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
Juvenile Unit for Specialized Treatment (JUST) and Twin Oaks
Vocational Academy (TOVA) II
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
29481 Liberty Wilderness Road
Sumatra, Florida 32335
Review Date(s): Janury 13 - 16, 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:
Andre Watson, Office of Accountability and Program Support, Lead Reviewer (Standard1)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Dehryl McCall, Office of Education, Education Coordinator (Education Standard 2)
Patrick McKinstry, Office of Accountability and Program Support, Lead Reviewer (Interviews)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: JUST/TOVA II MQI Program Code: 1086
Provider Name: Twin Oaks Development, Inc. Contract Number: 10696
Location: Liberty County / Circuit 2 Number of Beds: 44
Review Date(s): January 13-16, 2026 Lead Reviewer Code: 228
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
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
3.10 Suicide Prevention Services*
This monitoring report reflects the Department’s assessment of program compliance with applicable standards during the established review period. Monitoring reports represent a snapshot of program operations and
documentation at the time the review was conducted. When areas of limited or failed compliance are identified, the Department works with the provider through established processes to address those issues and ensure
corrective actions are implemented as outlined in FDJJ 2000. Follow-up monitoring, verification activities, and corrective action processes are used to confirm identified deficiencies are addressed and programs return to
compliance with applicable standards.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 66 (Revised August 2025)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment and Management Response to Allegations* Satisfactory
1.04 Incident Reporting (CCC)* Satisfactory
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory
1.06 Pre-Service/Certification Requirements* Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievance Process Satisfactory
1.09 Delinquency Interventions and Facilitator Training Satisfactory
1.10 Life Skills Training Provided to Youth Satisfactory
1.11 Restorative Justice Programming Satisfactory
1.12 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.13 Youth Records (Healthcare and Management) Satisfactory
1.14 Advisory Board Satisfactory
1.15 Staff Performance Satisfactory
1.16 Special Contract Conditions Satisfactory
1.17 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 66 (Revised August 2025)
Standard 2: Assessment and Performance Plan Residential Rating
Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Assessments and Reassessments Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals, and Transmittal* Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
2.18 Educational Access (Residential Contract Provider)* Satisfactory
2.19 Contract Specific Career and Technical Education Services (Residential Contract Provider) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 66 (Revised August 2025)
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* Limited
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 66 (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 66 (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* Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test* Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 66 (Revised August 2025)
Program Overview
The Juvenile Unit for Specialist Treatment (JUST) and Twin Oaks Vocational Academy (TOVA)
II is a forty-four-bed program, for ten to seventeen-year-old males, located in Sumatra, Florida.
The program is operated by Twin Oaks Juvenile Development, Inc., through a contract with the
Department. Both components of the program provide intensive mental health services. In
addition, the program fosters each youth by providing Skillstreaming the Adolescent, Life Skills
Training, Impact of Crime (IOC), and Trauma Affect Regulation: Guide for Education and
Therapy (TARGET). The youth at the programs also have an opportunity to participate in Boys
and Girls Club and Department of Transportation (DOT) projects. Additional treatment services
provided include family therapy, individual therapy, intensive mental health services, Mental
Health Overlay Services (MHOS), group, and recreational therapy. Program administration is
comprised of a program director, assistant program director, director of operations,
administrative assistant, and shift supervisors. Case management services are provided by
three case managers and a transition case manager. Mental health staff at the program
includes a licensed mental health counselor who serves as the designated mental health
clinician authority (DMHCA) and five non-licensed master’s-level therapists. Medical services
are provided by a medical doctor who serves as the program’s designated health authority
(DHA), one health services authority, two licensed registered nurses (RN) and one licensed
practical nurse (LPN). There is nursing staff on-site seven days a week. Educational services
are provided by Florida Scholars Academy. The program is located in the Apalachicola National
Forest which spans 560,000 acres. The program’s administration building is centrally located in
the program and consists of administrative offices, case managers offices, and mental health
staff offices. Toward the rear of the administration building stands the medical clinic which also
serves as the dining area. Alongside the medical clinic stands the educational building and
teacher offices. There are also areas in the back of property where vocational and agricultural
classes are located, including animal care and aquaponics. The program has forty-six cameras
which are all operational. The program had no vacant positions at the time of the annual
compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 66 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a policy and procedures addressing background screening for
volunteers, mentors, and interns who work with youth less than ten hours a month requiring
sight and sound supervision. According to the employee roster provided by the program, there
was a total of twenty-four staff hired during the scope of the annual compliance review period
which required an initial background screening. Reviewed personnel records confirmed each
staff had a completed background screening completed prior to contact with youth and
confidential youth records. Each record also contained evidence of a reviewed criminal history
report. An exemption was not applicable for any of the reviewed records. One of the twenty-four
staff had a break in service. For this staff, there was documentation to confirm a new
background screening was completed. Eighteen of twenty-four staff were applicable for a pre-
employment assessment tool. Seventeen of eighteen had documentation of this tool within their
personnel records, along with the posted passing score. The remaining staff’s record did not
contain documentation. Each of the twenty-four staff were added to the program’s employee
roster in Clearinghouse. Twenty-two of twenty-four staff records contained a signed contraband
attestation form. The remaining two records did not contain documentation of a signed
contraband attestation form.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
A review of the program’s employee roster found two staff eligible for five-year re-screening
requirements. Each employee’s record included documentation the five-year re-screening was
completed at the five-year interval as required, which was calculated by the Clearinghouse
prints expiration date. The rescreening was submitted to the Background Screening
Unit/Clearinghouse prior to the five-year anniversary date as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 66 (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 policy and procedures which addresses the provisions of an abuse
free environment. The procedures notate all staff, volunteers, interns, or contracted staff shall
immediately report any allegations or suspicion of an incident of abuse or harassment which has
occurred in the program to the Florida Abuse Hotline, and the Department’s Central
Communications Center (CCC) for youth eighteen years of age or older. Five staff personnel
records were reviewed and each included evidence of a signed code of conduct. Visual
observation confirmed the program has postings of the Florida Abuse Hotline and CCC
telephone numbers in various locations which are visible for youth and staff. The program’s
steps for reporting abuse consists of staff notifying a supervisor and either making the telephone
call, or the supervisor makes the call to Florida Abuse Hotline or CCC. If a youth wishes to
report abuse, the staff makes the call then allows youth to report accusations. The program’s
Trauma Responsive and Caring Environment (TRACE) self-assessment was completed July 1,
2025. A review of CCC reports found a total of seven incidents involving allegations related to
physical, psychological, and emotional abuse for the scope of this annual compliance review.
made. Five incidents were reviewed and found three were substantiated for physical,
psychological, and emotional abuse. One was noted as founded for violation of policy, one was
noted as failure to report timely by staff, and the remaining substantiated allegation was noted
as excessive use of force and violation of policy. This incident was not substantiated by outside
agency investigation for maltreatment of physical injury. One of the other two allegations was
found unsubstantiated, and the remaining incident is still under investigation. Each included
evidence showing management took immediate action to address allegations of physical,
psychological, and emotional abuse. None of the allegations included evidence of any potential
human trafficking, child sexual exploitation, or labor trafficking. Documentation review confirmed
one staff member was terminated resulting from disciplinary action.
The program director (PD) was interviewed and was able to document staff’s code of conduct
as well as what actions are taken if violations of conduct are used. The program incorporates
trauma-responsive practices through daily practices such as supervision, staff training, and all
youth interactions. Any staff member who witnesses or suspects physical or verbal abuse must
take immediate action to ensure the youth’s safety. This includes separating youth. The
Department’s CCC and Florida Abuse Hotline must be contacted immediately after the PD has
been informed. The PD was further able articulate how staff and youth are knowledgeable in
contacting the Florida Abuse Hotline and CCC. The program’s Trauma Responsive and Caring
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 66 (Revised August 2025)
Environment (TRACE) self-assessment was completed July 1, 2025. The PD verified there was
one staff member terminated because of disciplinary action due to abuse allegations. The PD
further described management response to abuse allegations, stating employees are placed on
leave pending the completion of an internal investigation. Calls are made to CCC, Florida Abuse
Hotline, and the local sheriff’s office. Staff are terminated if abuse is found to have occurred.
Five youth were interviewed and each reported feeling safe at the program. Each reported
never having been stopped from reporting abuse to the Florida Abuse Hotline or CCC. Five of
five youth reported either knowing the Florida Abuse Hotline number or knowing where the
number is located. Each youth reported staff are respectful when talking to youth. Three of five
youth reported never having heard staff use curse words when speaking to youth. One of five
youth reported having heard staff use curse words when speaking to youth once and the
remaining youth reported having heard staff use curse words when speaking to youth often.
Administrative staff were made aware of interview results and confirmed a retraining will be
conducted with staff. All five youth reported never having exchanged email, telephone numbers,
or social medica information with staff. Five staff were interviewed and each was able to explain
the process for allowing youth to call the Florida Abuse Hotline or CCC. Each staff reported
never having observed a staff telling youth they could not call the Florida Abuse Hotline or ever
having heard another staff using profanity while speaking with youth.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
A review of the Department’s Central Communications Center (CCC) found there were thirty-
five incidents reported during the annual compliance review period. A sample of nine CCCs
were reviewed for completion requirements. Eight of nine were found to have been reported
within the required two-hour timeframe. The remaining incident was reported twenty-three hours
late. All nine were documented in the program’s logbook or shift report. A review of internal
incident reports and grievances was completed and found there were no additional incidents
which should have been reported to the CCC. During the previous annual compliance review,
the program had a total of thirteen CCC reports. This number increased by twenty-two for the
current annual review period. An informal interview with the program director (PD) was
conducted. The PD reported the increase in CCC’s can be attributed to a combination of
personnel and policy changes. The interviewed PD stated any staff member who witnesses or
suspects physical or verbal abuse must take immediate action to ensure a youth’s safety which
may include separating youth. The CCC and/or the Florida Abuse Hotline must be contacted
immediately after the PD has been informed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 66 (Revised August 2025)
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a Right Interactions Plan (RI) which was updated December 3, 2025, and
approved by the Department December 5, 2025. The program provided all RI incidents for the
scope of the annual compliance review. The program had a total of three RI incidents during the
annual compliance review period. The program’s PAR/RI rate during the annual compliance
review period was .037, which is below the statewide Residential PAR/RI rate of 2.57. All three
RI incidents were reviewed. Each of the three included statements from all staff involved with
the incidents by the end of their workday. None of the incidents included the usage of
mechanical restraints or resulted in injury to youth. None of the incidents included evidence the
youth alleged abuse and therefore the incident was not reported to the Florida Abuse Hotline.
Each incident had evidence confirming the report was reviewed by a supervisor or acting
supervising as well as an RI instructor or RI certified supervisor. One of three required a medical
review as indicated by the post RI interview. Documentation review confirmed the medical
review was conducted within the required timeframe. Each of the reports contained
documentation the administrator, or designee, reviewed the report within seventy-two hours of
the incident. The program director (PD) was interviewed and was able to articulate the process
for monitoring RI incidents. Five staff were interviewed and each were able to articulate the
process staff use in the event RI is utilized. The staff gave examples such as using verbal
communication to calm the youth; however, if necessary, there may be a need to escort the
youth away. Documentation is completed and the supervisor on duty is notified for all incidents.
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.
Supervisors and team leaders are the only staff members who are considered direct care staff
and are counted in the staff to youth ratio. The program’s instructor was qualified to deliver
training. The program submitted a pre-service training plan, which was approved by the
program director, the Department’s residential regional director, and director of the Office of
Talent, Leadership, and Culture. A review of the Department’s Learning Management System
(SkillPro), staff training plans, training records, and the program’s training tracker was reviewed
for pre-service training. Five reviewed pre-service records found all five records had the
required 120 hours of training within the first 180 days. Each staff completed more than 120
hours. All five staff records contained all essential skills training required prior to any contact
with youth. Four of five staff were missing additional training in Motivational Interviewing (MI).
An informal interview with the assistant program director was conducted and documentation
provided confirmed MI training was cancelled by the instructor. As of the end annual compliance
review, the training has not yet been rescheduled. Follow-up communication was also provided
by the program during the annual compliance review to confirm clarification of anticipated
rescheduled dates for training. Potential training dates provided were January 27, 2026, or
January 29, 2026. A date of February 17, 2026, was also provided for staff to attend if unable to
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 66 (Revised August 2025)
attend dates provided in January. All five staff had all other additional trainings as well as those
trainings required by other rules or manuals, contract, and specialized services. None of the
staff were applicable as a newly hired supervisor. No returning direct care staff records were
reviewed. Three newly hired staff under 180 days of hire were reviewed and each staff member
completed their required pre-service training to be in the presence of any youth.
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 Department’s Learning Management System (SkillPro), staff training plans, training
records, and the program’s training tracker were reviewed for in-service training. A total of five
staff training records were reviewed for in-service training requirements. One of the five staff
reviewed had completed ninety hours of in-service training, two staff completed over 100 hours,
and two staff completed over 200 hours of trainings during the annual compliance review period.
All mandatory trainings, as well as those required by other rules and contract, were completed
as required. Three supervisory staff were able to be reviewed for the additional eight hours of
supervisory training required. For each supervisory staff member, there was documentation of
eight hours of additional supervisory training completed in coaching, leadership personal
accountability, and medication administration. The program provided documentation which
indicated all training staff were qualified and maintained credentials and certifications for
delivery of training provided, such as Right Interactions (RI) and cardiopulmonary resuscitation
(CPR) and first-aid. The program submits an in-service training plan prior to implementation
which has been approved by all required parties.
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 policy and procedures addressing the grievance process which
includes the training requirements for staff. The program’s grievance process includes the
informal phase, formal phase, and appeal phase. The program’s informal process states the first
step in the grievance procedure is face-to-face counseling. It is the youth’s duty to contact the
staff directly involved to council with them in a respectable manner. Grievances will be reviewed
by the assigned staff member within two days of the assignment. If not resolved at this level, a
supervisor will investigate and respond within two days. Youth will sign and date the
documentation signifying satisfaction with the process. If the youth is still not satisfied, the
grievance will continue to the next two phases. A sample of five grievances were reviewed for
completion and response requirements. All five grievances were resolved with one in the
informal phase, one in the formal phase, and three in the appeal phase. Four of five were noted
as resolved within the required timeframe. The remaining was resolved seven days outside of
the required supervisor level timeframe. A review of documentation found the program practice
correlates with their process. The program maintains all grievances in a binder for the past
twelve months. Five youth were interviewed and each was able to explain the process of filing a
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 66 (Revised August 2025)
grievance, and each reported they can ask for assistance in completing a grievance form. Five
staff were interviewed and each was able to explain the program’s grievance process. The
program director (PD) was interviewed and was able to explain the program’s grievance
process.
1.09 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program maintains a policy and procedures addressing interventions and facilitator training.
The program offers EQUIP as its non-clinical, non-primary group. An informal interview was
conducted with the designated mental health clinician authority (DMHCA) who informed all
additional groups and curriculum are considered primary or clinical. EQUIP group is conducted
daily during sessions the program titled “Pow Wows”. A total of thirteen direct care staff
consisting of in-service and pre-service records were reviewed in sampling of intervention and
facilitator training. The staffs’ education and work experience was considered by the program
when determining staff delivery of services. Documentation review confirmed each was
appropriately trained in groups they were facilitating. The program’s group schedule reflected
groups were being provided as required. The program’s activity schedule was reviewed for
determination of the program providing structured, planned programming, and/or activities and
found them to be least sixty percent of the youth’s awake hours. The program director (PD) was
interviewed and was able to provide a listing of staff who facilitated groups during the annual
compliance review period. The PD was also able to list the delinquency intervention models
which included Life Skills Training, Impact of Crime, Trauma Affect Regulation Guide for
Education Therapy (TARGET), and Skillstreaming the Adolescent.
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 policy and procedures addressing the instruction of life and social
skills activities provided to youth. Youth at the program receive services based on symptoms
and diagnoses and specific goals identified in their Individual Treatment Plan (ITP). Services are
delivered utilizing individual therapy, group therapy, family counseling, psychosocial skills
training, crisis counseling, psychiatric services, and psychological services. The program offers
Life Skills Training (LST), Trauma Affect Regulation Guide for Education Therapy (TARGET),
Impact of Crime (IOC), Living in Balance, Skillstreaming the Adolescent, and Coping with
Depression as primary and clinical services. EQUIP is the program’s non-clinical, non-primary
group. EQUIP group is conducted daily and addresses required topics for life and social skills
activities. The program provides life and social skills activities which include communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
critical thinking, problem-solving, and decision-making. The program also addresses the needs
of the targeted gender group through training in health and hygiene, physical environment, life
and social skills training, and leisure and recreational activities. Youth handout packets with
agenda topics and youth signatures were provided to confirm life and social skills activities were
provided as required. Nursing staff also provide healthy hygiene training to all youth upon
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admittance to the program. Five youth were interviewed and each was able to articulate life
skills groups/activities they have participated in while at the program, and each youth was able
to articulate how they practiced new skills they learned in group. The program director (PD) was
interviewed and confirmed youth participate in groups. Youth participate in daily groups to
include IOC, Skillstreaming the Adolescent, LST, TARGET, coping with depression, and Living in
Balance (LIB). The PD also reported the program only serves male youth. Youth have large
muscle activities and on and off campus trips. The designated mental health clinician authority
(DMHCA) was interviewed and reported clinical coordinators provide individual, family, and
group mental health and substance abuse services. Youth needs are determined by screenings
and assessments and goals. All program youth are offered Skill streaming, IOC, Coping with
Depression, and LIB for substance abuse diagnosed or prevention education. Youth are offered
medication management if on medications with monitoring. All youth are assessed for services
and treatment is determined by needs.
1.11 Rehabilitative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Juvenile Unit for Specialized Treatment (JUST) Twin Oaks Vocational
Academy (TOVA) II. For details related specific to IOC service delivery, please refer to the
annual SPEP report.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a policy and procedures to determine how new alerts are identified,
documented, updated, and communicated to staff. The program’s procedure states any staff
member may place a youth on alert status. Alerts are communicated though the program’s
internal alert system, which a copy is in the supervisor’s office. Alerts are included in the daily
shift report and all direct care staff will sign the daily shift report as acknowledgment of the
briefing. A qualified mental health professional is the only person who can remove a youth from
a suicide risk and or mental health alert status. Only a medical professional is the only staff who
can remove a youth after a health condition or health risk situation. The program director (PD) is
responsible for removing a youth from the alert system for safety and security. A total of eight
Department of Juvenile Justice Information System (JJIS) alerts were reviewed for the annual
compliance review. Alerts were all entered by the required program staff. All reviewed alerts
matched the program’s internal alerts and documentation required in the program logbook.
Seven of the eight were entered on the date the alert was identified. For one alert, the youth
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was approved for a home pass, and the alert was noted as beginning December 24, 2025, but
was not entered until December 30, 2025, six days late. Five interviewed staff all confirmed they
are made aware of youth alerts in the program. Staff gave examples of this process such as
being notified through email notifications, shift briefings, shift reports, alert book in the
supervisor’s office, and medical alert book. The PD was interviewed and was able to explain the
program’s procedure for healthcare staff in reviewing youth medical issues as well as the
program’s internal alert process. The nurse was interviewed and reported nursing staff are
responsible for updating the internal medical alert system.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains youth records in three separate binders which include the youth
individual healthcare record, individual management record, and mental health record.
Individual management records contain all required youth information and are divided into the
following sections: Legal, Demographics and Chronological, Correspondence, Case
Management and Treatment Team Activities, and Miscellaneous. All records observed were
labeled ‘Confidential’ and were maintained inaccessible to youth. Records were maintained in a
locked room or filing cabinet, which was also marked ‘Confidential’.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has scheduled two advisory board meetings during the annual compliance period
within ninety to 120 days between meetings. The program director (PD) has a mailing list of
advisory board members including a law enforcement representative, a judge, community
partners, business members, representative of a faith community, victim services
representative, and a parent/guardian of a youth previously involved in the juvenile justice
system. The program had meetings scheduled for September 25th and December 30th, 2025,
and provided an agenda, meeting minutes, email notices to board members, as well as
recruitment letters for potential board members. An informal interview with the PD was
conducted who revealed many of the previous board members are no longer active, which is
why many new recruitment letters were forwarded. The program has been actively recruiting
since October. The PD also informed next quarter’s meeting has not been scheduled but will
tentatively be scheduled for late February or March based on availability of new members. The
PD was formally interviewed and reported the advisory board meets quarterly and there is
current involvement with organizations and programs to benefit homeless youth. Most current
members are new and are encouraging growth with processes. An interview with a board
member was conducted and the board member confirmed participation, current role, and
excitement as a member to help encourage and foster more community involvement.
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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 policy and procedures addressing staff performance. A total of five
position descriptions were reviewed, and the review confirmed each staff’s performance
standards were clearly identified. A total of five performance evaluations were reviewed to
ensure the evaluations were completed as outlined. Reviewed documentation confirmed
evaluations were conducted annually. Performance standards reviewed matched the job
description for each staff and all staff job functions included the implementation of the program’s
behavior management system (BMS). The program’s contractual agreement was reviewed to
ensure all specific contractually required positions were maintained and performance as
outlined. All key staff positions were being held at the time of the annual compliance review. The
program’s contract requires a recreational therapist. The program’s staffing roster as well as the
therapist’s credentials, schedule, and services provided to youth were reviewed and met all
requirements. The program director (PD) was interviewed and reported when there is a
vacancy, the program advertises to fill any vacancies. For staff morale, the program identifies an
employee of the quarter, as well as conducts monthly meetings with staff rewards. The PD
further reported staff performance evaluations are conducted on a yearly basis. Five staff were
interviewed. Four of five staff reported formal evaluations are conducted on an annual basis,
and the remaining staff reported formal evaluations are conducted every six months.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of special contract conditions was completed and found the program is implementing
items and services negotiated and outlined in the contract which are considered Special
Contract Conditions. The program provides visitation on weekends for parents who are unable
to attend regular visitation. The program director (PD) confirmed alternate schedules are
approved for parents/guardians who are unable to attend regularly scheduled visitation.
Parents/guardians are also permitted to participate in zoom meetings through mental health.
The program will provide thirty-minute Skype sessions. The PD confirmed service is provided
when requested, as needed, and this service is available to all youth. Youth are involved in
weekly activities which service the surrounding communities. The PD stated all youth leave the
program with a minimum of 100 hours of community service, which is documented in the youth’s
record. Community service included building porches for the elderly, picking up trash along
roadways and beaches, acting as attendants and helpers at high school football games, and
participating in the community farm share. Youth will participate in community service projects,
which the PD stated youth are allowed to participate in when they reach appropriate behavior
management level and pass risk assessments. This included projects such as The Liberty
County Christmas Train, Farm Share, feeding at risk community members, operating as
grounds crew for the State Dixie League Baseball and Softball tournaments, disaster clean-up
and repair, and assisting House of Hope women’s crisis shelter with building repair. The
program shall provide pre-vocational and vocational programs, which the PD confirmed all youth
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assigned to the Juvenile Unit for Specialized Treatment (JUST) program are eligible for this
service. Certain aspects require youth to reach transition phase of the program such as job
shadowing. The interviewed PD also reported the Department of Transportation (DOT) and
Boys & Girls Club contract negotiated items are offered at the program.
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 utilizes Trendstat as their practice regarding trend analysis. Trendstat data, such
as Central Communication Center (CCC) reports, vocational certification, training, workers
compensation, injuries, groups, and other topics, are collected from all disciplines within the
program. The information is compiled into a single report and discussed quarterly with providers
and stakeholders. The information is also discussed and shared with program staff during
weekly all team meetings. Reviewed documentation supports the program’s practice. Areas of
concern identified by data trends are addressed by administration. Collected data is analyzed
and prioritized. Based on data trends, action is taken to rectify deficiencies, improve processes
and delivery services, update policy and procedures, and introduce memorandums. Actions
may include corrective action and/or retraining.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures outlining the process to ensure initial contacts are
made with the youth’s parent/guardian, committing court, and juvenile probation officer (JPO).
Five youth case management records were reviewed for initial contact to parent/guardians. All
five records contained evidence the program notified the parent/guardian by telephone within
twenty-four hours of the youth admission to the program. All five records had evidence the
program notified the parent/guardian within forty-eight hours by mail. All five records included
evidence the committing court and juvenile probation officer (JPO) were also notified within five
working days from admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the youth orientation process. Five youth
case management records were reviewed for orientation practices upon admission, which
documentation confirmed was provided as required. The program’s orientation process included
the program rules and expectations, services available, daily schedule, behavior management
system (BMS), availability and access to medical and mental health services, sexual
misconduct policies, contraband rules and items, performance planning process and
expectations for release, dress code and hygiene practices, emergency procedures, procedures
for visitation, mail, and use of the telephone, community access, grievance procedures, access
to the Florida Abuse Hotline and the Department’s Central Communications Center (CCC), a
facility tour, and assignment to a living area. An observation of a new admission was unable to
be observed as there were no new admissions during the annual compliance review week. All
five interviewed youth confirmed a review of program rules, procedures, and schedules was
included during their orientation which was completed on the first day or 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.
A review of five case management records found two of the five were applicable and reviewed
for written consent requirements for youth eighteen years of age or older. The program provided
one additional record for review. Each of the three records documented written consent prior to
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providing or discussing information with the parent/guardian 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 has a policy and procedures outlining the classification process for youth upon
admission to the program which promotes safety and security, effective delivery of treatment
services based on individual needs and risk factors, and completion of reassessments every
thirty days or as necessary. The program’s classification process and forms included the youth’s
physical characteristics, age, maturity, special needs, history of violence, gang affiliation,
criminal behavior, perception of vulnerability, history of potential or verified human trafficking,
and sexual aggression or vulnerability to victimization. Five youth records were reviewed and
each included evidence classification forms were used to assess youth risks such as medical,
suicide, escape, and security. A review of the Department’s Juvenile Justice Information System
(JJIS) alert information was also used in classifying new youth to assign youth to a living area,
sleeping room, and group or staff advisor. Medical, mental health, substance abuse, security,
and special needs factors were identified and entered into the program’s internal alert system
and JJIS. All five youth records reviewed were applicable for reclassification and included the
documentation in the records. All five records included evidence of the reclassification assessed
an increase in the youth’s privileges and freedom of movement and participation in work
projects. Three of the youth reviewed were applicable for participation in off-campus activities
based on the reclassifications completed. The program director (PD) was interviewed regarding
the program’s classification system. The PD explained how factors such as mental health
status, physical health status, cognitive performance, age, and prior victimization are considered
when assigning youth to a living unit/sleeping room.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures outlining the gang identification and notification of law
enforcement. None of the five reviewed case management records were applicable for gang
identification and notification. The program did not have any youth identified as being involved
with gang activities during the annual compliance review period; however, the program has
processes in place for notification to law enforcement when a youth is identified as being
involved with a gang. The process includes entering gang alerts into the Department’s Juvenile
Justice Information System (JJIS) upon identification and sharing the information with the
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education provider or local school district providing services at the residential program 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 has a policy and procedures to address a youth’s participation in gang prevention
and intervention activities. The policy also included providing youth the opportunity to develop a
plan to disaffiliate with a criminal street gang, which the program will meet with both parents and
youth and discuss safe emergency procedures such as aid with relocation, new school, or aid
with employment. During this annual compliance review period, there were no youth applicable
for gang identification prevention and intervention. Any youth identified as a gang member, have
gang affiliations, or are at a high risk of gang involvement will participate in Impact of Crimes
(IOC) groups weekly. In addition, a goal shall be included in their individual performance plan
pertaining to gang membership and/or affiliation containing interventions and strategies of gang
prevention and intervention. The program director (PD) was interviewed and indicated the
program’s gang intervention and prevention strategies include the IOC curriculum. Additionally,
the PD indicated youth performance plans also included relevant goals and objectives related to
gang intervention strategies. The PD also reported administration and staff meet with the youth
once a month for an informal review to address gang involvement.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure an initial Residential Assessment for Youth
(RAY) is conducted within thirty days of admission and reassessments every ninety days
thereafter. Five youth case management records were reviewed and each has a RAY
completed within thirty days of admission. The initial assessments were maintained in the
youth’s record and in the Department’s Juvenile Justice Information System (JJIS). All five
reviewed youth records contained reassessment, which were completed at least every ninety
days after completion of the initial RAY. All reassessments were maintained in the youth records
as required.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to ensure a Youth Needs Assessment Summary
(YNAS) for each youth is conducted within thirty days of admission. Five youth case
management records were reviewed and each contained documentation of the completed
YNAS within thirty days of admission. Each were entered into the Department’s Juvenile Justice
Information System (JJIS) and included the youths’ top three criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a policy and procedures in which the intervention and treatment team,
including the youth, shall meet and develop the Individual Performance Plan (IPP) based on the
findings of the youth’s initial assessment, within thirty days of admission. Each of the five
reviewed youth case management records included performance plans which were completed
within thirty days of admission in the Department’s Juvenile Justice Information System (JJIS).
Each plan was completed after completion of the Youth Needs Assessment Summary (YNAS)
and Residential Assessment for Youth (RAY). Documentation in each record indicated the
intervention and treatment team, including the youth, intervention leader, administration, living
unit representative, treatment staff, and education, were present to develop and provide input
into the performance plans. All performance plan goals were measurable and included target
completion dates. The individualized goals included in each performance plan were based upon
the prioritized needs reflecting the risk and protective factors identified ensuring the initial
assessment process. Each goal identified specific delinquency interventions based on the RAY
results. Performance plan goals also identified responsibilities of staff and youth, the top three
criminogenic needs identified in the YNAS, transition goals, and targeted court-ordered
sanctions which could be reasonably initiated or completed while the youth was at the program.
Performance plans were signed by the treatment team leader, youth, and other parties who
have responsibilities in goal completion. Original performance plans were maintained in all five
youth case management records. All five youth case management records included
performance plan transmittal letters which were sent out to all applicable parties within the
required time frame. Each of the five youth interviews reflected each youth participated in the
development of their performance plan.
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2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in which performance reviews will result in revisions
to the youth’s Individualized Performance Plan (IPP) when determined necessary by the
intervention and treatment team. All five reviewed case management records were applicable
for performance plan revisions. Each youth’s treatment team was involved in determining the
need for performance plan revisions. Revisions were made based on Residential Assessment
for Youth (RAY) Reassessment results, new information revealed, and goal progress. Three of
the five youth were applicable for reassessments to facilitate transition activities and received
reassessments as required. Each applicable youth had additional plans, including academic, or
treatment plans, incorporated into the performance plan. The program advised none of the
youth were served by the Department of Children and Families and/or the Agency for Persons
with Disabilities.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures outlining Performance Summaries and transmittals. A
review of five youth records indicated all five were applicable for Performance Summaries. Four
of the five applicable records had evidence six summaries were completed every ninety
calendar days as required. One record had one summary completed ninety-five days late.
Release summaries were not applicable for the five reviewed youth records. Each applicable
Performance Summary included each youth’s status on each performance plan goal, overall
treatment progress, behavior, academic status and credits earned in the program if the youth
was a high school student, including performance and behavior in school, significant events,
interactions with peers and staff, level of motivation and readiness to change, overall behavior
adjustment to the program, and all other required elements. Each record indicated the youth
were allowed to read and add comments before signing the Performance Summary. Each youth
was provided a copy of the summary, and the original copy was filed in the youth’s record. All
records contained the date and the signature of the staff preparing the summary, youth, and
program director, or designee. Each reviewed record documented the program sent a copy of
the youth’s Performance Summary within ten working days to the youth’s committing court,
assigned juvenile probation officer (JPO), and parent/guardian. None of the youth were
applicable for requiring notification to the Department of Children and Families (DCF). A review
of three closed case management records verified each release summary included the
justification for release and Pre-Release Notification (PRN). None of the youth were applicable
for being a direct discharge. The release summary and PRN for all three youth were sent at
least forty-five days prior to release. None of the youth were applicable for the Sexually Violent
Predator Program. A signed copy of the release summary and PRN was maintained in each
youth’s case management record. None of the youth were applicable for the court objecting to
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their release. Once approved, the program provided written notification to each youth’s
parent/guardian. Each closed case management record contained an Exit Residential
Assessment for Youth. None of the reviewed records were applicable for victim notification.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures outlining parent/guardian involvement in case
management services. Five reviewed case management records included documentation
confirming program staff attempted to involve parent/guardian in the assessment process,
performance plan development, transition planning, and progress review. Parents/guardians
were provided with opportunities to attend or participate in these events through advanced
notice of formal treatment team meetings dates and times. If unable to attend, the
parent/guardian is provided the opportunity to participate by telephone or video conferencing, or
to provide verbal, or written input prior to the meeting. A treatment team meeting was observed
during the annual compliance review week which confirmed parents/guardians were called by
the program and participated in the process. The program director (PD) interview indicated the
program encourages parental involvement in the case management processes through ongoing
contact as evidenced by monthly meetings and written and electronic invitations. Additionally,
monthly calls are also made to update parents/guardians on the youth's progress or lack thereof
and any upcoming events or meetings. The case management team also encourages
parents/guardians to participate in visitation and family day. Five interviewed youth stated their
parent/guardian are involved in their case management through participation in treatment team
meetings.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures to ensure all required treatment team members meet
bi-weekly, formally and informally, to review each youth’s performance. Five youth case
management records were reviewed for formal and informal treatment team reviews. Four of the
five applicable case management records included formal treatment team reviews completed at
least once every thirty days as required. The remaining case management record had three
formal treatment team reviews completed five days late, with four being completed in the
required timeframe. All five reviewed records were applicable for informal bi-weekly treatment
team meetings and all were completed in the required timeframes. Treatment team reviews
included youth name, date of review, required attendees, input from treatment team members,
how youth are progressing, youth behavior, any physical interventions, and Residential
Assessment for Youth (RAY) Reassessment results when applicable. All other elements were
included in the treatment team documentation as applicable, and the documentation was
maintained in each youth’s record. The youth’s treatment team members, juvenile probation
officer (JPO), and parent/guardian were invited, and encouraged to participate in youth formal
treatment team reviews. A treatment team meeting was observed during the annual compliance
review week. The youth was present, along with the case manager, treatment team leader, and
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representatives from all required program areas. The parents/guardians and assigned juvenile
probation officers (JPO) participated by telephone. Representatives from each program area
discussed the status of each youth, progress and/or lack of progress in the program, and
performance plan goals. The youth was given the opportunity to speak about behavior and
provide input. Five interviewed youth stated staff talk about their performance to include
progress on performance plan goals, positive and negative behavior, and treatment progress.
Additionally, interviewed youth reported during treatment team, they show the skills they have
learned in the program by reiterating their goals, identifying areas of improvement, and
recognizing coping skills.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures which outline transition planning, conferences, and
Community Re-Entry Team (CRT) meetings. Three closed youth records were reviewed for
transition planning and CRT requirements. Each contained documentation the transition
conference was held at least sixty days prior to the youth’s targeted release date. Reviewed
documentation indicated all required treatment team members attended the transition
conference. None of the youth reviewed were applicable for human trafficking notification. A
review of each youth’s transition conference activities found each included a review of transition
activities, performance plan, identified additional transition activities, target dates for completion,
and treatment team leader and attendees’ signatures representing their acknowledgement of
the transition goals and accountability for completion. For all three reviewed closed records,
transition plans were transmitted electronically to the assigned juvenile probation officer (JPO)
and included the read receipt email of acknowledgement of receipt by the JPO. Documentation
confirmed a CRT meeting was conducted and participated in by the case manager and youth
prior to the youth’s release in all three records, which also included documentation of the
invitation to participate in the CRT meeting by email.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures which the residential commitment program will
assemble an exit portfolio for each youth to assist when released back into the community.
Three youth closed records were reviewed for exit portfolio requirements and each documented
the exit portfolio was discussed and initiated for the youth during the transition conference. Each
exit portfolio included a state issued identification card, social security card, birth certificate,
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copy of the youth’s transition plan, calendar with dates, times and locations of upcoming
community events and appointments, and a completed sample of employment application.
Vocational and educational information was not included as this information is provided by
Florida Scholars Academy separate from the program requirements. All three exit portfolios
reviewed were confirmed during the exit conference and documentation indicated each youth
was given their portfolios upon their release. Case management in each record indicated staff
forwarded the exit portfolio to the assigned juvenile probation officer (JPO). A review of the
program’s contractual agreement did not reveal additional requirements for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures which indicate an Exit Conference shall be
conducted, in addition to formal or informal meetings, to review the status of goals developed at
the transition conference and finalize release plans. Three closed youth records were reviewed,
and each contained an exit conference which was conducted after the program notified the
youth’s juvenile probation officer (JPO) of the youth’s release date and was held at least
fourteen days prior to the youth’s release date. A review of documentation indicated the date of
the conference, signatures, and a summary of pending transition goals were included. Each
youth record contained the youth’s date of admission and date of termination documented in the
case record, which correlated with the Department’s Juvenile Justice Information System (JJIS).
The Exit Conference included a review of transition conference goals, a summary of pending
transition goals, provisions for continuation of education and/or employment, evidence the
youth’s JPO and parent/guardian are aware of the plan, post-release discharge plans, and
signatures for all required participating parties. The youth’s JPO and parent/guardian
participated by telephone. The Exit Conference was held separately from the transition and
Community Re-Entry Team (CRT) meetings in all three reviewed records.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to promote formal constructive input by youth. The
program director was interviewed and reported the program's formal process to solicit input from
youth on systemic issues impacting the residential program including recommendations to
improve conditions and enhance the quality of life for staff and youth are through the completion
of exit surveys, Pow Wows, and dorm meetings which are held with all youth in their assigned
dorm to discuss any issues youth may have. Five interviewed youth reported they are able to
provide input about what happens at the program in such ways as notifying the assistant
program director or supervisor, speaking with staff, or writing a grievance. The program has an
agreement with the Boys and Girls Club, who holds quarterly Student Advisory Board Meetings
to discuss campus issues and activities. Samples of meeting agendas were provided along with
sign-in sheets which confirmed the practice. The program also facilitates Juvenile Quality of
Living (JQOL) surveys, which are administered by case managers at each youth’s intake and
then again at the youth’s exit, in the form of a Client Satisfaction Survey, and then again ninety-
days after the youth leaves the program completed telephonically with the youth by the case
manager. Copies of the completed JQOL surveys were observed in the youth records. Parent
Satisfaction Surveys are also completed during the youth transition period prior to their release,
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which documentation was reviewed to confirm the practice. The program completes youth
surveys every six months. Survey questions consist of questions such as asking about youth
treatment plans and progress with goals, any medical issues, feeling safe in the program, staff
interaction, and therapeutic issues. Pow Wows are dorm meetings which are held with all youth
in their assigned dorm to discuss any issues youth may have. Samples of meeting agendas
were provided along with sign-in sheets which confirmed the practice. In addition to these
activities, youth participate in formal and informal treatment team meetings regularly with team
member representatives from program areas and can express any issues they may have during
this time. Grievances are also available for youth if they have issues or concerns to express
formally.
2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The center
provides education services through Florida Virtual School (FLVS) provided by Florida Scholars
Academy. A review of the program’s activity schedule and the daily academic schedule
indicated the activity schedule incorporates the daily school schedule. No discrepancies were
found. Observations of the program video for three days showed classes did not begin and end
on time as scheduled. On day one, youth arrived at their first period class one minute late and
left for their break ten minutes early. Additionally, youth departed their fourth period class eleven
minutes late, fifth period class one minute early, and sixth period class eighteen minutes early.
On the second day reviewed, youth arrived at their first period class three minutes late and left
for their break thirteen minutes early. Also, youth arrived at their third period class one minute
late, departed fourth period thirteen minutes early, arrived at fifth period two minutes early, and
left sixth period eighteen minutes early. On the third day reviewed, youth arrived at their first
period class four minutes early and left for their break six minutes early. Additionally, youth
arrived at their third period class one minute late, departed fourth period seven minutes early,
arrived at fifth period two minutes early, and departed sixth period five minutes early. Five
interviewed youth reported there are no interruptions during school. A review of randomly
selected days in the logbook throughout the annual compliance review period indicated
education classes started on time and ended on time except for three days. One day youth were
transitioned from school ten minutes early, another day youth were transitioned from school
twelve minutes early, and another time youth were transitioned from school thirty minutes early.
The logbook also indicated on three of the selected days youth did not attend school as classes
were cancelled. Reasons cited included a snowstorm, teacher planning day, and holiday.
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
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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.
A review of documentation confirmed the provider is providing and documenting the contract-
mandated foundational credentials: Occupational Safety and Health Administration 10 (OSHA
10), Florida Ready to Work (Soft Skills Credential), and cardiopulmonary resuscitation
(CPR)/first-aid. Twenty-one youth earned their OSHA 10 certificate, thirty youth obtained their
CPR/first-aid certifications, and four youth completed their Ready to Work - Digital Skills
certificate. During the annual compliance review period, three youth were reviewed and only
completed their OSHA 10 course within the required timeframes. None of the youth completed
their CPR/first-aid certifications. One youth earned Ready to Work-Digital Skills certification and
one youth is currently completing badges towards their certificate. One youth was referred to
Florida Youth College however did not participate. The program also offers Career and
Technical Education (CTE) instruction in both Construction and Welding to all youth, both of
which can lead to industry credentials found on the Master Credentials List. The facility is in the
process of providing the National Center for Construction Education and Research (NCCER)
credentialing to enhance their existing CTE programs. Five interviewed youth stated the
program provided youth with CTE services, which included Florida Ready to Work, OSHA,
online college courses, carpentry, and welding.
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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’s clinical director is the designated mental health clinician authority (DMHCA) who
is a licensed mental health counselor (LMHC), with a clear and active license in the State of
Florida expiring on March 31, 2027. The clinical director is an employee of the program working
forty hours on-site during the week, as well as on weekends when necessary to provide
emergency coverage. The DMHCA provides the coordination and implementation of mental
health and substance abuse services. The program’s back-up DMHCA is a psychologist with a
clear and active license expiring on May 31, 2026. The DMHCA provides coverage twenty-four
hours a day, seven days a week as required by contract, and can be on-site in the event of an
emergency. A review of the DMHCA’s position description indicated the DMHCA provides
specialized treatment services and is the single licensed mental health professional responsible
for the coordination and implementation of mental health and substance abuse services. The
DMHCA was interviewed and stated their role is to provide supervision to the clinical staff
members and oversight of mental health and substance abuse services. The DMHCA also
provides direct services including crisis intervention, suicide prevention, individual, family, and
group counseling. The DMHCA meets with the psychiatrist to discuss benefits and effects of
medications for the youth. The DMCHA coordinates with the back-up DMHCA for coverage
when out of the area for immediate responses when on leave. The DMCHA reports on
communicating with the clinical staff daily through email, messenger, and phone.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program does not employ any other licensed staff other than the designated mental health
clinician authority (DMHCA) and the back-up DMHCA per contract. The clinical director, who is
the DMHCA, has been the only DMHCA throughout the annual compliance review period.
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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 has four current, non-licensed clinical staff working under the designated mental
health clinician authority (DMHCA) supervision, which the DMHCA and a review of job
description verified are performing services they are qualified to provide based on education,
training, and experience. The clinical director provided on-site face-to-face direct supervision to
each non-licensed clinician for no less than one hour a week. The direct supervision
documentation was recorded on a form which included all elements of the Department’s
Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals
Direct Supervision Log form. The program has a Chapter 397 license located in the
administration building, which expires on July 25, 2026, and reviewed documentation verified
the substance abuse services were conducted by the DMHCA and in accordance with the
current contract and Florida Administrative Code. Reviewed documentation confirmed the non-
licensed clinical staffing coverage is in accordance with the current contract for forty hours. All
non-licensed clinical staff who worked at the program during the annual compliance review were
found qualified to provide services, based upon education, training, and experience. All four
non-licensed clinical staff held master’s-level degrees from an accredited university or college in
an appropriate human services field. Two interns worked at the program during the annual
compliance review period which were contracted with a local university and held a bachelor’s
degree in a human service field. Two of the four full time non-licensed clinical staff completed
training and supervision assessing suicide risk, mental health crisis intervention, and emergency
mental health services. Both staff had their training for assessing suicide risks documented on
the non-licensed health clinical staff person’s training on the Assessment of Suicide Risk form.
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.
Five youth mental health and substance abuse records were reviewed for mental health and
substance abuse admission screening. The admission screening process includes reviewing the
youth’s commitment packets and any existing reports and documentation of prior mental health,
substance abuse, or traumatic events in the youth’s history Each record contained a
Massachusetts Youth Screening Instrument –Second Version (MAYSI-2) which was completed
on the date of the youth’s admission to the program. Each screening was completed by trained
staff in a confidential manner and documented in the Department’s Juvenile Justice Information
System (JJIS). All five of the reviewed MAYSI-2 screenings indicated further assessment was
required and a referral for further evaluation was completed to the designated mental health
clinician authority (DMHCA). The program does not utilize a separate clinical mental health and
substance abuse screening. Each record indicated the program director was notified and
confirmed an Assessment of Suicide Risk (ASR) was conducted within twenty-four hours. One
of the five records included a MAYSI-2 resulting in the youth being placed on Precautionary
Observation. All five records included documentation each youth was referred for an
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Assessment of Suicide Risk (ASR), comprehensive evaluation, and each included the reason
for the referrals. The program director is responsible for developing a policy and procedures for
the implementation of a standardized admission/intake mental health and substance abuse
screening process. The reviewed policy confirmed the process includes a review of commitment
packet information, reports and records, administration of the MAYSI-2 in JJIS by a qualified
professional, and a referral of youth identified by screenings as in need of further evaluation or
immediate attention. The policy outlines staff training in mental health and substance abuse
issues and administration of the MAYSI-2, and a standardized process for youth requiring
immediate attention and transfer to a Baker Act or Marchman Act receiving unit. The program
director was interviewed and able to relay the process for identifying youth at risk for mental
health and substance abuse problems and suicide.
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.
A review of five youth records found the program completed a combined comprehensive mental
health and substance abuse evaluation for each youth. Youth are assigned a clinical coordinator
who serves as the youth’s assigned therapist and completes the substance abuse and
biopsychosocial assessments. The program’s practice is to complete a new combined
comprehensive mental health and substance abuse evaluation within thirty calendar days of
each youth’s admission. A review of five youth records found evaluations were completed within
thirty calendar days of the youth’s admission to the program. Consent was obtained for
substance abuse services for all five youth. All five evaluations were completed by a non-
licensed clinical staff which were reviewed and signed by the DMHCA within ten calendar days
of the evaluation being conducted. The mental health evaluation included youth demographics,
reason for evaluation, relevant background information, behavioral observations, mental status
examinations, interview or procedures administered, discussion of findings, diagnostic
impressions including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnosis, patterns of alcohol and other drug abuse, impact of alcohol and other drug
abuse on major life areas, risk factors of continued alcohol and other drug abuse, and
recommendations. The designated mental health clinician authority (DMHCA) was interviewed
regarding the mental health and substance abuse evaluations. The DMHCA reports youth are
referred by the case managers based on mental health needs identified during intake or by the
MAYSI-2.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a policy and procedures regarding the program’s mental health and
substance abuse treatment services for youth who have been determined to have a serious
mental disorder or substance abuse impairment. Five youth records were reviewed and
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confirmed an Initial Treatment Plan was developed within seven days of each youth admission.
Each plan was documented on the program’s form and included all elements of the
Department’s Initial Mental Health/Substance Abuse Initial Treatment Plan form. All five records
included the youth’s psychiatric needs, including medication and frequency of monitoring by the
psychiatrist. All five Initial Treatment Plans were completed by non-licensed clinical staff and
were signed by the designated mental health clinician authority (DMHCA) within ten days of
completion, as well as signed by all treatment team members who participated in the
development of the plan including the youth, treatment team leader, program management, and
when the parent could not participate by phone, the Initial Treatment Plan was mailed out to the
parent. All five reviewed records were applicable for Individualized Treatment Plans and
treatment plan reviews. All five records included documentation of psychiatric services including
psychotropic medication and frequency of monitoring by the psychiatrist. Each treatment plan
review was documented on a form which contained all the required elements of the
Department’s form. All five records included documentation of the treatment team reviews being
conducted every month with thirty-nine of forty-three reviews being completed within thirty days.
One record contained a review which was twelve days late and another record had three
reviews which were five days late. Each treatment plan review was completed by mental health
and substance abuse clinical staff and signed by the youth, treatment team leader, and program
management. All five records documented whether the parents/guardians participated by
telephone and when the plan was mailed out. Services and frequency were outlined within each
youth’s Individualized Treatment Plan, including individual counseling, family counseling, group
counseling, and psychiatric services. All services were individualized for each youth. A video
review of mental health and substance abuse groups for three random days was completed,
and all groups were observed to be one hour in length. The DMHCA was interviewed and states
youth participate in scheduled activities, visitation, and sessions for individual, family, and group
sessions. The DMHCA describes the process for reviewing and updating individual treatment
plans includes completing updates received monthly during treatment team meetings with case
managers. Youth are also able to review treatment goals and objectives during any individual or
family session.
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.
A review of five youth records reflected each youth was assigned to a treatment team upon
arrival to the program. Reviewed documentation for each record confirmed the multidisciplinary
treatment teams were comprised of the youth, program administration, residential living unit,
education, medical staff, mental health clinical staff, and parents/guardians. A review of five
records reflected each youth received individual, group, and/or family counseling provided by a
licensed qualified professional, or a non-licensed clinical staff in accordance with the youth’s
initial or individualized treatment plan. A review of five youth records all contained an executed
Authority for Evaluation and Treatment (AET) form. Additionally, each youth record contained a
signed Department’s Youth Consent for Substance Abuse Treatment and Youth Consent for
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Substance Abuse Treatment Records form. All reviewed mental health or substance abuse
treatment notes were documented on the program’s form which included all requirements of the
Department’s Counseling/Therapy Progress Notes form. Reviewed progress notes confirmed
treatment services included individual psychotherapy or counseling and psychosocial skills
training. Five reviewed treatment plans in comparison with progress notes confirmed the youth
received services as stipulated on their treatment plans. Three closed records were reviewed for
discharge plans. All three discharge plans were completed on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form. None of the three reviewed
closed records were applicable for the youth being released on suicide alert/precautions. Each
of the three reviewed summaries documented the future services needed. A review of
documentation reflected each of the three discharge plans were discussed with the youth,
parents/guardians, and juvenile probation officers (JPO) during the exit conference. A copy of
the Mental Health/Substance Abuse Treatment Discharge Summary was provided to the youth,
JPO, and parent/guardian. The designated mental health clinician authority (DMHCA) interview
describes the process for individualized mental health treatment planning as the youth’s
treatment plans are developed based on the strengths, needs, and assessed areas. Youth can
identify their goals and preferences of how to meet their needs. Objectives are identified and
include specifics along the way to meet program requirements for completion and the judicial
orders/sanctions. The DMHCA describes the process for individualized substance abuse
treatment planning as the youth have all screenings and assessments completed, the parent
interview is completed by mail or on family sessions and the youth identifies goals as it relates
to substance use diagnosis and 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.”
A review of the program’s contract and clinical program description found the program provides
Mental Health Treatment Overlay Services (MHOS) and Intensive Mental Health (IMH) services.
The counselor to youth ratio for MHOS and IMH youth were met. The program provides clinical
group therapy of all required groups according to the contract. The services include individual,
group, and family therapy as part of each youth’s treatment plan. Groups are provided four to
five times a week, individual counseling is weekly to bi-weekly, and family counseling is one to
two times a month; as well as receiving daily therapeutic activities by qualified staff. Reviewed
documentation confirmed group therapy sessions were limited to no more than ten participants.
The program is licensed under Chapter 397; therefore, a qualified professional, who is the
designated mental health clinician authority (DMHCA), is on site five days each week. The
program has a licensed psychiatrist who provides psychiatric evaluations and medication
management for the youth every two weeks and participates in treatment planning. Clinical staff
are on-site seven days a week and counselor caseloads are limited to no more than twelve
youth for each clinician. All five interviewed youth stated they participated in individual and
family counseling. Five staff were interviewed and each stated they do not facilitate any mental
health or substance abuse groups. An interview with the program director indicated MHOS
services are provided for the Twin Oaks Youth Academy (TOVA) youth and MHOS and IMH
services are provided to the Juvenile Unit Specialized Treatment (JUST) youth. Interview with
the DMHCA confirmed youth are scheduled for activities such as visitation and sessions for
individual, family, and group therapy.
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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 has policy and procedures regarding a Suicide Prevention Plan to safely assess
and protect youth with elevated risk of suicide in the least restrictive means possible. The
program maintains a Suicide Prevention Plan which was last reviewed and signed by the
program director on January 1, 2026. A review of the plan included identification and
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,
facility 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) Limited 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.
Five youth records were reviewed for suicide prevention services. All five records included an
Assessment of Suicide Risk (ASR) completed for all youth on intake to the program. One record
included a Massachusetts Youth Screening Instrument –Second Version (MAYSI-2) completed
with indicators for the youth identified as a possible suicide risk. The intake ASR was completed
with no notation the youth was discontinued from Precautionary Observation (PO) and placed
on standard supervision, nor was a PO log started. Three of the five youth each had two
incidents of receiving suicide prevention services. Five of the six incidents were identified for
suicide risk by the youth’s statements and one incident was from staff observations of the youth.
In five of the six incidents the youth was placed on PO and seen by a mental health clinical staff
trained to administer an Assessment of Suicide Risk (ASR). The first youth with two incidents
which included the youth making a statement, in the first incident the youth was seen
immediately by the DMHCA for an ASR which discontinued the youth from PO, placed the youth
on standard supervision, and the suicide risk alert reflected the youth’s placement. In the other
incident the youth made a statement, a PO log was not created, the ASR did not reflect the
youth was discontinued from PO and placed on standard, and no suicide risk alert was
generated for this incident. The second youth with two incidents which included the youth
making a statement, in the first incident the youth was seen by the DMHCA immediately and
kept on PO with PO logs documenting the youth’s supervision on PO for two days. On the
second day, a follow-up ASR was completed by a non-licensed clinical staff placing the youth on
close supervision with the DMHCA and program director’s signatures four days later. The next
day another follow-up ASR was completed by non-licensed clinical staff which discontinued the
youth from close supervision and returned the youth to standard supervision. The suicide risk
alert was opened and closed at the time of the supervision placements. The DMHCA signed the
follow-up ASR three days later and the program director signed the follow-up ASR the same
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day. The second incident for this youth included the youth being placed on PO with a PO log
starting. The ASR was completed by the DMHCA within twenty-four hours, which discontinued
the youth from PO and placed the youth on close supervision. The next day the PO logs
documented the youth’s discontinuation of close supervision to standard; however, there was no
follow-up ASR noting the discontinuation from close supervision to standard. A follow-up ASR
was provided for this incident to review, which was dated the same day as the ASR, both
completed by the DMHCA, both placing the youth on close supervision, with two different
program director signatures and the time of the follow-up signature for the program director was
earlier than the signature of the program director on the ASR. The suicide risk alert was opened
at the time of the youth’s PO supervision, but was not closed until fifty-five days after the youth
returned to standard supervision. The third youth with two incidents included the youth being
placed on PO due to staff observations of cuts on the youth’s arm and the second due to
statements made by the youth. In the first incident, the DMHCA completed an ASR immediately
upon the staff’s observation which continued the youth on PO. A follow-up ASR was completed
two days later by the DMHCA which discontinued PO and placed the youth on close
supervision. The next day a non-licensed clinical staff completed a follow-up ASR, discontinuing
close supervision and placing the youth on standard supervision with signature from the
DMHCA and program director on the same day. The second incident for the third youth, the
youth made a statement and was seen by the DMHCA immediately. An ASR was completed
continuing the youth on PO supervision and PO logs were started. The next day, the PO logs
reflected the youth was moved from PO to close supervision and close supervision logs were
started. No follow-up ASR was provided for the change in supervision status. The next day after
being placed on close supervision, a follow-up ASR was completed discontinuing the youth from
close to standard supervision. There was no signature of staff completing the follow-up ASR,
however, the DMHCA and program director signed the document the same day. An alert was
entered on the day the youth was placed on PO, but was not closed until seventy-five days after
the youth returned to standard supervision. All of the ASRs were completed on the Department’s
ASR form. Documentation verified the parents/guardians and assigned juvenile probation officer
(JPO) in each reviewed ASR were notified of the youth’s potential suicide risk when necessary.
All ASRs were completed by appropriately trained non-licensed or licensed staff. All youth
placed on PO were allowed to participate in select activities with other youth in designated safe
housing areas as indicated on the precautionary observation logs. A video observation was
completed of a youth placed on PO and found the youth was left alone twice while on constant
sight and sound for seven minutes and again for four minutes. The DMHCA was interviewed
and stated if a youth appears acutely suicidal, the staff maintain safety of youth by immediate
response, youth placed on suicide precautions, notification to the DMHCA and director, a
suicide assessment is completed, and Baker Act initiated if needed. The DMHCA reports prior to
revising a youth's supervision level, they discuss with the superintendent/designee and this
communication is documented on the suicide risk assessment, logbook, and youth record. The
program director and parent/guardian are notified regarding any potential suicide or attempted
suicide of a youth. The DMHCA reported the program has had one youth with a suicide attempt
and one youth who self-injured or mutilated themselves. Both youth were Baker Acted and no
longer at the program.
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 Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of five records
confirmed an Assessment of Suicide Risk (ASR) was completed for all youth on intake to the
program. One record included a Massachusetts Youth Screening Instrument –Second Version
(MAYSI-2) completed with indicators for the youth to be a suicide risk. The intake ASR was
completed with no notation the youth was discontinued from Precautionary Observation (PO)
and placed on standard supervision, nor was a PO log completed. Three of the five records
reviewed included youth with two placements each on PO. Each youth record contained
documentation where a Precaution Observation (PO) Log was maintained for the duration the
youth was on precautions. All PO logs documented safe housing requirements. Youth behaviors
were documented in real time and not exceeding thirty-minute intervals for each youth. Each of
the reviewed PO logs indicated review and signature by the shift supervisor and mental health
clinical staff.
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 Suicide Prevention Plan which outlines suicide prevention training
requirements. A review of five pre-service and five in-service training records documented staff
completed the required suicide prevention training. The program has a fully equipped suicide
response kit in each of the four dormitories, one in medical, and one in each of the three
transport vehicles, all co-located with first-aid kits. The program is required to complete one
mock suicide drill for each shift, quarterly. A review of suicide drills since the last annual
compliance review reflected the program conducted a quarterly drill for each shift, with one drill
missing for one quarter on one shift. Reviewed mock drills included the use of lifesaving
measures to an emergency response to a suicide attempt or incident of serious self-inflicted
injury which included the use of cardiopulmonary resuscitation (CPR), suicide kits, first-aid kits,
and an automated external defibrillator (AED). Documentation verified staff who were not
present during a quarterly drill had the opportunity to review each drill scenario and procedure to
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or self-inflicted injury. Video observation revealed the simulated drill demonstrated staff
conducting CPR and AED practices and did not utilize program youth. The program director
reported the program conducts monthly training on emergency drills which includes emergency
responses to suicide attempts or self-inflicted injury. Five staff were interviewed and all five
confirmed the process of notifying mental health staff when a youth makes suicide statements.
Four staff reported they would stay with the youth and talk with them and three staff stated they
would place the youth on constant sight and sound and document supervision. All five staff were
aware of where suicide kits are located and all five staff reported monthly suicide drills were
completed.
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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 has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan. A review of the plan verified it included notification and alert
system, means of referral including youth self-referral, communication, supervision,
documentation, and review
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 has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan. A review of five records indicated none were applicable for
the review of crisis assessments. The program had one applicable youth during the annual
compliance review period and provided this record for review. The youth was determined to be
in crisis and received a Crisis Assessment immediately. The Crisis Assessment included the
reason for assessment, mental health status examination and interview, a determination of
danger to self and/or others, initial clinical impressions, supervision and treatment
recommendations, and recommendations for follow-up. The Crisis Assessment was conducted
by the designated mental health clinician authority (DMHCA). The youth was assessed
immediately after the referral and was found not to be in crisis; therefore, notification to
parent/guardian of follow-up treatment was non-applicable. No follow-up crisis assessment or
Prison Rape Elimination Act (PREA) event was determined or required.
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 has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan. A review of the plan included all elements of the plan which
include immediate staff response, notifications, communication, supervision, authorization to
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transport for emergency mental health or substance abuse services, transport for emergency
mental health evaluation and treatment under Chapter 394 Florida Statutes (Baker Act),
transport for emergency substance abuse assessment and treatment under Chapter 397 Florida
Statutes (Marchman Act), documentation, training, and documentation of management reviews.
The program utilizes a local behavioral health center for Baker Act crisis stabilization and
substance abuse Marchman Act.
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.
Five youth records were reviewed for Baker and/or Marchman Act documentation. None of the
five records were applicable for review and only two additional records were provided to
review Baker Act documentation for the annual compliance review period. In both records, the
youth were believed to be in imminent danger to themselves or others. These incidents resulted
in the determination both youth required emergency mental health care. Each youth
was immediately placed on Precautionary Observation (PO), and notifications were made to
the designated mental health clinician authority (DMHCA). A mental health referral was
submitted, and a Mental Status Examination (MSE) was completed. In both cases,
documentation confirmed the youth remained on PO until they were removed from the program
and transported by local law enforcement in accordance with program protocol and neither
youth returned to the program.
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.
Five youth records were reviewed in reference to safety planning. Documentation review found
initial safety plans were completed within fourteen days of admission, jointly prepared by the
youth, parents/guardians, and the program’s clinical staff. Each safety plan incorporated
recommendations from previous or current clinical assessments and/or screening instruments
and incorporated trauma responsive practices. Each safety plan was updated every thirty days
from the original plan and documented the review of safety plans by staff during treatment plan
reviews. Each reviewed safety plan contained warning signs indicating a youth was escalating
in their behavior. Each safety plan included the youth’s baseline behavior gathered from
collateral contacts, parents/guardians, youth history, and evaluations. All records included
documentation of the perception of the youth and staff for verbal and non-verbal stimuli which
positively and negatively affects each youth. All safety plans included jointly developed coping
strategies, to include people and healthy environments as defined by the youth, intervention
strategies preferred by the youth, and a debriefing process. The safety plans were maintained in
the youth’s mental health records and within a centralized binder in the supervisor’s office which
is easily accessible to all staff. Five interviewed youth reported they contributed to the
development of their safety plan. The interviewed program director reported safety plans are
reviewed monthly and updated as needed.
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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.
A review of the contract management folder confirmed the program’s designated health
authority’s (DHA) credentials were reviewed and approved. The program also has an advanced
practical registered nurse (APRN) who holds required specialty training. The APRN’s license
expiration date is April 30, 2027. The DHA had no disciplinary cases/public complaints on
record. The program has a Collaborative Practice Protocol (CPP) in place for the APRN, which
is maintained on-site at the program. Weekly on-site visits by the DHA were reviewed. During
the annual compliance review period, the program was under a deficiency for DHA visits as
identified by the Department’s Office of Health Services (OHS). The deficiency was identified
July 7, 2025, with an anticipated date of correction for October 1, 2025. A review of weekly sign-
in/out logs for the annual compliance review period was conducted and confirmed the DHA was
on-site at least once a week since the date of correction. A review of the provider’s contractual
agreement, as well as an interview with program medical staff and administration confirmed the
program does not require or perform tele-psychiatry or tele-medicine/health services. The
program’s DHA was interviewed and stated they perform weekly on-site visits completing
Comprehensive Physical Assessments (CPA's), sick call, periodic evaluations, chronic clinic
visits, policy and procedure reviews, and nursing department reviews. The DHA stated they
provide on-site clinical services and are available twenty-four hours a day, seven days a week.
The nursing department contacts the DHA for anything which is needed with the youth. When
youth are needing further evaluation the nursing staff will contact the DHA for further orders.
This documentation can be found in the youths’ medical record.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program’s medical staff currently consists of a registered nurse (RN), who serves as the
health services administrator (HSA). In addition, the program has two other full-time RN’s and
one full-time licensed practical nurse (LPN). The program also has one RN who is employed
part-time. There were no vacancies reported for the medical department. The HSA was
providing direction to the LPN and reviewing all medical cases daily with the LPN including
available on-call consultation. A review of nurse license credentials was conducted and
revealed all medical staff held clear and active licenses according to the Florida Department of
Health Medical Quality Assurance website. All nursing staff training records also revealed each
held current certifications for cardiopulmonary resuscitation (CPR) and first-aid. The program’s
nursing staff were in compliance with the contracted requirements for on-site coverage, which
was for seven days a week for 120 hours.
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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.
A review of documentation confirmed the designated health authority (DHA) and program
director signed and dated all respective treatment facility operating procedures (FOPs). These
procedures were signed by the DHA and program director September 9, 2025, and signed by
the psychiatrist September 4, 2025. Nursing staff also reviewed, signed, and dated the cover
page for all FOPs, healthcare protocols, and other procedures on September 9, 2025. All newly
employed healthcare personnel received a comprehensive clinical orientation to the
Department’s healthcare policies and procedures, as given by a licensed healthcare
professional. Approval of treatment protocols or any standing procedures are 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.
Five youth individual healthcare records were reviewed. All five contained a legible Authority for
Evaluation and Treatment (AET) copy, which was filed in the appropriate section of their
healthcare record. One of the five youth was eighteen years of age when he was admitted to the
program and did not require signatures from the parent/guardian. For this record, there was
evidence of a documented release of information. The remaining four youth AETs had
parent/guardian signatures; however, one of these remaining four youth did turn eighteen years
of age after his admission and documentation confirmed the youth had a release of information.
All applicable records were signed by a Department representative. None of the five youth
records indicated the youth were in the care of the Department of Children and Families (DCF).
The health services administrator (HSA) was interviewed and stated a new AET is mailed out to
the parent/guardian. If the AET is not received in timely manner, then the nurse will contact the
juvenile probation officer (JPO) for assistance.
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.
Five youth individual healthcare records were reviewed for parental notification/consent
requirements. Two of five youth records revealed the youth did not require over-the-counter
(OTC) medications beyond those covered by the Authority for Evaluation and Treatment (AET).
For the remaining three youth, each had parental notification for OTC medications in the
records. Consent was received by the parent/guardian in all applicable records. Notification was
observed in the nurse’s progress notes. Written notifications were sent utilizing the
Department’s Parental Notification of Health-Related Care form and the Acknowledgement of
Receipt of the Clinical Psychiatric Progress Note (CPPN) when documented on the CPPN. All
five youth records indicated each were prescribed psychotropic medication at the time of their
admission. Two of the three records which wwere applicable for notification to the
parent/guardian for verbal consent of new psychotropic medication or changes were completed;
the third record did not indicate a witness and the call was made six days later. One youth was
eighteen and one youth who was admitted on psychotropic medication did not have any
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changes. Parental notification and consent were obtained and noted on the CPPN for all
applicable youth records for any new medications or changes ordered. All five records
confirmed verifications for vaccinations within thirty days of each admission. None of the five
youth required vaccinations or were applicable for religious exemption from immunization. The
health services administrator (HSA) was interviewed and stated parental notifications are made
when treatment and medications are ordered. When medication is initiated or changed the
parent is notified by phone then by mail. The nurse stated in the event a youth had a life-
threatening condition or emergency, the youth would be escorted by emergency medical
services (EMS) after notification to the designated health authority (DHA). Immunization records
are provided with youth at intake.. The HSA further stated youth come to the program having
Florida Certification of Immunization forms, which were verified at admission.
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.
Five youth individual healthcare records were reviewed and each contained a Department
Facility Entry Physical Health Screening (FEPHS) form completed on their date of admission. All
were completed by a registered nurse (RN). One of five experienced a change in physical
custody greater than twenty-four hours as they participated in a home visit. For this one youth,
there was evidence a new FEPHS was completed by the RN. The health services administrator
(HSA) was interviewed and stated the Department notifies the program via email of a new
intake date and the youth is seen as soon as he arrives to the program. The nurse completes
the admission screening and documents a review on the screening form. When there is a
change in physical custody, the HSA stated a new FEPHS is completed by the nurse on the
date of re-entry.
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.
Five youth individual healthcare records were reviewed and included the Department’s Health
Education Record and Medical Orientation Acknowledgement Form. Youth signatures were
observed on each form. All required topics were included in the orientation for the general
process of healthcare delivery services at the program, as well as all elements of the overall
health education. The health services administrator (HSA) reported youth are required to sign
these acknowledgement forms at the time of their admission, as well as throughout their stay in
the program, as the youth receive health education.
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.
Five youth individual healthcare records were reviewed. Four of five contained evidence of
notification made to the designated health authority (DHA) upon the youths’ admission to the
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program regardless of their current medical condition. For one youth, the referral was not
documented on the intake progress note, but the youth was seen by the DHA the following day
for a Comprehensive Physical Assessment (CPA). Notification for the DHA referral was
documented in the progress notes for the remaining four youth. None of the five reviewed youth
were applicable for requiring emergency care upon their admission. All five youth were taking
psychotropic medication upon their admission and each record contained evidence in the
progress notes of a referral and notification to the psychiatrist. The health services administrator
(HSA) was interviewed and stated the DHA meets with all youth for the CPA no later than seven
days of youth admission. In addition, f the DHA is notified by the medical staff of all youth
admissions regardless of their medical condition when they arrive.
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.
Five youth individual healthcare records were reviewed. All five contained a Health Related
History (HRH) form, completed at the time of admission to the program. Each was completed
prior to the youth’s Comprehensive Physical Assessment (CPA) as evidenced by the signature
and date. Each also included evidence of signature by the designated health authority (DHA) of
a review of the youth’s HRH. The health services administrator (HSA) was interviewed and
stated the HRH is completed by a nurse upon youth admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
Five youth individual healthcare records were reviewed for completion requirements of the
Comprehensive Physical Assessment (CPA). All five had a new CPA completed within seven
calendar days of the youth’s admission to the program. All were documented on the
Department’s CPA form. Each CPA was completed by the medical doctor who also serves as
the designated health authority (DHA). Each youth’s medical grade was also documented on
the forms. No missing elements were observed. All sections of each CPA reviewed were
marked with an “O” or an “X” as required. Documentation for each of the five youth refusals of
parts of the exam were noted as required on the CPA. In addition, a corresponding refusal form
was also present and signed by the youth reflecting the youth refused areas of the physical
examination for the five reviewed records. The Department Problem List was updated as
required in all applicable reviewed records. A verified Tuberculosis Skin Test (TST) was
documented on four of five of the CPA’s reviewed. For the remaining youth, there was
documentation the TST was not found upon the youth admission; therefore, another test was
completed and documented within seven days of the admission. Results of the TST were
documented on the CPA and Infectious and Communicable Disease (ICD) forms matched all
five records. The health services administrator (HSA) was interviewed and stated the DHA
completes a new CPA after one year of the youth being at the program.
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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.
Five youth individual healthcare records were reviewed for Sexually Transmitted Infection (STI)
and Human Immunodeficiency Virus (HIV) screening requirements. All five reviewed records
contained evidence of being clinically screened and evaluated for STIs. Each was referred to
the medical doctor, who also serves as the designated health authority (DHA). An interview with
the health services administrator (HSA) revealed all youth, when screened, are referred to the
DHA, who reviews and signs indicating whether further evaluation/treatment is needed. The
referral documentation was completed on the Department STI screening tool for all five records.
Testing was ordered for only one of the five reviewed records. The testing was ordered and
performed on the same date. Screening results were not observed documented on the
Department Infectious and Communicable Disease (ICD) form but were found in the Health
Education record and Lab Results section of the record. None of the five reviewed youth
records were applicable for requiring a re-screening. All reviewed youth had evidence they were
offered counseling, testing, and treatment/referral for HIV. Four of the five reviewed youth
refused the HIV testing. One of the five consented to the HIV testing. Documented consent from
the youth was observed in the youth’s individual healthcare record. Pre and post test counseling
was also documented in this youth’s record. The HSA stated pre and post test counseling is
provided by the health department. This was documented within the Health Education section of
the youth’s record using form HS013. No documentation was observed of the youth’s HIV status
and any other STI diagnosis on the program’s internal medical alert system was observed for
this youth. The HSA reported there were no additional youth currently in the program who have
consented to and completed HIV testing and counseling. The program has a written policy and
procedures which includes Florida Statue 381.004 regarding the disclosure of test results. The
HSA was interviewed and stated youth will receive an STI screening form and if testing is
requested a urine specimen is collected. Screenings are documented on the Health Education
form. New screenings may occur after thirty days for a youth who has been out of the
Department’s physical custody or when symptoms are present. When HIV testing is requested,
the youth will receive HIV counseling from the DHA and testing services are completed on-site.
Five interviewed youth reported they are able to ask for and receive HIV testing.
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.
Five youth individual healthcare records were reviewed for the sick call process. Each youth had
evidence of sick call complaints and documentation provided in their record. A total of eleven
sick calls were reviewed for the five reviewed youth. None of the youth presented with similar
sick call complaints three or more times within a two-week period. All sick calls were completed
using the Sick Call Request form. There was evidence in each the nurse completed the
appropriate sections of all the Sick Call Request forms reviewed. All sick calls were facilitated by
a registered nurse (RN). Sick Call forms were filed in each youth’s individual healthcare record
in reverse chronological order. None of the youth were applicable for having restricted housing,
seclusion, or controlled secure observation. Sick call forms were documented in accordance
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with Health Services Rule 63M-2 as required. No missing elements were observed. Ten of
eleven sick calls observed were found documented on the youth’s Sick Call Index. One was not
found documented on the Sick Call Index as required. All incidents which were found
documented on the Sick Call Index had dates corresponding with the sick calls themselves.
Four of eleven sick calls reviewed were not found on the Sick Call Referral Log. The remaining
seven were observed documented as required on the Log. The health services administrator
(HSA) reported sick call is provided seven days a week. The postings observed for sick call
indicate it is provided for the TOVA-II component Monday through Friday from 8:00 a.m. to 2:00
p.m. and Saturday and Sundays from 10:10 a.m. to 2:00 p.m. The JUST component of the
program has sick call hours posted from 8:20 a.m. to 3:00 p.m. Monday through Friday and
10:00 a.m. to 2:30 p.m. Saturday and Sunday. Postings are observed in the dining hall area and
medical building, along with available blank Sick Call forms. A drop box was also observed for
youth to complete the Sick Call forms and place them in the box, which is reportedly checked
daily by the medical staff. The program has a written policy and procedures which also
addresses procedures where the shift supervisor may review all sick call requests when a
licensed nurse is not on-site. The area used to perform sick calls was observed in the medical
office area of the program. An exam table was present as well as equipment to be used when
facilitating sick call complaints. The HSA was interviewed and stated when youth make health
complaints, they are seen the same day when the sick call is received by the nursing
department. If no sick call is received and the youth comes to medical with the complaint, then
the youth is seen at this time. The RN and licensed practical nurse (LPN) routinely conduct sick
calls. If the LPN conducts the sick call, the RN is notified immediately. The designated health
authority (DHA) also conducts sick calls when they are on-site. A sick call was observed during
the annual compliance review week. Consent was received from the youth to observe the
process. Youth were observed escorted by a team leader to the sick call area. The staff
positioned themselves outside the door to the exam room but was within sight and sound of the
youth. The area was private from any other youth. The youth was examined by the licensed
medical staff with all procedures followed and no issues noted. Five youth were interviewed.
Three of five reported they are seen immediately when making a sick call request. The
remaining two youth reported they have not completed a sick call request.
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.
Five youth individual healthcare records were reviewed for episodic, first-aid, and/or emergency
care requirements. Three of five were not applicable for having any incidents involving these;
therefore, an additional youth was selected to make a minimum sample size of three youth for
review. For the three applicable reviewed youth records, there were a total of six incidents
indicating the youth required on-site first-aid or episodic care. For each incident, on-site care
was provided by a licensed healthcare staff documented in standard narrative charting. The
health services administrator (HSA) stated in an interview the program was using a prior form,
which did not include all SOAP (Subjective, Objective, Assessment, and Plan) elements. A
recommendation from the Department’s Office of Health Services (OHS) in July of 2025 was
made to change the process and the program has since modified this and charted episodic
incidents as required. None of the reviewed incidents involved healthcare being provided by a
non-healthcare staff. The program has Episodic and Emergency Care procedures, which were
reviewed within the medical office area. The program has a total of eighteen first-aid kits located
throughout program areas, which includes kits to be used in vehicles for youth transport. First-
aid kits are stocked with designated health authority (DHA) approved contents. Three kits were
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opened and reviewed. All had plastic zip ties which had to be cut open to review the contents
inside. A list of the contents was located on the kits themselves. All items were present. Saline
and eye irrigation were listed separately on the content description/inventory list; however, only
saline liquid was observed in the boxes. The health services administrator (HSA) reported this is
used for both the eye irrigation and saline solution. One kit was observed brought up to medical
by a staff member. The kit was broken with the contents accessible. The HSA stated the kit
belonged to the vocational program and was reportedly dropped and damaged. The HSA stated
they will replace the damaged box with a new one. First-aid kits are reportedly checked monthly
by the medical staff. Monthly checks were observed documented in a binder located in the
medical office. The checks were observed completed for the scope of the annual compliance
review. The program has one automated external defibrillator (AED) which is located outside the
medical office within the dining hall building. The procedures are located with the device itself.
The medical staff checks the AED batteries and pads, and the device is checked daily by
medical. A registered nurse (RN) was observed performing a test on the device to ensure it was
operating as required. No issues were observed during this process. The date of the battery
expiration was July 31, 2029, and pads were February 11, 2026, with both last being changed
on January 12, 2024. The medical office has a list of emergency numbers including the Poison
Information Control Center posted within a binder, and accessible for non-licensed staff, while
inaccessible to youth. In addition, a binder is maintained in the medical office for authorization of
direct care staff who have been appropriately trained to administer the epinephrine auto-injector.
Five in-service and five pre-service staff training records each contained evidence all staff
received training in cardiopulmonary resuscitation (CPR) and first-aid. The program performs
mock medical drills on a quarterly basis for all shifts, as evident from drill documentation
provided. A review of drill documentation found direct care staff participated in at least one drill
which included the use of CPR annually. A video review was also conducted, which confirmed
the medical drills were being performed as required. No episodic care event was able to be
observed during the annual compliance review week. The program maintains Narcan in the
medical office area, which is only accessible by medical staff and supervisors. The program has
a written policy and procedures which reference their corporate policy for Narcan (Naloxone).
The policy indicates all staff will be trained to recognize general signs and symptoms of opioid
overdose and to administer Narcan. Training is included in the policy along with procedures,
purpose, and annual review. Documentation provided revealed staff have been trained in how to
use Narcan. Training is facilitated by the HSA. The HSA was interviewed and stated on-site
episodic care is completed by the nurse and documented in the youth’s healthcare record.
When non-healthcare staff administers care, they must complete the appropriate health services
form along with any approved treatment. Youth sent off-site for emergency care are placed on a
medical calendar. Emergency Medical drills are conducted quarterly for staff. Mock medical
drills are conducted monthly for the supervisors and team leaders. Five interviewed youth all
confirmed they are able to see a doctor and a dentist if needed. Five staff were interviewed.
Four of five confirmed they are able to call 9-1-1 in the event of an emergency. One of five staff
stated they would call the supervisor, and the supervisor would make the call.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Five youth individual healthcare records were reviewed for off-site care/referrals. Four of five
youth were applicable for having had off-site care conducted while at the program. There were
five total incidents involving off-site care for the four applicable youth. All applicable records
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included evidence of the completed Summary of Off-Site Care Consultation Report form. Four
of the five incidents were non-emergent and therefore is not required to be documented on the
Episodic Care Log. The one incident requiring off-site emergency care was not documented on
the Episodic Care Log. Parental notification was documented in all applicable records and
incidents reviewed. Discharge and other documentation were also filed in all applicable records
with the exception of one record not having filed an off-site visit to the dentist, which was later
provided after the review. There was evidence of review and sign-off by the designated health
authority (DHA) in all off-site care events with one exception of the one off-site visit to the
dentist. One of the five incidents required follow-up testing and appointments. For this one
record, there was documentation the referrals were tracked. The youth has a follow-up
appointment scheduled for a future date outside of the annual compliance review week. The
health services administrator (HSA) maintains and tracks these appointments electronically on a
medical calendar, which was observed. The HSA was interviewed and stated they ensure all
hospital orders are followed when the youth arrive back on-site, the orders are reviewed, and
the DHA is notified.
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.
Five youth individual healthcare records were reviewed for chronic conditions/periodic
evaluations requirements. Three of five were not applicable for having any incidents involving a
chronic condition; therefore, an additional youth was selected for a minimum sample size of
three youth. One of three applicable youth records reviewed indicated the chronic condition was
identified on the Facility Entry Physical Health Screening (FEPHS) form. For the remaining two
youth, the identification of the chronic condition was not made at the time of the FEPHS but was
expressed by the youth five days later when the Comprehensive Physical Assessment (CPA)
was conducted by the designated health authority (DHA). Two youth were noted as having a
history of asthma, and one youth was noted as having low Body Mass Index (BMI). All youth
had a classification as a Medical Grade five, as all applicable youth reviewed were on
psychotropic medications upon their arrival to the program or placed shortly thereafter. All three
applicable youth were placed on the chronic illness list. Each youth had evidence of receiving
periodic evaluations at least every ninety-days as required. None of the periodic evaluations
were conducted off-site or required follow-up with the DHA after receiving off-site care. There
were no indications or lapses in care or missed periodic evaluations. The Department’s Problem
List was observed updated as required for all applicable records reviewed. The DHA was
interviewed and stated periodic evaluations are conducted on sixty to ninety-day intervals and
as needed. The youth are kept on the medical calendar by the nursing staff. The program
director was interviewed and stated formal staffing’s and daily communications and alerts are in
place with the healthcare staff to review the important youth medical issues. The health services
administrator (HSA) was interviewed and confirmed the program monitors youth with chronic
conditions using the medical calendar and internal medical alerts.
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.
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Five youth individual healthcare records were reviewed for medication management. All five
youth records contained evidence the Facility Entry Physical Health Screening (FEPHS) and
progress notes indicated each youth was admitted with medications. The medications were
verified as all youth entered from Department detention centers. Prescription medication
verification was included in the progress notes reviewed for all applicable records. All five youth
were admitted on psychotropic medication. There was observed notification to the psychiatrist
upon admission for all five reviewed youth. All medications had a current, valid order and
administered pursuant to a current prescription. The program utilized e-script (Electronic
Prescription) electronic orders for medications along with the Department’s Practitioner Order
Form. One youth, who was prescribed Seroquel, did not have a Practitioner Order Form, but did
have the e-script, as well as the order indicated within the Clinical Psychiatric Progress Note
(CPPN) page three. A monitoring summary was observed documented by the Department’s
Office of Health Services (OHS) for technical assistance in October 2025 to address this, as
well as other issues within the program’s Health Services Department. According to telephone
contact with OHS registered nurse (RN) consultant made during the annual compliance review
week, this issue had previously been addressed during the technical assistance provided, and
since this time, the program has been utilizing the Practitioner Order form for inclusion in the
youth healthcare record. For over-the-counter medications not listed on the Authority for
Evaluation and Treatment (AET), one youth was applicable and had evidence in the record of
the medication being administered according to the Practitioner’s Order. One youth Medication
Administration Record (MAR) reviewed had a medication notated on the MAR, however no
order was discovered in the individual healthcare record. The Department’s OHS was contacted
regarding this issue and conducted a follow-up inquiry into this medication, which concluded the
item was a prescription strength toothpaste, but there was no documentation in the youth’s
healthcare record of where the medication originated from. The medication was given in
December of 2025 and has since stopped being administered as of mid-January 2026. On
January 29, 2026, the health services administrator (HSA) located and provided the order from
the dentist for the item which was dated December 15, 2025.
The program uses the Department’s MAR forms for all five youth records reviewed. The MAR
forms contained all required elements. Start and Stop dates were noted on all MAR forms and
pages with the following exceptions. One month of one youth’s medication there was no clear
start date, all other months had a clear start date. For another youth, there was no start date
noted for a medication noted for the two months, however the start dates were verified on the
prior MAR months and the CPPN. In addition, for this youth, one month’s stop date for a
medication was not indicated, but the medication ordered noted it was to be administered for
seven days, which matched the day count in the MAR itself. There was indication of staff
training by the medical staff for non-healthcare staff administering medications to youth. The
program has a total of nine staff who have been trained to administer these mediations if
necessary. Youth initials were observed documented for all applicable records when non-
licensed staff administered medication delivery. Initials for staff, youth, and healthcare staff
administering of medications were found documented on all five reviewed records, with the
following exceptions noted: one youth’s MAR was missing staff initial on one medication
administration and one youth’s MAR had an initial missing for two medication administrations.
During the annual compliance review, OHS was contacted by telephone to discuss these
exceptions for missed initials. The OHS RN consultant stated this was not indicative of a missed
medication, but only as an oversight by staff. The were no undocumented explanations for
lapses or errors in any of the medication administrations. Of the five youth records reviewed,
only one youth record was observed having a refusal for medication. For this record, there was
evidence the youth signed the Refusal of Treatment form as required. The refusal was also
clearly marked on the MAR itself. Nursing staff documented weekly side-effect monitoring on
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the MARs as required. None of the five reviewed records indicated youth required parenteral
medication. The program has no standing orders, emergency treatment orders, or pro re nata
(PRN) orders for psychotropic medications.
A medication pass was observed conducted during the annual compliance review. The youth’s
verbal consent was obtained prior to observing the practice. The youth was seen escorted to
medical by a therapeutic manager. The youth approached the nursing staff individually and the
medical provider identified themselves to state why the youth was there and was observed
preparing the medication. The nurse verified the allergy and alert status and was seen
documenting and initialing the MAR. Six Rights of Medication Deliver/Administration were
verified. Staff observed youth to make sure medication was swallowed. Five youth interviews
were conducted. All five youth confirmed the nurse gives them their medication. Each were able
to summarize the medication delivery process. All five also confirmed once the medication is
taken, the nurse checks their mouth to confirm the medication was taken. The HSA was
interviewed and stated the process to which medications are verified includes the youth who is
admitted with medications is verified by the intake nurse by calling the parent of the youth. If
there is a discrepancy with the youth’s medications, then the intake nurse will contact the
previous program for clarification. Non-healthcare staff do not verify medications upon
admission. Medications are written onsite by the designated health authority (DHA).
Psychotropic medications are sent via e-script then faxed or emailed to the pharmacy. The HSA
verified medication pass times and dates.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has an agreement with a psychiatrist who provides services such as evaluations,
consultation, medication management, and medical supportive counseling services for youth. A
review of the contract management folder confirmed approval of the program’s current
psychiatrist. The program’s psychiatrist is available for emergency consultation twenty-four
hours a day, seven days a week. The program’s contractual agreement does not incorporate
the usage of tele-psychiatry services. The program also has a psychiatric advanced practical
registered nurse (APRN) who serves as a back-up for the psychiatrist when needed. The
psychiatric APRN has a clear and active license with an expiration date of April 20, 2027. The
program’s psychiatrist and psychiatric APRN’s education, experience, and certification/licensure
is validated on the Department of Health Website. The program has a Collaborative Practice
Protocol in place for the APRN, which is maintained on-site and with the psychiatrist. A review
of sign-in/out logs for the annual compliance review period confirmed the visits are conducted
as required by the contractual agreement. The psychiatrist actively participates in, manages,
and supervises psychotropic medication services in the program, which includes briefing a
representative of the treatment team regarding all psychiatric statuses. When duties were
delegated to the psychiatric APRN, the psychiatrist was available to the APRN by telephone
when not physically available on the premises and provided bi-weekly on-site supervision of the
APRN’s medication management services, confirmed by review of documentation. The
psychiatrist was interviewed and reported they provide psychiatric evaluation of every child
admitted to the program within one week of admission, and prescribe or manage psychotropic
medication if appropriate, with follow up appointments scheduled every twenty-eight days or
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less. This pertains to both components of the program. The psychiatrist reported they are on-
site weekly and provides psychiatric consultation and medication management. Nursing staff
administer the medications, monitor for side effects, and report concerns. Psychiatrist indicated
they meet with nursing staff weekly to discuss youth receiving psychiatric services, and they can
contact the psychiatrist twenty-four hours a day seven days a week in the event of an
emergency. The psychiatrist has no concerns with mental health or substance abuse services at
the program. The designated mental health clinical authority (DMHCA) was interviewed and
stated they meet most weeks with the psychiatrist to discuss youth receiving psychiatric
services.
Five youth healthcare records were reviewed for psychiatric services. All five youth records
indicated the youth entered the program on psychotropic medication. All were referred for a
psychiatric interview. All received a diagnostic interview within fourteen days of their admission.
Each youth’s Initial Diagnostic Psychiatric Interview included all required information with the
following exception: one youth’s risk and benefits of taking the medication was left blank on
page three of the Clinical Psychiatric Progress Note (CPPN) within the initial evaluation. All
youth initial evaluations are captured on the Department’s Initial Psychiatric Evaluation form and
includes page three of the CPPN. Medication reviews were completed by the psychiatrist every
thirty days for all youth with one exception. For one youth, a medication review was done four
days late, the other six were completed on time. Four of the five youth’s evaluations resulted in
changed in medication and page three of the CPPN was completed. The remaining youth did
not have a change in medication. For all five reviewed records, there was documentation on the
CPPN page three of identifying data, diagnosis, target symptoms, prescribed medication,
evaluation and description of effect of medication and target symptoms, youth’s adherence to
the medication regime, and height, weight, blood pressure, and drug levels or laboratory
findings. Side effects were documented in all youth records reviewed with exception of one
youth who had had psychotropic medication side effect monitoring found completed for
September, October, and November, but signed off as reviewed by the psychiatrist in December
2025. Tardive Dyskinesia screening was notated on page three of all CPPNs for this youth by
the psychiatrist in all three months. When applicable, parent/guardian notification was made for
youth to discuss medication. For all five records reviewed, each CPPN included the psychiatrist
or psychiatrist APRN signature and date of signature. One of five youth had the Tardive
Dyskinesia marked off on page three of their CPPN done for nine out of ten, with one month not
marked as monitored however the side effects monitoring was marked. All other four youth
records documented receiving monitoring every month.
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’s medical office and areas used to store medications were observed. Medical
equipment classified as sharps were observed secured and inventoried utilizing a routine
perpetual inventory descending count as each sharp was utilized and disposed. All medications
were identified and secured in a locked area designated for storage of medications. Different
medications such as injectables, topicals, drops, and liquids are separated. The medication cart
was clean and organized with stock items separate from youth-specific medications. All
controlled substances have a perpetual inventory and were stored separately from other
medications. All medications were secured and inaccessible to youth. Controlled medications
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were stored behind two locks, not including the door to the medical office. Medications which
require refrigeration were stored in a secured refrigerator used for medication only. The program
had a process for the destruction and disposal and return of expired and/or discontinued
medications which were addressed in their written policy and procedures. Documentation
verified all sharps and over-the-counter (OTC) medications have perpetual and weekly
inventories as required. All controlled medications were documented on the youth’s
Individualized Controlled Medication Inventory Record which documented the shift-to-shift
inventory count. There was indication of supervisory-level staff training by the medical staff for
nonhealthcare staff administering medications to youth. The program has a total of nine staff
who have been trained by a registered nurse (RN) to administer these mediations if necessary.
Three controlled medications were reviewed based on the inventory provided. All three
medication numbers matched both the observed count and count as indicated on the inventory
documentation provided. Shift-to-shift inventory was observed as required with no
discrepancies. Three OTC medications and three sharps were also observed. Both the OTCs
and sharps reviewed inventory counts matched the total numbers of the items themselves with
no discrepancies noted. The program’s written policy and procedures reference reporting
criteria and procedures regarding inventory discrepancies which state if there is a discrepancy
between the actual balance of mediations or sharps and which is listed in the inventory, the
discovering nurse is responsible for completing an incident report. This report will be given to
the site medical director for investigation and well as notification to the program director,
designated health authority (DHA), and the Department’s Central Communication Center.
Subsequent measures will be based on investigative findings. The health services administrator
(HSA) was interviewed and stated all medications are secured behind lock and key in which the
nurses have keys to these medications.
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 has infection control procedures in place which include prevention, containment,
treatment, and reporting requirements related to infectious diseases, as according to the
Occupation Safety and Health Association (OSHA) federal regulations and the Centers for
Disease Control (CDC) and Prevention guidelines. The program provided documentation
indicating the designated health authority (DHA) and program director reviewed and signed the
plan September 9, 2025. The infection control procedures included all required elements. The
program reported they do not provide Hepatitis B immunizations for staff; however, staff do have
access to protective equipment. The program reported having had no instances for the scope of
this annual compliance review period where the local count health department, CDC, or Central
Communications Center (CCC) should have been notified of an infectious disease. The
program’s exposure control plan was observed written in accordance with OSHA standards and
is available to all staff. The plan was reviewed and signed by the program administration on
August 27, 2025. The program has a process for needle-stick post-exposure evaluation which
includes evaluation/follow-up and beginning medication regimen. The program director
established a separate filing system maintained for youth and staff who have experienced a
facility/occupational exposure. The program director was interviewed and stated the location of
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the exposure and infection control plans are with the medical and training coordinator’s office
areas. The health services administrator (HSA) was interviewed and stated the program’s
training coordinator conducts infection control training for staff. Infection control training for
youth is conducted at intake. The HSA also confirmed the exposure control plan is available in
the medical department.
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 policy and procedures ensuring staff maintain active supervision of
youth by interacting positively, supporting the core values, engaging during activities, and
consistently applying the program’s behavior management system. The Juvenile Unit for
Specialized Treatment (JUST) program maintains a staff to youth ratio of one staff to eight youth
during day and nighttime activities and the Twin Oaks Vocational Academy (TOVA) II program
maintains a staff-to-youth ratio of one staff to six youth during day and nighttime activities.
Visual observations conducted each day of the annual compliance review determined the
program’s level of active supervision was being adhered to and confirmed staff were actively
supervising youth who were fully engaged in the daily activity schedule. An interview with three
random staff confirmed they were able to articulate the proper number of youth they were
supervising. A tour of the program revealed the daily activity schedule is posted on each youth
dormitory, in the classrooms, and in the administrative building. Documentation was provided
showing staff observing youth while in their sleeping rooms. There are no obstructions to the
youth rooms, which would impact the direct line of sight of youth. A review of the Department’s
Central Communications Center (CCC) reports revealed the program had one escape incident
during the annual compliance review period. The escape review determined the program
followed all procedures.
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 policy and procedures implementing a comprehensive and consistent
behavior management system (BMS), which includes protocols where staff are provided
feedback regarding the implementation of the BMS. Documentation confirmed all required
parties were involved in the development, implementation, and on-doing maintenance of the
BMS. Documentation revealed the program has an agreement with the school related to the
BMS. Training rosters were reviewed, showing all education staff have received BMS training,
which the facility training coordinator is responsible for providing. A review of five youth case
management records showed each youth received an orientation at the time of admission,
which included a review of the program’s BMS. Five staff records were reviewed for staff whose
job functions include implementation of the program’s BMS, each showing BMS implementation
on the position descriptions. Five pre-service staff training records were reviewed, each
confirming the completion of training in the program’s BMS policy and procedures. During a tour
of the program, no BMS postings were observed. The program provides each youth with a copy
of the orientation booklet, which has the program’s BMS policy. The facility training coordinator
and maintenance staff ensured new documentation for the BMS policy was posted throughout
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the program which was accessible to youth and included the rules governing conduct and
positive and negative consequences. A tour was completed which confirmed the postings. The
BMS has not had any modifications during the annual compliance review period. A review of the
program’s written BMS confirmed the inclusion of promoting safety, respect, and fairness,
promoting and protecting youth rights, positive and negative consequences, constructive
disciplinary actions/non-punitive, opportunities for positive reinforcement, recognition of
accomplishments and positive behaviors at a 4:1 ratio, promoting socially acceptable means for
youth to meet their needs, process for explaining to youth the reasons for any sanctions
imposed, youth having the opportunity to explain their behavior, opportunities for staff and youth
to discuss the impact of behavior on others, reasonable reparations for harm caused to others,
discussions of alternate behaviors, and promoting positive dialogue and peaceful conflict
resolution. The program’s BMS does not include increased length of stay, denial of a youth’s
basic rights or services, promotion of group discipline, punishment of youth by other youth, or
disciplinary confinement, wherein a youth is isolated in a locked room as discipline for
misbehavior. Staff and youth interactions were observed daily, of which all appeared to be in
compliance with the program’s BMS policy and procedures. The program offers various rewards
and incentives, such as the point store, off-campus trips, phone calls, liberty bucks, and camper
of the month. The provider shall provide incentive events for youth who have met their level, as
stated in the program’s contract. Five staff were interviewed about the program’s BMS. Each
staff was able to verbally explain the program’s BMS and the types of rewards the program
provides as a part of the BMS. Staff provided examples such as trips, point store, parties, movie
nights, and home visits. Each staff reported the basic rights of youth cannot be taken away as a
consequence. Each staff was able to verbalize how youth are informed of consequences and
how they can explain their behavior. Five youth were interviewed, and each youth was able to
verbalize what consequences the program has for negative behaviors. Youth provided examples
such as a behavioral report, becoming a security risk, and losing points on their point card.
Reward examples, according to the youth, can be camper of the month, point store, trips, extra
phone calls, and dorm manager. Four of five youth stated the staff are consistent with rewards
and consequences, with one youth stating sometimes the point store runs out of supplies. Each
youth was able to explain the difference between each level and how to move from level to
level. Each of the five interviewed youth reported youth are not allowed to punish other youth.
The program director was interviewed, responding with thorough knowledge of the program’s
BMS. According to the program director, rewards are monitored through the program level
board. Youth consequences are monitored through treatment team and the level board, while
staff implementation of the BMS is monitored through performance evaluations, camera
monitoring. and the grievance system.
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 as non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a policy and procedures ensuring staff will observe youth at least every
ten minutes while youth are in their sleeping quarters. The program currently has a total of forty-
six cameras, all of which were fully operational. The video recording system maintains
recordings for a minimum of thirty days. A video review of nine samples of thirty-minute
increments were reviewed, revealing thirty-four of thirty-five checks were completed as required,
and only one check was conducted late by one minute. A total of twelve logs, one day for each
month during the annual compliance review period of thirty-minute increments were reviewed
and showed all checks were completed as required with the exception of one check which was
conducted eight minutes late. Video review also revealed checks were conducted and
documented in real time, completed in fidelity as procedures required, and staff who completed
the checks initialed or signed the check sheet. Five staff were interviewed and each staff stated
room checks are conducted every ten minutes. The program director was interviewed, stating
the program has forty-six cameras with a thirty-day recording capacity.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures addressing the census, counts, and tracking of
youth. The policy states youth movement shall be communicated over the radio; direct care staff
shall know the exact number and location of youth under their supervision; the supervisor shall
conduct a formal count at a minimum of six times daily; informal counts are conducted each day
by the team leader or supervisor at various intervals to include during breaks and prior to
departure and upon arriving back from off campus activities; during emergency situations, direct
care staff shall conduct a sight and sound count after securing youth in a safe area. Counts
shall be documented in the daily operations log. All admissions, releases, transfers, leave of
absences, and appointments will be reflected and documented in the facility logbook. Youth
movement and population shall be clearly communicated to the shift supervisor and if staff
cannot account for any youth whereabouts, an emergency count shall be conducted after
securing all youth in a safe position/area and take follow-up actions as needed. The shift
supervisor shall document daily census at the beginning and end of each shift in the program’s
shift report, which is submitted to the program director or designee. An observation of counts
was observed which the shift supervisor called out to all staff to stop movement and conduct
youth counts. The shift supervisor then called out to each area, asking for total youth and staff
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count. The counts were verified utilizing live closed-circuit television (CCTV), in the supervisor
office. Once counts were cleared, the supervisor called up an all clear for counts, notifying staff
they can resume movement. The counts were then documented in the logbook. A sample of
logbooks for the annual compliance review period was reviewed, one full day each month. Each
logbook contained a daily youth census being documented at the beginning of each shift, after
each outdoor activity, and during emergency situations. Documentation was also conducted,
showing random headcounts, youth movements, transfers, and youth temporarily away from the
program. Five staff were interviewed and each stated counts are conducted at every movement,
every hour, or throughout the day. Each staff was able to verbalize what to do when a youth
count cannot be reconciled. Examples included stopping youth movement, notifying the
supervisor or director, calling a master count, conducting a physical count, and contact the local
law enforcement or the Department’s Central Communications Center (CCC) if the youth has
not been found. Each staff stated emergency counts are conducted before or after an
emergency situation such as a natural disaster, escape, youth fight or a riot.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures to maintain logbooks, entries, and shift report
reviews. A sample was reviewed for one full day, each month, during the annual compliance
review period was conducted. All logbooks were bound with numbered pages. All entries were
made in ink, with no erasures or white-out areas. No logbook entries were found to be
destroyed or removed. One day of logbook entries revealed the staff had made two errors. The
errors were crossed out with a single line but were not initialed at the spot where the error was
corrected. All entries included 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. When applicable, internal incidents reported to the Florida Abuse Hotline or the
Department’s Central Communication Center (CCC) were also documented in the logbook. One
day reviewed did not show the start of education. Documentation was provided by the education
department, indicating class started on time. All other logbook documentation indicated the daily
activity schedule was followed, and education classes were conducted as scheduled with
minimal interference. Two days reviewed did not show documentation of outside recreation
being provided for the youth, however, the nine other applicable days reviewed did show
recreation being conducted as scheduled. Logbooks are maintained in the supervisor office. A
review of shift reports summarized events, incidents, and activities documented in the program’s
logbooks and the incoming staff signed and dated the shift reports for the previous shift to
confirm the review of the content. A copy of shift reports are maintained on the living units for
forty-eight hours. There was no documentation of emergency situations or incidents, including
the use of mechanical restraints, removal of any youth from the mainstream population, or
information relating to escapes during the days reviewed. Documentation in the logbook did
contain special instructions for supervision and monitoring of youth, population counts at the
beginning and end of each shift, perimeter security checks, transports away from the facility,
requests by law enforcement, and admissions and releases.
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5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures outlining a key control system, which includes key
assignments 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. Key distribution was not able to be observed during the annual
compliance review as distribution occurred outside of annual compliance review hours. An
informal interview with the supervisor revealed staff will turn their keys into master control upon
being searched. Supervisors will assign keys at the beginning of the shift. At the end of the shift,
the staff will turn in their program keys, which is then documented on the key sheet for daily
tracking purposes. Restricted keys are not provided to floor staff. The access for restricted keys
is only granted to the supervisor or administration. Permanent keys are assigned to approved
staff. The key will be notated on a permanent key sheet, notating the key ring number, number
of keys, and staff assigned. The staff will sign the sheet when approved for permanent keys.
When the staff vacates the position, the keys are turned back in and documented on the original
form. The program has a key machine on site, with the ability to cut and replace keys which are
lost or damaged. Any lost or damaged key is documented, an incident report is completed, then
documentation is provided to maintenance who will then replace the key. A review of the
Department’s Central Communications Center (CCC) and Program Monitoring and
Management (PMM) was conducted and there were no incidents reporting key control issues.
The program has two key boxes, one in the supervisor’s office and one in the facility training
coordinator’s office. Both offices remain locked when not in use and the key box is also locked.
Each key box contained a master key list and inventory. Five keys were randomly selected, of
which each key ring and number of keys matched with the master key inventory. Three staff
were informally interviewed, in which each staff was able to identify the function of each key on
their assigned key ring. At the beginning and end of each shift, supervisors conduct key counts
to ensure all keys are accounted for, which is then documented on the daily shift report. Five
staff were interviewed regarding the program’s key control process. Each staff was able to
verbalize the process starting from arriving to the facility, being searched, assigned a key,
maintaining the key throughout the shift, and returning the key at the end of the shift.
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
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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 policy and procedures in place to prevent contraband entering the
facility which includes the program defining items/material considered contraband, as well as
exemptions, providing youth with a list of contraband, informing youth of consequences if found
with contraband, searching the physical plant, searching the facility grounds, searching the
youth, searching incoming mail, and searching outgoing mail. The facility visitor log did not
contain a contraband attestation statement; however, there was notation of the person signing in
should read the program’s policy and procedures on contraband. The program’s policy and
procedures for contraband are readily available for visitors and within close proximity. The
program policy and procedures are posted on the wall directly above the visitor sign-in log. A
review of new staff documentation showed twenty-two of twenty-four new hires, within the
annual compliance review period, had signed the contraband attestation form. The program’s
policy and procedures address any staff who is found in possession of contraband in a program
will be subject to disciplinary action up to and including dismissal as outlined in Florida
Administrative Code. The program’s policy further states law enforcement is to be contacted if
any found item would be considered illegal as defined in Florida Statutes, or if there is evidence
of any type of unlawful activity. The program clearly delineates items which are considered
contraband. A review of the Department’s Central Communications Center (CCC) reports
indicated the program had six incidents during the annual compliance review period involving
contraband items. None of the six incidents indicated the need for contraband to be turned over
to law enforcement. The disposal of non-illegal contraband items was documented in the
logbook, of which all were discarded. Documentation of facility logbooks, incident reports, and
search reports were reviewed, determining the frequency and quality of searches and the
results of each search. Five staff were interviewed. Each staff was able to verbalize the process
for youth room searches, stating room searches are conducted and documented daily. The
program director was interviewed, reporting contraband is not disposed of, but is kept in the
supervisor’s office. The youth’s name is also placed on the contraband item. Behavioral referrals
are also utilized and contained in the case management folder.
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 policy and procedures ensuring searches and full body visual
searches are performed to ensure no contraband is introduced into the program. Youth were
observed during movement, upon returning from off-campus activities with the Department of
Transportation (DOT), and following access or ability to obtain tools or other equipment.
Observation of searches revealed the youth are treated with dignity and respect, conducted by
the appropriate number of staff and gender, and as required by Right Interactions (RI) training.
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Staff were observed providing youth with instructions throughout the search process,
maintaining a positive environment for the youth. During the annual compliance review,
observations of searches before and after transport, during admission, and before and after
visitation was not able to be observed due to no events or activities occurring during the hours
the review team was on-site. Video observation of staff and visitors was completed. Five
searches were reviewed, of which two searches conducted missed the staff or visitors’ shoes
and bags. All other reviewed searches were completed thoroughly and as procedures required.
Five staff were interviewed, each stating youth are searched after every movement. Five youth
were interviewed and each confirmed searches are conducted after every movement, work
detail, after visitation, and after outdoor activities.
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 policy and procedures ensuring any vehicle utilized to transport youth
is properly maintained and documentation regarding the use and maintenance of vehicles is
maintained. The program has a total of two vehicles utilized for transportation of youth. Both
transport vehicles and five staff personal vehicles were checked, of which each were locked and
secured when not in use. Each transport vehicle had an annual safety inspection documented,
each with no deficiencies identified. Both vehicles had maintenance records documented. Each
transport vehicle contained a fire extinguisher, seatbelt cutter, window punch, and an
appropriate number of seat belts. Doors to the youth passenger cannot be opened from the
inside. Neither vehicle contained safety screens as the program is not a secure program.
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 policy and procedures to maintain staff to youth ratio while youth are
transported off facility grounds to ensure safety and security of youth, staff, and the public.
Based off the review of the program’s policy and procedures as well as five staff interviews, of
which only four staff have conducted transports, it was determined the program issues a cellular
telephone and radio each time a youth is transported away from the program. A transport was
not able to be observed during the annual compliance review period to determine if the program
complies with staff-to-youth ratios, whether staff of the same gender were on the transport, or
whether seat belts are worn during transportation. Observation of transportation was unable to
be conducted as no youth transports were scheduled during the annual compliance review
week. The program does have a policy and procedures in place, covering each requirement.
Youth are not permitted to drive program or staff vehicles. The corporate office for the program
conducts license checks every three to five months to ensure staff have a valid driver’s license.
Staff are also added to the company’s insurance. Five staff were interviewed about the
program’s process for transporting youth. Two of five staff stated they have not completed a
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transport of youth. Three staff stated youth are secured with hand cuffs, leg irons, and a
seatbelt. Four of five staff stated the program provides a cell phone for transportation, with two
adding the program also provides a radio. Three staff stated the program vehicles contain a fire
extinguisher, three staff stated there are first aid kits, and one staff stated there is a knife for life
in each vehicle. Each of the five staff confirmed they are not allowed to use their personal
vehicles to transport youth, and all transport vehicles are searched before and after transport.
Four of five staff were able to articulate the process for an emergency during transport. Four of
five staff reported varying youth-to-staff ratios to be utilized while on transport. Five youth were
interviewed. Each youth confirmed they have not been handcuffed to any part of the vehicle
while on transport and they have not seen anyone place 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 policy and procedures outlining the audit/inspection process to include
who is responsible for conducting the weekly security audits and safety inspections, the
development and implementation of corrective actions warranted as a result of safety and
security deficiencies found during any internal or external review, audit, or inspection, an internal
system to verify the deficiencies are corrected and existing systems are improved or new
systems are instituted as needed to maintain compliance, and all requirements of Florida
Administrative Code. The safety and security specialist, along with the maintenance staff, are
responsible for completing the weekly safety and security audits. A review of weekly safety and
security audit documentation revealed forty-seven of fifty-two weeks had safety and security
audits completed, and five did not have the audits completed. A review of the Department’s
Program Monitoring and Management (PMM) system indicated no issues during the annual
compliance review period. The program’s Preventative Maintenance Checklist was reviewed,
indicating all maintenance schedules and repairs were conducted accordingly. The program
director was interviewed and reported the program uses Trendstat and safety and security forms
to track safety and security deficiencies. Any deficiencies found will be reported to the
maintenance manager and fixed accordingly.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures in place to address the issuance, inventory, and
control of equipment and tools. All tools are inventoried prior to being issued for work. All tools
are inventoried following work activities. Staff utilized daily in and out logs to track the use of
tools. There are also master tool rosters at both locations where tools are secured, which
documentation indicated tools are inventoried each day. The program prohibits machetes, bowie
knives, or other long blade knives. The program’s procedures for missing tools includes
stopping youth movement, locking up the shop, completing searches, completing reports, and
viewing closed-circuit television (CCTV) to locate the missing tools. There were no tools
replaced within the timeframe of the annual compliance review. An informal interview with
maintenance revealed the tool would be turned into maintenance, a disposal form will be
completed, and the tool will then be replaced and added back to the master roster. The program
will be responsible for contacting the Department’s Central Communication Center (CCC) to file
a report should a tool not be found within two hours. A random review of ten tools was
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conducted. Each tool was secured in the proper tool chest or cabinet, contained marking for
easy identification, and was accurately inventoried.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing the safe handling and supervision of
youth with tools. The policy and procedures include supervision requirements when youth use
tools, issuing tools to youth and staff, including an assessment to determine a youth’s risk to self
and others, established ratios, tool distribution and collection, and search criteria during work
projects, a one-to-five ratio during activities involving tool use, a one-to-three ratio during
disciplinary work projects, and a one-to-five ratio during vocational training. An observation was
conducted of youth utilizing tools. The program maintained a one-to-three ratio throughout the
duration of the tool use. At the end of the period, youth secured the tools, the tools were then
documented as returned, tool inventory was conducted, and the youth were then searched prior
to leaving the area. Staff then called on the radio to advise the supervisor of the searches and
return of the tools. Five youth records were reviewed, of which each contained documentation of
being trained in the intended and safe use of tools. Each youth record also contained completed
risk assessments. Five staff were interviewed. Each staff reported youth are able to utilize tools
only in vocation classes, after the youth has been trained. Five youth were interviewed, also
confirming tools are only used in vocational class, under direct supervision.
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 policy and procedures addressing the required elements for outside
contractors which includes information regarding tool control and restrictions. All outside
contractors and vendors will be required to read the program’s tool control policies and sign an
agreement, which included all required guidelines for workers and tools. Each contractor will
provide a photo identification card. Each vendor will maintain a personal inventory of all tools
before working on campus. The vendor will complete a tool inventory form before and after the
scope of the work. The tools will be verified by the safety and security specialist or maintenance.
The vendor will always keep tools within clear sight and not allow youth to handle the tools.
Three outside contractors sign-in and instruction sheets were reviewed. Each sheet contained
the vendor’s signature, date, purpose of visit, and an inventory of tools being utilized. Three
project invoices were reviewed, each containing the project completion date and total amount to
be charged for completed service. The vendor or outside contractor log was reviewed,
confirming the vendors signed in and out on the day the services were provided. The program
director or safety and security specialist are responsible for providing approval for vendors to
use electronic devices if needed for the scope of work to be completed.
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5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a policy and procedures for conducting fire, safety, and evacuation drills
to ensure youth and staff are prepared for immediate implementation or mobilization in the
event of an emergency or disaster. A review of documentation confirmed the program conducts
emergency and Continuity of Operations Plan (COOP) drills monthly on each shift on a rotating
basis. Documentation confirmed all drill forms completed contained the type of drill, date and
time, participants, brief scenario, and findings and recommendations. Fire evacuation routes
and egress plans were observed throughout the facility. The program has a total of nineteen fire
extinguishers. Documentation for fire extinguishers was reviewed, confirming each one was
inspected monthly. A visual observation was conducted confirming an annual inspection had
been completed for each fire extinguisher. Five staff were interviewed for participation in drills
within the last twelve months. Each staff verbally confirmed participation in drills such as fire,
medical, active shooter, escape, evacuation, or utilizing Narcan. Five youth were interviewed,
each youth confirmed they have been instructed on what to do in case of a fire. Four youth
stated they have participated in at least one fire drill with one you stating they never did a drill.
The program director was interviewed and confirmed drills are conducted monthly.
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 Disaster and Continuity of Operations Planning (COOP), which is
located in the director of operations, facility training coordinator. and supervisor offices. The plan
is readily available to all staff. The COOP was reviewed and updated on February 25, 2025. The
COOP was submitted and approved by the Department on March 17, 2025. All COOP supplies
are stored in the blue dormitory COOP supply room. The supplies include water and meals
ready to eat (MRE). The program has the ability to purchase additional supplies if needed or
receive supplies from headquarters. The program utilizes both electronic and hard copies of
youth records for information. In the event of an emergency which requires an evacuation, the
program director will collect the hard copy information and place the information within the
program vehicle, traveling to the alternate site location. Five youth records were reviewed for
critical information. Each record contained the youth’s full name, Department of Juvenile Justice
Identification number, admission date, date of birth, gender, race, name, address, and telephone
numbers for the parent/guardian, an emergency contact, the youth’s juvenile probation officer’s
(JPO) name and circuit/unit, the committing judge, state attorney, public defender, committing
offense, judicial circuit, if the judge retains jurisdiction, victim notification contact information,
physical description of the youth, overall health status, personal physician, and a photograph of
the youth. The program director was interviewed, verifying a copy of the COOP is available in all
offices, to include the supervisor’s office.
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5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedures addressing the storage and inventory of
flammable, poisonous, and toxic items and materials. The program’s policy and procedures
state flammable, toxic, poisonous, and caustic materials shall only be drawn by an authorized
employee and be stored in secure areas which are inaccessible to youth and meets the
standard specified by the State Fire Marshall. An observation confirmed the program’s
flammable, poisonous, and toxic items and materials are stored in the supervisor’s office,
inaccessible to youth. The program maintains a daily inventory of all flammable, poisonous, and
toxic items and materials. All staff are trained and approved to handle flammable, poisonous,
and toxic items and materials. An informal interview with the program’s maintenance supervisor
revealed the program’s policy and procedures on the disposal of flammable, toxic, caustic, and
poisonous items include bagging the items for transport, taking the items to the Liberty County
landfill, and disposing of the items per safety data sheet (SDS) and local ordinance. All disposal
procedures are in accordance with Occupational Safety and Health Administration (OSHA)
standard. The disposal of flammable, poisonous, and toxic items and materials is then
documented on a disposal form and stored in the safety and security specialist’s office. There
were no instances of disposal to review during the annual compliance review period. The
program’s policy and procedures also address ensuring hazardous liquid waste is disposed of in
accordance with the SDS. An informal interview with maintenance revealed the program does
not store hazardous liquid waste at the program. Only liquid waste, such as dirty mop water, is
disposed of in the plumbing drains. The program does not have an on-site kitchen, as meals are
provided by a co-located Department of Children and Families program, operated by the same
provider. An informal interview with the program safety and security specialist revealed the
program had no incidents involving chemical spills during the annual compliance review period.
Based upon the program’s policy and procedures, the program’s process for handling chemical
spill clean-up consists of notifying master control of the location, the shift supervisor/master
control shall direct the shut-down of all air handlers and ventilation systems and close all
window and doors at the direction of the on-scene supervisor or program director, and any
assistance from outside the facility shall be contacted, as necessary, consistent with emergency
procedures. An informal interview with the program director revealed the program only utilizes
one chemical, which is secured in a location inaccessible to youth. The program maintains an
inventory for the chemical, which was observed with no discrepancies, along with SDS sheets.
The program director was interviewed, verifying the program’s disposal practice for flammable,
toxic, caustic and poisonous items is to take them to the Liberty County landfill and to dispose of
per local guidance and the SDS.
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
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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 policy and procedures addressing youth handling and supervision for
flammable, poisonous, toxic items and materials, stating youth will only use such chemicals
under the direct staff supervision and with proper protective equipment. These items are
secured when not in use. Staff and/or youth shall use appropriate personal protection to include
such things as gloves or safety glasses when required. The program is to maintain strict control
of flammable, poisonous, and toxic items and materials. Youth are not allowed to use, handle, or
clean-up dangerous or hazardous chemicals or any person’s bio-hazardous material, bodily
fluids, or human waste. All areas where chemicals are stored are restricted to youth access.
During the annual review compliance, an observation was not able to be conducted of youth
during daily cleaning activities. Five youth were interviewed. Four youth stated they do not use
any chemicals or cleaning products. One youth revealed the approval to use paint, only in
carpentry class under direct supervision.
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.
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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 policy and procedures outlining visitation and communication for youth
while in the program. The program’s policy and procedures related to visitation and
communication is to provide systemic, safe, and secure visitation for youth, staff, and approved
visitors which encourages and enables visitation and communication between youth and their
families. The visitation schedule is posted in the administrative lobby and all youth dormitories. A
review of the logbook and visitation logs revealed forty of fifty-two days reviewed had
documentation of visitation being provided, with twelve not being documented or with “no
visitation” being documented. An informal interview with the program director revealed due to
the program not being close to most of the youth’s home counties, parents are unable to make
the drive each week, leaving many weeks without visitation being conducted. A review of
telephone logs showed documentation phone calls are offered every Tuesday and Thursday for
a minimum of eight minutes. The program does allow for alternate days due to parent/guardian
schedule. Mail correspondence is able to be sent and received each day with no limit to how
many letters can be sent or received, at no cost to the youth. All incoming and outgoing mail is
searched, in the presence of the youth, by the case manager for any contraband. The program
offers Zoom, Teams, and Skype as an alternative for visitation when needed. The director of
operations confirmed the program does not currently have any youth with a history of human
trafficking. The program does not have a third-party agreement with a provider for language
services, utilizing current staff members who are fluent in foreign languages. Five youth were
interviewed regarding communication with their parent/guardian, with each youth stating they
are able to call their parent/guardian or send a letter. The program director was interviewed. The
program utilizes current staff to translate for youth whom English is not their primary language.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures outlining the provisions of recreation and
leisure activities. A review of the program’s activity schedule confirmed they offer a range of
supervised and structured indoor and outdoor recreation and leisure activities for the youth for
at least one hour daily, which includes large muscle activity. A review of logbooks confirmed
recreation was conducted, as scheduled. The activities the program offers promote social and
cognitive skill development, creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. Recreational activities were observed to ensure the program takes
precautionary measures to prevent overexertion, heat stress, dehydration, frostbite,
hypothermia, and exacerbation of existing illness or physical injury. The program’s contract
requires a recreation therapist. The recreation therapist credentials, schedule, and services
provided to youth were reviewed to ensure requirements were met. Five youth records were
reviewed, each confirming the inclusion of a recreational therapy goal. Five youth were
interviewed, each stating physical activities are provided for at least one hour. Examples
provided included basketball, football, badminton, and volleyball. Five staff were interviewed.
Each staff stated indoor and outdoor activities are provided such as basketball, football, walking,
board games, field day, frisbee, and ping pong.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 66 (Revised August 2025)
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 66 (Revised August 2025)

report_type: QI Residential

file_name: JUST-TOVA-FINAL REPORT - 2526.pdf

program_name_raw: Juvenile Unit for Specialized Treatment (JUST) & Twin Oaks Vocational Academy II

rule: Indicator 3.10

excerpt: Suicide Prevention Services (Critical)

rating: Limited Compliance