summary: QI Residential - FY25-26 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Palm Beach Youth Academy
Rite of Passage, Inc.
(Contract Provider)
9680 Weisman Way
West Palm Beach, Florida 33411
Review Date(s): January 27-30, 2026
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:
Serena Brown, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Lidia Clarke, Florida Youth College, Workforce Development Manager, South Region (Standard
2)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Amari Exalien, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Interviews)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Palm Beach Youth Academy MQI Program Code: 1417
Provider Name: Rite of Passage, Inc. Contract Number: 10341
Location: Palm Beach County / Circuit 15 Number of Beds: 78
Review Date(s): January 27-30, 2026 Lead Reviewer Code: 226
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 68 (Revised August 2025)
O v e ra ll R a tin g S u m m a ry
T h e fo llo w in g lim ite 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 .
Lim ited R atings Failed R atings
5.04 Ten M inute C hecks*
This m onitoring report reflects the D epartm ent’s assessm ent of program com pliance w ith applicable standards during the established review period. M onitoring reports represent a snapshot of program operations and
docum entation at the tim e the review w as conducted. W hen areas of lim ited or failed com pliance are identified, the D epartm ent w orks w ith the provider through established processes to address those issues and ensure
corrective actions are im plem ented as outlined in FD JJ 2000. Follow -up m onitoring, verification activities, and corrective action processes are used to confirm identified deficiencies are addressed and program s return to
com pliance w ith applicable standards.
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 68 (Revised August 2025)
In d ic a t o r R a t in g s
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 P ro g ra m m in g 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
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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 68 (Revised August 2025)
In d ic a t o r R a t in g s
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 l A c c e s s (R e s id e n tia l C o n tra c t 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
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff* Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning* Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Suicide Prevention Plan* Satisfactory
3.10 Suicide Prevention Services* Satisfactory
3.11 Secure Observation* Non-Applicable
3.12 Suicide Precaution Observation Logs* Satisfactory
3.13 Suicide Prevention Training* Satisfactory
3.14 Mental Health Crisis Intervention Services* Satisfactory
3.15 Crisis Assessments* Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services* Satisfactory
3.17 Baker and Marchman Acts* Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 68 (Revised August 2025)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission Screening & 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/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Conditions/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 68 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision* Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks* Limited
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test* Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Overall Rating Summary for Standard 5
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 68 (Revised August 2025)
Program Overview
Palm Beach Youth Academy is a seventy-eight-bed program for thirteen to eighteen-year-old
males, located in West Palm Beach, Florida. The program is operated by Rite of Passage, Inc
through a contract with the Department. The program provides Mental Health Overlay Services
(MHOS) and Substance Abuse Treatment Overlay Services (SAOS). In addition, the program
fosters each youth by providing delinquency programming including Impact of Crime (IOC),
Aggression Replacement Training (ART), Coping with Stress: A Cognitive Behavioral Therapy
(CBT), Adolescents Coping with Depression (CWD-A), Trauma Focused CBT, Seeking Safety,
and health and sexuality education. Additional treatment services provided include individual,
group, and family therapy, pre-vocational and vocational services, job training placement, self-
sufficiency planning, recreational and leisure time activities, religious/spiritual opportunities, and
rehabilitative justice philosophy programming. Program administration is comprised of a
program director (PD), two directors of group living (DGL), a designated mental health clinician
authority (DMHCA) who serves as the clinical director, a registered nurse (RN) serving as the
health services administrator (HSA), a director of student services (DSS), a training and
compliance manager, a community liaison, a human resources coordinator, a physical plant
manager, and a food services manager. Case management services are provided by the DSS,
and five case managers. Mental health staff at the program include a DMHCA, a licensed
therapeutic manager, an additional licensed therapist, three master’s-level non-licensed
therapists, and one recreation therapist. Medical services are offered and are provided by a
contracted licensed medical doctor (MD) who serves as the designated health authority (DHA),
one HSA who is a full-time RN, one additional full-time RN, one part-time RN, one pro re nata
RN, and one licensed practical nurse (LPN). Educational services are provided through the
Florida Scholar’s Academy/Florida Virtual School. The layout of the program includes two living
phases comprised of six total living units. The program has one hundred twenty-two operating
security cameras providing coverage. The program had no reported vacancies during the week
of the annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 68 (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 maintains a written policy and procedures to ensure all newly hired staff and
volunteers receive an initial background screening. The program had thirty-four newly hired staff
since the last annual compliance review. A review of the staff records found thirty-three staff
received a background screening prior to contact with youth and confidential records, and one
staff record showed the initial background screening was in progress. Documentation reflected
a criminal history report was reviewed and the Department’s Staff Verification System (SVS)
module was updated for each staff. None of the reviewed records were applicable for obtaining
an exemption prior to working with youth. One of the reviewed staff had a break in service as
indicated in SVS, and documentation supported the staff had a new background screening
completed prior to working with youth. The program utilizes a pre-employment assessment tool
for all direct care staff. Reviewed documentation reflected each of the applicable newly hired
staff received a passing score on the pre-employment assessment tool prior to hire.
Documentation supported each of the thirty-four newly hired staff had a signed contraband
attestation form in their record.
1.02 Five-Year Rescreening Non-Applicable
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
There have not been any staff applicable for a five-year rescreening during the annual
compliance review period; therefore, this indicator is rated as non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 68 (Revised August 2025)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures which provides an environment for staff,
youth, and others to feel safe and secure from any form of abuse or harassment. The program’s
policy requires the Florida Abuse Hotline and the Department's Central Communications Center
(CCC) telephone numbers to be posted and accessible to all. A tour of the program confirmed
the Florida Abuse Hotline and CCC numbers were posted throughout, allowing unhindered
access for youth and staff to report allegations of abuse. A review of nine staff records indicated
all staff signed the code of conduct documentation in the employee handbook. The program’s
steps to report abuse when a youth requests to make a call is for the staff to provide the youth
with telephone access in a controlled observable area to make a confidential call. Then, the shift
supervisor is notified and a call to the CCC is made within two hours of the program becoming
aware of the incident. Staff will document any incident number generated by other agencies in a
logbook. The program had three allegations of abuse in the program during the annual
compliance review period. Reviewed documentation confirmed two staff received written
reprimands and the third incident was still under investigation. All incidents were documented for
having evidence management took immediate action to address allegations of abuse. The
program completed the Trauma Responsive and Caring Environment (TRACE) self-assessment
on February 13, 2025. The program director (PD) was interviewed and stated the staff code of
conduct prohibits physical abuse, threats, intimidation, harassment, profanity, or any form of
degrading or inappropriate behavior towards youth and reinforces zero tolerance for abuse,
neglect, or exploitation. If such conduct occurs or is alleged, immediate action is taken to ensure
youth safety, including removal of the staff from direct youth contact, mandatory reporting to the
Florida Abuse Hotline, and required notifications to the CCC and program leadership. The
incident is then investigated in cooperation with oversight authorities, with disciplinary action up
to, and including termination taken as warranted, and corrective measures implemented to
ensure compliance and accountability. According to the PD the program incorporates trauma-
responsive clinical services, including individual, group, and family therapy, within a supportive
residential environment, helping youth build emotional regulation, resilience, and personal
growth while addressing behavioral health and mental health needs. The program maintains a
clear, mandatory incident reporting process for any suspected or alleged abuse, neglect,
abandonment, or exploitation. All staff are trained and mandated reporters who immediately
report concerns directly to the Florida Abuse Hotline without internal screening, while taking
prompt action to ensure youth safety. Nine youth were interviewed, and all youth indicated they
felt safe at the program and have never been stopped from reporting abuse to the Florida Abuse
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 68 (Revised August 2025)
Hotline or CCC. All youth responded they knew where to locate the telephone numbers for
contacting the Florida Abuse Hotline and CCC. All youth agreed staff speak respectfully and
have never heard staff using profanity towards youth. One youth stated staff are polite when you
need to talk to them. All nine interviewed youth reported they never exchanged telephone
numbers or social media contact information with staff. Nine interviewed staff were asked about
allowing a youth to call the Florida Abuse Hotline. Each staff reported youth are allowed to make
calls if needed, staff will notify the supervisor, and the shift supervisor, case manager, or PD will
give the youth the call. All nine staff stated they have not observed a youth being denied an
abuse call. Six out of nine staff agreed they never observed other staff using profanity toward
youth. Three staff reported they occasionally observed staff using profanity towards youth.
Additionally, staff explained they observed program staff using profanity while staff and youth
were in a disagreement. It was reported this issue has been addressed with staff in monthly
meetings.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures for documenting and reporting incidents.
The program’s policy requires the program to notify the Department's Central Communications
Center (CCC) within two hours of gaining knowledge of an incident. The program had fifty-one
CCC incidents reported during the annual compliance review period. A review of nine incident
reports confirmed all incidents were reported within two hours. A review of the program’s
logbook confirmed all nine incidents were documented. The program experienced an increase
in reportable incidents to the CCC since the last annual compliance review. An informal
interview with the program director (PD) confirmed the program had an increase in contraband
incidents since the last annual compliance review.
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 maintains a written policy and procedures to ensure the proper use of Right
Interactions (RI) techniques by staff. The program submitted all RI incident data to the
Department on or before the fifteenth of every month during the annual compliance review
period. The program’s RI training plan was submitted to and signed by the Department’s Office
of Talent, Leadership, and Culture (TLC) on December 2, 2025. The program had sixty
incidents of utilizing RI during the annual compliance review period. Nine RI Reports were
reviewed, and all reports were completed by the end of the staff’s shift and included statements
from all staff involved. Mechanical restraints were not utilized in any of the RI incidents. One of
the nine RI Reports indicated injury to the youth or staff, and the Department's Central
Communications Center (CCC) was contacted within two hours. None of the incidents were
applicable for a youth alleging abuse. All nine reports documented a review by an RI certified
instructor and shift supervisor. The reviewed reports confirmed a post-RI interview was
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 68 (Revised August 2025)
conducted with each youth by the program director (PD) or designee to assess the need for
further medical review. Four of the nine RI Reports were applicable for medical review, which
was conducted no longer than thirty minutes after each incident. All nine reports were reviewed
by an administrator within seventy-two hours of the incident. The program’s RI rate during the
previous quarter was 2.06, which is below the statewide Residential RI rate of 2.94. Eight of
nine interviewed staff were direct care staff trained in RI. All applicable staff stated RI is used to
de-escalate situations with youth. During an interview with the PD, it was confirmed the program
monitors RI incidents and use of force through immediate reporting, supervisory review, and
administrative oversight. They reported all incidents are documented promptly and reviewed to
ensure interventions were necessary, proportionate, and consistent with approved behavior
management and de-escalation practices.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program maintains a written policy and procedures outlining the pre-service training and
certification requirements for all new staff. Staff are required to complete a minimum of 120
hours of training within 180 days of hire. Nine staff records were reviewed, and each staff
exceeded 120 hours of training. Prior to any contact with youth, and according to the training
policy, each staff completed skill training in cardiopulmonary resuscitation (CPR), first-aid, and
automated external defibrillator (AED), emergency procedures, the program’s operating
procedures, Prison Rape Elimination Act (PREA), professionalism, interpersonal
communication, and ethics, including standards of conduct, Right Interactions (RI) and suicide
awareness and prevention. Additional training included active shooter preparedness, adolescent
development and behavior, balanced approach to rehabilitative justice, the Department’s
Central Communications Center (CCC) incident reporting, civil rights, communication, and
confidentiality/Health Insurance Portability and Accountability Act (HIPAA). In addition,
Department of Juvenile Justice (DJJ) legacy, equal employment opportunity, gang awareness,
human trafficking intervention, infection control/bloodborne pathogens, information security
awareness, the Department’s Juvenile Justice Information System (JJIS), mental health and
substance abuse, Motivational Interviewing (MI), quality report writing, safety, security, and
supervision of youth, sexual harassment, effective and respectful treatment of youth, and
trauma responsive practices trainings were completed. Training in the grievance process,
infection control, the Exposure Control Plan, behavior management system, and the intended
and safe use of tools were completed by all staff in accordance with the program’s policy. A
review of three staff who were still within their first 180 days of hire were reviewed. Each staff
was complying with their training plans and completed training in child abuse recognition,
reporting, and prevention, CPR, AED, emergency procedures, program operating procedures,
PREA, professionalism, interpersonal communication and ethics, RI, and suicide awareness
and professionalism. Each staff received specialized service training in the program’s treatment
models, to include Mental Health Overlay Services and Substance Abuse Treatment Services.
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1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a written policy and procedures ensuring all staff maintain the necessary
training to meet the needs of the program and youth in their care. The program has an annual
in-service training calendar/plan which updates as changes occur. The plan was submitted prior
to implementation and was approved by the highest-ranking official at the location, the assistant
secretary for Residential services, and the director of the Department’s Office of Talent,
Leadership, and Culture (TLC). Nine staff records were reviewed for in-service training. All staff
exceeded the twenty-four hour training requirement. Each staff completed trainings in active
shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking, information security awareness, mental health and
substance abuse, Prison Rape Elimination Act (PREA), Right Interactions (RI), professionalism,
interpersonal communications and ethics, sexual harassment, suicide awareness and
prevention, trauma responsive practices, emergency response and emergency drills, infection
control, blood-borne pathogens, the Exposure Control Plan, Mental Health Overlay Services,
and Substance Abuse Treatment Overlay Services Four of the staff records reviewed were for
supervisors, and all three completed training in coaching, leadership, and personal
accountability. All instructors were qualified to deliver the training provided.
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 maintains a written policy and procedures for the youth grievance process. The
program’s policy requires each youth to be treated fairly and not discriminated against by
program staff for exercising their right to grieve. The program’s grievance process includes
three phases, including an informal, formal, and appeal process. Grievance forms were
observed on each living module during the program tour. The grievance box was observed in
the west and east wing hallways. An informal interview with the program director (PD) confirmed
the informal phase process includes youth utilizing the program’s Request to Speak form to
communicate with their case manager and/or the grievance coordinator. The grievance box is
checked daily by the grievance coordinator and grievances are discussed in the morning
department head meeting. The program’s practice correlated with their policy, and the program
maintained copies of the grievances for the past twelve months. A review of eleven grievances
confirmed the program filed the grievances in a program binder. Seven out of eleven grievances
were resolved during the informal process and four were resolved during the formal phase.
Each grievance included the date of grievance, response date, and resolution. Each was
resolved within the required time frame. Nine youth were interviewed and each stated grievance
forms are placed throughout the program. Eight youth indicated the grievance process included
three phases and six youth stated each phase has a time frame. All nine-youth agreed they can
receive assistance when completing a grievance form. Nine interviewed staff reported grievance
forms are accessible throughout the program and youth can request assistance in completing a
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grievance form. Four of the nine staff stated the supervisor and PD reviews grievances. The PD
was interviewed and was able to explain the steps for youth completing a grievance and
appeals process.
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
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 maintains a written policy and procedures for providing life skills training to the
program youth. The program’s policy requires treatment curriculum focusing on developmental
and social skills. The program provides Positive Organizational Change (POC) and Positive
Skills Development (PSD) groups. Both groups included activities addressing communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
critical thinking, problem-solving, and decision-making. The program addressed the needs of
the program’s target gender group. A review of the sign-in sheets from January 18, 2025, to
January 26, 2026, for the PSD groups confirmed youth were provided with life skills training
three times a week. A review of the sign-in sheets from January 18, 2025 to January 26, 2026,
for POC groups confirmed the group was held twice a week on the weekends. The groups
provided youth life and social skills services/activities as required. Additional life and social skill
intervention services provided at the program were health/hygiene education, educational life
skills, inter-personal, financial, independent living, and employment skills. The designated
mental health clinician authority (DMHCA) was interviewed and stated licensed and non-
licensed mental health professionals provide group, individual, family, and supportive sessions.
The program’s recreation therapist provides therapeutic activities. Nine interviewed youth stated
they participated in POC and PSD groups and were learning skills on problem-solving and how
to express their feelings. The interviewed program director (PD) confirmed POC and PSD
groups were the current curricula used to address the specialized needs of the population.
1.11 Rehabilitative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Palm Beach Youth Academy. For details related specific to IOC service
delivery, please refer to the annual SPEP report.
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1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures outlining the process for which staff
should identify, document, and update alerts, and how alerts are entered into the Department’s
Juvenile Justice Information System (JJIS). This allows alerts to be accessible to staff and
keeps them alerted to youth who pose a risk to security or safety, including escape, sexual
offending and other assaultive or violent behavior risks, suicide, and/or other mental health
concerns, and health-related concerns, including food allergies and special diets. Alerts include
security or safety risk, escape risk, suicide, mental health risk, health related concerns, sexual
offender risk, assaultive or violent behavior risk, and suspected gang affiliation alerts. A review
of the program’s internal alerts binder showed it correlated with JJIS for updated youth alerts. A
review of nine youth records showed youth were identified with alert risks and were placed in
the alert system. None of the alerts observed were entered late. All alerts documented were
observed in the alert book and shift reports. The interviewed nurse stated nursing staff are
responsible for updating the alert system followed by the health services administrator (HSA),
who reviews the alert system to make sure information is correct. The interviewed program
director (PD) stated alerts are entered into JJIS by designated clinical, medical, or
administrative staff based on their area of responsibility and are updated as conditions change.
Staff are informed about youth alert information or changes to alerts during daily briefings, alert
boards, treatment team meetings, through supervisors, by email, and from JJIS.
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 a written policy and procedures for maintaining all the program’s youth
healthcare and case management records. The program’s policy requires the program to
protect and store youth records in a secure cabinet. Observations during the program tour
showed the Individual Healthcare Records (IHCRs) and individual case management records
were stored separately in a secure records cabinet labeled confidential. IHCRs were further
divided into medical and mental health and substance abuse records. Each youth’s individual
case management record contained the youth’s name, Department identification number, date
of birth, county of residence, and committing offense. Additionally, each individual case
management record contained sections for legal information, demographics and chronological
information, correspondence, miscellaneous, case management, and treatment team activities.
All observed records were labeled “confidential” and were securely maintained.
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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 maintains a written policy and procedures to establish a community advisory
board. The program’s policy requires the program to have quarterly meetings with stakeholders
and community partners, who serve as support to the program. The program’s community
support and advisory board quarterly meetings were held on February 10, May 19, August 12,
and December 2, 2025. A review of meeting notification emails, sign-in sheets, agendas, and
meeting minutes confirmed the program director (PD) solicited active involvement from law
enforcement, Florida Scholar’s Academy, faith, business, judiciary, and other community
partners. A parent/guardian of a youth formerly involved in the juvenile justice system and a
victim advocate were recruited by the PD. None of the advisory board meetings were
rescheduled within the quarter. Email documentation confirmed the program attempted to hold
virtual meetings for board members’ convenience. According to the interview with the PD, the
advisory board members include stakeholders, service providers, educators, faith-based
representatives, and program leadership. During the annual compliance review week an attempt
to contact an advisory board member was conducted. A message was left and no return
telephone call was received.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures for evaluating staff, performance
standards, and the frequency of evaluations. Staff are evaluated during their first ninety-days of
employment and then annually thereafter on their established performance standards. A review
of nine staff position/job descriptions was conducted and determined each staff’s performance
standards were clearly identified. Nine staff personnel records were reviewed, and each staff
received an annual performance evaluation, as required, which was based on established
performance standards. A review of nine staff position descriptions confirmed each staff’s
performance standards were clearly identified and the performance standards matched the job
descriptions. An interview with the program director (PD) confirmed the program has a system
in place for evaluating staff and ensuring staff promote accountability, professional growth, and
quality service delivery. The PD indicated the program’s management team actively monitors
staffing patterns, uses recognition and appreciation initiatives, promotes clear communication
and supportive supervision, and provides opportunities for professional development and
advancement. An interview with nine staff was conducted, and seven staff reported they receive
yearly evaluations, two stated evaluations are conducted quarterly, and one stated evaluations
are conducted monthly.
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1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program shall implement all items or services either negotiated or outlined in the contract,
and applicable Memorandum of Negotiation. These items typically exceed the minimum
requirements outlined in Florida Statutes and Florida Administrative Code. Special provisions
identified in the program’s contract include the use of trained volunteers, mentors, and other
members from the community to provide positive modeling and experiences with youth, the
provision of regular faith-based opportunities encompassing all faiths, and opportunities for
community involvement. The community involvement opportunities shall include supervised
community service hours, and/or participation in group community service projects. The contract
requires specific staffing and corporate oversight to include a regional clinical director who visits
the program at least once a month, a chief executive officer (CEO) who comes on-site twice
each year, a regional human resources staff who is on-site once each quarter, and a community
liaison who is responsible for fostering ongoing community partnerships. Sign-in logs confirmed
the required staff were providing oversight at the required frequencies. A review of activities
binders, case management records, visitor sign-in logs, and staff logs, in addition to interviews
with the program director and training coordinator, supported the program was meeting the
contract requirements. Speakers, mentors, and religious activities included multiple guest
speakers, training camps, mentorship group visits, community church service attendance,
baptisms, a charity walk, letters to law enforcement, and youth coordinating with supervisors for
the completion of on-site community service. Community service logs were maintained in each
youth’s exit portfolio.
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 maintains a written policy and procedures which address data trend analysis
components. The program’s administration and management policy addresses research efforts
to enhance operations and contribute to the base knowledge of juvenile justice. The program
tracks trends using an electronic system. The provider-wide data collection platform distributes
reports and analyses data on-demand. The platform is used for discussions in a weekly call with
all Florida regional directors. Documentation review confirmed Right Interactions (RI) incidents,
grievance, and behavior management reports are tracked. The program conducts weekly safety
and security audits. The report identifies any deficiencies and potential issues within the
program and anticipated resolution dates. Information and data collection is shared with
providers quarterly through a virtual meeting platform and as needed for emergent situations.
Stakeholders meet quarterly to discuss and share program practices. The community advisory
board assists in trend analysis information and program support. The program shares the
collected data on a weekly basis with the provider’s statewide directors and regional operations
team. During the meetings, the program director (PD) discusses trends and program
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occurrences to review for potential policy changes, procedural changes, and/or needed program
support.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a written policy and procedures ensuring initial contacts with
parents/guardians and court notifications are completed. A review of nine youth case
management records confirmed the program notified each parent/guardian by telephone within
twenty-four hours of admission. Each of the nine applicable reviewed records confirmed the
program notified the parent/guardian in writing within forty-eight hours of the youth’s admission.
Documentation review confirmed the court, juvenile probation officer (JPO), and applicable post
residential counselor were notified within five working days of each youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program maintains a written policy and procedures regarding youth orientation. The
program’s orientation included services available, daily schedule, expectations, and
responsibilities of youth. The written behavior management system (BMS) was posted
throughout the program and provided in a handbook to allow easy access for youth. The
orientation included rules governing conduct and positive and negative consequences for
behavior, availability of and access to medical and mental health and substance abuse services,
and access to the Florida Abuse Hotline, or if a youth is eighteen years old or older, the
Department’s Central Communications Center (CCC). Youth orientation included the program’s
zero-tolerance policy regarding sexual misconduct, including how to report incidents or
suspicions of sexual misconduct. Special accommodations were available to ensure all written
information about sexual misconduct policies, including how to report sexual misconduct, was
conveyed verbally to youth with limited reading skills or who were visually impaired, deaf, or
otherwise disabled. Additionally, orientation topics included the right to be free from sexual
misconduct, right to be free from retaliation for reporting such misconduct, the agency’s sexual
misconduct response policies and procedures, items considered contraband, including illegal
prohibited items in which possession may result in a youth being prosecuted, the performance
planning process involving the development of goals for each youth to achieve, dress code, and
hygiene practices. Furthermore, orientation services included procedures on visitation, mail and
use of the telephone, expectations for release from the program, including each youth’s
successful completion of their Individualized Performance Plan (IPP) goals, recommendations
to the court for release based on the youth’s performance in the program, and the court’s
decision to release, community access, grievance procedures, emergency procedures,
including procedures for fire drills and building evacuation, program tour, assignment to a living
unit and room, treatment team, and if applicable, a staff advisor or youth group. During the
annual compliance review, the program had an admission. An observation was completed with
the youth and program staff. The youth was screened in the intake area. The youth was
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searched, drug tested, and provided bed linens. A therapist met with the youth to complete the
orientation process, and the youth was assigned to a residential case manager and therapist.
The youth was assessed for medical and mental health concerns during the admission process.
Upon completion of the medical assessment with the nurse, the youth was assigned to a living
unit. Nine youth were interviewed and reported their orientation to the program included
program rules, procedures, and schedules. Each youth explained the orientation process and
reported the orientation to the program was conducted within twenty-four hours of admission.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures regarding obtaining written consent of
youth who are eighteen years of age or older. Nine records were reviewed and no youth were
applicable for being over the age of eighteen. Three additional applicable youth case
management records were reviewed. Each reviewed youth case management record confirmed
a written consent was obtained before the release of information related to the youth’s physical
or mental health screenings, assessments, or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program maintains a written policy and procedures regarding the classification process for
youth upon admission to the program and the completion of reassessments as warranted. A
review of nine youth case management records confirmed each record contained an Admission
Classification form which included all required elements. The program’s classification form
included physical characteristics of each youth, age and maturity level, identified special needs,
history of violence, gang affiliation, criminal behavior, sexual aggression or vulnerability to
victimization, youth’s perception of vulnerability, youth’s history of potential or verified human
trafficking, suicide risk, medical risk, escape risk, and security risk. Nine youth case
management records each documented the date of the youth’s classification, included all
elements on the classification form, and confirmed they were completed on the day of
admission. A review of the Department’s Juvenile Justice Information System (JJIS) alerts, and
the program’s internal alerts indicated two youth had an alert due to suicide risk, seven had a
medical alert, and four records were applicable for a security risk alert. Each of the nine youth
were classified for purposes of assignment to a living area, sleeping room, and youth group or
staff advisor. Reclassifications were conducted for each of the nine reviewed youth and
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revealed there was an increase in each youth’s privileges or freedom of movement. Reviewed
documentation confirmed the program’s policy and procedures clearly outlined the classification
process and included a classification system promoting safety and security, and effective
delivery of treatment services, based on the determination of each youth’s individual needs and
risk factors. The program’s policy regarding reassessment ensures all program youth may be
re-classified at intervals throughout their length of stay. Staff shall reclassify youth when
warranted based upon changes in youth supervision status, new or updated alerts, behavioral
concerns, and relevant information to the treatment team to ensure safety and security of each
youth and program. An interview with the program director (PD) confirmed the program
considers multiple individualized factors when assigning youth to a living unit and sleeping
room. Placement decisions are informed by each youth’s mental health and physical health
status, cognitive functioning, age, developmental needs, prior victimization, and overall safety
considerations. Clinical, medical, and supervisory staff collaborate to ensure housing
assignments promote safety, compatibility, supervision needs, and therapeutic support, with
placements reviewed and adjusted as needed to protect youth well-being.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program maintains a written policy and procedures regarding gang identification including
notification to law enforcement. A review of nine youth case management records showed none
of the youth were applicable for notification to law enforcement of suspected gang association.
Three additional case management records were provided by the program. Each of the three
applicable records documented local law enforcement was notified of suspected gang activity
prior to the Monitoring and Quality Improvement (MQI) seven-day notice. Reviewed
documentation confirmed each youth’s home county law enforcement agency was notified of
the youth’s gang affiliation. Reviewed documentation reflected all gang alerts were maintained
in the Department’s Juvenile Justice Information System (JJIS) and updated as required, upon
identification. Each of the three applicable records documented gang information was shared
with educational staff at the program, the youth’s post-residential services counselor, and the
youth’s juvenile probation officer (JPO).
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a written policy and procedures regarding youth participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth with
an opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. At the
time of the annual compliance review the program had three youth documented for having gang
involvement. All three youth were provided with gang prevention and intervention strategies,
which were included on each youth’s performance plan. The program utilizes prevention and
intervention activities for youth identified with gang affiliations and provide youth with assistance
and guidance to formulate a plan to disassociate themselves from their gang affiliation. These
intervention strategies consist of Impact of Crime (IOC) and Gang Resistance and Drug
Education (GRADE) curricula for all gang affiliated youth. A review of the program’s gang
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intervention sign-in sheets confirmed the program is conducting groups according to the
required frequency. An interview with the program director (PD) confirmed the implemented
gang intervention and prevention strategies address gang involvement as a criminogenic risk
factor through assessment, supervision, and targeted programming. The program incorporates
structured group interventions focused on decision-making, pro-social identity development,
conflict resolution, and the consequences of gang affiliation. Staff monitor gang-related
behaviors, prohibit gang symbolism or activity within the program, and provide individualized
counseling and support to help youth disengage from gang influence while promoting positive
peer relationships and community reintegration, gang intervention, and prevention strategies.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program maintains a written policy and procedures requiring the Residential Assessment
for Youth (RAY) to be completed for each youth within thirty days of admission. A review of nine
youth case management records showed each record contained a RAY completed within thirty
days of admission. Each record contained an initial RAY, which was documented in the
Department’s Juvenile Justice Information System (JJIS). Nine reviewed records showed eight
youth records were applicable for RAY Reassessments completed at least every ninety-days
and the remaining youth’s reassessment was not yet due. All other updates or reassessments
were completed when deemed necessary by the intervention and treatment team to effectively
manage each youth’s case. All reassessment documentation was maintained in each youth’s
official case record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program maintains a written policy and procedures regarding the completion of the Youth
Needs Assessment Summary (YNAS). Nine reviewed youth case management records
revealed the YNAS was completed within thirty days of admission for each youth. Each YNAS
was documented in the Department’s Juvenile Justice Information System (JJIS). Each youth’s
case management record confirmed the YNAS documented the youth’s top three criminogenic
needs.
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program maintains a written policy and procedures outlining performance plan
development, goals, and transmittal. A review of nine youth case management records
confirmed eight youth’s Individualized Performance Plans (IPP) were developed within thirty
days of the youth’s admission and developed after the completion of the initial Residential
Assessment for Youth (RAY) and the Youth Needs Assessment Summary (YNAS), the
remaining youth did not require IPP development due to being a transfer from another program
run by the same provider. Each of the reviewed IPPs were signed by the treatment team leader,
youth, administrative representatives, living unit representatives, treatment staff, education staff,
and all parties who had significant responsibility in goal completion. A review of documentation
showed each of the completed IPPs were mailed to each youth’s parent/guardian requesting a
signature. Each of the nine IPPs had the signature sheet of parties who had significant
responsibility in goal completion filed in the youth’s official case management record. Each
reviewed IPP included the youth’s individualized goals based upon the prioritized needs
identified during the initial assessment, addressing the youth’s three top criminogenic needs,
specific delinquency interventions based on RAY results, court-ordered sanctions, and transition
activities targeted for the last sixty-days of the youth’s anticipated stay. Each IPP outlined
program staff responsibilities and target dates for goal completion. Each of the IPPs were sent
to each youth’s committing court judge, juvenile probation officer (JPO), and parent/guardian.
None of the nine youth were involved with the Department of Children and Families (DCF). Nine
interviewed youth confirmed they participated in the development of their IPP treatment goals
and received a copy of their IPP.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program maintains a written policy and procedures ensuring revisions to a youth’s
performance plan. A review of nine youth case management records revealed all youth were
applicable for Individualized Performance Plan (IPP) revisions. Each of the IPP revisions were
based on the Residential Assessment for Youth (RAY) Reassessment results, when acquired
information warranted updates, based on the youth demonstrating progress toward completing
a goal, and when needed to facilitate transition activities. None of the nine records were
applicable for youth demonstrating lack of progress toward completing a goal. Each of the nine
reviewed youth had additional plans, to include academic or treatment plans, included in their
performance plans.
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program maintains a written policy and procedures outlining the completion of Performance
Summaries and transmittals. A review of nine youth case management records showed
Individualized Performance Plans (IPPs) were completed with documented completion dates.
Each of the Performance Summaries were completed every ninety calendar days following the
signing of the IPP, or at shorter intervals if requested by the court. Each youth’s summary
documented the date of the summary, the youth’s status on each performance plan goal, the
youth’s overall treatment progress, the youth’s academic status, the youth’s behavior, level of
motivation/readiness to change, interaction with peers, interaction with staff, overall behavior
adjustment to the program, and significant positive and negative events. A review of
documentation regarding Performance Summaries reflected each youth was allowed to read
and added comments prior to signing, each youth was provided a copy of the summary, and the
original summary was filed in the youth’s case management record. Each Performance
Summary was signed and dated by the treatment team leader, staff preparing the summary,
program director or designee, and youth. Documentation confirmed a copy of each summary
was sent within ten working days to the committing court, the youth’s juvenile probation officer
(JPO), parents/guardians, and Department of Children and Families (DCF), if applicable. A
review of three closed case management records confirmed each release summary included
the original summary, along with justification for release, and was sent with the Pre-Release
Notification (PRN) to the JPO. One of the three reviewed case management records was
applicable for direct discharge. None of the youth were at the program for less than forty-five
days and the release summary and PRNs were all sent at least forty-five days prior to the
youth’s release with the date noted. A signed copy was retained in each youth’s case
management record. Documentation confirmed once release was approved, the program
provided written notification to each youth’s parent/guardian regarding the planned release, and
the program completed a Residential Assessment for Youth (RAY) exit assessment. None of
the three reviewed youth closed case management records were applicable for the sexually
violent predator program (SVPP) or for notification to a victim.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures regarding parental/guardian
involvement in case management services. A review of documentation showed the program
makes efforts to include each parent/guardian in the assessment process, development of the
youth’s performance plan, progress reviews, and transition planning. If unable to attend, each
parent/guardian was given the opportunity to participate by telephone/video conferencing or
provide verbal/written input prior to the meetings. During the week of the annual compliance
review, an observation of a treatment team meeting was conducted and showed the program’s
practice of having parents/guardians participate by telephone. During the intake process,
families are mailed the treatment team and visitation schedules for the year, and an invite is
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provided to families thirty days in advance for family days, holiday celebrations, graduations, or
any other specialized activities. The interviewed program director (PD) reported the program
encourages parent/guardian involvement in the case management process by maintaining
regular communication and active engagement with families. Parents/guardians are invited to
participate in treatment planning, meetings, family counseling, and progress reviews, and are
kept informed of youth goals, behavior, and program expectations. Case management staff
facilitate ongoing contact and collaboration to support youth progress, strengthen family
connections, and promote successful transition and reintegration. Nine youth were interviewed
and stated their parent/guardian participated in treatment team meetings, counseling, and
therapy sessions.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program maintains a written policy and procedures regarding treatment team meetings. A
review of nine youth case management records determined formal treatment team meetings
were held every thirty days for each youth, and informal meetings were held biweekly, as
required. Documentation for each of the formal and informal treatment team review meetings
included the youth’s name, date of review, required attendees, comments from treatment team
members or others, a brief synopsis of the youth’s progress, performance plan revisions,
performance plan goals, positive and negative behaviors, behaviors resulting in physical
interventions, the youth’s documented opportunity to demonstrate skills acquired in the
program, treatment progress, and Residential Assessment for Youth (RAY) Reassessment
results. All nine records contained formal treatment team documentation in the youth’s case
management record. All required parties were present either in person or by telephone during
each formal and informal treatment team meeting. A treatment team meeting was observed
during the annual compliance review week. All required participants were present during the
meeting. An interview with nine youth indicated their parent/guardian appeared by telephone
and actively participated in the meetings. Youth reported staff talk about their performance to
include progress on performance plan goals, positive and negative behavior, and treatment
progress. All nine youth were able to articulate examples of showing learned skills during their
treatment team meeting, to include filling out forms and speaking verbally in front of the team.
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.
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The program maintains a written policy and procedures regarding transition planning
conferences, and Community Re-Entry Team (CRT) meetings. A review of three closed youth
case management records confirmed a transition conference was held at least sixty days prior
to each youth’s targeted release date. A review of documentation showed each youth, treatment
team leader, program director (PD) or designee, and other team members attended the
transition conference. Documentation confirmed the treatment team leader invited and
encouraged participation of each youth’s juvenile probation officer (JPO), parent/guardian,
education staff, and any other pertinent parties through advance notification. A review of
documentation confirmed, during each transition conference, the participants reviewed transition
activities on the youth’s performance plan, revised performance plans, if necessary, identified
additional transition activities as needed, identified target completion dates, and identified
persons responsible for completion. The treatment team leader obtained attendees’ dated
signatures representing their acknowledgment of the transition goals, and accountability for
completion for each youth. A copy of each plan was sent with a request for return with signature
to anyone not in attendance who had a responsibility for completion of transition goals. If a plan
was transmitted electronically to the JPO, the return email acknowledgment receipt was printed
and filed with the plan. Documentation revealed a Community Re-Entry Team (CRT) meeting
was conducted prior to each youth’s release. Each record contained evidence each youth and
assigned case manager were invited to and attended the CRT meetings.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures regarding the requirements for each
youth’s exit portfolio. A review of three closed youth case management records revealed the exit
portfolio was discussed and initiated for each youth during the transition conference. Each
youth’s exit portfolio was discussed during the exit conference and documentation indicated
each exit portfolio was completed and given to the youth upon release. Two of the three closed
case management records did not contain a state-issued identification card. None of the three
closed youth case management records showed documentation of the youth’s Social Security
card. One of the three youth had a birth certificate. An interview with the case manager and
reviewed documentation showed the program continuously made efforts to obtain all of the
missing documentation by mail, email, and asked the parent/guardian of each youth to provide a
copy; however, the program was not successful in obtaining the documents. Each exit portfolio
included educational and/or vocational certificates earned in the program, all educational
records/documents, school transcripts, résumé, and sample employment application. Each of
the three youth’s exit portfolios were verified during the exit conference and reviewed
documentation revealed each exit portfolio was completed and given to the youth upon release.
Reviewed documentation showed the program’s case management staff forwarded each exit
portfolio to the youth’s juvenile probation officer (JPO). The program’s contract does not include
any additional requirements for exit portfolios.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program maintains a written policy and procedures regarding the completion of an exit
conference. A review of three closed youth case management records revealed an exit
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conference was conducted for each youth after the program notified the juvenile probation
officer (JPO) of the release. Each conference was conducted at least fourteen days prior to
release. The reviewed documentation included the date of each conference, signatures, and a
summary of pending transition goals. Reviewed documentation confirmed each youth’s date of
admission and date of termination correlated with the Department’s Juvenile Justice Information
System (JJIS). Each exit conference documented the status of transition activities established at
the transition conference and plans were finalized for each youth’s release. Reviewed
documentation confirmed provisions for continuation of education and/or employment were
discussed during each exit conference and each youth’s exit portfolio was reviewed.
Documentation showed each youth, the youth’s parent/guardian, case manager, and JPO were
aware of the vocational plan for the youth. A review of documentation showed the intervention
and treatment team leader, parent/guardian, education representative, JPO, youth, and other
pertinent parties all participated in each exit conference. Reviewed documentation indicated
each exit conference was conducted separately from the transition conferences and the
Community Re-Entry Team (CRT) meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a written policy and procedures regarding written provisions for youth
input. The program’s formal process to promote constructive input from youth is through youth
surveys, community meetings, informal and formal treatment team meetings, one to one's, and
Request to Speak and grievance forms. A review of the program’s efforts to solicit input from
youth through avenues such as youth advisory board minutes, program surveys, and
suggestion forms, were maintained in the youth advisory council board binder. Advisory board
meetings were held at least every ninety to 120 days. A review of the program’s sign-in sheets,
agendas, and meeting minutes confirmed the meetings were being held as required. An
interview with nine youth indicated they can voice their input on their progress and/or concerns
as needed. Youth will speak with a supervisor or inform a staff of an idea or concern. An
interview with the program director (PD) reported youth are provided with structured
opportunities to share feedback through community meetings, youth councils, grievance
processes, and facilitated group discussions focused on program operations and living
conditions. Youth recommendations related to safety, daily routines, programming, and quality
of life are documented, reviewed by management, and considered for implementation. Program
leadership communicates outcomes and changes to youth, reinforcing transparency, youth
voice, and continuous program improvement for both youth and staff.
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 maintains a written policy and procedures regarding educational access. The daily
school schedule is incorporated into the program’s activity schedule. A logbook review of
randomly selected days for each month, from February 2025 through December 2025, indicated
education classes started early and ended between five and twenty-five minutes early. An
interview with the program’s administration reported when there is no teacher, classes will
transition early. The interviewed program director reported the program would be sure to clearly
document the reason for changes to the educational schedule in the logbooks moving forward.
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Video observations of three random days showed youth were attending educational instruction
according to the bell schedule. Nine youth were interviewed and seven reported there were no
interruptions during the school day. Two youth reported they have received their high school
diploma while in the program.
2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program’s career and technical education services were being provided as required with
Florida Ready to Work Soft Skills, Occupational Safety and Health Administration Ten (OSHA-
10), and first-aid/cardiopulmonary resuscitation (CPR) certifications. The program provides
contracted services for food handling and Microsoft Word. The Microsoft Word certification can
lead to the Microsoft Fundamentals and/or Microsoft Office Specialist certifications on the
Master Credentials List (MCL). The food handling certification can lead to the Food Safety and
Science certification on the MCL. Program staff provide career and technical education services
through the facilitation of first-aid/CPR, Florida Ready to Work - Soft Skills, and OSHA-10. Both
facilitators are certified in first-aid/CPR facilitation. Certification is not required to facilitate
Florida Ready to Work - Soft Skills and OSHA-10, as those are certified by each organization
upon youth passing web-based modules and assessments. During the annual compliance
review week there were thirty-four youth enrolled in coursework towards earning a Soft Skill
certification. The program reported, since the last annual compliance review, forty-three youth
received OSHA-10 certifications, twenty-six completed the food handler certification course,
eighty-three received their first-aid/CPR credentials, and twelve youth completed Florida Ready
to Work - Soft Skills. Additionally, five youth participated in the National Center for Construction
Education and Research training for core, construction site safety orientation, and basic
construction skills sponsored by Florida Youth College (FYC) and earned certifications. Six
reviewed youth records confirmed each youth completed the required OSHA-10, and first-
aid/CPR course; however, three OSHA-10 and one first-aid/CPR certification was earned
beyond the ninety days after admission requirement. The Florida Ready to Work - Soft Skills
credentials were not dated and unavailable on the platform to determine timeliness. Nine youth
were interviewed and four reported the program provided career and technical education (CTE).
During the interview with the program director (PD), it was reported the program provides CTE
through work readiness skill development, employability skills, and basic career planning.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program maintains a written policy and procedures requiring a designated mental health
clinician authority (DMHCA). The program has a clinical director who serves as the program’s
DMHCA. The program’s contract requires the DMHCA to be on-site at least forty hours each
week, to ensure appropriate coordination and implementation of mental health and substance
abuse services in the program. The DMHCA is a licensed mental health counselor (LMHC) with
a free and clear license in the State of Florida with an expiration date of March 31, 2027. As part
of the assigned responsibilities, the DMHCA ensures consistent and appropriate services in
addition to being on-call twenty-four hours a day, seven days each week for emergency
consultation. The DMHCA is responsible for supervising clinical staff, reviewing treatment plans,
monitoring and guiding treatment planning, and ensuring evidence-based practices are
implemented consistently and with fidelity. The DMHCA coordinates with direct care staff,
medical providers, educational staff, and community partners to maintain an integrated
approach to care. The DMHCA is responsible for ensuring the program’s clinical treatment
programming complies with all requirements outlined within the specialty services guidelines for
Mental Health Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services
(SAOS). Reviewed documentation and an interview with the DMHCA confirmed, the DMHCA
was on-site weekly to ensure the appropriate coordination and implementation of mental health
and substance abuse services provided to youth, as required by the contract. The DMHCA
reported the program has a licensed clinical social worker (LCSW) who serves as the back-up
DMHCA as needed. The program’s back-up DMHCA has a free and clear license in the State of
Florida with an expiration date of March 31, 2027. An interview with the DMHCA confirmed the
role of the DMHCA is to coordinate and ensure the implementation of mental health and
substance abuse services at the program and to ensure documentation is completed.
Additionally, the DMHCA shall provide oversight, leadership, and quality assurance to ensure all
services meet the individualized needs of youth while aligning with Department standards. The
DMHCA provides emergency coverage twenty-four hours a day, seven days a week, in the
event of a mental health emergency. The DMHCA indicated communication with program staff
takes place during weekly treatment team meetings and clinical supervision sessions where
each youth’s progress, challenges, and treatment goals are reviewed.
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.
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The program maintains a written policy and procedures which establishes requirements for
qualified professionals in the delivery of mental health and substance abuse services. The
program’s licensed designated mental health clinician authority (DMHCA) serves as the
program’s supervisor for all on-site clinical staff. A review of the program’s staff listing, and
contractual requirements verified there are two additional licensed staff requirements beyond
the DMHCA. The program had two full-time licensed clinical social workers (LCSW) who held
free and clear licenses in the State of Florida both expiring March 31, 2027. The DMHCA
ensures licensed clinical staff perform services they are qualified to provide based on education,
training, and experience in accordance with the job description. Copies of all licenses were
available and displayed on-site. A review of mental health licenses which included the LMHC
and LCSWs confirmed each had a license which was free and clear in the State of Florida. The
program is licensed under Chapter 397 through the Department of Children and Families (DCF)
to provide substance abuse services to youth. The license was observed and displayed in the
lobby with the program’s physical address listed and had an expiration date of March 22, 2026.
The program’s clinical staffing required by contract included one DMHCA, two licensed
therapists, and three non-licensed mental health clinicians. The program did not have any
mental health and substance abuse clinical staff vacancies during the annual compliance review
week.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures regarding non-licensed clinical staff. An
informal interview with the designated mental health clinician authority (DMHCA) verified they
supervise non-licensed clinical staff, ensuring all non-licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. The program’s practice is to complete group and/or individual clinical
supervision for non-licensed clinicians and the recreation therapist. A review of clinical
supervision logs during the annual compliance review period verified clinical supervision was
documented on the program’s supervision logs and included all elements on the Department’s
Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals
Direct Supervision Log form. Documentation verified all non-licensed clinical staff received
clinical supervision for each week they provided services. All non-licensed clinical staff were in
accordance with the contract, and staff were on-site for forty hours each week. The program is
licensed under Chapter 397 through the Department of Children and Families (DCF) to provide
substance abuse services to adolescents. The license was displayed in the lobby with the
program’s physical address listed and had an expiration date of March 22, 2026. The program’s
contract requires one DMHCA, two licensed therapists, and three non-licensed mental health
clinicians. Education documentation for each clinician supported requirements were in
accordance with contract. A review of the education documentation for the three non-licensed
mental health clinicians reflected each held a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or a related human
services field. Reviewed documentation confirmed non-licensed mental health clinical staff who
conducted Assessments of Suicide Risk (ASRs) completed twenty hours of training and
supervised experience in assessing suicide risk, mental health crisis intervention, and
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emergency mental health services. The program reported no mental health and substance
abuse clinical staff vacancies during the annual compliance review week.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures regarding mental health and substance
abuse admission screenings. The program’s policy requires staff to review commitment packet
information, reports and records, and to administer the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) in the Department’s Juvenile Justice Information System
(JJIS) for each youth. A review of nine youth mental health and substance abuse records
indicated all youth received a MAYSI-2 on their date of admission. All nine youth records
documented clinical staff reviewed available information to include the commitment packet,
reports, mental health records, and any documentation of human trafficking. Each reviewed
MAYSI-2 was completed in full in JJIS and included the date of completion and the name of the
staff who completed the screening. Reviewed documentation verified each staff who completed
a MAYSI-2 was trained. Eight of the nine reviewed MAYSI-2s indicated further assessment was
required; however, it is the programs practice to refer all youth for further evaluation regardless
of screening results. None of the reviewed youth records were applicable for emergency
procedures or for the youth being in crisis. No reviewed youth records were applicable for
suicidal ideation. All nine youth were referred for a comprehensive evaluation and an
Assessment of Suicide Risk (ASR) regardless of results on their MAYSI-2, and each included
the reason for the referrals, which was to gather and review information to assist in developing
the youth’s individualized treatment plan. None of the youth were placed on precautionary
observation. The designated mental health clinician authority (DMHCA) and the program
director (PD) were notified of each youth’s admission screening results. The interviewed PD
reported a MAYSI-2 screening, ASR, and the Substance Abuse Subtle Tool Screening
Inventory (SASSI) is completed during intake to identify suicidal risk factors. The PD reported
the screenings used to identify youth at risk for mental health and substance abuse problems
and suicide risk are completed during admission. All youth undergo comprehensive mental
health, substance abuse, and suicide risk screenings. Screenings are conducted using
standardized instruments and procedures to ensure consistency and accuracy. This process
includes a review of each youth’s history, presenting behaviors, prior treatment information, and
assessments for urgent or emergency needs. Screening results guide immediate safety
precautions, referrals for further assessment, and the development of individualized treatment
and supervision plans, with ongoing reassessments conducted as needed.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to establish an assessment and
evaluation process to guide the development of each youth’s individualized treatment plan. The
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program ensures the mental health and substance abuse needs of each youth are identified
through a comprehensive mental health and substance abuse evaluation process. Each youth
receives an in-depth assessment within the first thirty days of residential placement. Nine youth
mental health and substance abuse records were reviewed. Each of the nine reviewed records
indicated a new combined mental health and substance abuse evaluation was completed for the
youth. Clinical staff obtained consent for substance abuse services for all nine reviewed youth.
All assessments were completed by a licensed mental health professional or mental health
clinical staff working under the direct supervision of a licensed mental health professional. Each
of the nine evaluations were completed within thirty days of admission and each youth
consented to substance abuse services prior to the evaluation. Each reviewed assessment was
completed and signed by a licensed staff within ten days. Each of the comprehensive
evaluations included the date of referral/admission and all required elements including
identifying information, reason for the evaluation, relevant background information, behavioral
observation, a Mental Status Exam, documentation of an interview, discussion of findings,
diagnostic impressions which included the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnosis, patterns of alcohol and/or drug abuse, how alcohol
and other drugs are affecting the major life areas, risk factors for continued use of alcohol
and/or drugs, and recommendations. None of the reviewed mental health and substance abuse
records had or required an updated evaluation. An interview with the designated mental health
clinician authority (DMHCA) confirmed the process for obtaining a comprehensive mental health
and/or substance abuse assessment during each initial screening. Additionally, the DMHCA
indicated, during admission, if a youth exhibits behaviors or other needs which require further
evaluations, mental health staff will assess and/or refer the youth and this will be documented in
the Mental Health Substance Abuse Referral Summary form.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures to establish individualized treatment
planning processes which outline the program’s mental health and substance abuse treatment
services. At admission each youth is assigned to an intervention and treatment team comprised
of the youth, representatives from program administration and residential living unit, and others
responsible for the delivery of delinquency interventions and treatment services for the youth.
Each youth’s treatment team is responsible for assessing the youth’s rehabilitative treatment
needs, assisting in the development and implementation of the youth’s performance plan, and
for youth receiving mental health, substance abuse, and/or developmental disability services,
assisting in developing, reviewing, and updating the youth’s individualized and initial mental
health/substance abuse treatment plans. A review of nine youth records indicated each
contained an initial mental health and substance abuse treatment plan completed within seven
days of admission. Each reviewed initial plan was documented on the program’s form and
included all elements of the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form. Eight of the nine records indicated the initial plan included the need for a psychiatric
evaluation. Each of the nine initial plans were completed by mental health clinical staff. Seven of
the nine initial treatment plans were completed by a non-licensed mental health clinical staff and
were signed by the licensed designated mental health clinician authority (DMHCA), within ten
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days of completion. The remaining two initial plans were completed and signed by the licensed
DMHCA. Each initial plan was signed by the youth and all treatment team members to include
the treatment team leader, program management, the living unit representative, education, and
other applicable treatment team members who participated in the development of the plan.
Each initial plan documented the participation of the assigned juvenile probation officer (JPO)
and the parent/guardian by telephone. Eight youth were applicable for being on psychotropic
medication at the time of the individualized plan development, and the plans listed the
medication details and monitoring frequency. Each of the nine records were applicable for an
individualized treatment plan to be created within thirty days and a total of fifty-seven treatment
plan reviews to be completed at thirty-day intervals. Each review was completed at least every
thirty days as required. All treatment plans were completed on the program’s form and
contained all elements on the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan Review form. Each individualized treatment plan and review documented
signatures of the youth, parent/guardian, JPO, treatment team leader, program administration,
living unit staff, and education staff. Each plan was signed by the licensed DMHCA on the day
of completion. Each plan included individual counseling, group counseling, family counseling,
psychiatric services, medication management, and applicable psychotherapy. The treatment
plan goals and objectives were individualized for each youth. A comparison of video to the
logbooks and sign-in sheets for three randomly selected groups indicated they were occurring
as scheduled and as documented. An interview with the DMHCA confirmed the program’s
process to ensure services are provided to youth in accordance with the curriculum standard as
well as with their individualized treatment needs. Additionally, they indicated each youth’s
progress and goals are reviewed and updated in the youth’s individualized treatment plan
reviews on a monthly basis during the youth’s treatment team meetings, which include the
program’s multi-disciplinary team, the youth, the youth’s assigned JPO, and the youth’s family.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program maintains a written policy and procedures regarding discharge and transition
planning requirements for mental health and substance abuse treatment services. Discharge
planning processes begin at the time of admission and are included within the initial screening,
assessment, and treatment plan development processes. Initial discharge planning and a
tentative projected release date are established for each admitted youth. Each youth’s treatment
team will regularly review the youth’s individualized mental health and substance abuse
treatment plan through the monthly treatment plan review processes. Each treatment plan
review will be documented using the Department’s Individualized Mental Health/Substance
Abuse Treatment Plan Review form. A review of nine youth records indicated each youth was
assigned to a treatment team upon arrival to the program. Reviewed treatment team
documentation and treatment team assignment forms for each reviewed record confirmed the
treatment team members were comprised of the youth, program administration, residential living
unit, vocational, education, medical staff, mental health and substance abuse staff, and
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parents/guardians. Each youth with mental health and substance abuse treatment goals
received treatment by a qualified professional. All youth records had a completed Authority for
Evaluation and Treatment (AET) form and signed Youth Consent for Substance Abuse
Treatment. The program is licensed under Chapter 397 to provide substance abuse services to
youth. Reviewed progress notes were documented on the program’s form and contained all
elements of the Department’s Counseling/Therapy Progress Notes form. Reviewed progress
notes verified treatment included individual psychotherapy and psychosocial skills. Each
reviewed record verified services were provided as stipulated in the youth’s treatment plan.
Three closed youth records were reviewed for discharge summaries/plans. Each of the three
reviewed discharge summaries were documented on the Department’s Mental Health and
Substance Abuse Treatment Discharge Summary form. None of the reviewed closed records
were applicable for the youth being released while on suicide alert/precautions. Each of the
three reviewed summaries documented the future services needed. Reviewed documentation
supported the plans were discussed during each youth’s exit conference with the youth,
parent/guardian, and assigned juvenile probation officer (JPO). Each record documented the
youth and parent/guardian signed the plan and the plan was sent to the assigned JPO. An
interview with the designated mental health clinician authority (DMHCA) confirmed the
program’s process for the use of individualized treatment planning for both mental health and
substance abuse needs. Additionally, the DMHCA indicated the process for each youth’s
treatment planning begins at the youth’s admission to the program and each of the youth’s
treatment plans are developed according to the youth’s specified individual treatment needs.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a policy and procedures to establish a delivery protocol for Substance
Abuse Overlay Services (SAOS) and Mental Health Overlay Services (MHOS) programming.
Substance abuse and mental health treatment is provided on-site through the provisions of
SAOS and MHOS. Required clinical treatment groups include life skills training, Aggression
Replacement Therapy (ART), Coping with Stress: a Cognitive Behavioral Therapy (CBT),
Adolescents Coping with Depression (CWD-A), Trauma Focused CBT, and Seeking Safety.
Documentation confirmed the designated mental health clinician authority (DMHCA) was on-site
for forty-hours each week. Reviewed staff credentials confirmed all non-licensed clinical staff
held at a minimum a master’s-level degree. The program provides substance abuse and mental
health services through group therapy, individual therapy, family therapy, and psychiatric
services. The program has a Chapter 397 license through the Department of Children and
Families to provide substance abuse treatment services to youth. The required counselor to
youth ratio is not to exceed one counselor to sixteen youth. A review of caseload assignments
indicated they were between ten and sixteen youth. The program provides individual therapy
once every two weeks, family therapy at least monthly, applicable psychiatric services every
week, and mental health/substance abuse groups four times each week as required. A review of
youth records, youth interviews, group sign-in sheets, and an interview with the designated
mental health clinician authority (DMHCA) verified individual, group, and family therapy were
part of each youth’s treatment plan. The program has an independent contract with a licensed
psychiatrist who provides services at least once a week. A review of the program’s contract and
an interview with the DMHCA confirmed the program provides individualized treatment through
evidence-based curriculums and individual, family, and group therapy services. Supportive
counseling and crisis interventions are provided as needed. Youth receive three mental health-
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based groups weekly and one substance abuse education and/or prevention group each week.
An interview with the program director (PD) reported the program provides mental health and
substance abuse services for youth identified through the Department’s screening and
placement criteria. Services include comprehensive individualized clinical assessments,
evaluations, and development and review of individualized treatment plans. The program
provides targeted therapeutic interventions such as individual counseling, group therapy, and
other evidence-based curricula. The specialized services ensure youth with complex behavioral
health needs receive appropriate and effective treatment, in accordance with the contract. Nine
interviewed youth reported participating in individual and family therapy services, and
participating in groups at the program, at least on a weekly and/or biweekly basis. Nine staff
were interviewed, and three mental health staff indicated they facilitate mental health or
substance abuse groups, while six direct-care staff indicated they do not facilitate any mental
health or substance abuse groups.
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 written policy and procedures regarding the implementation of a
Suicide Prevention Plan, which describes the essential components and provides guidelines for
the identification, management, and assessment of a potential suicide or at-risk youth. Acutely
suicidal youth who attempt suicide or present an imminent threat of suicide must be treated as
an emergency and the program’s Emergency Response Plan shall be implemented. The
program maintains a Suicide Prevention Plan which was last signed and reviewed by the
program director (PD) and director of operations on January 10, 2025, and December 21, 2025.
A review of the plan reflected it included identification, assessment, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review included circumstances surrounding the event, procedures relevant to the
incident, relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan which serves as the program’s suicide
prevention procedures. The Suicide Prevention Plan addresses the program’s suicide
prevention services, suicide precautions, observation logs, and suicide prevention training. The
program’s practice is to complete an Assessment of Suicide Risk (ASR) for all youth admitted
and re-admitted to the program. A review of nine youth records was conducted and indicated
one youth was applicable for suicide precautions placement outside of the routine intake
screening process; therefore, two additional records were requested and reviewed. A review of
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the three applicable ASRs indicated each was completed in full on the Department’s form. Each
of the three youth were placed on precautionary observation due to staff observations. Each
reviewed ASR included the precautionary observation start date, and ASR referral date. All
three records included the level of supervision. There was documentation showing the
parent/guardian and juvenile probation officer (JPO) were notified of each youth being placed on
precautionary observation status. Documentation verified mental health staff provided daily
supportive services while each youth was on precautionary observation. Reviewed
documentation confirmed each ASR was completed within twenty-four hours. Each ASR
documented a conference between the designated mental health clinician authority (DMHCA),
and the program director (PD) regarding the decision to continue each youth on precautionary
observation. Two assessments were completed by licensed staff and one assessment was
completed by a non-licensed clinical staff under the supervision of a licensed mental health
professional. The ASR was reviewed and signed within twenty-four hours by a licensed staff.
The discontinuation of precautionary observation for each youth was documented in the
program’s logbook and the actual date/time the clinicians conferred with the program director
(PD) or designee, and licensed mental health professional was recorded on each ASR in the
date/time sections. A review of the Department’s Juvenile Justice Information System (JJIS)
reflected accurate alerts were entered and updated as required. A Follow-Up ASR was needed
and completed for all three youth prior to the removal of the youth from precautionary
observation. Each Follow-Up ASR was documented on the Department’s Follow-Up ASR form.
Each youth was maintained on suicide precautions and constant supervision until the Follow-Up
ASR indicated suicide precautions could be discontinued. When the youth’s Follow-Up ASR
indicated suicide precautions could be discontinued, each youth was stepped down to close
supervision prior to transition to normal routine and standard supervision. Close supervision was
maintained until it was determined to be no longer necessary by the DMHCA for each youth.
Reviewed documentation indicated a conference was held by the PD and licensed DMHCA to
reduce each youth’s level of supervision. Discontinuation of close supervision was documented
in accordance with the program’s Suicide Prevention Plan and logbooks included the date and
time each youth was stepped down. JJIS suicide alerts were initiated for each youth placed on
suicide precautions and accurately closed following the recommendations of the Follow-Up
ASRs. Documentation supported all youth on suicide precautions were able to participate in
activities with other program youth in the specified safe housing areas. Logbooks documented
the placement and removal of precautionary observation and close supervision. During the
annual compliance review week, a review of the program’s logbooks and video observations
confirmed the program’s practice with the placement and sight and sound supervision of youth
on precautionary observation, for youth with suicidal ideation. An interview with the DMHCA
confirmed all mental health staff are trained and supervised in assessing suicide risk, crisis
interventions, and in emergency mental health services.
3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
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3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written policy and procedures requiring staff to always maintain at
least constant supervision of youth on precautionary observation and to document their
observations of youth on the Suicide Precautions-Observation Log in intervals which do not
exceed thirty minutes. A review of nine youth records indicated one was applicable for being
placed on precautionary observations; therefore, two additional records were requested and
reviewed. A review of three precautionary observation events indicated supervision was
documented on the Department’s Suicide Precautions-Observation Log. The applicable
reviewed youth records identified each youth as being a suicide risk after staff observations and
confirmed they were placed on precautionary observation. Each youth record contained
documentation where a Suicide Precautions-Observation Log was maintained for the duration
the youth was placed on precautionary observation. Youth behaviors were documented in real
time and did not exceed thirty-minute intervals for each youth. Each youth was applicable for
warning sign observations, and notifications to mental health clinicians were clearly
documented. Each Suicide Precautions-Observation Log was reviewed and signed by a shift
supervisor and mental health clinical staff. Each Suicide Precautions-Observation 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 a written Suicide Prevention Plan which details suicide prevention
training requirements. The program’s Suicide Prevention Plan requires six hours of annual
training which includes suicide training in the Department’s Learning Management System
(SkillPro). A review of nine pre-service and nine in-service training records documented
program staff completed the required six hours of suicide training. The program has four suicide
response kits which are co-located with first-aid kits in master control, medical, and both sub-
control rooms. Training included recognition of warning signs, implementation of suicide
precautions, and appropriate emergency response procedures. All staff who work with youth
must be trained in suicide precautions and emergency response procedures and participate in
mock suicide drills quarterly, on each shift. The program conducts mock emergency response
drills which simulate suicide attempts or self-inflicted injuries. These drills reinforce staff
readiness, ensure consistency in emergency protocols, and verify staff can respond effectively
to protect each youth’s safety. A review of suicide drill documentation during the annual
compliance review period reflected the program conducted a quarterly drill on each shift as
required. Reviewed drills consistently included the use of lifesaving measures to include the use
of cardiopulmonary resuscitation (CPR), suicide kits, first-aid kits, and the automated external
defibrillator (AED). Reviewed video observations for drills confirmed each drill was simulated,
and youth were not utilized in any of the suicide prevention drills. Reviewed documentation
confirmed applicable staff participated in at least one drill which involved the use of CPR
annually. The program’s practice is to review drills during monthly all-staff meetings. Staff who
did not participate in a quarterly drill can review each drill scenario and procedures in an effort to
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understand the process and receive the necessary training to respond to an incident of a suicide
attempt, or serious self-inflicted injury. An interview with the program director (PD) confirmed the
program’s practice for training and conducting drills which includes emergency response to
suicide prevention, risk recognition, supervision, intervention, notification protocols, and other
emergencies requiring responses. Nine staff were interviewed and asked, in the case of a youth
expressing suicidal thoughts, what is direct care staff responsible for. Each staff indicated they
are responsible for notifying mental health staff, providing sight and sound supervision,
searching the youth’s room for sharp objects, and documenting supervision. Nine staff were
interviewed and asked where the program’s suicide response kits were maintained, and each
staff indicated the kits are located in the master control room, in the sub-control offices, in the
medical office, and one staff stated in the administrator’s office. Nine staff were interviewed, and
each reported medical emergency and suicide drills are conducted at least once a month.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services, emergency mental health, and substance abuse services. Crisis intervention shall be
provided to youth in crisis in the least restrictive means possible to protect the safety of youth,
staff, and others while maintaining control and safety of the program. A review of the plan
verified it included notification and alert systems, means of referrals including youth self-referral,
communication, supervision, documentation, and review. The Crisis Intervention Plan was
signed and reviewed by the designated mental health clinician authority (DMHCA) on December
21, 2025.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. A review of nine mental health records indicated none were applicable for
a Crisis Assessment. The program had no youth applicable for a Crisis Assessment during the
annual compliance review period.
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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 policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be in imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for mental health and substance abuse services includes immediate
staff response, notifications, communication, supervision, authorization to transport for
emergency mental health and substance abuse services, transport for emergency Baker Act,
transport for emergency Marchman Act, documentation, training, and review. A review of the
plan confirmed all requirements were included. The program’s Emergency Response Plan was
signed and reviewed by the designated mental health clinician authority (DMHCA) on April 21,
2025.
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.
The program maintains a written Emergency Response Plan for mental health and substance
abuse emergencies to serve as the program’s emergency response procedures. The plan
outlines procedures for emergency mental health and substance abuse services and Baker and
Marchman Acts. A review of three Baker Acts during the annual compliance review period was
conducted. Each event requiring emergency care resulted in a Baker Act and each youth was
placed on supervision at the time of discovery. Reviewed documentation indicated staff
immediately referred each youth for a mental health assessment and placed each youth on
precautionary observation and/or on one-to-one supervision, once warning signs were
presented. The program’s clinical staff assessed each youth and referred each youth for an
evaluation at a Baker Act facility. Mental health staff and the program director (PD) authorized
transportation. Each youth was transported by law enforcement and returned to the program on
precautionary observation until assessed by mental health staff. Each youth was maintained on
precautionary observation until an Assessment of Suicide Risk (ASR) and a Mental Status
Examination were completed. Each of the applicable ASRs were completed by a licensed staff.
An interview with the designated mental health clinician authority (DMHCA) confirmed the
program’s practice for referring and assessing youth who appear acutely suicidal, and the
immediate safety measures taken to ensure each youth’s safety. The DMHCA indicated if a
youth presents with any signs of suicide-risk, the youth shall be placed on constant supervision,
be referred/assessed by a mental health professional, a suicide risk alert is entered into the
Departments Juvenile Justice Information System (JJIS), and a comprehensive suicide risk
assessment will be completed to determine the level of risk and appropriate interventions. If the
assessment indicates imminent danger, or it is determined an emergency exists, the youth may
be referred to an appropriate higher level of care, such as a crisis stabilization unit or Baker Act
facility.
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3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures for an ongoing safety planning process
for each admitted youth. Each Safety Plan shall identify stimuli which have both positive and
negative effects on the youth. A review of nine youth records confirmed each contained a Safety
Plan. Each youth had a Safety Plan completed within fourteen days of admission. All Safety
Plans were jointly prepared by the youth, parent(s)/guardian(s) or family member, and the
program’s clinical staff. Each plan incorporated recommendations from previous or current
clinical assessments or screening instruments and incorporated trauma responsive practices.
The nine youth were applicable for fifty-seven plan reviews. Each plan was reviewed and
updated at least every thirty days. All Safety Plans included warning signs, baseline behaviors,
coping strategies, crisis recognition, intervention strategies, and a debriefing process. Safety
Plans were reviewed and updated regularly to reflect changes in youth triggers, coping skills, or
progress in treatment. Furthermore, updates occurred at admission and within the first few days
of placement, during treatment, whenever new risk factors or triggers were identified, in
coordination with treatment plan reviews, when clinically indicated by changes in youth
behavior, when safety needs were identified, or as the result of family input, to ensure each
Safety Plan was current, relevant, and effective, supporting the youth’s emotional and physical
well-being. Safety Plans were reviewed by unit staff and plans were maintained in youth records
located in the mental health office and in the administration office, accessible to staff. Nine
interviewed youth confirmed they participated in the development of their Safety Plan. An
interview with the program director (PD) confirmed the program’s practice regarding the creation
and development of Safety Plans. Additionally, Safety Plans are reviewed and updated upon
admission, following any incident of self-harm, suicidal ideation, or significant behavioral
change, after critical incidents, and during routine treatment plan reviews.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program maintains a written policy and procedures stipulating the requirements of clinical
responsibility for the medical care of all youth at the program. The program contracts with a
licensed medical doctor (MD) with specialty training as an osteopathic physician to serve as the
designated health authority (DHA). The DHA holds an unrestricted license and meets the
requirements for independent and unsupervised practice in the State of Florida. The DHA has a
clear and active license in the State of Florida, which expires on March 31, 2028. The DHA is a
current member of the American Board of Pediatrics and has no disciplinary cases and/or public
complaints on record. 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. A review of the DHA sign-in
sheets since the last annual compliance review confirmed the DHA was on-site for a minimum
of two hours each week and at no time did more than nine days pass between on-site visits.
The program has a back-up DHA who is a licensed MD with a clear and active license in the
State of Florida which expires on July 31, 2028; however, the back-up DHA was not utilized
since the last annual compliance review. The program does not utilize telehealth, and all
medical services were provided in-person. The interviewed DHA stated they are on-site once
each week and when they are on vacation or during scheduled absences there is a back-up
DHA arranged to cover. An interview with the DHA confirmed their role in the program is to
conduct Comprehensive Physical Assessments (CPAs), physical exams, periodic evaluations,
and focused evaluations for sick complaints. Additionally, they develop, review, and edit all
medical policies, procedures, and all nursing protocols. The DHA examines every new youth
intake, performs routine check-ups on all youth, and performs follow-up exams for youth with
chronic medical illnesses or conditions.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program maintains a written policy and procedures for licensed medical staff. The
program’s contract with the Department outlines the requirements for a health service
administrator (HSA) and for additional coverage to be provided by a registered nurse (RN). The
program has one HSA who is a full-time RN, one additional full-time RN, one part-time RN, one
pro re nata RN, and one licensed practical nurse (LPN) on-site. A review of nurse licensure
credentials for nurses who provided services during the annual compliance review period
confirmed licenses were clear and active. Each held a current certification in cardiopulmonary
resuscitation (CPR) and first-aid. The required on-site hours for nursing staff were forty hours for
RNs and forty hours for the HSA weekly. A review of the nursing schedule confirmed the HSA
and full-time RN were both on-site for forty hours a week. The schedule confirmed the part-time
RN is on-site twenty hours every other weekend or fills in as needed.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) is solely responsible for
an annual review of all health-related policies, procedures, and protocols. Reviewed policies
and procedures indicated the DHA, psychiatrist, and program director (PD) signed and dated all
respective treatment FOPs on July 28, 2025. Nursing staff reviewed, signed, and dated the
cover page of all FOPs, healthcare protocols, and other procedures on July 28, 2025. On July
28, 2025, an annual review of medical FOPs and protocols was conducted. Reviewed
documentation indicated all newly employed healthcare personnel received a comprehensive
clinical orientation to the Department’s healthcare policies and procedures, given by a
registered nurse (RN) or designated healthcare professional. All approval of treatment protocols
or standing procedures were written and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program maintains a written policy and procedures requiring the completion of the Authority
for Evaluation and Treatment (AET) for all youth admitted into the program. The program utilizes
a separate form for youth eighteen years of age or older providing consent for release of
specific information as noted on the Release of Information Authorization for Youth Eighteen
Years of Age and Older form and to whom the information can be released and shared. Nine
youth Individual Healthcare Records (IHCRs) were reviewed for an AET, and each of the nine
included a valid and legible copy of an AET and the word “Copy” was clearly stamped on each
AET. Each applicable reviewed AET form was signed by the youth’s parent/guardian and by a
Department representative. Reviewed documentation showed there were no parent/guardian
refusals to sign the AET. None of the reviewed youth were applicable for turning eighteen while
at the program. None of the nine reviewed youth were applicable for having a limited consent or
a court order authorizing treatment while admitted to the program. An interview with the nurse
confirmed the policy for obtaining a new or current AET is for the clinical manager or designated
staff member to contact the Department’s representative or contact the case manager for a
court order. The nurse revealed the policy for documenting consent for youth eighteen years of
age or older is for the youth to sign an authorization to release information, and from there the
youth can make their own decisions for care.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program maintains a written policy and procedures requiring each youth’s parent/guardian
to be informed of significant changes in the youth’s condition and consent to be obtained when
new medications and treatments are prescribed. Nine youth Individual Healthcare Records
(IHCRs) were reviewed for parent/guardian notification. Nine reviewed youth were applicable for
consent from the youth’s parent/guardian for all new medications, over-the-counter medications
beyond those covered by the Authority for Evaluation and Treatment (AET), or new
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psychotropic medications prior to administration. Parent/guardian consent was provided for
each applicable youth, and written notifications were sent utilizing the Department’s Parental
Notification of Health-Related Care form. Four youth were admitted with psychotropic
medication, and four youth were prescribed psychotropic medications while at the program.
Each of the applicable reviewed records indicated whenever a new psychotropic medication
was prescribed or discontinued, or the drug dosage was significantly changed, a
parent/guardian provided verbal consent for psychotropic medications, which were documented
on the Clinical Psychiatric Progress Note (CPPN). A review of documentation indicated staff
witnessed all telephone call attempts and conversations for psychotropic medications for the
applicable youth Each of the nine reviewed IHCRs documented vaccinations were verified
within thirty days of the youth’s admission. No youth were applicable for obtaining vaccinations
or a religious exemption for vaccinations. An interview with the nurse revealed parent/guardian
notifications are conducted when a youth is put on new medications not covered by the AET,
medication doses change significantly, medications are discontinued, and when there is a
change in a youth’s condition. Parent/guardian notifications are made in real-time and if a nurse
is unable to contact a parent/guardian, another attempt is made, documented, and logged in the
youth’s IHCR. Each parent/guardian will be contacted by telephone for a verbal consent which
is witnessed by another staff member. Consent for psychotropic medications will be
documented on the last page of the CPPN, and a consent form will be mailed out with a copy of
the CPPN for written consent. Additionally, the nurse explained the process for documenting
exemption from immunization is to document the exemption form, which is signed by the
parent/guardian, and is placed on file at the local health department.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program maintains a written policy and procedures outlining youth healthcare admission
screening and rescreening each time the physical custody of a youth changes. The program’s
practice is to complete a rescreening and to complete the Department’s Facility Entry Physical
Health Screening (FEPHS) form anytime a youth is admitted into the program and each time the
physical custody of a youth changes with subsequent return or readmission to the program. A
review of nine youth Individual Healthcare Records (IHCRs) indicated all nine youth had a
FEPHS completed on the date of admission. Each form was completed by a registered nurse
(RN). None of the FEPHS were completed by direct care staff. Three of the nine youth were
applicable for a change in custody greater than twenty-four hours. The program completed a
FEPHS rescreening for each returning youth for each return date after a change in custody
occurred lasting greater than twenty-four hours. An interview with nursing staff confirmed the
practice of completing the FEPHS at every admission.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a written policy and procedures requiring each youth admitted into the
program to receive a healthcare orientation on the general process of the healthcare services
the youth will receive at the program. The orientation addresses the topics of sick call, access to
medical care, the medication process including side effect monitoring, what constitutes an
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emergency and when to notify staff, the right to refuse care and how it is documented, the non-
disciplinary role of healthcare providers, and standard universal precautions. A review of nine
youth Individual Healthcare Records (IHCRs) indicated each youth received a general
healthcare admission orientation. Each youth’s orientation topics included access to medical
care, sick call, what constitutes an emergency and when to notify staff, medication processes to
include side effect monitoring, the right to refuse care and how it is documented, what to do in
the case of a sexual assault or attempted sexual assault, the non-disciplinary role of healthcare
providers, and standard universal precautions. A review of the Health Education sign-in sheets
in each youth’s IHCR indicated various healthcare topics were discussed with each youth. The
program maintains an education/orientation binder for youth who refuse to sign the orientation
sheet. Each of the nine reviewed youth were provided health education on seatbelt usage,
alcohol and drug related problems, sexually transmitted disease/infections, tobacco products,
including smoking, dental and basic personal hygiene, immunizations, infection control,
prevention of sexual and other physical violence, nutrition, physical fitness, testicular self-
examination, and chronic conditions monthly.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a written policy and procedures requiring the designated health authority
(DHA) to be notified of all youth admitted into the program with known or suspected chronic
health conditions or in need of emergency care. A review of nine youth Individual Healthcare
Records (IHCRs) indicated seven youth were admitted with a chronic condition and a referral to
the physician was made. None of the applicable youth were identified as in need of emergency
care upon admission. The DHA was notified within twelve hours for each applicable youth.
Reviewed documentation confirmed the program’s practice is to notify the DHA of all newly
admitted youth regardless of the youth’s status. Four of the nine reviewed youth were applicable
for taking psychotropic medication at the time of their admission and the psychiatrist was
notified. An interview with the nurse was conducted and indicated healthcare staff must notify
the DHA immediately at admission of any youth with serious or chronic conditions. These
notifications are made to the DHA and documented within the youth’s IHCR.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. A review of nine youth Individual Healthcare
Records (IHCRs) confirmed each HRH was completed within seven calendar days of the
youth’s admission, and prior to the CPA. Each HRH was completed by a registered nurse (RN).
Each HRH was reviewed by the designated health authority (DHA) as indicated by a checkbox
on the CPA. The interviewed nurse reported the program’s practice is to complete the HRH
immediately upon admission.
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4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a written policy and procedures ensuring the completion of the
Department’s standardized Comprehensive Physical Assessment (CPA) form for all youth
admitted into the program. A review of nine youth Individual Healthcare Records (IHCRs)
indicated each contained a new CPA completed by the designated health authority (DHA) within
seven days of admission. Each of the nine reviewed CPAs documented the Medical Grade for
the reviewed youth. There were no indications of any missing or incomplete elements in any of
the reviewed CPAs, which were completed on the Department’s form. All sections of the CPAs
were marked with an “O” or an “X”. Each of the nine-youth refused part of the examination, and
each CPA documented the refusal and included the youth’s signature by the applicable portion
of the CPA. Each youth had at least one verified Tuberculosis Skin Test (TST) within the last
year which was documented on the Infectious and Communicable Disease (ICD) form. A review
of documentation showed the Department’s Problem List was updated as needed for each
youth. An interview with the nurse confirmed the DHA completes a new CPA within seven days
of admission and Tuberculosis screenings are conducted at intake.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program maintains a written policy and procedures requiring all admitted youth to be
clinically screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). The policy reflected HIV test results may only be disclosed to the
youth and entities approved by Florida Administrative Code. A review of nine youth Individual
Healthcare Records (IHCRs) indicated each youth was clinically screened and evaluated for
STIs. Two of the nine reviewed youth required further screenings or evaluations, and both youth
were referred to the designated health authority (DHA) and the referral was documented on the
STI screening tool. A test was ordered and performed for each youth. Testing, testing dates,
screening results, clinical evaluations, and diagnosis were documented on the Infectious and
Communicable Disease (ICD) form and filed in the lab section of each youth’s IHCR. A review of
nine youth’s IHCRs found each youth was offered the opportunity to receive counseling and
testing for HIV. Two youth documented consent, and the HIV results were filed confidentially in a
sealed envelope marked “Confidential,” and included a documented review by a practitioner on
the sealed envelope. Both youth had documentation of pre/post-test counseling in their progress
notes. Each applicable youth’s confidentiality was protected by not including the youth’s HIV
status or any other STI diagnosis on the program’s internal alert system. Nine youth were
interviewed and reported they can request an HIV test if needed. The program’s nurse indicated
all sexually active youth are screened for STIs, and if screening indicates a need for further
evaluation, the DHA will write an order for the youth’s testing. Once performed, the result
information is documented on the ICD form in the youth’s IHCR. A youth is rescreened if they
have been out of the program's physical custody for more than thirty days and/or symptoms are
present. All HIV testing results are kept in the IHCR in a sealed envelope marked confidential. A
certified HIV counselor, licensed nurse, or the DHA will perform pre-counseling, testing, and
post-counseling. Additionally, youth can request HIV testing and/or counseling at any time.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program maintains a written policy and procedures requiring all youth to be able to make
sick call requests and have their complaints treated appropriately through the sick call system.
Sick call care is to be provided by licensed healthcare professionals pursuant to their scope of
practice and according to protocols approved by the designated health authority (DHA). When a
licensed healthcare professional is not on-site, the shift supervisor is to review all sick call
requests within the required time frame. A review of nine youth Individual Healthcare Records
(IHCRs) indicated five youth were applicable for having submitted a sick call. None of the five
applicable youth presented with a similar sick call complaint three or more times within a two-
week period. A Sick Call Request form was completed for each of the sick call requests
reviewed. Each of the reviewed Sick Call Request forms were completed by a registered nurse
(RN). All sick calls were documented on the Sick Call Index, the program’s Sick Call Referral
Log, and filed within each youth’s IHCR in reverse chronological order. None of the five
reviewed sick call instances were for youth in restricted housing, as the program does not utilize
restricted housing. A review of the posted daily schedule, and nursing interview showed sick call
was conducted daily, pursuant to contract requirements. Sick calls are provided seven days a
week, twice daily, Monday through Friday at 1:15 p.m. and 2:25 p.m., and Saturday and Sunday
from 11:30 a.m. to 12:35 p.m. and from 5:00 p.m. to 6:00 p.m. The sick call hours are posted in
phase one and phase two dorms, on the walls in the hallways, and in medical. The program has
a procedure whereby the licensed nurse assigned to sick call care for the day conducts all sick
calls; however, if the sick call is being performed by a licensed practical nurse (LPN), the sick
call will be reviewed by the RN on shift or telephonically. Sick Call Request forms are available
to all youth. An exam table and equipment is used to perform sick calls. Nine youth interviews
were conducted, and each youth reported they can see a doctor or dentist if needed. Each of
the nine youth were asked how quickly they can see a nurse once they make a sick call request
and four youth responded they could see a nurse within one day, one youth stated within three
days, and the other four stated they had never requested a sick call. The program’s nurse
reported the process for referring youth to the DHA when youth have repeated complaints is to
place them on the DHA log and the youth will be seen on the next visit regarding the complaint.
At the time of the annual compliance review, there was an observation of a sick call, and the
nurse followed all protocols in conducting a sick call. The youth was escorted by a supervisor to
the nursing department, nursing staff identified themselves and explained to the youth the
reason the youth was there. The youth was seen in a private area in medical, and the
examination was given by licensed medical staff, while the escorting staff waited for the youth
outside of the front door.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a written policy and procedures regarding the provision of episodic and
emergency care. A review of nine youth Individual Healthcare Records (IHCRs) showed three
were applicable for episodic care encounters. Each of the three applicable reviewed IHCRs
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documented first-aid/episodic care was provided by a licensed healthcare staff and was
documented in the progress notes under the notation of episodic care. All notes were completed
in subjective, objective, assessment, and plan (SOAP) format. The program has eight first-aid
kits located in master control, one in each of the three transport vehicles, phase one, phase two,
kitchen, and medical. The program’s process for ensuring contents are maintained and stored in
accordance with guidelines to prevent expiration or deterioration, includes documenting first-aid
kit contents in a binder, checking kits weekly, and replenishing the kits as needed. A review of
documentation indicated medical staff checked the first-aid kits weekly and replenished the kits
as needed. Two observed first-aid kits were fully stocked with DHA approved contents. The
reviewed first-aid kit binder showed the first-aid kits were monitored as required. The program
has two automated external defibrillators (AED) located in master control and the program’s
medical office. On-site nursing staff check weekly to ensure the AEDs are operable. During the
annual compliance review week, the nurse conducted a self-test of the AED in front of the
Monitoring and Quality Improvement (MQI) regional monitor with no issues noted. Reviewed
documentation showed the AED batteries expire in December 2032 in master control and March
2031 in medical. The batteries were last changed in September 2022 in master control and
December 2022 in medical. The pads expire on July 2, 2027, in master control and May 4,
2026, in medical. The pads were changed in September 2022 in master control and December
2022, in medical. Both AEDs provide audible step-by-step instructions when in use. Written
AED procedures are attached to the AEDs. A list of emergency numbers was posted and
accessible for non-licensed and licensed staff and these numbers were inaccessible to all youth
in the program. A review of nine staff training records revealed each completed episodic, first-
aid, and emergency care training. A review of the program’s emergency medical drills
conducted since the last annual compliance review was conducted. Emergency medical drills
included the demonstration of cardiopulmonary resuscitation (CPR), first-aid, and AED use at
least quarterly. The emergency medical drills consisted of both announced and unannounced
drills and were conducted at least monthly on each of the two shifts. A review of drill
documentation showed direct care staff had the opportunity to participate in at least one
emergency “man down” drill annually. Video observations showed the conducted drills
simulated episodic care events which called for immediate first-aid care and/or administration of
CPR techniques. During an informal interview, the health services administrator (HSA) reported
the process for documenting on-site episodic care if non-healthcare staff provide the care to
youth is by way of documenting the episodic care on the Episodic Care Log. Staff will follow the
emergency/non-medical protocol guides and complete the report on an On-Site Healthcare by
Non-Healthcare Staff form. The tracking of youth who are sent off-site for emergency care are
kept in a logbook. An interview with the designated mental health clinician authority (DMHCA)
confirmed staff who are not present during medical emergency drills can review each drill
scenario during staff meetings. Additionally, reviewed documentation confirmed staff signed drill
review sign-in sheets to confirm they were provided the opportunity to review the scenario.
During the annual compliance review week, there was no observation of an episodic care event.
The program maintains a written policy and procedures for the use, access, and inventory of
Narcan by licensed healthcare staff and non-healthcare staff trained by a registered nurse (RN)
to administer medication. The program stores the Narcan in a locked box behind a locked door.
The program’s inventory process of Narcan is for weekly counts to be conducted by medical
staff. Narcan is maintained in the medication cart located in the medical area and can be
accessed by medical staff and supervisors only. Nine staff were interviewed, and each reported
they are personally allowed to call 9-1-1 if needed. Nine youth interviews were conducted, and
each youth reported they may see a doctor or dentist if needed. An interview with the nurse
confirmed the locations of the first-aid kits. The nurse reported youth who are sent off-site for
emergency care are tracked through an off-site care log. The nurse added, drills are conducted
monthly on both shifts.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a written policy and procedures requiring the provision of timely
referrals, coordination, and documentation of medical services provided to youth by off-site
healthcare providers. The designated health authority (DHA) reviews, signs, and dates all
received off-site care findings and information. A review of nine youth Individual Healthcare
Records (IHCRs) revealed three youth required off-site care. Each of the three records showed
the Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. Each
reviewed IHCR showed the off-site emergency care was documented on the Episodic Care Log.
Each IHCR documented parent/guardian notification. Each IHCR documented the DHA
reviewed and signed/initialed all off-site care instructions, information, and findings. Two of the
three applicable reviewed youth required follow-up testing, referrals, and appointments. For the
first applicable youth the follow-ups were completed December 8, 2025, and January 24, 2026.
For the other applicable youth, the follow-ups were completed on January 14, 2026, and
January 19, 2026. Each applicable referral was tracked, and youth received appropriate, timely
follow-up care as needed. An interview with the program’s nurse indicated youth who are sent
off-site for first-aid or emergency care needs have a Summary of Off-Site Care Consultation
report completed and filed in the youth’s IHCR. All hospital orders are followed by requesting
dictation notes and documents from the outside provider. These orders will be reviewed and
witnessed with another nurse. Additionally, it was reported the DHA shall review and initial all
off-site care findings, instructions, and information and the designated registered nurse (RN)
must review the youth’s chart afterwards to make sure the DHA signed and dated the
documents to specify they have been reviewed. The RN tracks the follow-up testing, referrals,
and appointments on the program’s medical tracker.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a written policy and procedures requiring youth with chronic illnesses to
receive regularly scheduled evaluations and the required follow-up. A review of nine youth
Individual Healthcare Records (IHCRs) showed seven of the nine youth were applicable for
having been admitted with a chronic condition. None of the seven applicable youth were
identified as having a communicable disease. Each of the reviewed youth were taking
prescribed medication on an on-going basis and undergoing treatment for physical health
conditions. Seven reviewed youth were classified with a Medical Grade of two through four.
Each applicable youth was placed on the chronic illness list and periodic evaluations were
conducted when applicable every ninety days. None of the reviewed youth were taking anti-
Tuberculosis medications. Periodic evaluations were conducted for each youth prior to
renewing a prescription medication which expired. An interview with the program director (PD)
reported the healthcare staff review the important youth medical issues with program leadership
on a scheduled, routine basis, and as needed to review medical conditions, medication
management, chronic health needs, dietary restrictions, and medical accommodations. These
meetings ensure timely communication, continuity of care, and appropriate follow-up, with
additional consultations occurring immediately when urgent medical concerns arise. The
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designated health authority (DHA) reported periodic evaluations for youth with chronic
conditions are completed and tracked every three months and for complicated cases the DHA
will request monthly. Additionally, to ensure all youth with a chronic condition receive periodic
evaluations as required the DHA utilizes a medical tracker. An interview with nursing staff
indicated the program monitors youth with chronic conditions by a follow-up with the DHA every
ninety-days.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures which detail the process for the receipt,
storage, inventory, and administration of medication in a safe and effective manner. A review of
nine youth Individual Healthcare Records (IHCRs) confirmed five youth were applicable for
having been admitted to the program with medication. A review of documentation revealed each
applicable youth’s medication was confirmed prior to being accepted into the program. Each
applicable youth’s prescription verification was documented in a chronological progress note.
Documentation indicated the designated health authority (DHA) and/or psychiatrist was
contacted to obtain an order to resume/continue the specified medications prescribed prior to
admission. The DHA placed an order on the Practitioner Order form for all continued
medications. All nine reviewed youth were administered medication at the program. The
program utilizes a pre-printed Medication Administration Record (MAR) to document all
medication and treatment. Each MAR clearly indicated medication start and stop dates. There
were no undocumented explanations for a lapse or errors in medication administration.
Reviewed documentation showed nursing staff documented weekly side-effect monitoring on
the MARs. One youth was applicable for a refusal of medication, and the youth signed the
Refusal of Treatment form. Each applicable MAR clearly documented the refusals. Each
reviewed MAR documented all required elements to include the youth’s name, Department of
Juvenile Justice identification number (DJJID), date of birth, youth allergies, precautions,
Medical Grade, medical alerts, a current picture of the youth, and the youth’s initials. Both the
youth and nursing staff initialed each MAR indicating medication was given. There were no
indications of any type of standing orders for psychotropic medications, any emergency
treatment orders for psychotropic medication, or indication of any pro re nata (PRN) orders for
psychotropic medications. At the time of the annual compliance review, one medication
administration was observed with no issues noted. The youth was escorted to the medical office
by a supervisor, and the registered nurse (RN) provided the medication. The Six Rights of
Medication Administration were verified by the RN. The RN administered the medication as
required and did not pre-pour any of the medications. Nine youth interviews were conducted.
Four youth reported the nurse gives them their medication and were able to explain the process,
and the other five reported they did not take medication. An interview with the nurse confirmed
the pre-printed pharmacy MAR is used. The interviewed nurse reported all medication is verified
and the DHA is notified for continued use of medication. The nurse reported medication
administration times are daily at 7:30 a.m., 12:00 p.m., and 5:30 p.m.
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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 maintains a written policy and procedures for the provision of psychiatric services
within the program and maintains a contract with a psychiatrist who is responsible for providing
psychiatric services. The psychiatrist has a clear and active license in the State of Florida,
expiring January 31, 2028. The psychiatrist is available for emergency consultation twenty-four
hours a day, seven days a week. The psychiatrist provided psychiatric services by telephone
briefly as a representative of treatment team and psychiatric recommendations for youth are
incorporated into evaluations and planning at the program. The program did not utilize a back-
up psychiatrist during the annual compliance review period. Psychiatric sign-in logs were
reviewed and showed the psychiatrist was on-site biweekly, as required. A review of
documentation confirmed the psychiatrist actively participated, managed, and supervised
psychotropic medication services in the program. A review of nine youth Individual Healthcare
Records (IHCRs) indicated four youth were admitted with prescribed psychotropic medications
and four youth were prescribed medications after admission. Each applicable youth was
referred for a psychiatric interview, and each youth received a Diagnostic Psychiatric Interview
within fourteen days of admission. Each of the reviewed youth were prescribed psychotropic
medications as a result of the interview. Each reviewed youth’s Initial Diagnostic Psychiatric
Interview was documented on the Department’s Clinical Psychotropic Progress Note (CPPN)
form. Psychotropic medication and changes to each youth’s existing and psychotropic
medication regimen, were documented on the CPPN. Each of the reviewed Initial Diagnostic
Psychiatric Interviews included all required elements. Documentation indicated each of the
applicable youth were seen by a psychiatrist at least every thirty days for medication reviews.
Each instance where page three of the CPPN was used, the psychiatrist documented the
identifying data, diagnosis, target symptoms of each medication, effects of the medication,
medication dosage, dosage range, frequency, route of administration, side effects, adherence to
the medication regime, height, weight, laboratory findings, and whether there was telephone
contact with the youth’s parent/guardian. Reviewed documentation revealed each CPPN was
signed and dated by the psychiatrist. Each of the youth were applicable for monitoring of Tardive
Dyskinesia, which was documented as required. Each of the nine reviewed youth were
applicable for receiving tele-psychiatry services. The standard of psychiatric care delivered was
the same as rendered in person. Tele-psychiatry was only utilized for youth who agreed to
participate in the tele-psychiatry session and when the parent/guardian provided consent. An
interview with the psychiatrist and designated mental health clinician authority (DMHCA),
verified the psychiatric treatment processes at the program.
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 maintains a written policy and procedures stipulating the requirements for the
tracking of inventory for all medication and medical equipment. The program’s policy requires all
medical equipment to be classified and perpetually inventoried. An observation was conducted
of the medical office and revealed controlled medications were secured behind a locked door,
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and controlled substances were locked in a secure medical cart, inside of another locked box.
Observations showed the medication cart was clean and organized, with stock items separated
from youth-specific medications. At the time of the annual compliance review the program did
not have any medications requiring refrigeration; however, the program has a secure
refrigerator, which is designated for medication only. Observations confirmed 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, observations confirmed
there was a shift-to-shift inventory count of all controlled substances documented on each
applicable youth’s individualized Controlled Medication Inventory Record. The medical
equipment classified as sharps included scissors, syringes, suture removal kits, and needles. All
were secured and inventoried utilizing a routine perpetual inventory. The medications were
stored in a separate secured area which was not accessible to any youth. The medications and
sharps were all stored in a designated locked area which was clearly labeled. A review of nine
staff training records confirmed the registered nurse (RN) conducted the training for oversight of
medication self-administration and delivery. At the time of the annual compliance review, an
observation was conducted for counts of three controlled medications, three OTC medications,
and three sharps, and each inventory count was accurate and coincided with the documented
inventory. The interviewed nurse reported if there is a discrepancy with the inventory, the
nursing staff will double check/count the medication and report the inventory discrepancies to
the health service administrator (HSA). Additionally, the regional medical supervisor and
program director (PD) or designee on-site will be notified of the discrepancy, and an internal
investigation will be initiated. Additionally, the Department's Central Communications Center
(CCC) will be contacted. The interviewed HSA confirmed the program’s disposal process is
conducted with the HSA and the pharmacist, and each signs the medication disposal form. The
program maintains a copy of the local pharmacist license in the medical office. The pharmacist
conducts monthly on-site checks of all the medications and nurses are required to count the
controlled medications shift-to-shift. The counts are conducted with two nurses and a third will
be used if necessary.
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-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program maintains a written policy and procedures for infection and exposure control. The
program’s policy requires infection control procedures for prevention, containment, treatment,
and reporting requirements related to infectious diseases. The program’s infection control policy
and procedures were signed by the designated health authority (DHA) and the program director
(PD) on July 28, 2025, to acknowledge their review of the policy. Nursing staff reviewed the
policy on August 25, 2025. The procedures included common, infectious diseases of childhood,
self-limiting, episodic contagious illnesses, viral or bacterial infections, tuberculosis, Hepatitis A,
B, and C, human immunodeficiency virus (HIV), Methicillin-Resistant Staphylococcus Aureus
(MRSA), bio-terrorist agents, chemical exposures, outbreaks of lice, and epidemics. Reviewed
documentation showed staff have access to protective equipment and Hepatitis B
immunizations are available for program staff. A review of the program’s facility/occupational
exposure book was conducted and showed there were no incidents where the local health
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department or the Department's Central Communications Center (CCC) should have been
contacted at the time of the annual compliance review. The Exposure Control Plan was written
in accordance with Occupational Safety and Health Administration (OSHA) standards. The
program maintains a separate record for youth and staff who experienced a facility/occupational
exposure. The health service administrator (HSA) explained the program’s process for needle
stick post-exposure evaluation. Staff will dispose of the needle into the sharp’s container,
immediately wash the exposed area, notify the supervisor, or PD, and contact the CCC. An
interview with the nursing staff indicated exposure control training is provided by the HSA
annually for staff and new hires. An interview with the PD stated the Exposure Control Plan is
reviewed yearly with direct care staff and training is provided to youth at the time of admission.
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 maintains a written policy and procedures for maintaining safety and security by
requiring all program staff to always know the location of all youth through active supervision,
monitoring, and utilizing emergency counts. The program’s policy requires staff-to-youth ratios
to be one-to-eight during awake hours and one-to-twelve during sleep hours. A review of the
program’s policy confirmed staff shall maintain active supervision of each youth, including any
behavior changes, engage in a full schedule of constructive activities, and consistently apply the
behavior management system (BMS). A program tour verified the daily youth activity schedule
was posted throughout the program and was designed to keep youth engaged in a full schedule
of activities. During the annual compliance review week observations were conducted of youth
supervision including line movements, youth head counts, classroom activities, youth searches,
meal activities, and outdoor/indoor recreation activities. In addition, observations were made of
an admission. An observation of a line movement confirmed staff were keeping a continual
count of all youth in their group by having youth count when walking through a door. An informal
interview with three staff confirmed staff immediately knew the number of youth they were
supervising. The observations ensured staff-to-youth ratios were maintained, as required.
Observations of interactions between program staff and youth reflected the interactions were
positive and consistent with the program’s BMS. A tour of the program verified the program and
living units were clean, graffiti free, with no unusual odors, and were well maintained. The daily
schedule, grievance forms, and sick call forms were posted in the dayroom and living unit
accessible to each youth. Youth were always observed engaging in activities during the annual
compliance review week. A perimeter check was conducted, and the program’s privacy fencing
appeared to be in good repair. Video observations of ten-minute checks confirmed youth
supervision continued during sleep hours. A review of the Department's Central
Communications Center (CCC) reports confirmed, during the annual compliance review period,
there were no escapes reported.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a written policy and procedures for implementation of the behavior
management system (BMS) and staff training. The program’s policy requires all staff to be
trained in the BMS. A review of documentation confirmed all required parties were involved in
the development, implementation, and on-going maintenance of the BMS. The policy and
procedures include a protocol where staff are provided with feedback regarding the
implementation of the BMS. The program has an agreement with the education provider related
to the BMS. Education staff were trained on the BMS by the regional training coordinator. A
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 68 (Revised August 2025)
review of nine youth case management records confirmed the youth orientation and handbook
included the program’s BMS. A review of staff job descriptions showed they included
implementation of the program’s BMS. Each staff record included documents which confirmed
the BMS training was completed. While conducting a program observation tour, BMS posters
and signage were present on each living module and throughout the program. The BMS has not
changed during the annual compliance review period. The BMS included all the required
elements. A review of the youth handbook indicated the BMS is designed to promote safety,
respect, and fairness. The BMS promotes and protects youth rights and has opportunities for
positive reinforcement. The BMS includes positive and negative consequences and uses
constructive disciplinary actions. The BMS promotes socially acceptable means for youth to
meet their needs, includes a process for explaining to youth the reasons sanctions are being
imposed, youth have the opportunity to explain their behavior, there are opportunities for staff
and youth to discuss the impact of behavior to others, includes reasonable reparations for harm
caused by others, there are discussions of alternative behaviors, promotes positive dialogue,
and minimizes separation of youth from the population. A review of the BMS confirmed it is not
used solely to increase a youth’s length of stay, deny basic rights or services, promote the use
of group punishment, allow youth to punish other youth, or include disciplinary confinement.
Staff and youth interactions were observed for adherence to the elements of the BMS, including
rewards and negative consequences, which were in direct relation to the severity or seriousness
of inappropriate behavior exhibited by youth. The program’s BMS included a process wherein
staff explain to youth the reason for any sanction imposed prior to the end of the staff’s workday,
youth are given an opportunity to explain their behavior, and staff and youth discuss the
behavior’s impact on others, reasonable reparations for harm caused to others, and alternative
acceptable behaviors. There are a variety of rewards/incentives which include using their level
to earn daily canteen, weekly canteen, monthly canteen, participating in off-campus activities,
monthly birthday events, restaurant meals, extra hygiene products, and receiving extra snacks.
Nine youth were interviewed, and youth stated the consequences the program has for
inappropriate behaviors include level freeze, canteen freeze, incentive freeze, and early
bedtime. Nine interviewed staff stated the program's BMS is a process to track and monitor
youth behavior by using a point system. Each staff stated rewards are granted once a week and
include canteen, pizza parties, outings, access to the incentive room, and recreation privileges.
Each interviewed youth stated they can earn snacks, canteen, incentive room access, level
increase, and outings as rewards at the program. Each interviewed youth stated staff are
consistent in what behaviors they give rewards and consequences to. Interviewed staff stated
basic rights cannot be taken away from youth as a consequence. All nine youth were able to
explain the difference between each level and how they move from level to level. All nine-youth
verified youth are never allowed to punish other youth. An interview with the program director
(PD) confirmed the program utilizes a level BMS. The system is implemented through
coordinated input from direct care staff, clinical, case management, education, and medical staff
to ensure consistent, trauma-responsive support for youth. Behavior expectations, interventions,
and progress are reviewed collaboratively by the multi-disciplinary team, allowing responses to
be individualized, developmentally appropriate, and aligned with treatment goals. Positive
behavior is reinforced through incentives and graduated privileges, while behavioral concerns
are addressed through coaching and structured corrective actions focused on skill-building and
accountability. This team-based approach ensures consistency across shifts and services while
supporting youth engagement and successful program completion. The PD stated
consequences are monitored and reviewed by supervisors and the multidisciplinary team to
ensure consistency with policy, trauma-responsive practices, and youth treatment plans.
Management conducts regular reviews and trend analysis to identify patterns, prevent overuse,
and ensure corrective actions remain balanced with positive reinforcement.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Limited Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a written policy and procedures in place to conduct and document ten-
minute checks during sleep hours, or at other times such as during an illness to ensure the
safety and security of each youth. The program has a total of one-hundred twenty-two video
surveillance cameras. All cameras were operational at the time of the annual compliance
review. Video recordings are stored for thirty days. At the time of the annual compliance review,
the program had an open major deficiency for ten-minute checks, which was identified on
December 31, 2025. Staff are required to conduct room checks every ten-minutes and
document the time of the check on the Ten-Minute Check Log when youth are sleeping. A video
review of ten-minute checks from the overnight shift and from each living unit, for a total of nine
samples verified in eight of the nine video samples staff conducted checks every ten-minutes
and documented the times accurately on the Ten-Minute Check Log. In one video sample one
staff conducted a check seven minutes late and completed the next check within ten minutes. A
review of twenty-seven Ten-Minute Check Logs since the last annual compliance review over
various days, times, and shifts indicated the ten-minute checks were completed within the
required frequencies. An interview was conducted with the program director (PD) who indicated
the program has one hundred twenty-two operational security cameras. Video footage is
maintained in the system for thirty days. An interview with nine staff indicated all room checks
are conducted at a minimum of eight-to-ten-minute intervals while youth are in their sleeping
rooms.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
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Office of Accountability and Program Support Page 56 of 68 (Revised August 2025)
The program maintains a written policy and procedures for census, counts, and tracking of
youth at various times throughout the day. The program’s policy requires the program to have a
chronological record of the daily youth census. In addition, the policy indicated counts are
conducted during power outages, escapes, program disturbances, or any other disruptions
which may occur. A review of the Continuity of Operations Plan (COOP) verified program staff
must always account for the whereabouts of each youth in the care and custody of the program.
This includes the need for continual head counts to be conducted minimally, at the beginning of
each shift, during any emergency situation, and at regular intervals. The program monitors
youth using a counting system of scheduled, unscheduled, and emergency counts.
Observations conducted during the annual compliance review week and a review of program
logbooks for the annual compliance review period confirmed youth daily census counts, head
counts, and youth movements were documented at the beginning of each shift and after each
outdoor activity. In addition, the master control operator documented the headcounts in the
program’s logbook. A logbook review for twelve randomly selected dates and times, for census
counts and tracking was conducted during the annual compliance review period. Documentation
validated head counts and movements were conducted at the beginning of each shift, after
outdoor activities, after transfers, during emergency situations such as program disturbances,
and during actual and/or simulated drills. Nine staff were interviewed, and each confirmed youth
counts are conducted prior to youth movements, and every hour throughout the day. In addition,
all staff reported when a youth count cannot be reconciled, all movements stop, a recount is
conducted, and if a recount is still not correct the shift supervisor and/or director of group living
conducts a physical headcount. Finally, notification will be made to the local police department if
the count can still not be reconciled. An emergency headcount is conducted whenever the
original count is not accurate, after a power outage, and when a code is called.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a written policy and procedures for documenting chronological events,
incidents, headcounts, shift changes, group movements, and activities in the master control
logbook. The program’s policy requires the program to maintain one logbook in master control
and all the program staff to be briefed when coming on-duty. During the annual compliance
review week, a total of twelve logbooks were reviewed. Each reviewed logbook was bound with
numbered pages, had no destroyed or removed entries, entries were made in ink with no
erasures or white-out areas, and errors were struck through with a single line and initialed by
the staff correcting the error. Reviewed entries included the dates and times of events, with the
names of the staff and youth involved, brief descriptions of the events, and the names and
signatures of the staff making the entries. A review of the logbooks confirmed the program
documented emergency situations, incidents with use of mechanical restraints, special
instructions for supervision of youth, population counts, information regarding escapes or
attempts of escape, transports, admissions and releases, the education schedule, notations of
youth arrival to and departing from school and recreation areas, perimeter security checks,
transports, and calls to the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC). Shift reports are maintained in the master control logbook. A
review of documentation confirmed staff signed and dated the shift logbook in
acknowledgement they have reviewed or been verbally briefed about its contents.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 68 (Revised August 2025)
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures for assignment, inventory, tracking, and
storage of program keys. The program’s policy requires all staff to follow the guidelines and to
be trained on the key control policy. The program’s policy includes key assignment and usage
including restrictions, 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 director (PD) has overall responsibility for key control management. Program keys
are maintained in master control in a lockbox with the corresponding tracking number.
Observations made throughout the annual compliance review week found all staff surrendered
their personal keys upon entering the program and keys were stored within the master control
office. Observations conducted during the annual compliance review week found staff were
assigned program keys and logged assignments in the key log. During the annual compliance
review week, observations confirmed staff were aware of program keys in their possession. The
process for reporting or replacing lost or damaged keys is for staff to notify the shift supervisor,
and complete a broken key incident report. The physical plant manager receives the incident
report, removes the broken key from the key ring, and replaces it with a new key. If the lock is
broken and a locksmith vendor is needed, the physical plant manager will contact the locksmith
vendor for repair and/or replacement. The program had no incidents regarding lost/broken keys
reported to the Department's Central Communications Center (CCC) during the annual
compliance review period. All program keys are maintained within the master control area,
which is located at the entrance of the program. Keys are maintained inside a locked cabinet
within the master control room, and are only accessible by master control staff, and
administration. The program has a list of staff who are assigned permanent keys. The PD,
clinical director, director of group living, and physical plant manager are assigned permanent
keys. A sample of five random keys compared to the inventory list indicated the keys were
accounted for and master control staff knew which area each key was assigned to. All keys
were logged in the key logbook, and each included the correct number of keys on the key rings.
An informal interview with master control staff indicated the program’s practice is when direct
care staff arrive at the program, personal keys are collected by master control and placed on the
key box, while the visitors' keys are placed on a board in master control. An informal interview
with three random staff was conducted and each staff confirmed the number of keys on their
key ring and the function of each key. An interview with nine staff confirmed each staff’s
personal keys are given to master control upon entry, personal keys are securely stored, staff
are assigned program keys by the master control operator, all visitor’s personal keys are placed
in the lock box, and all staff reported youth do not have access to staff keys.
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Office of Accountability and Program Support Page 58 of 68 (Revised August 2025)
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to identify materials considered to be
contraband and to prevent prohibited items from entering the program. The program’s policy
identifies the items considered to be contraband including sharps, escape paraphernalia,
tobacco products, lighters, electronic or vaporless cigarettes, and unauthorized food or clothing.
The program has a system in placed to prevent contraband from entering the program which
includes defining items/materials considered contraband, providing youth with the list, informing
youth of consequences if contraband is found, searching the physical plant and program
grounds, searching youth, and searching incoming and outgoing mail. The program has a
contraband sign located outside the program’s main gate with a list of unauthorized items on it.
A review of the program’s visitor’s log in the main lobby confirmed the log includes a contraband
attestation statement. A total of thirty-four newly hired staff all signed the attestation forms
during the annual compliance review period. The contraband statement addresses
consequences for any staff who is found in possession of contraband and the provision for law
enforcement to be notified if there is evidence of unlawful activity. The program clearly identifies
contraband, to 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’s policy is to confiscate any contraband and turn items over to law enforcement. All
incidents of contraband must be reported to the Department's Central Communications Center
(CCC). Searches are documented in the program’s logbook, incident reports, and search
reports. The interviewed program director (PD) confirmed all prohibited items are immediately
secured, documented, and reported to supervisory staff. Legal contraband is disposed of or
stored according to policy, while illegal contraband is preserved as evidence and reported to law
enforcement and the Department as required. Management ensures proper documentation,
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chain of custody, and safe disposal procedures to maintain program security and regulatory
compliance. A total of nine staff were interviewed about the program’s process for searching
youth rooms, and all staff confirmed youth rooms are randomly searched daily and throughout
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 maintains a written policy and procedures for searches and full body visual
searches to be conducted to ensure no contraband is being introduced into the program. The
program’s policy requires searches to be conducted throughout the program including searches
of youth, visitors, property, staff, and the program’s physical plant. During the annual
compliance review week youth searches were observed. Youth were searched before every
movement. Regional monitor observed youth being searched in the hallway leaving class,
before entering the cafeteria, when being escorted to the medical office, and after school before
returning to the living units. In all observations, staff treated youth with dignity and respect. Two
male staff were observed explaining and instructing a newly admitted youth through the search
process minimizing the youth’s stress and embarrassment. No off-campus activities took place
during the annual compliance review week. A video review of five randomly selected dates and
times indicated staff and visitor searches were being conducted in accordance with policy
and/or the Right Interactions (RI) training manual. Seven of nine interviewed youth stated they
are searched leaving outdoor activities, after meals, and after visitation. Four youth stated they
are searched when items are missing, when returning from off campus, after work details, or
after any movement. Nine interviewed staff all reported youth are searched after every
movement throughout the program.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a written policy and procedures to ensure all program vehicles used to
transport youth are properly maintained. The program’s policy requires each vehicle to have a
safety inspection annually. The program has a total of three vehicles used to transport youth.
Observations were conducted of the vehicles, and they appeared to be maintained. All three
vehicles were inspected annually and had maintenance records. Each van was secured and
contained a fire extinguisher, seatbelt cutter, window punch, appropriate number of seatbelts,
and the door to the youth passenger area could not be opened from the inside. The first-aid kits
are not kept in the vehicles and are brought in each vehicle by staff for transport. None of the
transportation vehicles were required to contain a safety screen. A random check of ten staff
personal vehicles during the annual compliance review week was conducted to ensure vehicles
were locked and secured when not in use. Each was locked as required.
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Office of Accountability and Program Support Page 60 of 68 (Revised August 2025)
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures to ensure the safety and security of
youth and the community when youth are transported outside of the program. The program’s
human resources staff obtain monthly driving record information from the Department of
Highway Safety and Motor Vehicles for all staff designated to transport youth. The program
assigns a ratio of one staff to five youth during transport, not including the driver. There were no
transports scheduled during the annual compliance review week; therefore, a transport could
not be observed. The program’s policy states youth are not permitted to drive program or staff
vehicles. Nine staff were interviewed, and each stated prior to each transport each youth and
vehicle are searched for contraband, and youth are secured in the vehicle. Each interviewed
staff stated the emergency response process during vehicle transport is to use the program’s
cellular telephone to call the program and 9-1-1 if there is an emergency. Each interviewed staff
knew the staff-to-youth ratio during transport. All staff reported they are not allowed to use
personal vehicles to transport youth. In addition, staff reported the safety equipment in the
transport vehicles include seatbelts, first-aid kits, fire extinguisher, club, and roadside assistance
kits. Nine interviewed youth stated while on a transport they have never been handcuffed to any
part of the vehicle. Nine interviewed youth stated they never 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 maintains a written policy and procedures to ensure safety and security of the
physical plant, grounds, and perimeter. The program’s policy requires weekly safety and
security audits to be conducted by the program director (PD) or designee and documented on
the Safety and Security Audit Inspection form. The physical plant manager is responsible for
ensuring weekly safety and security audits are conducted, reviewed, and submitted to the
Department, and to ensure verification of all deficiencies, corrections, and implementations are
in compliance. A review of the program’s Safety and Security Audit Inspection forms during the
annual compliance review period confirmed the physical plant manager conducted weekly
safety/security inspections, maintenance schedules were maintained, and repairs were
conducted as required. The physical plant manager conducted perimeter checks at the
beginning of each day and after youth returned from recreation. A review of the program
logbook confirmed the perimeter checks were documented daily. A review of deficiencies
entered in the Department’s Juvenile Justice Information System (JJIS) verified there were no
deficiencies assigned regarding safety and security audits during the annual compliance review
period. An interview with the PD indicated deficiencies are identified through routine safety
inspections, shift briefings, incident reports, audits, and staff and youth feedback. Identified
issues are documented, entered into tracking logs, and reviewed by management to determine
corrective actions. The program assigns responsibility, establishes timelines for resolution, and
monitors follow-up to ensure deficiencies are promptly addressed, with trends reviewed to
support continuous improvement and to maintain a safe and secure environment.
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Office of Accountability and Program Support Page 61 of 68 (Revised August 2025)
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures to address the tool management system
which ensures youth do not use tools or equipment as a weapon or security breach. The
program’s policy requires all tools in the program including maintenance, vocational, food
services, and medical equipment to be inventoried and kept in a secure location. The program’s
procedures require staff and youth to be trained on the intended safe use of tools. A
documentation review of the Tool Inventory Sheet confirmed all tools including sharp-edge and
pointed tools are inventoried daily prior to being used for work and following work activities.
Machetes, bowie knives, or other long blade knives are prohibited in the physical plant. In
instances of missing tools, the program’s policy is to go into lockdown, staff will notify
administration, fill out an incident report, master control staff will document the incident in the
logbook, call the Department's Central Communications Center (CCC), and the program will be
searched until the tool is found/located. The program has a policy and procedures for tools
requiring disposal. An informal interview with the physical plant manager confirmed tools are
destroyed at the program if a tool is broken or inoperable, the physical plant manager is
responsible for disposal of the broken tool, and then administration and the physical plant
manager work together to replace the broken tool. The destroyed tool is then removed from the
Tool Inventory Sheet. An observation and inventory of ten tools was conducted. Five tools were
inventoried from the kitchen and five from the maintenance office, and observations confirmed
all tools were secured with the correct markings for easy identification and inventoried correctly
on the logs. Five inventoried tools from the kitchen included the French knife, butcher knife,
vegetable peeler, eight-ounce spoon, and six-ounce spool. Five inventoried tools located in the
maintenance office were the pipe cutter, rivet gun, pliers, wrench, and caulking gun. The
program has a sign-in and sign-out log for Class A and Class B tools.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth are handling tools
safely and are supervised appropriately to prevent injuries to other youth and staff. The
program’s policy requires staff and youth to be trained in the intended safe use of tools. Youth
are allowed to use Class B tools and non-hazardous tools only. A review of the program’s policy
confirmed the policy includes supervision requirements for when youth use tools and for when
issuing tools to youth and staff, including an assessment to determine a youth’s risk to self or
others. The policy established the ratios, tool distribution process, and collection procedures
during special work projects. The ratio of one staff to five youth when activities involve usage of
tools is required. During the annual compliance review week, youth were observed taking out
the trash with no issues noted. No additional tool usage was observed. A review of nine youth
case management records confirmed all nine youth signed and acknowledged the rules and
regulations regarding tool usage. Nine staff were interviewed, and seven staff stated youth are
allowed to use scrub brushes, mops, and brooms for cleaning purposes, and youth are not
allowed to use kitchen knives, saws, or an axe. Two staff stated youth do not use tools. Nine
youth were interviewed, and three youth indicated the only tools they are allowed to use are
cleaning tools such as mops and brooms. Six youth stated youth are not allowed to use tools.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 68 (Revised August 2025)
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures for outside contractors. The program’s
policy requires all private contractors to receive written instructions detailing responsibilities
regarding tool management and contraband. The program requires all outside contractors
entering the program to sign a visitor log. The physical plant manager or designee inspects all
tools upon the arrival of outside contractors and is responsible for providing approval if such
tools are required. All tools are accounted for prior to departure. All tools and equipment brought
into the program will be searched and inventoried on the Outside Contractor On-Site
Worksheet. All contractors will be escorted by the physical plant manager. A review of the sign-
in sheet/logbook, and three randomly chosen work invoices verified the contractors were on-site
on the same date the documents were signed. The Outside Contractor On-Site Worksheets
confirmed the tools were checked upon entering and departing the program, restricted tools
were not allowed, any missing tools had a follow-up, and youth were restricted from the work
area while the vendor was on-site. A review of the work project logs confirmed all vendors
signed a contraband attestation agreement prohibiting unauthorized items from being brought
into the program.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a written policy and procedures to ensure youth and staff are prepared
for fire, safety, and evacuation emergencies. The program has a written Continuity of
Operations Plan (COOP) which was approved by the Department. The program’s COOP
addresses fire, safety, and evacuation emergency processes and the frequency of conducting
drills at random times, and under varied conditions. A review of documentation since the last
annual compliance review, confirmed fire drills were conducted on each of the program’s two
shifts monthly, as required. The program conducted emergency COOP drills which included fire,
riot, severe weather, flooding, hostage situations, chemical spills, medical situations, and bomb
threats. Documented drills included the type of drill, date and time, participants, a brief scenario,
and findings. Observations during the program tour confirmed the fire evacuation routes and
egress plans were posted throughout the program. The program had a total of twenty-six fire
extinguishers which were all tagged with annual inspection dates. Nine staff were interviewed,
and each stated they have participated in suicide, medical, fire, and COOP drills. Nine
interviewed youth all indicated they have been instructed on what to do in case of a fire. An
interview with the program director (PD) indicated the program conducts regular emergency
preparedness drills in accordance with policy. The PD confirmed all fire drills are conducted
monthly on each shift and COOP drills are conducted monthly on each shift.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a written policy and procedures requiring the development of a
Continuity of Operations Plan (COOP), which is updated as necessary, and maintained in
compliance with state law and Department policy. The program’s COOP is available to all staff
and is located in master control and the administration office. A review of the COOP validated
the plan was reviewed and submitted on December 29, 2025, and approved by the Department
on January 14, 2026. The COOP addresses alternative relocation sites approved by the
Department’s regional director/designee and provides for basic care and custody of youth in the
event of an emergency or disaster. The program’s Emergency Disaster Preparedness Plan and
COOP are combined. The program has provisions of equipment and supplies maintained in the
event of an emergency. During the program tour, observations of emergency supplies included
batteries, flashlights, a radio, and a satellite telephone which is maintained in the intake office.
Additionally, food, drinks, and water bottles were located in the kitchen. The program maintains
an administrative hard copy record for each youth in case of an emergency. A review of nine
youth hard copy records confirmed each contained the youth’s name, Department of Juvenile
Justice identification number (DJJID), admission date, date of birth, gender, and race. The
records documented the name, address, and telephone number of the parent/guardian,
emergency contact, assigned juvenile probation officer (JPO), committing judge, state attorney,
public defender, victim notification information, physical description of youth, overall health
status, and personal physician for each youth. An interview with the program director (PD)
confirmed the COOP is located in master control, training office, PD’s office, and the
supervisor’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a written policy and procedures for storage and inventory of all
flammables, toxic, poisonous, and caustic materials. The program’s policy is for all flammable,
poisonous, and toxic items to be stored in a secure area not accessible to youth. Toxic items
were stored and observed in the locked tool shed inaccessible to youth. Observation of the
storage area indicated it was clearly marked as containing hazardous chemicals and was
securely locked. Chemicals are inventoried on the Chemical Inventory Log. A review of the
inventory logs confirmed the inventory lists were maintained. The program director (PD),
director of group living, dietary staff, physical plant manager, and shift supervisor are authorized
to handle flammable, toxic, and poisonous items and dispose of the items. In addition, the
program maintains a written policy and procedures to ensure all flammable, toxic, caustic, and
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poisonous items are disposed appropriately. The disposal procedures are in accordance with
the Occupational Safety and Health Administration (OSHA) Standards, and in accordance with
the Safety Data Sheets (SDS). Additionally, items are disposed of as needed at the local waste
management facility. Used mop water, liquid waste, and used beverages are disposed of down
the plumbing drains. In an informal interview the physical plant manager confirmed the program
makes every effort to use up all chemicals, used kitchen grease and waste is stored in a large
container, and any unused chemicals are taken to the local waste management company. All
liquid waste from work details is disposed of down plumbing drains. A review of the storage area
verified the number and type of chemicals were maintained on the inventory list. A random
sample of ten chemicals verified all chemical counts matched the inventory logs. All the
chemicals were secure. The SDSs were present for all items reviewed. An interview with the PD
confirmed flammable, toxic, caustic, and poisonous items are securely stored in approved,
clearly labeled containers, with restricted staff access and are disposed of according to
manufacturer instructions, SDSs, and applicable local, state, and federal regulations. Disposal is
coordinated with approved vendors or designated waste services, documented appropriately,
and overseen by management to ensure safe handling and environmental compliance.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. The program’s policy states youth are not
permitted to use, handle, or clean with dangerous or hazardous chemicals, respond to chemical
spills or clean, handle, or dispose of any other person’s biohazardous material, bodily fluids, or
human waste. Youth are strictly prohibited from the maintenance area where toxic items and
chemicals are stored. During the annual compliance review week, there were observations of
youth cleaning, verifying youth were not using any chemicals. Nine youth were interviewed, and
each youth stated they do not use any chemicals or cleaning products.
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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.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures for allowing visitation and
communication for youth at the program. The program’s policy requires the program to provide
opportunities for communication and engagement with each youth and family. The visitation
schedule was observed hung up in the living unit, lobby, and dayroom wall. The program has
designated the cafeteria for the visitation area. Visitation sessions are offered on Sunday from
1:00 p.m. to 3:00 p.m. The program’s policy states the case manager will mail an admission
letter to each youth’s parent/guardian within forty-eight hours of admission to the program,
which includes the visitation rules and information. A review of nine randomly selected youth
case management records confirmed a copy of the mailed document was in each youth record
with a corresponding letter. During an informal interview with a case manager, they indicated
the program provides visitation to youth every Sunday. The program organizes family sessions
for family members who cannot attend during visitation days. In addition, the case manager
confirmed youth contact their families through weekly telephone calls. A review of weekly
telephone logs confirmed telephone calls are conducted Monday through Friday. Youth are
given an opportunity to communicate with family members by mail. According to the case
manager, the program receives necessary information for any youth with a history of human
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trafficking from the assigned juvenile probation officer (JPO). The program has access to a
translation service provider when the need exists for services or information in a language other
than English. Nine youth were interviewed, and each youth stated they are allowed to call their
parent/guardian. An interview with the program director (PD) indicated the program utilizes
bilingual staff, professional interpretation services, and translated written materials to ensure
youth can effectively communicate, and understand program rules, treatment plans, and
grievance processes. These supports are provided as needed to ensure meaningful access to
services, promote equity, and support youth safety and engagement.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. The program’s policy requires the program to provide social
and cognitive skill development, creativity, teamwork, healthy competition, mental stimulation,
and physical fitness. Youth are provided with at least one hour of large muscle activity daily.
Daily observations of youth during the annual compliance review week confirmed youth were
engaged in large muscle activity daily. Youth were observed walking around the recreation yard
and exercising. A review of the staff roster confirmed the program has a recreation therapist,
who met all requirements for the position. The program’s activity schedule was seen posted
throughout the living units and common areas of the program, which included at least one hour
of recreation daily. An informal interview with the recreation therapist and reviewed
documentation of nine youth records verified recreational therapy is part of each youth’s initial
wellness plan. Nine youth were interviewed, and each youth indicated they are provided at least
one hour of physical activity which includes playing football and basketball. Nine staff were
interviewed, and each indicated youth participate in outdoor-football, basketball, board games,
and incentive room activities.
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 practices 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 practices confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
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Office of Accountability and Program Support Page 67 of 68 (Revised August 2025)
The program’s policy, procedures, and practices 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 68 of 68 (Revised August 2025)

report_type: QI Residential

program_name_raw: Palm Beach Youth Academy

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)

rating: Limited Compliance