealed all required groups were being held on the scheduled days
and times and for the required length of time.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
Seven youth mental health and substance abuse records were reviewed for treatment and
discharge planning. Review of records confirmed each youth was assigned to a treatment team
upon arrival to the program. Documentation review further confirmed in six of seven records, all
required team members were present. The remaining record’s review indicated parent/guardian
was not present. Documentation provided verified the program made diligent attempts to
contact parent/guardian by telephone as well as advanced notification invitation for participation.
Each youth record contained a properly executed Authority for Evaluation and Treatment (AED)
and a signed Department Consent for Substance Abuse Treatment form. Each record contained
mental health or substance abuse treatment notes documented on a form which included all
required elements from the Department’s Counseling/Therapy Progress Notes form. All seven
youth were receiving individual psychotherapy and/or counseling and psychosocial skills
training. A review of the progress notes revealed each applicable youth was receiving
substance abuse services as stipulated in the individualized treatment plans. Three closed
youth mental health and substance abuse records were reviewed for discharge planning.
Documentation review confirmed each record contained a discharge plan which was
documented on the Department’s Mental Health and Substance Abuse Treatment Discharge
Summary form, contained documentation of future services needed, was discussed with the
youth, parents/guardians, and juvenile probation officers (JPO) during the exit conference, and
a copy of the discharge summaries was provided to the youth, JPOs, and parents/guardians.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
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According to contractual requirements, the provide will provide Seeking Safety, Living in
Balance, and Anger Replacement Therapy (ART) as clinical groups. The program is contracted
to provide Substance Abuse Treatment Overlay Services (SAOS) for those youth who are
assessed and determined to be in need. The program’s counselor to youth ratio is one
counselor to sixteen youth. All non-licensed staff hold a Master’s-level degree. SAOS treatment
groups are conducted four days a week. Individual therapy is conducted once a week at
minimum. Family therapy and psychiatric services are once a month, or as needed. The
designated mental health clinician authority (DMHCA) is on-site for forty-hours a week and
clinical staff are on-site seven days a week. Documentation review confirmed each youth record
contained the number of times a youth received individual, group, and family counseling on the
individualized treatment plans. Daily therapeutic activities are provided by mental health clinical
staff. A licensed psychiatrist provides psychiatric evaluations, medication management, and
participates in treatment planning. Seven youth were interviewed, and each youth reported
participating in individual therapy once per week and family therapy once per month. Seven staff
were interviewed, and six of seven staff reported not facilitating any mental health groups. The
remaining staff reported facilitating Seeking Safety, Living in Balance, and ART groups. The
designated mental health clinician authority (DMHCA) was interviewed and reported the
program provides SAOS, individual, family, and group therapy sessions to include Seeking
Safety, Living in Balance, and ART. The program director was interviewed and was able to
describe the program’s provided specialized treatment services.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures to address the adherence to a suicide
prevention plan which safely assess and protects youth with elevated risk of suicide. The plan
details suicide prevention procedures and incorporates required elements such as identification
and assessment of youth at risk of suicide, staff training, suicide precautions, levels of
supervision, referrals, communication, notifications, documentation, immediate staff response
and a review process. The plan’s review process for suicide attempts and mortality reviews
contains required elements such as circumstances surrounding the event, relevant facility
procedures, all relevant training of involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations for change in policy,
training, medical or mental health services and operating procedures if warranted. The suicide
prevention plan was reviewed and signed by the program director and designated mental health
clinician authority (DMHCA) on September 30, 2025.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
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Seven youth mental health and substance abuse records were reviewed for suicide prevention
services. One of the seven youth records was applicable. A request was made for the program
to provide two additional records to meet minimum requirements. Documentation within each of
the three applicable records indicated how and when the youth was determined to be at risk.
Each reviewed Assessment of Suicide Risk (ASR) documented the Precautionary Observation
(PO) start date, ARS referral date, and level of supervision. Each youth was placed on constant
supervision. Each ASR was completed on the Department’s appropriate form. Each record
contained documentation of parental and juvenile probation officer (JPO) notification of the
youth’s potential risk. Mental health staff did provide daily supportive services for the duration
the youth was placed on precautions. Each assessment was completed by clinical staff under
the supervision of a licensed mental health professional. Each youth was placed on close
supervision based on results of the ASR. Each ASR was completed within twenty-four hours of
screening, completed by trained non-licensed staff and each was reviewed by the designated
mental health clinician authority (DMHCA) within twenty-four hours. Each youth’s documented
discontinuation was reviewed and signed by the DMHCA. Each discontinuation of close
supervision was documented in the program’s logbooks. Close supervision was maintained for
all three youth until it was determined to be no longer necessary by the DMHCA and a
conference was held with the program director. The actual date and time of concurrence with
the DMHCA and the program director was recorded on each ASR. No youth required a follow-
up ASR. Documentation review confirmed the program is following the written suicide
prevention plan. A review of the Department’s Juvenile Justice Information System (JJIS)
revealed all three youth had an alert entered when the youth was placed on PO. This alert was
also closed properly in the system. Each youth was allowed to participate in specific activities
while on PO, which was documented in the designated safe housing portion of each ASR. Video
camera footage was observed for precautionary observation (PO) monitoring. Video footage
review confirmed proper supervision and documentation was maintained during the time the
youth was placed on PO.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator will be rated non-
applicable.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Seven youth mental health and substance abuse records were reviewed for suicide precaution
observation (PO) logs. Only one youth record was applicable. A request was made for the
program to provide two additional youth records to meet minimum requirement. Each of the
three applicable youth records contained PO logs which were maintained for the duration the
youth was on suicide precautions. Appropriate supervision level and youth behavior was
documented in real time and not exceeding thirty-minute intervals for each youth. Two of three
PO logs were applicable and contained documentation of observed warning signs.
Documentation review confirmed notification for each was provided to the program director and
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designated mental health clinician authority (DHMCA). Each PO log was reviewed and signed
by the shift supervisor and mental health clinical staff. Each PO log documented safe housing
requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains five suicide response kits, which include the knife-for-life, wire cutters,
and needle nose pliers. The kits are in the dining hall, A cottage, B Cottage, main control, and
education. All suicide kits were co-located with first-aid kits. Fourteen staff training records were
reviewed to include seven pre-service and seven in-service. Each staff received training for
suicide prevention. A review of mock suicide drills revealed drills were held no less than
quarterly on each shift. Video review of drills confirmed simulation. All drill scenarios were in
response to a suicide attempt or serious self-injury. Practice of cardiopulmonary resuscitation
(CPR) was incorporated in the semi-annually provided training on emergency response
procedures to a suicide attempt or incident of serious self-inflicted injury. No program youth
were used in drill simulations. Seven staff were interviewed, and each was able to articulate
staff’s responsibility when a youth expresses suicidal thoughts. Some examples provided was to
notify mental health staff and place the youth on precautionary observation. The program
director was interviewed and was able to describe the program process for conducting and
providing training for staff in emergency response situations.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written Crisis Intervention plan. The crisis intervention plan contains all
required elements such as notification and alert system, means of referral, communication,
supervision, documentation, and review procedures
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
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Seven youth mental health and substance abuse records were reviewed for Crisis
Assessments. None of the records were applicable. A request was made for the program to
provide three additional records to meet minimum requirements. The program provided one
additional youth record and reported the record as the only one meeting requirements for crisis
assessment criteria for the scope of the annual compliance review period. Documentation
review confirmed the Crisis Assessment was conducted within the required timeframe and
contained all the required elements such as reason for assessment, mental status examination
and interview, determination of danger to self and/or others, initial clinical impressions,
supervision recommendations, treatment recommendations, recommendations for follow-up or
further evaluation, and notification to parent/guardian of follow-up treatment. The assessment
was conducted by a licensed mental health professional, an appropriate mental health alert was
entered into the Department’s Juvenile Justice Information System (JJIS) after the youth was
placed on precautions, and the youth remained on alert until a follow-up Mental Status
Examination (MSE) was completed. One-to-one supervision was documented on the
Department’s appropriate observation log. Upon the youth’s return from the off-site assessment,
the youth was placed on constant supervision until a mental health clinical staff reviewed the off-
site assessment documents and provided a follow-up Crisis Assessment. The follow-up Crisis
Assessment was completed by a licensed mental health clinical staff. The youth was not
identified as an alleged victim of a Prison Rape Elimination Act (PREA) event.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written emergency mental health and substance abuse plan.
Documentation review confirmed the emergency mental health and substance abuse services
plan contains all required elements such as immediate staff response, notifications,
communications, supervision, authorization to transport for emergency mental health or
substance abuse services, transport under Baker Act, transport under Marchman Act,
documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth mental health and substance abuse records were reviewed for Baker and
Marchman Act criteria. None of the records were applicable. A request was made for the
program to provide three additional records to meet minimum requirements. The program
provided two additional records meeting requirements for Baker Act or Marchman Act criteria for
the scope of the annual compliance review period. Each youth was determined to be in need of
emergency care by direct care staff. Each youth was placed on precautionary observation and
notified the designated mental health clinician authority (DMHCA). Baker Act procedures were
initiated for each youth. Both youths were transported away from the program by local law
enforcement with authorization from the DMHCA. Upon return to the program from Baker Act,
each youth was placed on constant supervision and a Mental Status Examination (MSE)
completed. The DMHCA completed the Crisis Assessment for one youth and the non-licensed
clinical staff completed an Assessment of Suicide Risk for the remaining youth which was
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reviewed by the DMHCA. Each youth’s supervision level was maintained until it was appropriate
for the youth to be stepped down to a lower level of supervision.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Seven youth mental health and substance abuse records were reviewed for safety planning
process for youth. Documentation review confirmed each safety plan was completed within
fourteen days of admission and was jointly prepared by the youth, parents/guardians, and the
program’s clinical staff. Each safety plan incorporated recommendations from previous or
current clinical assessments or screening instruments and incorporated trauma responsive
practices. Each safety plan was reviewed and updated at least every thirty-days. None of the
safety plans required updating after significant behavior or mental health event identified by the
youth’s intervention and treatment team. Each safety plan was reviewed and updated
accordingly. Each safety plan included required elements such as warning signs indicating a
youth was escalating in their behaviors, youth’s baseline behavior gathered from collateral
contacts, parents/guardians, youth history, and evaluations, the youth and program staff’s
perception of verbal and non-verbal stimuli which has positive and negative effects on the youth.
Each safety plan contained jointly developed coping strategies, to include people and healthy
environments as defined by the youth, intervention strategies preferred by the youth, and a
debriefing process. The safety plans were maintained in the youth’s case management record
and within a binder located in the program’s conference room for easy access for all staff. Five
interviewed youth reported they contributed to the development of their safety plan. The
program director as interviewed and reported Safety Plans are updated every thirty days or
following a significant behavioral or mental health event as identified by treatment team.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a board-certified physician who is a licensed physician (MD), holding an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida to serve as the designated health authority (DHA), with a license expiration date of
January 31, 2026. The DHA did not have any disciplinary cases/public complaints on record.
The DHA has designated an advanced practice registered nurse (APRN) for clinical duties, and
the APRN holds an unrestricted, clear, and active license to practice in Florida with the license
expiring January 31, 2027. The APRN’s academic specialty is in Family Health and the APRN
has a Collaborative Practice Protocol (CPP) in place. The CPP is maintained on-site at the
program. A review of sign-in/out logs during the annual compliance review period confirmed the
DHA was on-site at least once a week, with a week defined as the seven-day period beginning
on Sunday and ending on Saturday, with no more than nine days passing between each visit. If
the DHA is on vacation or scheduled absences, a back-up DHA is utilized. The back-up DHA is
an osteopathic physician (DO), with a number of equal licensure and a license expiration of
March 31, 2026. If the DHA designates another medical doctor (MD) or advanced practical
registered nurse (APRN) to provide the clinical services on-site, the actual DHA performs the
administrative duties. The program does not utilize telemedicine or telehealth services.
An interview with the DHA confirmed the DHA performs Comprehensive Physical Assessments
(CPAs), conducts chronic condition treatments and follow-ups, conducts sick call, and develops
facility operating procedures for medical care. The DHA is on-site once per week and
communicates with program staff regarding youth medical needs through the program’s nursing
staff. The DHA confirmed they are available by phone when not on-site. The DHA confirmed
provides on-site clinical services, and ensures off-site care findings, instructions, and
information is reviewed by reviewing the binder used by nurses to keep the off-site care
documentation. The DHA and nursing staff review important medical issues pertaining to the
youth at the program weekly when on-site. The DHA confirmed when not available, such as on
vacation or during scheduled absences, a back-up DHA is utilized.
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.
Daily clinical care is performed by registered nurses (RNs) or licensed practical nurses (LPNs)
according to developed and authorized protocols. A review of nurse licensure credentials for all
nurses who provided services during the annual compliance review period confirmed the
licenses were clear and active for each nurse according to Florida Department of Health
Medical Quality Assurance web site. All nursing staff have current cardiopulmonary
resuscitation (CPR) certifications, as required. According to the program’s contract, the required
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on-site hours for the nursing staff are eighty hours per week and the nursing staff is following
the contracted requirements.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) and program director (PD) signed and dated all
respective treatment facility operating procedures (FOPs). The DHA signed on January 30, the
psychiatrist signed on January 13, and the PD signed on January 29, 2025. Nursing staff
reviewed, signed, and dated the cover page on which all FOPs, healthcare protocols, and other
procedures were listed, as required. New policies or changes in policies made during the year
were reviewed, signed, and dated by each nurse on the individual policy changes which
occurred between annual compliance reviews or as signature pages added with the specific
policy listed, date of revision, and signatures, as required. The annual review of medical FOPs
and protocols was conducted and signed on January 29, 2025. All newly employed healthcare
personnel receive a comprehensive clinical orientation to the Department’s healthcare policies
and procedures, given by a registered nurse or designated, licensed health care professional,
as required. The approval of treatment protocols or standing procedures was written and
authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
Seven youth individual health care records (IHCR) were reviewed for Authority for Evaluation
and Treatment (AET) forms. For all seven youth records the original AET form or legible copy
was filed in the youth’s IHCR and was signed by the youth’s parent/guardian and Department
representative. None of the parent/guardians refused to sign the AET forms, and no youth
required a court ordered AET. All seven youth AETs were valid. One of the youth reviewed was
eighteen years of age or older, and the youth’s record included a documented release of
information once turned eighteen. None of the youth were in the care of the Department of
Children and Families (DCF). An interview with the nurse concluded new AET’s are obtained
through a youth’s juvenile probation officer (JPO); any youth turning eighteen will sign a
Release of Information form.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures regarding parental notification/consent. Seven youth
individual health care records (IHCRs) were reviewed for documentation of parental notification
for over-the-counter (OTC) medications beyond those covered by the Authority for Evaluation
and Treatment (AET). None of the youth were applicable for receiving OTC medication, as
such, the program provided three additional records. For all three applicable youth, consent was
provided by the youths’ parent/guardians. None of the youth were applicable for new
medications. Two of seven youth were taking psychotropic medication at admission, as such,
the program provided an additional record for review. For all six applicable youth, written
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notifications were sent utilizing the Department’s Parental Notification of Health-Related Care
form. A staff witnessed all telephone call attempts and conversations for psychotropic
medications for all three applicable youth. None of the youth were applicable for new
psychotropic medication prescribed or discontinued, or the drug dosage was significantly
changed. None of the youth were in the care of the Department of Children and Families (DCF).
Vaccinations were verified within thirty days of the youth’s admission in all six applicable records
reviewed. None of the youth reviewed were applicable for requiring the administration of
vaccinations. None of the records were applicable to refusal of consent for immunizations. The
program uses the electronic commitment packet prior to a youth’s arrival to determine the
youth’s immunization status. Review and sign-off of immunizations is completed within twenty-
four hours of intake.
An interview with the nurse confirmed parental notification is made when there is a significant
change in the youth condition, and/or when consent is needed for new medication and
treatment. When a youth’s illness or injury requires emergency medical services or is life
threatening, the program will notify the parents and the Department’s Central Communication’s
Center (CCC). When a youth requires new psychotropic medications, discontinuances, or
psychotropic medication adjustments, the youth’s parent/guardian is contacted while the
physiatrist is on site to get consent for new medications or change in medication and the nurse
is in the room to witness the contact. Vaccinations are provided on-site, and immunization
records are obtained through the Florida SHOTS website. Nursing staff have twenty-four hours
to review immunization records for youth who enter the program. If parent/guardians want
exemption from immunizations, they must fill out and provide an exemption form.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures for youth screened upon admission for healthcare
concerns which may require a referral for further assessment by healthcare staff. Seven youth
individual health care records (IHCR) were reviewed for Facility Entry Physical Health Screening
Forms (FEPHS). For all seven records, the FEPHS was completed on the date of admission by
a registered nurse (RN) or licensed practical nurse (LPN). None of the youth were applicable to
a change in physical custody greater than twenty-four hours. An interview with the program
nurse confirmed all newly admitted youth are seen by a nurse within an hour of arrival to the
facility. When a youth arrives at the program, the nurse receives an email notification, and the
youth is escorted to medical upon arrival. A nurse always completes the youth’s admission
screening on site. If there is a change in the physical custody of a youth after admission, a new
FEPHS form will be completed by the RN, to include a tuberculosis screening.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. All youth receive a general care
admission orientation which includes access to medical care, sick call, what constitutes an
emergency and when to notify staff, the medication process to include side effects monitoring,
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right to refuse care and how it is documented, what to do in the case of a sexual assault or
attempted sexual assault, non-disciplinary role of healthcare providers, and standard universal
precautions. The program provides monthly health education, as required by contract. Health
education includes, but is not limited to, seatbelt usage, alcohol and drug related problems,
sexually transmitted diseases/infections, tobacco products and smoking cessation, dental
hygiene and care, immunizations, infection control, prevention of sexual and physical violence,
nutrition, testicular self-examinations, parenting skills, prenatal, postpartum and parenting
education, as applicable, and chronic conditions/medications, as applicable.
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 has a policy and procedures for the designated health authority (DHA) or designee
to be notified when youth admitted require emergency care or routine notification. Seven youth
individual health care records (IHCR) were reviewed for chronic conditions. Four of seven youth
were applicable for having a chronic condition. For all four youth with known or suspected
chronic conditions, there was evidence of a referral to the physician. None of the youth were
identified as in-need of emergency care upon admission. The DHA is notified upon admission
for each youth regardless of chronic condition; all four youth had DHA notification in their IHCR
within twelve hours of admission. Two youth were taking psychotropic medication upon
admission and the psychiatrist was notified in both records. An interview with the nurse
confirmed when a youth is admitted with serious or chronic conditions, the nurse on duty notifies
the DHA immediately upon admission. Referrals to the DHA are documented on the youth’s
admission form.
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 has a policy and procedures to use the Department’s Health-Related History
(HRH) form for all youth admitted into the physical custody of a Department facility. Seven youth
individual health care records (IHCR) were reviewed for completion of the HRH. All seven youth
had HRH forms completed within seven calendar days of admission prior to the completion of
the Comprehensive Physical Assessment (CPA), as evidenced by the signature and date on the
forms. The physician reviewed the HRH form in all seven records reviewed. An interview with
the nurse confirmed the HRH is completed by nursing staff within seven days of 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 has a policy and procedures for the use of the standardized Comprehensive
Physical Assessment (CPA) form for all youth admitted into the physical custody of a
Department program. Seven youth individual health care records were reviewed and all seven
showed the youth’s physical assessment was completed on the Department’s CPA form. All
seven youth received a new CPA and each were completed within seven calendar days of
admission by the program’s DHA, and each youth’s medical grade was documented on the
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CPA. None of the youth were applicable to a gynecological exam as this is a male program. All
sections of the CPA were marked as required on all seven CPA’s, and if any portion of the exam
was refused, the DHA notated on the CPA as required. The Department’s Problem List was
updated in all seven records, as required. All seven youth received a Tuberculosis Skin Test
(TST) within seven days of admission, and the results were documented on the CPA and
Infections and Communicable Disease (ICD) forms, which matched. An interview with the nurse
confirmed a new CPA is completed within seven days of admission by the DHA and yearly, as
needed. If the youth has not had a TST within a year, nursing staff have seven days from the
time of admission to complete one.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs) and Human Immunodeficiency Virus (HIV).
Seven youth individual health care records (IHCR) were reviewed. All seven youth were
clinically screened and evaluated for STIs on the day of admission. One youth required further
evaluation and the youth was referred to the program’s medical doctor and testing was ordered
and performed. The referral was documented on the Department’s STI screening tool for all
applicable records. Testing, screening results, clinical evaluations, and diagnoses were
documented on the Infectious and Communicable Diseases (ICD) form, as applicable. All six
remaining youth refused STI testing. None of the youth were out of the Department’s physical
custody. All seven youth were offered counseling, testing and a treatment/referral for HIV. All
seven youth refused HIV testing.
The program has a policy reflecting HIV test results are only disclosed to the youth and the
youth’s legally authorized representative, health care providers during the course of
consultation, diagnosis, or treatment of the individual, the Department of Health for purposes of
reporting and control of spread of disease, health facility staff committees conducting program
monitoring, evaluation, and service reviews, medical personnel who have been subject to a
significant exposure, and health care facility personnel or agents for the healthcare provider who
have a need to know in the course of patient care activities or administrative operations. The
designated health authority (DHA) provides HIV pre-testing, post-testing and counseling
services. Seven interviewed youth confirmed they are able to ask for an HIV/Aids test. An
interview with the nurse confirmed all youth complete a STI screening form at admission. If the
form indicates a need for further evaluations, the form is flagged in the youth’s IHCR for the
DHA to review. STI screenings, evaluations, referrals, and testing are documented on the
Infections and Communicable Disease Form in the youth’s IHCR. If a youth has been out of the
program's/Department's physical custody for more than thirty days and/or symptoms present,
youth are rescreened. Youth are asked on admission if they would like an HIV test. They are
provided HIV education, counseling, and testing services and can request to be tested at any
time. HIV testing results are kept in the youth’s IHCR. The DHA provides HIV pre-counseling,
testing, and post-counseling. The process for HIV testing is documented on the DHA roster.
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
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youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures for all youth to submit sick call requests and have
complaints treated appropriately through the sick call system. Seven youth individual health
care records (IHCRs) were reviewed for sick call process. None of the seven records were
applicable for the youth presenting with similar sick call complaints three or more times within a
two-week period. Three of seven youth completed a Sick Call Request form, and the nurse
completed the appropriate section of the Sick Call Request Form. None of the records showed a
licensed practical nurse (LPN) conducted sick call; only registered nurses (RNs) conducted sick
call. The Sick Call Request forms were filed in the youth’s IHCR in reverse chronological order
in all three records. None of the youth were applicable to restricted housing of any kind. Sick call
forms or progress notes were documented in accordance with Health Services Rule 63M-2 in all
three records. The youths’ sick calls were documented on the Sick Call Index and the program’s
Sick Call Referral Log in all three records. The dates listed on the Sick Call Index corresponded
to the completed Sick Call forms located in the IHCR in all three records.
A review of the daily schedule, posted schedule, and nurse interview confirmed sick call is
conducted twice daily. The sick call hours and sick call request forms are posted and available
in the cottages and on the medical office door. Only licensed nurses conduct sick call. When
there is not a licensed nurse on-site, the program has procedures whereby the designated
health authority (DHA) is contacted to conduct sick call. An exam table and equipment are used
to perform sick call. An interview with the nurse confirmed the process for youth requesting to
see a nurse and/or physician for health complaints is to complete and submit a sick call form.
Sick call is conducted twice daily by nursing staff or the DHA if sick call is scheduled when
he/she is on-site. Sick call is conducted seven days a week, twice a day. Youth are referred to
the DHA when they have presented with repeated similar sick call complaints more than once in
a week. The program has DHA approved treatment protocols. Seven youth were interviewed
and advised a nurse will see them within one day once a sick call request is submitted. Sick call
observation was not completed as there were no sick calls submitted during the annual
compliance review.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures which include a comprehensive process for the
provision of episodic care and first-aid care. Seven youth individual health care records were
reviewed, and none showed the youth required on-site episodic or first-aid care. The program
provided three additional records for review. The on-site care was provided by licensed
healthcare staff and documented either in problem-oriented or standard narrative charting in all
three records. The program has a total of eight first-aid kits with one in education, the dining
hall, cottages A and B, the training building, and three in backpacks for the transport vehicles.
The program first-aid kits are opened/checked for issues such as expiration/deterioration and
then re-secured with pop-tabs monthly. A review of documentation confirmed the kits were
monitored, as required. An inspection of first-aid kits confirmed the first-aid kits were fully
stocked with designated health authority (DHA) approved contents.
The program has four automated external defibrillators (AED) located in Cottage A, Cottage B,
the dining hall, and education. The procedures for the AEDs are co-located with the AEDs in the
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AED box. On-site nursing staff checked to ensure the AED batteries and pads are operable.
Staff conducted a self-test of the AED in front of regional monitor during the annual compliance
review and the color of the AED battery indicator light was green. The AED batteries expire
March 2033 and December 2033, and were last changed in June 2024. The AED pads expire
November 2028, January and February 2029, and December 2033, and were last changed
January 2024. A list of emergency numbers, including the Poison Information Control Center,
was posted and accessible for non-licensed and licensed staff, but are inaccessible to youth.
The numbers are posted in the supervisor’s office located within the medical office, where youth
are not permitted. Authorized direct care staff are appropriately trained on the administration of
the epinephrine auto-injector. Seven in-service staff training records were reviewed, and training
requirements were met regarding episodic, first-aid, and emergency care.
Direct care staff participated in at least one drill which included the use of cardio-pulmonary
resuscitation (CPR) annually, as required. Video review confirmed the drills were simulated. The
drills simulated an episodic care event which calls for immediate first-aid and/or administration
of CPR techniques and the initiation of the emergency procedures to follow when a life-
threatening emergency occurs. The program maintains documentation for emergency drills.
Announced or unannounced emergency medical drills were conducted at least quarterly, on
each shift. The program did not have any episodic care events during the annual compliance
review, as such, no observations were made. The program has a policy on Narcan which states
Narcan nasal spray is to be given right away for an overdose and does not take the place of
emergency care. If a youth must use Narcan, the youth must be seen by Emergency Medical
Services (EMS). Nursing staff check monthly for expirations. The Narcan is stored on Cottage
A, Cottage B, education, master control, and the dining hall, but is accessible to all staff. Each
staff with access to Narcan has been trained on when and how to use it. The Narcan is in a
breakaway tempered glass box and is inventoried weekly during the over-the-counter (OTC)
inventory by nursing staff and monthly during AED checks.
An interview with the nurse confirmed the program has eight first eight kits; five in various
locations in the building and three for the transport vehicles. If a youth required episodic care
the nursing staff complete the care and record it on the episodic care log. If episodic care is
conducted by non-healthcare staff, the Department’s Report of On-Site Health Care by Non-
Health Care Staff form is completed. Youth sent off-site for emergency care are tracked using
the Emergency Room Report. Emergency medical drills are conducted monthly following the
program’s drill calendar. Seven youth were interviewed and all seven confirmed they could see
a doctor and dentist, as needed. Seven staff were interviewed and asked if they were personally
allowed to call 9-1-1 if a youth has a medical emergency. Six staff advised being allowed to
make the call and one staff advised the supervisor makes the call.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to provide for timely referrals and coordination of
medical services to an off-site health care provider. Seven youth individual health care records
(IHCRs) were reviewed for off-site care referrals. None of the youth required off-site care, as
such, the program provided three additional records for review. For all three youth, the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. None of
the youth required off-site emergency care. Parental notification efforts were documented for all
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three youth and discharge and other applicable documents were filed the youth’s IHCR, as
required. The designated health authority (DHA) or designee reviewed and signed/initialed all
off-site care findings, instructions, and information for all three records. None of the three youth
required follow-up appointments and there was evidence indicating the referrals were tracked
and youth received the appropriate, timely, follow-up care, as needed. An interview with the
nurse confirmed youth who are sent off-site for first-aid or emergency care needs are tracked
through consultation notes with the DHA. The DHA reviews any hospital orders and gives
consent to follow recommendations. To ensure the DHA is reviewing and initialing all off-site
care findings, instructions, and information, the forms are flagged in the IHCR. Nursing staff
track follow-up testing, referrals, and appointments in the chronic roster.
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 has a policy and procedures which ensures youth who have chronic conditions
receive regularly scheduled evaluations and necessary follow-up. Seven youth individual health
care records (IHCRs) were reviewed for chronic conditions and two youth were applicable. One
addition record was requested and received for review. The youth were identified on the Facility
Entry Physical Health Screening (FEPHS) form with a current chronic condition in each records.
None of the youth had a communicable disease. Two of the youth were taking medications on
an ongoing basis. One youth was undergoing treatment for a physical health condition. All three
youth were classified with a medical grade two or five, as one of the youth was also taking
psychotropic medications. Each applicable youth were placed on the program’s program chronic
list and received a periodic evaluations every ninety-days, as required. None of the youth were
taking anti-tuberculosis meds. None of the youth were applicable for having an evaluation
conducted off-site. The Department’s Problem List was updated in accordance with the Health
Services Rule for all three applicable youth, as required. An interview with the designated health
authority (DHA) confirmed youth with chronic conditions receive periodic evaluations every
ninety days or less, which is tracked by the program’s nursing staff. An interview with nursing
staff confirmed the program monitors youth with chronic conditions with a chronic condition
running roster which is updated with every DHA or psychiatrist visit.
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 has a policy and procedures for medication to be received, stored, inventoried,
and provided in a safe and effective manner. Seven youth individual health care records
(IHCRs) were reviewed for medication management. Two of seven youth records had the
Facility Entry Physical Health Screening (FEPHS) form and progress notes indicating the youth
was admitted with medication, as such, an additional record was provided by the program. For
all three youth taking medication at admission, the medication was verified prior to being
admitted into the program and the prescription verification was included in the Chronological
Progress Note, in the IHCR/Electronic Medical Record (EMR) and/or by utilizing the
Department’s Prescription Medication Verification Checklist. For all three records, the
designated health authority (DHA)/designee, and when applicable, the psychiatrist, was
contacted to obtain the order to resume the specified medications prescribed prior to admission.
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When current medications were continued, discontinued, changed, or new ones were ordered,
the DHA placed an order on the Practitioner Order Form in all three records reviewed. None of
the youth were applicable to restricted housing.
None of the records were applicable over-the-counter (OTC) medications not listed on AET form
being administered. Three youth were applicable to taking medications of any kind. The
standard Department Medication Administration Record (MAR) was used to document all
medication and treatment, and the MAR clearly indicated medication start and stop dates for all
three youth. Only licensed healthcare staff delivered medications, and the staff initialed each
medication entry for all three records, as required. There were no undocumented explanations
for lapses or errors in medication administration in any of the three records reviewed. The
nursing staff documented weekly side-effect monitoring on the MAR for all three records
reviewed. One record was applicable for refusing medication and the youth signed the Refusal
of Treatment form indicating the refusal, and the refusal was clearly documented on the MAR.
All seven youth records contained a MARS which included all the required elements including
name, Department of Juvenile Justice identification number (DJJID), date of birth, allergies,
precautions, Medical Grade, medical alerts, and a current picture of the youth attached to the
MAR. All three youth applicable to receiving medication while at the program initialed each
provided medication entry, as required. The remaining youth records contained a MAR, but the
youth had not received any medication while at the program. None of the youth required
parenteral medication.
There were no standing orders for psychotropic medications, emergency treatment orders for
psychotropic medication, or pro-re nata orders for psychotropic medications. Medication delivery
is the sole responsibility of the nurse/staff person during the time of administration. Medication
administration was observed by video review, as medical administration was outside the scope
of the hours of operation during the annual compliance review. Direct care staff escorted youth
to the medical office. The youth approached the nurse administering medication individually.
Only the registered nurse provided medications. Staff observed the youth to make sure the
medication was swallowed. Prescription medications were not pre-poured from original
packaging and placed in another container for subsequent administration.
An interview with the nurse confirmed medication regimens are verified by old MARs, parent
consents, and physician orders; non-healthcare staff do not verify medications. The program
uses Department MARs. Non-healthcare staff who provide medications are trained by nursing
staff and the approved staff list is kept in the MAR. Medication pass is conducted at 6:30 a.m.
and 5:30 p.m. daily. Medication prescriptions are procured by the DHA order or through a
vendor. The program utilizes a psychiatrist, on-site, and services include medication therapy. Six
of the seven interviewed youth stated the nurse gives the medication, with one youth stated they
do not take medication.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures for psychiatric services to include psychiatric
evaluation, psychiatric consultation, medication management, and medical supportive
counseling provided to youth with a diagnosed mental disorder and each youth receiving
psychotropic medication in the program. Psychiatric services are provided by a psychiatrist with
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a clear and active license, or a psychiatric advanced practice registered nurse (APRN), meeting
requirements in Florida Administrative Code. The psychiatrist has a clear and active license in
the state of Florida with a license expiring January 31, 2026. The psychiatrist is available for
emergency consultation twenty-four hours a day, seven days a week. The psychiatrist or
psychiatric APRN providing psychiatric services briefs a representative of the treatment team
regarding the psychiatric status of each youth receiving psychiatric services who is scheduled
for treatment team review. The psychiatrist or psychiatric APRN’s evaluation and
recommendations for the youth are incorporated into the mental health clinical staff’s
evaluations of the youth and the youth’s individualized mental health or substance abuse
treatment plan. The psychiatric APRN position is a designee for clinical responsibilities only. The
psychiatric APRN has a clear and active license in the state of Florida with a license expiring
July 31, 2026. The psychiatric APRN’s education, experience, and certification/licensure is in
psychiatry/mental health, as stated on the Department of Health website. The psychiatric APRN
has a Collaborative Practice Protocol in place. A review of the Collaborative Practice Protocol
with the APRN verified a copy is maintained on-site and specifies to be with the psychiatrist on-
site. A review of sign-in/out logs confirmed visits during the annual compliance review period
were conducted as required by the contract or agreement. The psychiatrist actively participates
in, manages, and supervise psychotropic medication services in the program. When duties were
delegated to the psychiatric APRN, reviewed documentation indicated the psychiatrist provided
biweekly on-site supervision of the APRN’s medication management services and was available
to evaluate and monitor youth as needed. When duties were delegated to the psychiatric APRN,
the psychiatrist was available to the APRN by telephone or by another communication device
when not physically available on the premises. The program did not utilize a back-up
psychiatrist during the annual compliance review period. The program does not provide
telepsychiatry.
An interview with the nurse confirmed medication is destroyed by two nurses and controlled
medication is destroyed with a nurse and the pharmacy consultant. Controlled substances are
locked in a lock box on the medication cart which is also locked. A consultant pharmacist is on-
site monthly. Their duties are to ensure medication is stored properly and medication given is
documented properly. The program maintains a copy of a pharmacy consultant license on-site,
which is a Consultant Pharmacy License (CPH), as required. Documentation confirmed the
program maintains a copy of the Exposure Control Plan which is in the health services
administrator’s (HSA) office. The HSA conducts infection control training for staff, and youth
training is provided by medical staff yearly. Medical staff are responsible for providing training to
staff on the program’s Exposure Control Plan. Medication is locked in the medication cart, and
the pill pack is counted when the first pill has been removed. The interviewed psychiatrist
confirmed they evaluate new admissions and access for medication, complete psychiatric
evaluations and medication evaluations, as well as contact parent/guardians on record for
comments. The psychiatrist is on-site every two weeks and stated they meet with the clinical
team as needed, as well as on call for telephone communication when a youth is admitted and
to discuss any medical issues as they occur.
Seven youth records were reviewed for psychiatric services. Two of the youth were applicable
for entering the program on psychotropic medications. The program provided an additional
record for review. All three youth were referred for a psychiatric interview. Each youth was
admitted on psychotropic medications and received a diagnostic interview within fourteen days
of admission, as required. For all three youth reviewed, the Initial Diagnostic Psychiatric
Interview included all the required elements. The interview was completed on the Department’s
Clinical Psychotropic Progress (CPPN) form for all three records and was clearly identified as
the “Initial Diagnostic Psychiatric Interview.” When the initial psychiatric diagnostic interview
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resulted in the prescription of psychotropic medications or changes to the youth’s existing
psychotropic medication regimen, page three of the CPPN was completed, as required. The
reviewed documentation supported the youth were seen for a medication review by the
psychiatrist or psychiatric advanced practice registered nurse (APRN), at a minimum, every
thirty days in in all three records reviewed. For all three youth, all the required documentation on
page three of the CPPN was completed when psychotropic medication was
prescribed/dispensed/administered by the psychiatrist or psychiatric APRN. The program does
not use telepsychiatry.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures regarding medical equipment classified as sharps
and 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 medical equipment classified as sharps (e.g., syringes, needles, scissors,
and suture removal kits) were secured and inventoried utilizing a routine perpetual inventory
descending count as each sharp was utilized and disposed, as required. All medications were
identified and secured in the locked area designated for storage of medications, and different
medications such as injectable, topicals, drops, liquids were separated. All controlled
substances have a perpetual inventory and are stored separately from other medications. All
medications are stored in a separate, secured (locked) area, inaccessible to youth. Narcotics
and other controlled medications are stored behind two locks. Medications which require
refrigeration are stored in a secured refrigerator, which is used for medication only. The
program’s process for discontinued medications includes filling out a form which includes the
medication information and returning it to the pharmacy. Perpetual and weekly inventories of all
sharps and stock over-the-counter (OTC) medications were completed as required. Pursuant to
Board of Pharmacy regulatory requirements, there are shift-to-shift inventory counts of all
controlled substances documented on the youth’s Individualized Controlled Medication
Inventory Record. Three supervisory-level, non-healthcare staff are trained in the delivery and
oversight of medication self-administration, which was delivered by the program’s registered
nurse (RN). Counts were conducted for the one controlled substance currently in use at the
program, three OTC medications, and three sharps, and all counts matched the ending
inventory numbers. If the medication cannot be accounted for due to discrepancies or
errors/omissions, after attempts by medical staff, the regional supervisor, and program director
(PD) are automatically contacted to conduct camera review. If the medication still cannot be
accounted for, the Department’s Central Communications Center (CCC), prescribing
practitioner, and parent/guardian is notified (if applicable), and a root cause analysis is
completed and reviewed with the medical department, pharmacy, office of health services, and
PD.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
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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 had a facility operating procedure (FOPs) to include implemented Infection Control
procedures including prevention, containment, treatment, and reporting requirements related to
infectious diseases, as according to Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
FOPs were signed by the program’s designated health authority (DHA) and program director
(PD) on September 20, 2025. The infection control procedures include all the required
elements. Hepatitis B immunizations are available for all staff and staff have access to
protective equipment. There were no instances in which the local county health department,
CDC, and/or Department’s Central Communication Center (CCC) should have been notified of
an infectious disease. The PD has established a separate file used for containing all documents
for youth and staff who have experienced a facility/occupational exposure. The exposure control
plan was written in accordance with OSHA standards and is available to all staff. The plan is
reviewed and signed annually by the administration of the program and/or designees and was
signed September 20, 2025. The program’s process for needle stick post-exposure evaluation
includes the PD arranging for a confidential medical evaluation, follow-up post-exposure
analysis and counseling as required by the OSHA standard. The PD established a separate file
maintained for youth and staff who have experienced a facility/occupational exposure. There
were not three or more cases of any reportable infectious diseases which needed to be reported
to the local county health department and/or CDC during the review period.
4.20 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures addressing youth supervision. Observations were
made daily at the program during the annual compliance review week. During the week, youth
were primarily observed in the classrooms for education. Other observations made included
breakfast, movements, and recreation. During these observations, staff to youth ratio pursuant
to contract of one to eight was met. All observed movements revealed staff ensured youth were
lined up, searched properly, obtained proper count, and a request to move was called to master
control. Movement to the next location did not happen until cleared by master control. During
the week, there were positive interactions observed between staff and youth. One incident was
observed where a youth needed additional counseling, to which the staff maintained a
professional and positive demeanor, ensuring the incident did not escalate further. Three staff
were asked how many youth they were supervising. Each of the staff were able to articulate the
number of youth they were supervising accurately.
The program considers active supervision to be providing safety and security of the youth and
staff and ensuring the program’s mission, goals, and outcomes can be achieved 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 changes in behavior,
and consistently applying the program’s behavior management system. It shall be the policy of
the program to ensure proper staffing ratios as established by the Department and as set by
contract. Staffing ratios consist of one staff to eight youth during awake hours and one staff to
twelve youth during non-awake hours. A daily activity schedule is posted and available to youth
in each living cottage. During the annual compliance review, it appeared all youth were engaged
in a full schedule of activities through observations made. Observations of youth rooms
confirmed windows were not covered or heavily scratched. There were no documented escapes
during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the program’s behavior management
system (BMS). A review of the program’s BMS revealed appropriate parties were involved in the
development and implementation. An agreement between the program and school related to
BMS was found posted in classrooms. A review of documentation showed BMS training is
completed each week with the education staff by the director of group living. A review of seven
youth case management records confirmed youth orientation included the program’s BMS
practices. Five position descriptions were reviewed, each showing the job functions include the
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implementation of the program’s BMS. A review of seven pre-service training records reflected
staff have completed training in the program’s BMS. Observations made during the week
revealed BMS postings on each of the youth cottages, the dining hall, and in the education
classes. There was no posting in the Charlie classroom; however, the program made sure to
have the BMS posted in the classroom prior to the end of the review week. The rules governing
conduct and positive and negative consequences were found in areas accessible to youth. The
program’s BMS was documented in the youth handbook. No revisions to the program’s BMS
have been required. The program’s BMS meets all requirements as outlined within Florida
Administrative Code, contract, and included all required elements. The BMS does not include or
encourage increase length of stay, denial of youth’s basic rights or services, promotion of group
discipline, punishment of youth by other youth, or disciplinary confinement. A few staff and
youth interactions were observed, each adhered to the elements outlined with the program’s
BMS for behaviors demonstrated. The program’s BMS allows for a variety or rewards and
incentives. Such examples include, but are not limited to, off-site trips, snacks, special activities,
video games, different dress attire, and later bedtimes. The BMS included a process wherein
staff explain to the youth the reason for any sanction imposed, the youth is given an opportunity
to explain their behavior, staff and youth discuss the behavior’s impact on others, reasonable
reparation for harm caused to others, and alternative acceptable behavior.
Seven staff were interviewed and were able to explain parts of the program’s BMS. All staff
notated there are steps to the BMS, and youth must have consistent good behavior to move up
through the levels. Staff agreed, no basic rights can be taken away from youth as a
consequence. Staff also noted examples of rewards are home passes, video games, outings,
snacks, and ram bucks to use for the program store. All staff notated when a youth is informed
of their consequences to their behavior, they are given the opportunity to explain their
behaviors. The youth are provided the opportunity to speak with the staff and the supervisor.
Seven youth were interviewed about consequences for negative behavior. All youth stated they
can be given early bedtime for negative behavior, while six youth also stated they will not
receive leisure time. Six of seven interviewed youth notated various incentives which can be
earned through positive behavior, such as snacks, off-site trips and special activities. One youth
stated there are not really any incentives. Five of seven youth stated the staff are consistent
with the BMS, while two stated staff show favoritism. Each of the seven youth demonstrated
knowledge in the difference in the BMS levels and how they are able to move from level to level.
Two youth stated youth are allowed to punish other youth, with the ability for RAMs to write on
the daily progress note. The program director (PD) was asked about the potential of youth
punishing other youth, to which it was stated the program had its first ever RAM (highest level)
within the last week. No youth are allowed to fill out other youth progress notes or punish youth.
The PD was interviewed and was able to relay the policy regarding the implementation and
consistency of the BMS program, the BMS rewards and consequences.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a total of fifty-three cameras, of which all are operational. An informal
interview with the program director revealed cameras have a recording capacity of thirty days.
Observations of ten-minute checks were conducted to reflect if checks were conducted in the
required frequency and in real time and to ensure the checks are met with fidelity. Nine separate
thirty-minute intervals of ten-minute checks for the last thirty days were observed by logs and
video review. The program does complete ten-minute checks at a minimum of approximately
eight minutes. Staff were seen conducting room checks, stopping at doors, looking into the
room, and recording findings in an eight to ten-minute period. A sample of logs to verify ten-
minute checks throughout the annual compliance review period were reviewed. The samples
included one thirty-minute increment from each of the nine months for both shifts while youth
were in their rooms; all checks were completed as required with the exception of four instances
where checks were one-minute late. Seven staff were interviewed about how often room checks
are conducted when a youth is placed in their room for sleeping. Six of seven staff stated the
checks are conducted in ten-minute increments while one staff was not sure. It should be noted
the one staff who did not know is a transition manager and does not conduct supervision of
youth during sleep hours. The program director was interviewed regarding operation of security
cameras. It was revealed the program has fifty-three cameras, all operational, recording for
thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures regarding youth census, counts, and tracking.
Program staff shall be able to account for the whereabouts of youth under their supervision at all
times. The program’s system for accounting of youth requires the physical counting of youth at
various times throughout the day. Staff shall conduct and document counts minimally at the
beginning of each shift, after each outdoor activity, and during emergency situations such as
escapes or riots. An observation of counts being conducted revealed radio calls made to master
control during youth movement. Master control also conducts headcounts every thirty minutes.
A review of logbooks, one day of eleven months, annotated census, counts, and tracking are
captured accordingly with no exceptions for beginning of each shift, after outdoor activity,
emergency situations, daily census, head count, youth movements, transfers, and youth
temporary away from the program. Seven staff were interviewed, each identified youth counts
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are conducted every thirty minutes. Additionally, staff were able to identify practices necessary
when a youth count cannot be reconciled or when an emergency count is required.
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 chronological record of events, incidents, and activities in a central
logbook maintained at master control. A sample review of logbook entries for each month during
the review period demonstrated the program has maintained compliance with logbook and shift
report entries with no exceptions. The logbooks were bound with numbered pages, entries
made with ink, no entries were destroyed or removed, errors struck though with single line, and
entries included date and times, staff with signature and youth involved and brief descriptions.
The program’s logbooks document emergency situations, incidents, special instructions for
supervision and monitoring of youth, population counts, perimeter security checks, transports,
law enforcement requests, admissions and releases, and information relating to escapes. A
copy of the program’s reporting practices is maintained and accessible of logbooks to staff to
review for up to forty-eight hours. Living unit logbooks also indicated education classes being
conducted as scheduled, with arrival and departure of youth.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures addressing key control. The maintenance supervisor
is designated as the key control manager for the program and is responsible to govern the
control and use of keys, issuance of keys to all staff, maintenance of the inventory of keys and
inventory logs, making changes to key assignments, locations or duplication, retrieval of keys
from terminated staff, ensuring proper functioning of keys, quarterly checks of emergency keys
for proper functioning, annual key control audit, and ensuring all personal keys are secured and
accounted for. The maintenance staff shall act as assistant key control officer. Shift supervisors
shall be responsible for the inventory and issuance and return of keys from shift to shift. Keys
are classified as active, file, restricted, and emergency keys. Shift supervisors shall be
responsible for the issuance of keys each shift. Keys are issued to staff upon arrival for the
assigned shift by the shift supervisor. Staff must sign in and out assigned keys prior to and
following each assigned shift. When a staff member arrives on duty, they are responsible for the
issued set of keys. Shift supervisors will check the key cabinet area and log before the
beginning of the shift to ensure all keys have been appropriately signed for and returned at the
end of the previous shift. Staff should keep possession of keys at all times. Staff must keep keys
securely on their person where they are not accessible to youth at any time. Youth are never
permitted to access keys. Keys should be carried and used as inconspicuously as possible.
Keys should be carried in the front pants pocket or kept in their hands at all times. Keys should
not be hooked to pants or strapped around the staff neck. Staff should exchange keys hand to
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hand, never tossing or throwing keys. The numbered key ring should be confirmed when
exchanging keys from one staff member to another. Staff should avoid making reference to key
numbers or identifying information when in the presence of youth. In the event a staff member
mistakenly takes keys off the premises, communication should occur as soon as the error is
noted and keys must be immediately returned to the shift supervisor. The shift supervisor must
document the incident and report it to the program director (PD). Permanent issued keys are
kept to a minimum and must be authorized in writing by the PD. Personal keys shall not be
permitted in operational areas of the program where youth could gain access. All personal keys
shall be turned into master control upon entry to the facility. All personal keys will be secured in
a secured lock box. All key boxes shall be secured when not in use. All visitor keys will be
secured by master control staff upon entry into the program. Keys will be secured upon arrival;
visitors will be asked to sign into the facility and will be provided with general visitor instructions.
Vehicle keys shall be secured when not in use. Transporting staff shall be responsible to check
out and return all facility vehicle keys used in the transportation of youth. The shift supervisor
shall be responsible to ensure all vehicle keys are placed back into the locking cabinet following
use. The PD will ensure keys are checked back in and secured. Restricted keys are only
accessible to authorized staff who are assigned to specific job functions requiring restricted key
use. The following positions are assigned access to restricted keys: personal property storage,
food storage, health / medical areas, youth records, staff records, evidence storage, clothing
and hygiene, and maintenance. The PD is responsible for the inventory and tracking of all
program keys to include issuance, verification activities and tracking of keys including retrieval
of keys from terminated staff. All keys are maintained on a tamper proof, sealed number key
ring. Every key has a tag indicating the number of keys which are contained on the ring. A log of
all keys, keys rings, and assignment is maintained in the key inventory notebook. Permanent
issued keys are authorized in writing by the PD and is maintained by the maintenance
supervisor for verification and review. Quarterly inspections of emergency keys and an annual
key audit are conducted by the PD. Inspections and audits will verify keys, locations, inventory
and assignments as well as functioning of keys. All program keys are maintained in secure key
boxes which are locked when not in use. Un-issued keys are stored in a locked safe. Access to
the un-issued keys is limited to the PD and maintenance staff. Program vehicle keys are stored
in a locked cabinet in a locked area. A back up set of vehicle keys is stored in the double locked
office in the maintenance shop, only accessible to the PD and maintenance staff. In the event of
misplaced or lost keys, the immediate supervisor, maintenance supervisor, and PD shall be
notified. Staff shall indicate which keys were lost, when the loss was discovered and any
circumstances surrounding the loss. A written incident report shall be submitted as soon as
possible to the PD. A search shall be conducted immediately, and all youth movement will
cease to ensure the securing of living units and surrounding areas. Youth and staff will be
interviewed in an effort to obtain important and immediate information as to the last known
whereabouts and pertinent security information of the missing keys. Staff responsible for the
missing keys shall not leave their assigned shift until released to do so by the PD or designee. If
keys cannot be located, the PD may authorize re-keying the effected locks. Until the keys are
found or the locks are re-keyed, staff must ensure the security of youth and stand post in
accordance with supervisory direction. The PD must notify the residential director and the
Department’s Central Communication Center (CCC) when applicable for all missing keys to the
program, which cannot be located within two hours. Damaged keys shall be reported to the shift
supervisor and returned to the maintenance supervisor, who will be responsible for discarding,
updating inventories as applicable, and the issuance of replacement keys.
The distribution of keys was observed; the master control operator searched visitors and
requested keys, handed out chits for each set of keys. By end of day, chits were turned in and
keys handed back to each person. Security of doors and mechanical and electronic locks shall
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be formally checked during perimeter security checks on each shift. There were no incidents
reported to the CCC or deficiencies related to key control during the annual compliance review
period. An informal interview was conducted with the master control operator; only staff who are
allowed to have access to medical, mental health, and kitchen may check out restricted keys.
The program’s method for the daily tracking and reconciliation of keys is active-duty key sets will
be issued out to employees for the period of time they are on duty. Staff members/teachers turn
personal keys in to the master control operator located in the lobby, or secure in the staff
lockers located at the program entrance. The staff will retrieve their facility keys from the staff on
their assigned unit. Upon completing the shift or leaving the program the staff member will
return their facility keys to the master control operator and enter the time and initial the entry in
the daily key log. This process facilitates inventory of the keys and allows the master control to
know whether a set of keys has been returned or not. Each key ring includes a tag indicating the
number of keys on the ring. Upon receiving their duty key set, the employee will verify the key
set and the number of keys on the set. If the key count is incorrect, they will immediately notify
the shift supervisor of the problem. Observation of the key storage area was found located on a
wall in master control. The key box is locked with only a few people having access to
distribute/take up keys. The key inventory was reviewed to ensure the inventory matches the
actual key rings in use. Five keys were reviewed, of which each matched the inventory sheet for
key location, key number, accuracy on key log, and the correct number of keys on each key
ring. Three staff were informally interviewed to ensure they know the function of each key on
their key ring. Each of the three staff had an accurate set of keys, per the master key inventory,
and knew the function for each key on their assigned key ring. Seven staff were interviewed and
confirmed key accountability practices within the program.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system in place to prevent contraband entering the facility which includes
the program defining items/material considered contraband, providing youth with a list of
contraband, searching the physical plant, searching the facility ground, searching the youth, and
searching incoming and outgoing mail. The program’s visitor log also contains a contraband
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attestation form which all visitors are required to read prior to signing into the program. A review
of twenty-eight new hire records indicated each staff has completed a contraband attestation
form at the beginning of their employment. The program policy and procedures address any
staff who is found in possession of contraband in a program will be subject to disciplinary action
up to and including dismissal as outlined in Florida Administrative Code. Law enforcement is to
be contacted if any found item would be considered illegal as defined in Florida Statutes, or if
there is evidence of any type of unlawful activity. The program clearly delineates the items
which are to be considered contraband. The program had one incident of contraband, which
was documented, and the item was turned over to law enforcement. All searches are notated in
the facility logbooks.
The program director interview revealed the program provides for safety and security and
control of the introduction of materials considered contraband into the program. The program
shall adhere to the Department’s guiding principles which have been set forth as the foundation
in addressing contraband. Search practices shall be initiated to assist in prevention, detection,
and removal of all items considered contraband or unauthorized within the program. All staff
shall be trained to properly identify contraband items and the steps required for removal of
contraband. Search practices and observations shall be conducted throughout the facility and
shall include searches of youth, visitors, property, facility grounds, and the program’s physical
plant. All staff shall be diligent in efforts to prevent the introduction of contraband into the
program. Staying alert at all times, being observant in all supervision, and the execution of
appropriate search techniques will greatly enhance the ability to maintain safety and security
within the program.
Seven staff were interviewed about the program’s process for room searches and indicated
searches are completed at least one time each day.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures addressing search practices. Youth searches were
observed on two separate days of the annual compliance review. All youth were searched with
fidelity. The searches appeared to be in compliance with Right Interactions (RI) training and
policy. Two youth were brought to the program for intake. Both youth were searched upon their
arrival to the program, being searched with the wand and then frisk searched. The vehicle was
also searched for contraband. Each youth searched was treated with dignity and respect, and
searches were conducted with the appropriate number of staff and gender. A review of video
revealed five staff and five visitors were also searched thoroughly, in compliance with RI training
and policy. No youth searches were observed before and after visitation as there were no
visitations completed during the week of the annual compliance review and no youth searches
were observed upon return from off-campus activities as there were no off-campus activities
during annual compliance review week. No youth searches were observed following access or
ability to obtain tools or other equipment as no youth had access to tools during the annual
compliance review. Seven staff were interviewed and each staff was able to identify when youth
searches are conducted, however none of the staff articulated the process of how to search
youth. Seven youth were interviewed on when searches occur and each indicated searches are
conducted after every movement.
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5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has two vehicles used to transport youth. Both vehicles had an annual safety
inspection completed, along with monthly inspections. The program maintains a transport bag
which contains the vehicle fire extinguisher, first-aid kit, seatbelt cutter, window punch, and
vehicle logbook. Both vehicles were in good operational repair with the correct amount of seat
belts and the door to the youth passenger area was not able to be opened from the inside. A
review of five staff vehicles were also checked and found to be secured.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has written policy and procedures addressing transportation of youth and met all
requirements A review of seven staff records revealed each had a valid Florida Driver’s License.
A cellular telephone is issued to staff while conducting youth transports. Staff also take their
assigned radios on transports as well. A youth transport was observed and was found in
compliance with the staff-to-youth ratio. There were two staff and two youth, of which each staff
and youth were wearing their seatbelts. There was also one staff of the same gender as the
youth on the transport. The program human resource staff completes an approved driver check
on a monthly basis and forwards to the program director to ensure all staff operating program
vehicles have a current driver’s license. There was no indication of youth being permitted to
drive a program or staff vehicles. Seven staff were interviewed and each was able to identify
youth use seatbelts and a cellphone and or radio is carried during transports. Additionally,
safety equipment is in the transport vehicles. All seven staff confirmed they are not allowed to
use personal vehicles to transport youth. Staff agreed transport vehicles are searched for
contraband prior to and after each use. Staff were also able to explain the emergency response
process during a vehicle transport if necessary.
Seven youth were interviewed, and all agree they have never been handcuffed to any part of
the transport vehicle. In addition, none of the youth have ever witnessed anyone placing
contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures addressing weekly safety and security audits. The
program director (PD) or director of group living is responsible for conducting weekly security
and safety inspections. Corrective actions, when warranted, shall be developed and
implemented based upon the identified safety and security deficiencies found during any
internal or external review, audit, or inspection. The PD shall ensure a review of the findings are
submitted to the Department, along with a verification of all deficiency corrections and shall
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implement improvements when needed to maintain compliance, all according to the
requirements of Florida Administrative Code. A review of documentation showed safety and
security audits were completed each week throughout the annual compliance review period,
except for two weeks during the month of December. Documentation provided showed
preventative maintenance is completed quarterly and sent to residential operations.
The PD was interviewed about the process in identifying and tracking safety and security
deficiencies and how they are addressed by the program. The program provides for program
safety and security and to control the introduction of materials considered contraband into the
program. Weekly security audits and safety inspections shall be completed in an effort to
maintain a safe and secure physical plant, grounds, and perimeter. Corrective actions, when
warranted, shall be developed and implemented based upon the identified safety and security
deficiencies found during any internal or external review, audit, or inspection. The PD shall
ensure review of the findings, submission to the Department, verification of all deficiency
corrections, and shall implement improvements when needed to maintain compliance.
5.13 Tool Inventory and Management Limited Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing issuance, inventory, and control of
equipment and tools. A review of documentation showed tools are inventoried prior to being
issued for work and following work activities. All tools are inventoried daily such as sharp-edged,
pointed tools, except on days not used. The program prohibits machetes, bowie knives, and
other long blades. The program was maintaining a monthly inventory of tools which do not have
sharp edges or points; however, the inventory was not accurate. There was no documentation
provided for sharps inventory prior to August. A review of ten tools, including sharps in the
kitchen, revealed the shadow board does not match the master inventory. All tools had
identifying marks, although none of the tools matched the master inventory sheet. There was
also no documentation of quantity of tools notated. Residential leadership did provide
documentation from an internal audit which was conducted in September which revealed the
issues with tools and sharps. The program was given a corrective action date of October 19,
2025, to correct the deficiencies. The program maintains procedures for missing/lost tools. Any
missing/lost tools will be documented. The program director (PD) and director of group living will
be immediately notified. Sign in/out logs will be reviewed to see when the tool was last used.
Inventory will be referenced to ensure the tool is missing. All areas and youth will be searched.
If the item is not located within two hours, the Department’s Central Communications Center
(CCC) will be notified, and corrective action will take place if necessary. There were no incidents
during the annual review period where any tools needed to be replaced. An informal interview
with maintenance revealed if a tool needs to be replaced, it will be documented and then
replaced by the PD or director of group living.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures regarding supervision requirements when youth use
tools. The policy and procedures also cover issuing tools to youth and staff, including an
assessment to determine a youth’s risk to self and others. Ratios are established during
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activities involving tool use, one to five, and disciplinary work projects, one to three. A review of
seven youth records showed the youth were trained on the intended and safe use of tools and
each youth had a completed risk assessment. There was no observation made of youth with
tools during the review. An informal interview with maintenance revealed youth are observed at
a one staff to two youth ratios while using tools. Proper personal protective equipment is
assigned to the youth and all youth are searched prior to leaving the work area. Seven staff
were interviewed and confirmed youth use mops and brooms along with other tools, as long as
the youth pass the tool test. All staff confirmed which youth will only use tools under the
supervision of staff. Seven youth were interviewed and confirmed which various tools are
utilized, under direct supervision, and once the youth pass the test on tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has written policy and procedures addressing outside contractors. The program
will maintain strict control of secure storage and the purchase of tools and sensitive items. All
tools are to be considered as possible weapons as they can inflict great bodily harm, no matter
what class they are assigned to. All tools and sensitive items will be strictly under the control of
the physical plant manager. It is the responsibility of the physical plant manager and program
administrator to monitor use of all tools and equipment in this program. All violations or misuse
of tools and equipment are reported to administration and corrective action is initiated. Any tools
brought on-site from the outside, the program shall closely monitor the use of tools when
brought into the facility or onto facility grounds. When a repair person or other worker comes on-
site from the outside community with the tools of their trade, program staff should alert them to
the potential danger of tools used on grounds and request them to limit the tools used to only
those necessary to complete the job. In addition, staff are to check tools when they arrive and
leave, keep close track of tools while working on-site, and immediately notify program staff if
any tool missing. The outside worker or repairman will sign an acknowledgment form indicating
all tools must be inventoried upon entry into the program and exit from the program. This
acknowledgment shall be recorded on the appropriate inventory form. When outside workers
are on-site with tools, program staff should restrict youths’ access to the work area to the extent
possible, closely monitor the situation, and vigilantly supervise youth at all times. When the work
is completed, staff shall check the work area to ensure the repair person takes all tools (and
toxic substances, if applicable) with them when they leave. If any tool brought on-site under
these types of circumstances is found to be missing, staff shall take immediate action per the
program’s procedures. Three project invoices were provided for work completion. Sign-in logs
for each project verified vendors signed-in, were searched prior to work, completed the
guidelines form, and tools were checked at the beginning and end of the project. The program
director is responsible for providing approval/permissions for items required to complete projects
such as personal cellular phones or other electronic equipment capable of taking photographs
or audio/visual recording.
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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.
A review of the ten months during the annual compliance review period revealed drills are
conducted monthly across each of the program’s three shifts. All drills rotated through various
disaster and continuity of operations planning (COOP) drills and fire drills. Documentation for
each drill contained the type of drill, date and time, participants, brief scenario, and findings and
recommendations. Fire evacuation routes and egress plans were observed posted throughout
the program. A review of documentation reflected the fire extinguishers were inspected
annually, with the last annual inspection being completed May 2025. The program maintains
twenty-nine fire extinguishers. A review of each fire extinguisher revealed twenty-six fire
extinguishers had all monthly checks completed, with three missing checks for the month of
September. Seven staff were interviewed, and each identified having participated at a minimum
a fire drill in the past twelve months. Seven youth were interviewed, and each confirmed they
have been instructed on what to do in case of a fire. The program director was interviewed and
stated the program is to be well prepared to operate in the event of unforeseen circumstances
such as a fire, medical situation, adverse weather, man-made disasters, or other emergencies.
In order to do so, the program will conduct emergency drills to ensure staff and youth alike know
how to effectively respond to an emergency.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has written continuity of operations plan (COOP), addressing the basic care and
custody of youth in the event of an emergency or disaster. The programs’ COOP plan is located
in master control and the director of group living office, readily available for staff. The COOP
plan addresses alternative relocation sites approved by the applicable Department regional
director. The COOP was last reviewed and updated on February 25, 2025. The COOP plan was
last submitted to the Department for approval on March 12, 2025. The program’s COOP plan
was inclusive for equipment and supplies required for continuous operation and services during
emergency or disaster situations. The program’s practice for taking youth records with them
during an emergency, is to bring along the COOP youth binder located in master control, along
with medical and case management records, facility logbooks, and educational paperwork.
Seven separate youth records were reviewed. Four of seven records contained all critical
identifying information. Three records did not notate victim information, but did contain all other
information. The program director was interviewed and stated the COOP plan is located in
master control, available to all staff to access.
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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 has a written policy and procedures addressing the storage and inventory of
flammable, poisonous, and toxic items and materials. Observation of flammable, poisonous, and
toxic items (e.g. bleach, gas, cleaners, pesticides, antifreeze, etc.) were found to be secured at
all times and inaccessible to youth. The program maintains a list of positions authorized to
handle and disposal of flammable, toxic, caustic, and poisonous items. A review of ten separate
chemicals were observed. Each of the ten chemicals had an accurate count on the inventory,
which matched what was observed. Each chemical was secured and had Safety Data Sheets
(SDS) located in the same area as the chemicals. The programs disposal written procedures
appear to be in accordance with Occupational Safety and Health Administration (OSHA)
standards. An informal interview with maintenance revealed disposal of all substance is
documented in the disposal log and the program has not had to dispose of any hazardous
waste. The program has disposed of dirty mop water and or unused beverages (kitchen waste)
down drains located in the kitchen area. The program has not encountered any chemical spills
requiring any clean-up however if necessary, and spill will be relayed to maintenance and
administration, shut-down of ventilations systems and windows and doors, and will contact
outside assistance if necessary. The program director was interviewed and provided the
following addressing disposal practices for flammable, toxic, caustic, and poisonous items.
Disposal of hazardous chemicals is accomplished within parameters of state, local and federal
laws. The maintenance staff is responsible for the safe and lawful disposal of these items. Only
maintenance or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous waste or solid waste shall be responsible for disposing of hazardous
items and toxic materials. Dispose of hazardous items and toxic substance or chemicals in
accordance with OSHA standards.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handling and supervision of
flammable, poisonous, toxic items and materials. The youth are not allowed to handle
flammable, poisonous, and toxic items, and they will not have access where these items are
being used and stored. As they are considered potentially hazardous or dangerous, youth will
not be permitted to clean, handle, or dispose of any other person’s bio-hazardous material,
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bodily fluids, or human waste. All flammable, poisonous, and toxic fluids must remain secured
when not in use. All flammable materials (paints, fluids, gasoline, etcetera.) are stored in a metal
fireproof safety secured locker. All hazardous chemicals no longer used or outdated will be
disposed of by returning them back to the venders or hazardous waste center and in
accordance with the safety data sheet (SDS). All chemicals are stored in locked
cabinets/closets. SDS are completed and posted as required by the Occupational Safety and
Health Administration (OSHA). A video observation was made of youth cleaning. The video
review showed staff spraying sinks with the chemicals and providing youth rags and with mops.
No youth were observed handling any chemicals. Areas of where chemicals are stored are
restricted to any youth access. Seven youth were interviewed, one youth stated he was able to
pour gas, two stated they are able to paint, and five stated they do not use chemicals or
cleaning products. Program administration was notified about the interview results of a youth
handling gas. The program director ensured the handling of gas by youth is strictly prohibited.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 63 (Revised August 2025)
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has written policy and procedures addressing visitation, youth correspondence
(mail), and use of telephone. Visitation postings were observed in each of the youth cottages,
dining hall. and administrative building. Documentation was reviewed which showed visitation is
conducted each Saturday as posted. The program provided documentation showing completed
calls and incoming/outgoing mail for each youth. The program provides alternative visitation with
parents/guardians in the form of Zoom calls if necessary. There were no instances of a youth
with a history of human trafficking. There was no incoming/outgoing mail to be observed for
search practices. Seven youth were interviewed, and each agreed they can call a
parent/guardian or send a letter. The program director was interviewed and stated the program
utilizes language line for translation services for youth whom English is not their primary
language.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program’s activity schedule prepares the youth for an array of supervised and structured
indoor and outdoor recreational and leisure type activities. Large muscle activities are provided
to youth at a minimum one hour each day. A review of the program logbook indicates recreation
was conducted as scheduled. Activities at the program promote social and cognitive skill
development, along with creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. While on-site, recreational activities were observed, and measures were taken
to ensure youth and staff were safe to eliminate any physical stressors. The program’s contract
requires a recreation therapist, of which all requirements were met. A review of seven youth
records documented the inclusion of the recreation therapist input in the youth’s individualized
performance and/or treatment plan. Seven youth were interviewed, and each agreed they are
provided at least one hour of indoor or outdoor activities such as basketball, football, volleyball,
weight-lifting, and eighteen-twenties repetition exercises. Seven staff were interviewed and were
able to articulate types of indoor and or outdoor activities youth participate in at the program.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 63 (Revised August 2025)
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 63 (Revised August 2025)

source: DJJ

program_name_raw: Oak Grove Academy

rule: Indicator 1.07

rule: Indicator 5.13

excerpt: Tool Inventory and Management