summary: QI Residential - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Broward Youth Treatment Center
Youth Opportunity Investment, LLC
(Contract Provider)
8301 South Palm Drive, Building #2
Pembroke Pines, Florida 33205
Review Date(s): October 28-31, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Paula Friedrich, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Lidia Lanns Clarke, Office of Post Secondary & Workforce Education, Regional Workforce
Education Coordinator South (Standard 2)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tonya Gittens, Office of Accountability and Program Support, Regional Deputy Supervisor
(Standard 3)
Nick Johnson, Office of Education, Deputy Director of Education (Standard 2) Peter Keelan,
Office of Education, Central Education Coordinator, (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Interviews)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Broward Youth Treatment Center MQI Program Code: 1269
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10553
Location: Broward County / Circuit 17 Number of Beds: 40
Review Date(s): October 28-31,2025 Lead Reviewer Code: 139
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 66 (Revised August 2025)
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Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 66 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 66 (Revised August 2025)
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment * Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation * Non-Applicable
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 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 & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 66 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
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
Broward Youth Treatment Center is a forty-bed program, for thirteen to eighteen-year-old males,
located in Pembroke Pines, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides Substance
Abuse Treatment Overlay Services (SAOS), which includes substance abuse assessments,
evaluations, individualized substance abuse treatment planning, daily substance abuse services
which include individual, group, and family substance abuse treatment planning, daily substance
abuse counseling, crisis intervention therapy, suicide prevention services, mental health and
substance abuse treatment for youth with co-occurring mental health disorders, twenty-four hour
response capability, routine and random urinalysis, psychopharmacological therapy, and
psychiatric and psychological services. The program’s rehabilitative justice includes Thinking for
a Change and Impact of Crime groups, The program provides weekly clinical group therapy
services including the provision of the Living in Balance substance abuse curriculum and
Seeking Safety substance abuse/trauma treatment. Supplemental services include Men’s
Trauma Recovery and Empowerment Model and Trauma-Focused Cognitive Behavioral
Therapy based upon each youth’s identified needs. The program’s administration is comprised
of a facility administrator (FA), one assistant facility administrator (AFA), a clinical director, a
human resources/business manager, a case management supervisor, one health services
administrator, and one food services manager. Case management services are provided by the
director of case management, three case managers, and one transition services manager.
Mental health and substance abuse staff at the program include a designated mental health
clinician authority (DMHCA) who supervises three unlicensed therapists as well as one
recreation therapist. The program contracts with a licensed psychiatrist for the provision of
psychiatric services to all applicable youth. Medical services are provided seven days a week by
a licensed medical doctor who serves as the designated health authority (DHA), one registered
nurse (RN) who serves as the health service administrator (HSA), and two additional RNs.
Educational services are provided by the Florida Scholars Academy with post-secondary
services provided by Florida Youth College. The program is housed in one main building with
two hallway wings extending to the east and west sides of the program’s secure entrance and
master control office, with a large outdoor recreation area on the building’s north side. Youth
sleeping rooms are located on both the east and west wings of the program and staff offices are
in areas which are secured and inaccessible to youth. All meals are prepared on-site. The
program has seventy-one security cameras providing coverage with the capability of storing
video for thirty days, all of which were operational at the time of the annual compliance review.
At the time of the annual compliance review, the program was fully staffed with no vacant
positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 66 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a written policy and procedures requiring the completion of background
screenings for all staff, contracted staff, volunteers, interns, and mentors with access to youth
and confidential youth records. Volunteers, mentors, and interns who work with youth less than
ten hours a month do not require a background screening if they are under the constant and
direct supervision of screened program staff. The program submitted an Annual Affidavit of
Compliance with Level 2 Screening Standards form to the Department’s Background Screening
Unit (BSU)/Clearinghouse on January 14, 2025, meeting the annual requirement. Twenty staff
were hired since the last annual compliance review and documentation validated each had a
completed background screening and reviewed criminal history report completed prior to hire.
The program indicated they had no new volunteers during the review period, and each volunteer
previously completed background screening. No staff were applicable for a break in service, and
no staff were ineligible during their background screening; therefore, no exemptions were
required prior to working with youth. The program uses a pre-employment suitability
assessment prior to hiring all direct care applicants. Each reviewed staff had a passing score on
record and each staff was added to the program’s Clearinghouse Roster, as required.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a written policy and procedures requiring completion of a background
rescreening every five years. A background rescreening/resubmission is to be conducted for all
staff, volunteers, and mentors with access to youth and confidential youth records. The program
had one staff applicable for a five-year rescreening since the last annual compliance review.
Reviewed documentation of the rescreening showed it was submitted to the Department’s
Background Screening Unit (BSU)/Clearinghouse at least ten business days prior to the
retained prints expiration 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 has a written policy and procedures requiring the program to maintain an
environment in which youth and staff have a right to feel safe, secure, and without threats of
abuse or harassment. The program’s policy promotes an environment of physical,
psychological, and emotional safety and abuse is not tolerated within the program. Staff are
required to immediately report all allegations of abuse, neglect, or sexual harassment in addition
to any suspected incident of retaliation against any person who reported an allegation of abuse
to the Florida Abuse Hotline or the Department’s Central Communications Center (CCC), for
youth eighteen years of age or older. Staff are required to report any alleged neglect or violation
of responsibilities which may have contributed to an incident or retaliation. Once the call has
been completed, staff are to notify the facility administrator (FA) or supervisor on duty as soon
as possible at which time the FA or supervisor is to begin an immediate review. The program
reported two CCC incidents related to physical, psychological, and/or emotional abuse during
the annual compliance review period. There were no human trafficking victims, sexual
exploitation, or labor trafficking reported by the program. A review of seven staff records found
each record contained a signed code of conduct form, which was signed during orientation. A
tour of the program confirmed the Florida Abuse Hotline and the CCC telephone numbers were
posted throughout the program. Youth and staff are to have unhindered access for reporting
alleged abuse to the Florida Abuse Hotline. Any youth requesting to make an abuse call, is to
be provided with telephone access by staff in a controlled observed area in which the
confidential call may be made, and the shift supervisor is to be notified immediately of the
youth’s request. An internal incident report is to be completed and forwarded to the respective
supervisor once the call has been made to the Florida Abuse Hotline or CCC. Staff are to assist
the youth with placing the abuse call, recording the date, time, and the operator's name and
badge number and staff are to allow the youth the opportunity to speak freely while maintaining
sight of the youth. In the event the youth change their mind, a call refusal is to be documented
on an internal incident report. All documentation and notifications made are to be included on
the internal incident form. The program completed Trauma Responsive and Caring Environment
(TRACE) self-assessments on April 25 and 28, 2025. A review of all incidents since the last
annual compliance review indicated there were two incidents which involved complaints related
to physical, psychological, or emotional abuse. One was closed as unsubstantiated, and the
other was closed with inconclusive findings. Interviews were conducted with seven staff
regarding the process to report suspected abuse, and each stated they would allow the youth to
make the call and notify the supervisor the call was made. All interviewed staff reported they
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 66 (Revised August 2025)
had never observed another staff telling a youth they could not call the Florida Abuse Hotline.
Five staff reported never having heard another staff use profanity while speaking with youth,
while two reported it occurring once; however, the staff was redirected, and the staff is no longer
employed in the program. Seven youth were interviewed, and each said they felt safe at the
program, with all attributing feeling safe to the program’s staff. None of the youth reported they
had ever been or seen anyone being stopped from reporting abuse, and all seven youth stated
the phone numbers were posted throughout the program. All seven youth reported staff are
respectful when speaking with them. One youth reported hearing a staff curse on one occasion;
however, the staff is no longer working at the program. All seven-youth stated they had never
exchanged emails, phone numbers or social media contact information with staff. An interview
with the FA revealed the program’s staff code of conduct is outlined within the staff handbook. It
specifically addresses issues such as physical abuse, threats, and profanity towards youth.
These examples of rule infractions or misconduct may result in disciplinary action, including
termination of employment. The program has written policies and procedures requiring
immediate action be taken to address incidents of physical, psychological, and emotional abuse.
The program had two allegations related to physical, psychological, or emotional abuse
involving a staff since the last annual compliance review, both of which were thoroughly
reviewed. Reviewed documentation validated management took immediate action regarding the
staff involved in each incident by initiating an investigation for all cases. At the time of the
annual compliance review, there were no abuse allegations which were pending an internal
investigation.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a written policy and procedures requiring incidents to be reported to the
Department’s Central Communications Center (CCC) within two hours of the incident. The
program had twenty-nine incidents reported to the CCC since the last annual compliance
review. A review of five CCC reports confirmed each incident documented the incident date,
time, CCC number, and the time the program became aware of the incident, as required. Each
incident was reported to the CCC within the required two-hour time frame and documented in
the program’s incident report logbook and shift reports, as required. There were no incidents
reported late. A review of the program’s internal incident reports, youth grievances, and case
management records did not reveal any additional incidents which should have been reported to
the CCC and were not. The program maintains a separate record for all incident reports and has
an established system to track all incidents. The program did experience an increase in the
number of reportable incidents to the CCC in comparison to the previous annual compliance
review period, which was attributed to twelve of the twenty-nine reported incidents being for
medical transports or repeated Baker Acts involving the same youth.
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 written policy and procedures requiring the proper use of Right Interactions
(RI) and physical intervention techniques by staff. The program had eighty RI incidents since the
last annual compliance review. Reviewed documentation confirmed monthly summaries
maintained by the program of all RI incidents were submitted to the Department’s regional office
by the fifteenth of each month, during the annual compliance review period. The program’s RI
Plan was approved by the Department on December 10, 2024. The program’s RI rate during the
annual compliance review period was 7.06, which is above the statewide Residential RI rate of
2.57. An interview with the FA revealed RI incidents are tracked using incident report trackers
and monthly RI Reports. Surveillance camera video footage is reviewed to ensure the use of
force aligns with the RI Response Matrix. If there are any deviations from the matrix, staff are
either re-trained or provided a coaching notification. Once a month, the RI incident tracker is
reviewed with the corporate office to determine if there is an increase in incidents. If so,
corrective action plans are developed to prevent further incidents. Seven staff were interviewed
regarding the use of RI. One staff was not direct care and did not have to be RI trained and one
was newly hired and reported they must complete training before using RI. Five staff indicated
they were familiar with the process and had completed RI training. A review of eight RI incident
reports confirmed each report was completed by the end of the staff’s workday; however, only
six included written statements from each staff involved while two were missing statements from
one witness. The program provided the missing witness statements during the annual
compliance review week. Mechanical restraints were not used in any of the reviewed RI
incidents. All required reviews were documented by the supervisor on duty at the time of the
incident and reviewed by an RI certified instructor within the required time frame. None of the
eight reviewed RI Reports were applicable for a youth requiring medical attention or abuse
allegations. Each RI incident report was reviewed by the administrator or designee within
seventy-two hours of the incident.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a written policy and procedures which specifies the pre-service and
certification requirements to be completed by program staff within 180 days of hire as outlined
by Florida Administrative Code. The program’s policy requires all full-time and part-time staff
and volunteers to complete a minimum of 120 hours of pre-service training within their first 180
days of employment. Volunteers receive training appropriate to their assignments. The facility
administrator (FA), the assistant facility administrator (AFA), all supervisors, and all staff in
management positions must complete sixteen hours of supervisor specific pre-service training
within ninety-days of employment, including coaching, leadership and personal accountability.
All program staff are Right Interactions (RI) certified; however, only supervisors and direct care
staff are counted in the youth-to-staff ratio. All instructors were qualified to deliver the training
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provided. The program submitted the pre-service training plan to the Department on December
10, 2024; however, the approved plan signed by the Department was not provided to the
program; therefore, a second request for the signed plan was sent by email during the annual
compliance review week. A review of seven staff training records documented each newly hired
staff completed their required training within 180 days of hire. The seven reviewed staff records
were all for staff in direct care positions. Each reviewed training record confirmed the staff
completed the required training prior to having contact with youth and confidential records, and
all training was documented in the Department’s Learning Management System (SkillPro). Each
direct care staff, including three reviewed staff who were still within their first 180 days of hire,
completed the essential skills training topics prior to have any contact with youth, including
abuse recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR) certification,
first-aid certification, automated external defibrillator (AED), emergency procedures, program
operating procedures, Prison Rape Elimination Act (PREA), professionalism, interpersonal
communication, ethics including standards of conduct, RI model training, and suicide awareness
and prevention training. Additional training topics completed within the first 180 days of hire,
after having contact with youth, were active shooter preparedness, adolescent development and
behavior, balanced approach to rehabilitative justice, the Department’s Central Communications
Center incident reporting, civil rights, communication, confidentiality/Health Insurance Portability
and Accountability Act (HIPAA), Department of Juvenile Justice (DJJ) legacy/history, equal
employment opportunity, gang awareness, human trafficking, information security awareness,
the Department’s Juvenile Justice Information System (JJIS), mental health and substance
abuse, quality report writing, safety, security, and supervision of youth, sexual harassment,
effective and respectful treatment of youth, and trauma responsive practices. Four staff required
to complete Motivational Interviewing had not yet done so at the time of the annual compliance
review as the course had not yet been offered since their dates of hire and the four staff were
still within their first 180 days of hire. All seven reviewed staff completed training in the
grievance process, infection control, the Exposure Control Plan, behavior management system,
the intent and safe use of tools as required by the program’s manual, and specialized services
training including Substance Abuse Treatment Overlay Services. None of the reviewed pre-
service training records were applicable for being a supervisory staff or a returning direct care
staff.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written policy and procedures requiring staff to complete in-service training
including mandatory topics each calendar year effective the year after the staff completes pre-
service training. A review of seven staff training records, inclusive of three supervisory staff, was
conducted. Each staff was certified in cardiopulmonary resuscitation (CPR) and first-aid. Each
staff exceeded the required twenty-four hours of annual in-service training. A review of the in-
service training plans, and staff records confirmed all staff met the training requirements.
Completed annual trainings included active shooter preparedness, CPR, first-aid, automated
external defibrillator (AED), human trafficking intervention, information security awareness,
mental health and substance abuse, Prison Rape Elimination Act (PREA), sexual harassment,
Right Interactions (RI), professionalism, interpersonal communication and ethics, suicide
awareness and prevention, trauma responsive practices, emergency response and emergency
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drills, infection control, blood-borne pathogens, the program’s Exposure Control Plan, and
Substance Abuse Treatment Overlay Services. A review of three supervisor training records
reflected each staff exceeded the eight hours of management/supervisory training in the areas
of coaching, leadership, and personal accountability. The program has a training calendar which
is updated as changes occur. All trainings were delivered by qualified trainers and were
documented in the Department’s Learning Management System (SkillPro). The program
maintains a written in-service training plan and calendar which was submitted to the Department
on December 10, 2024, for approval by the Department’s assistant secretary for residential
services, and the director of Talent, Leadership, and Culture.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures regarding youth filing formal grievances. The
process is outlined with specific timelines for review and responses. Each reviewed grievance
included informal, formal, and appeal phase process instructions. Informal grievances provide
youth the opportunity to speak directly to staff members using verbal communication or a
Request to Speak form. Seven youth were interviewed and indicated they were aware of the
process for grievances and the location of the forms. In addition, each youth verified the timely
review of grievances stating administration responded within twenty-four hours unless
completed over the weekend. All seven interviewed staff and the facility administrator (FA)
confirmed youth may ask for assistance with grievances if necessary and attempt a resolution
with staff as needed. A review of five grievances submitted in the previous three months
confirmed all timelines were met for review and resolution, with a turnaround on the same day
and no more than twenty-four hours. The FA was interviewed and stated when a concern
arises, the youth are encouraged to make an effort to reach a resolution of the problem or
complaint. The youth may present an informal grievance to any staff member. The program’s
grievance officer is responsible for collecting submitted grievances from the locked boxes daily.
All grievances are reviewed in the daily management meeting and assigned to the appropriate
staff member for response. Investigated grievances are to be reviewed within two days and
efforts are made to conclude within five days.
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
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1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a written policy and procedures to address a focus on developing life and
social skill competencies in youth. The program’s practice is to provide evidence-based
interventions as primary life skills to addresses communication, interpersonal relationships, non-
violent resolution, anger management, critical thinking, and targeted activities specific to the
program’s male population. Reviewed sign-in sheets verified the required primary life and social
skills services curricula Living in Balance and Seeking Safety were both facilitated by a trained
professional. Seven youth were interviewed and confirmed participation in life skills activities
during group including coping skills, comprehensive sexuality education, environmental factors,
anger management, and different communication interventions. The designated mental health
clinician authority (DMHCA) and facility administrator interviews confirmed the facilitation of
Living in Balance and Seeking Safety groups which are conducted weekly. An informal interview
with the regional compliance manager revealed the program also utilizes the Daniel Memorial
Life Skills Assessment which evaluates an individual's ability to live independently. The
compliance manager has personally provided lessons on cleaning, how to open bank accounts,
and budgeting.
1.11 Rehabilitative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at the program. 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 has a written policy and procedures to determine how new alerts are identified,
updated, and communicated to staff members. The program is to utilize and maintain an internal
system which is easily accessible to program staff and keeps staff informed of youth medical,
security, or safety risks. Risks to be identified include dietary, allergies, violent behaviors,
escape, suicide, or mental health risks. Youth are placed on an alert when special risk factors or
special needs are identified during or after the classification process which occurs during
admission. It is the program’s practice for staff to immediately update the internal program alert
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information and the Department’s Juvenile Justice Information System (JJIS). Only appropriate
staff may recommend downgrading or discontinuing a youth’s internal alert status or JJIS alert
status. Licensed mental health staff and non-licensed mental health staff are responsible for
updating the system after verification. Seven youth records were reviewed, and all alerts were
entered into the internal alert system and JJIS. Each reviewed JJIS alert matched the internal
alerts system and logbook. The facility administrator confirmed internal alerts are addressed in
the daily management meeting and communicated to the staff during briefing meetings and
through the logbook. The department heads are to ensure alerts correlate and are updated in
JJIS. An interview with the nurse revealed only licensed healthcare staff update the alert
system. Seven staff were interviewed and verified the notification of alerts through briefings,
alert boards, administrative staff, and logbooks.
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 has a written policy and procedures to safeguard storage and maintenance of
Individual Healthcare Records (IHCRs) and individual case management records. The program
keeps two separate records, which are then further divided into health and mental
health/substance abuse records. The seven reviewed individual case management records
included the youth’s name, Department identification number, date of birth, county of residence,
and committing offense. Each reviewed record contained legal information, demographics,
correspondence, case management, treatment team activities, and miscellaneous sections.
Additionally, each reviewed record was labeled confidential and stored securely in the case
management office, not accessible to youth. The cabinet where case management records are
stored was observed to not be marked as confidential; however, the program posted a sign to
the door of the cabinet during the week of the annual compliance review.
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 a community advisory board which meets at least every ninety to 120 days to
support youth growth and connection to the community. A review of the program’s
documentation confirmed meetings were conducted on December 5, 2025, March 31, and
September 26, 2025. A meeting was scheduled and advertised to take place on June 25, 2025;
however, the meeting had to be cancelled at the last minute due to inclement weather and the
meeting was not rescheduled. The facility administrator (FA) provided documentation of
solicitations for active recruitment of different community partners for participation.
Documentation included communication with law enforcement, a judiciary representative, a
faith-based representative, a representative of the Florida Scholars Academy, and a community
business owner. In addition, the FA recruited a victim advocate and a parent/guardian with a
child who was previously involved in the juvenile justice system. The reviewed community
advisory binder contained all communications, agendas, and sign-in sheets. Each meeting was
conducted in-person at the program. An interview with the FA confirmed a meeting is held every
quarter and includes participation from law enforcement, judiciary, the school board, local
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community business owners, faith-based members, victims, and previously involved juvenile
justice system youths’ parents/guardians. A faith-based board member was interviewed by
telephone during the annual compliance review week and confirmed being a part of the board
for more than three years, attending board meetings quarterly, and receiving invite notifications
and reminders by email and telephone.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures which dictates the system for evaluating staff
based upon established performance standards. Staff are required to review their records
annually with the human resource manager. The program completes informal evaluations every
ninety days and a formal evaluation annually. Seven staff evaluations and position descriptions
were reviewed. The performance standards matched the job description for each staff. The
evaluation included a review of the program’s standards, program’s policies fitting their job
descriptions, and areas of improvement based on their performance for the period being
reviewed. Each formal evaluation was completed within the specified twelve-month period. Each
job description included the implementation of the program’s behavior management system
(BMS). The facility administrator’s interview confirmed the program follows a monthly orientation
plan for newly hired staff and retention plans are utilized to combat position vacancies. Seven
staff were interviewed with four reporting having monthly performance evaluations, three stating
evaluations occurred every six months, and two reporting annual evaluations.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program is required to implement all items and services detailed in the contract’s
memorandum of negotiation and special conditions included in the Secretary’s award letter.
These items typically exceed the minimum requirements outlined in Florida Statutes and Florida
Administrative Code. An interview with the facility administrator (FA), documentation review, and
contract review indicated the contract negotiated items of individualized treatment services are
offered at the program with weekly individual youth therapy sessions conducted for the first
month in the program and at least bi-weekly thereafter. Family therapy sessions are provided
monthly, and the program offers family meetings on-site after visitation. Virtual family meetings
are offered to families who are unable to travel, and the program offers quarterly family days on-
site. Reviewed documentation confirmed the program is utilizing Thinking for a Change. The
program is required to have the regional director on-site at least quarterly, and the director of
compliance on-site at least monthly to provide corporate oversight, which was confirmed by a
review of the visitor sign-in logs since the date of the last annual compliance review. One
requirement listed in the Secretary’s award letter stipulated having an employment specialist on
staff through the Broward County School District to support vocational programming; however,
the Department’s contract manager confirmed this requirement is no longer applicable and will
be removed by amendment of the contract.
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1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a written policy and procedures which addresses the program’s practices for
data trend analysis. The quality assurance program is designed to monitor and evaluate
program outcomes, system fidelity, compliance, appropriateness, and quality of care, ensuring
program services are consistent with prevailing professional standards and to identify and
resolve problems objectively and systematically. The program’s practice is comprised of the
conduction of satisfaction surveys whose results are incorporated into the monitoring and
verification activities as a part of the program’s internal quality assurance program. The
program’s satisfaction surveys are provided on a quarterly basis and include youth, family, and
staff surveys. Surveys inquire about admission activities, specific assessments, and program
discharge satisfaction. Survey data is reviewed and evaluated monthly at the program level and
during corporate leadership meetings. Survey outcomes are collected and communicated as
part of the ongoing program communication and quality improvement activities. Monthly incident
trackers which describe trends are distributed to the programs. Standardized Program
Evaluation Protocol (SPEP) internal and external evaluations are conducted using specific
quality of service delivery evaluation guidelines and findings are incorporated in monthly
monitoring, verification reporting, and the annual Department SPEP report. The program
gathers data, and the Department uses the data for long term planning and provisions for
staffing. A system of communication is used to keep staff and stakeholders informed and
provide opportunities for feedback, performance improvement, and budgeting. A review of
internal documentation confirmed the program’s practice utilizes review and analysis of data in
decision making practices and data trends are shared among administrators and with staff to
proactively make policy, practice, and programming changes designed to foster system and
program improvements.
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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 written policy and procedures regarding initial contact to each youth’s
parent/guardian and court notification upon each youth’s admission. The program’s policy
requires the program’s case manager to notify the parent/guardian upon the youth’s admission
to the program. A review of seven youth case management records confirmed the program
notified each parent/guardian by telephone within twenty-four hours of admission. A
documentation review of seven youth records confirmed each parent/guardian was notified in
writing within forty-eight hours of admission. Additional review of each youth’s case
management record indicated the court, assigned juvenile probation officer (JPO), and post-
residential services counselor were notified within five working days of each youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation. The program’s
policy requires the assigned case manager to conduct the youth’s orientation on the day of the
youth’s admission. A review of seven youth case management records confirmed an orientation
was conducted for each youth on the day of admission. There were no youth admissions during
the annual compliance review week; therefore, a youth admission was unable to be observed. A
review of the program’s orientation process confirmed the youth orientation included all the
necessary elements. Seven youth were interviewed and stated they were provided with a
handbook during the orientation process with the required information and were informed of the
program’s expectations. All seven interviewed youth validated the program’s orientation was
conducted within twenty-four hours of admission.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures regarding written consent of youth eighteen
years of age or older. The program’s policy requires written consent from any youth eighteen
years of age or older in order to provide the youth’s parent/guardian with any related information
regarding the youth. One of seven youth records was applicable for the youth being over age
eighteen. Two additional applicable youth records were requested for review. Each confirmed
the program obtained written consent from the youth over age eighteen before providing or
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discussing information related to the youth’s physical or mental health screening, assessment,
or treatment with the parent/guardian.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a written policy and procedures requiring the program to utilize a classification
system to promote safety and security and effective delivery of treatment services. The program
youth may be re-classified at intervals throughout their length of stay. Youth shall be re-
classified for changes in the youth’s supervision status, alert updates, behavioral concerns, and
additional relevant information to ensure safety and security of the youth and the program. A
review of seven youth case management records confirmed each Classification Form included
all required elements and the initial classification was completed during the admission process.
Provided documentation confirmed none of the youth were classified as an escape risk. Five of
the seven youth were classified as having medical and security risk factors. One of the five
youth was classified as having a suicide risk factor. In addition, four youth records indicated
other risk factors or special needs were identified during the classification process. A review of
the Department's Juvenile Justice Information System (JJIS) alerts list confirmed each youth’s
applicable risk factors were utilized to assist in classifying the youth for living, sleeping, and
youth group assignments. All seven youth were applicable for re-classifications completed for
an increase in the youth’s privileges or freedom of movement and participation in work projects.
None of the reviewed youth were applicable for off-campus activities. An interview with the
facility administrator (FA) indicated a classification meeting is held within twenty-four hours of
intake with the FA, clinical director, case manager, and parent/guardian. During the meeting a
Classification Form is utilized to obtain information to determine the youth's mental health
status, physical health, cognitive performance, age, prior victimization, gang membership, and
youth aggressiveness. An interview with the FA indicated the information obtained is used to
determine the youth's unit and room assignment.
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 written policy and procedures to address gang identification and notification
to law enforcement. The program’s policy requires staff to review each youth’s Face Sheet prior
to arrival at the program to identify alerts, including gang involvement, if known. A review of
seven youth case management records indicated none of the youth were identified as being
potentially involved in gang activity; therefore, three additional applicable records were provided
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for review. Each reviewed record indicated local law enforcement, law enforcement in the
youth’s home county, the educational provider, and the youth’s assigned juvenile probation
officer were all notified of each youth’s suspected gang involvement. Each youth had the
appropriate gang alerts entered into the program’s internal alert system and the Department's
Juvenile Justice Information System (JJIS). None of the youth were applicable for required
notification to a post-residential counselor.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures regarding gang prevention and interventions
strategies. The program’s policy requires gang prevention and intervention activities to be
implemented through the provision of the Impact of Crime curriculum when youth are identified
as a criminal street gang member, affiliated with a criminal street gang, or at high risk of
involvement. The program’s policy and procedures address providing youth an opportunity, if
they desire, to develop a plan to disaffiliate with a criminal street gang. Seven youth case
management records were reviewed, and none of the youth were applicable for gang
identification requiring prevention and intervention activities; therefore, three additional records
were requested for review. Each reviewed record identified the youth as a gang member or
affiliated gang member. A review of gang prevention and intervention strategy sign-in sheets
confirmed the youth participated in required groups. All three youth’s performance plans
included relevant goals and objectives related to gang intervention strategies for the youth to
complete prior to release from the program. An informal interview with the case manager
confirmed the program utilizes an anti-gang education awareness curriculum. Security checks
are conducted throughout the program to identify and prevent graffiti and gang activity. An
interview with the facility administrator (FA) and the case manager indicated the program meets
monthly with a local anti-gang organization, to provide resources, intervention, and prevention
strategies for identified, associated, or suspected gang members.
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 written policy and procedures requiring an initial assessment of each youth
to be conducted within thirty days of admission. The program’s policy requires the Residential
Assessment for Youth (RAY) to be conducted within thirty days of admission and documented in
the Department's Juvenile Justice Information System (JJIS). A review of seven youth case
management records and JJIS indicated the initial RAYs were completed for six youth within
thirty days of the youth’s admission to the program. One youth had a RAY completed eight days
late. All reviewed RAYs were maintained in JJIS, and all required updates or reassessments
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were completed at least every ninety-days after the initial RAY assessment. All initial RAYs and
completed reassessments were maintained in each youth’s case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a written policy and procedures requiring the Youth Needs Assessment
Summary (YNAS) process to be completed within thirty days of the youth’s admission. The
program’s policy requires the YNAS to be utilized to identify and prioritize youth needs. A review
of seven youth case management records indicated six contained a YNAS which was
completed within thirty days of the youth’s admission to the program. One youth had a YNAS
completed eight days late. Each YNAS was documented in the Department's Juvenile Justice
Information System (JJIS) and included each youth’s three top 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 written policy and procedures to address performance plan development,
goals, and transmittal. The program’s policy requires the Individualized Performance Plan (IPP)
to be developed from the findings of each youth’s initial assessment. A review of seven IPPs
confirmed six youth had an IPP developed within thirty-days of admission to the program. One
youth’s IPP was developed nine days late. All seven-youth had IPPs developed after the
completion of the initial Residential Assessment for Youth (RAY) and the Youth Needs
Assessment Summary (YNAS). Each reviewed IPP was developed and signed by the treatment
team leader, youth, administrative representative, living unit representative, treatment staff,
education staff, and other parties with a significant responsibility in goal completion. One youth
was applicable for current involvement with the Department of Children and Families (DCF) and
the DCF caseworker signed the plan. A review of each youth record confirmed the signature
sheet was attached to the original performance plan. Each reviewed IPP included goals based
upon the prioritized needs reflecting the risk and protective factors identified during the initial
assessment process, and the youth’s three top criminogenic needs. Each IPP included
delinquency interventions, target court-ordered sanctions, and detailed transition activities
targeted for the youth’s final sixty days in the program. In addition, each plan specified the
youth’s responsibilities for accomplishing goals, along with the program staff’s responsibilities in
supporting the youth with completing the goals. Every goal had a designated target date for
completion. A review of the youth records confirmed within ten working days of the completion
of each plan, the program sent a transmittal letter and a copy of the plan to each youth’s
committing court, assigned juvenile probation officer (JPO), and parent/guardian.
Documentation confirmed one youth was applicable for a having an email transmittal letter and
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a copy of the plan sent to the DCF case manager, which was completed as required. Seven
youth were interviewed, and each stated they participated in the development of their IPP.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a written policy and procedures regarding each youth’s Individualized
Performance Plan (IPP) to be revised as needed for completion of the program. The program’s
policy requires the intervention and treatment team to determine IPP revisions based on each
youth’s lack of progress. A review of seven youth case management records confirmed all
seven youth were applicable for performance plan revisions based on the Residential
Assessment for Youth (RAY) reassessment results, newly acquired/revealed information which
warranted a change, and/or demonstrated progress towards goal completion. Three of the five
reviewed youth records indicated the youth demonstrated lack of progress toward completing a
goal. All youth were applicable for revisions on the IPP for needing to facilitate transition
activities for the last sixty days of the youth’s stay in the program. Four of seven youth were
applicable for having additional academic or treatment plans incorporated into the youth’s
performance plan. One youth was applicable for having had their current behavior support plan
and performance plan coordinated with the Department of Children and Families (DCF). Each
applicable plan referenced or incorporated academic, treatment, or DCF plans as required.
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 written policy and procedures regarding performance summaries and
transmittals. The program’s policy requires the case manager to complete a Performance
Summary for each youth every ninety days after the development of the initial Individualized
Performance Plan, unless the committing court requests shorter intervals. A review of seven
youth case management records confirmed all youth were applicable for Performance
Summaries completed every ninety calendar days. All seven youth were applicable for
Performance Summaries prepared prior to the youth’s release, discharge, or transfer from the
program. Each reviewed summary included the youth’s status on each performance plan goal,
overall treatment progress, academic status, behavior, level of motivation and readiness to
change, interaction with peers and staff, overall behavior adjustment to the program, and
significant positive and negative events. Reviewed documentation in each youth’s case
management record confirmed the youth were allowed to read and add comments prior to
signing, and each received a copy of the summary. Each Performance Summary was signed
and dated by the treatment team leader, staff preparing the summary, facility administrator or
designee, and the youth. Each original summary was filed in the youth’s case management
record. Reviewed documentation indicated a copy of each summary was sent to the youth’s
committing court, assigned juvenile probation officer (JPO), parent/guardian, and Department of
Children and Families (DCF) caseworker, when applicable, within ten working days of the
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completion of the summary. A review of three closed records confirmed each release summary
included the original summary. None of the youth were applicable for direct discharge or
identified as a Sexually Violent Predator Program (SVPP) sexual offender. Each youth had a
release summary and Pre-Release Notification (PRN) sent to the JPO at least forty-five days
prior to release. A review of documentation confirmed the signed copies of the summaries were
retained in the youth’s case management records. None of the records indicated the court
objected to the youth’s release. Each closed record documented notification to the youth’s
parent/guardian of the youth’s planned release date once the program obtained the approved
PRN from the youth’s committing court. The program completed a Residential Assessment for
Youth (RAY) exit assessment for each of the reviewed youth. In addition, the program provided
the JPO with the transition plan, Performance Summary, and psychological/psychiatric reports
conducted while at the program for each reviewed youth. Two of the three youth were not
applicable for the program mailing the Victim Notification of Release letter to the victim.
Reviewed documentation confirmed the remaining youth was applicable for waived 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 written policy and procedures requiring parent/guardian involvement in the
program’s case management services. The program’s policy requires the case manager to
make efforts and document parent/guardian participation in treatment plan development,
meetings, visitation, and transition planning. Seven youth case management records were
reviewed during the annual compliance review. All seven records included documentation which
validated the program made efforts to include the parent/guardian in the assessment process,
the development of the youth’s performance plan, progress reviews, formal treatment team
meetings, and transition planning. An informal interview with the program’s case manager
clarified when a parent/guardian is unable to attend a meeting in person, they are afforded the
opportunity to participate by telephone, conference call, or may provide input prior to the
meetings by email. Additionally, each parent/guardian is informed of quarterly program events
for additional family support. During the annual compliance review a scheduled treatment team
meeting was observed. The youth’s parent/guardian was not available by telephone due to work
obligations. The parent/guardian was contacted after the meeting by the case manager. An
interview with the facility administrator (FA), indicated parents/guardians are encouraged to
participate in monthly treatment team meetings, weekly visitations, monthly family sessions,
quarterly family forums, and family days. Seven youth were interviewed and stated their
parent/guardian participated 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 written policy and procedures regarding the requirements for formal and
informal treatment team meetings. The program’s policy requires treatment team members to
develop, review, and update youth performance at the program. Seven youth case management
records were reviewed, and each record contained documentation to validate formal reviews
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were held at least every thirty days. A review of documentation confirmed informal reviews were
held bi-weekly each month for each youth. All formal and informal treatment team meetings
maintained in the youth’s records included the youth’s name, date of the review, all required
attendees, comments, a brief synopsis of the youth’s progress at the program, any performance
plan revisions, Residential Assessment for Youth (RAY) Reassessment results, positive and
negative behaviors, and treatment progress. Documentation supported each youth was
provided an opportunity to demonstrate skills acquired in the program during treatment team
meetings. A review of the treatment team meeting sign-in sheets confirmed the youth’s
assigned juvenile probation officer (JPO), parent/guardian, and other pertinent parties were
invited and encouraged to attend the meetings or provide either verbal or written input. During
the annual compliance review week, a treatment team meeting was observed. All required
parties were in attendance, including education. The youth’s JPO attended the meeting by
telephone. The case manager attempted to include the youth’s parent/guardian by telephone. A
review of the sign-in sheet for the treatment team meeting confirmed the parent/guardian was
notified on the same day of the treatment team about updates and changes regarding the
youth’s progress in the program. During an informal interview with the youth after the treatment
team meeting, the youth stated the case manager contacts their parent/guardian with updates
from the meeting due to scheduling difficulties. Seven youth were interviewed, and each stated
they participate in the treatment team meetings and can verbally explain their skills and goals to
the members of the treatment team.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a written policy and procedures to address transition planning, transition
conferences, and Community Re-Entry Team meeting (CRT) requirements. The program’s
policy requires a development process for transition planning, conferences, and CRT meetings
for youth to transition back into the community. A review of three closed youth case
management records indicated each youth had a transition conference held at least sixty days
prior to their targeted release date. Reviewed documentation confirmed the youth, treatment
team leader, facility administrator or designee, and other team members attended the transition
conference. All three youth records documented the involvement of the youth’s assigned
juvenile probation officer (JPO), parent/guardian, education staff, and other pertinent parties and
noted their input in the transition conference. A review of the transition conference
documentation confirmed the treatment team leader obtained attendees dated signatures and
copies were sent the youth’s JPO and parent/guardian by email. Each transition conference
included a review of transition activities on the youth’s performance plan, revision of the
performance plan as necessary, identified additional transition activities, identified target
completion dates, and the persons responsible for completion. A review of the CRT meeting
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documentation confirmed the meetings were conducted prior to each youth’s release, with the
youth and case manager participating. Each youth case management record validated emailed
invitations were sent to encourage participation in the CRT meeting.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures requiring assembly of an exit portfolio for each
youth released back into the community. Three closed youth case management records were
reviewed, and each documented the exit portfolio was discussed and initiated for the youth’s
transition conference. Two of the three exit portfolios did not contain a state issued
identification, Social Security card, or birth certificate. Documentation validated both
parents/guardians refused to provide the requested documents and denied the program’s
request to obtain a state issued identification for the youth. Case notes in one record showed
several attempts were made by the program’s case managers to obtain the documents. A copy
of the youth’s transition plan, education and/or vocational certification, resume, sample of
employment application were included in each youth’s exit portfolio. During the transition
conference, a plan documenting the persons responsible for working with the youth to obtain the
needed information was created. A review of the program’s contract confirmed there were no
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 written policy and procedures to address exit conferences and finalization of
release plans. The program’s policy requires an exit conference to be conducted prior to each
youth’s release from the program. A review of three closed youth case management records
confirmed an exit conference was conducted after the program notified the assigned juvenile
probation officer (JPO) of each youth’s planned release, and at least fourteen days prior to
release. Reviewed documentation included the date of the conference, participant signatures,
and the status of each youth’s transition activities. Each youth’s date of admission and date of
termination was documented in the case record which correlated with the Department's Juvenile
Justice Information System (JJIS). Each exit portfolio included provisions for continuation of
education or employment which were reviewed during the exit conference. Documentation
indicated the youth’s parent/guardian and JPO were aware of the vocational plan for each
youth. The three reviewed exit conference documents verified participants included the
intervention and treatment team leader, parent/guardian, education representative, JPO, the
youth, and all other pertinent parties. All three youth records documented the exit conference
was conducted separately from the transition conference and Community Re-Entry Team (CRT)
meeting.
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2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process to promote constructive input by youth, which includes
submission of Request to Speak forms and/or written grievances to the program’s facility
administrator (FA). During the facility tour the grievance and Request to Speak forms were
observed in the dayroom for youth access. Youth participate in formal and informal treatment
team meetings weekly. Additionally, the program conducts monthly youth student council
meetings and town hall meetings. An informal interview with the FA confirmed the program
conducts quarterly youth advisory board meetings and electronic surveys where youth may
provide input on the meals, activities, and canteen options. A review of the program’s sign-in
sheets, agendas, and meeting minutes confirmed the meetings were held as required. Four of
the seven interviewed youth stated they speak to a supervisor when they want to provide input
about the program. Three youth stated they request to speak to an administrator or anyone at
the program about concerns. An interview with the FA indicated student advisory council
meetings and town hall meetings are conducted to allow youth to provide input, communicate
their concerns, or to address any recommendations to improve conditions for staff and youth.
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 requiring the provision of access to education.
The program integrates education into the daily schedule. A review of three dates of
surveillance video footage in comparison with the entries for those dates in three master control
logbooks showed youth arriving to class and returning from class on time. In addition, randomly
selected logbook entries over the past year were reviewed and reported youth were moved
accordingly with little deviation. Seven youth were interviewed and reported there were no
interruptions during the school day.
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2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program is contractually required to ensure all youth receive Occupational Safety and
Health Administration 10 (OSHA 10), cardiopulmonary resuscitation (CPR), first-aid, and Florida
Ready to Work (FRW) credentials within ninety days of arrival. Additionally, the program is
required to initiate industry certification training within ninety days of the youth’s arrival.
Certifications are required to be listed on the Florida master credential list. Seven youth case
management records were reviewed, and two youth did not complete FRW certification. The
remaining five FRW youth certifications were completed more than sixty days late. Four
reviewed youth records documented the OSHA 10 credential was completed within ninety days
of arrival, as required; however, three youth records showed the OSHA 10 credential was
completed more than sixty days late. Six reviewed youth records showed the youth completed
CPR certification within ninety days of arrival, as required, and one youth completed CPR
certification fifteen days late. The program reported youth who had not yet earned certificates
required material to be read aloud and verbiage changed to meet their level of understanding.
The program did provide proof of enrollment and login documentation. Additionally, it was
reported several of the program’s youth had special education plans and significant educational
gaps prior to placement. These factors impacted their ability to read, process, and comprehend
material at the pace being required. None of the reviewed youth records showed any industry
certification offering from the Florida master credential list; however, the program reported thirty-
two youth completed the SafeStaff food handler certification and three youth completed a forklift
certification since the last annual compliance review. Additionally, nine youth received FRW
credentials, and sixteen attempted FRW certifications. Thirty-five youth earned CPR
certifications, and thirty-five earned OSHA 10 credentials during the annual compliance review
period. An interview with the facility administrator (FA) indicated the career and technical
education courses offered at the program include forklift, food handler, medical training, first-aid,
cardiopulmonary resuscitation (CPR), and Microsoft Office. Seven youth were interviewed and
all confirmed the program provides career and/or technical education services. Five youth
specifically mentioned CPR, two identified OSHA, and one youth stated they each, respectively,
participated in a forklift, FRW, or the electricity course.
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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 has a written policy and procedures regarding the designated mental health
clinician authority (DMHCA). The program’s DMHCA is a full-time staff who is on-site at least
forty hours each week and is responsible for the coordination and implementation of mental
health and substance abuse services in the program. The program’s DMHCA is a licensed
clinical social worker, whose license is free and clear in the State of Florida, which expires
March 31, 2027. There has only been one staff serving as the DMHCA since the last annual
compliance review. A review of the policies, job description, and an interview verified the
DMHCA is on-site Monday through Friday for at least forty hours each week. Additionally, the
DMHCA is on call twenty-four hours a day, seven days a week for emergency consultation. The
program’s regional staff serves as the back-up DMHCA. The back-up is a licensed mental
health counselor, and the reviewed license was free and clear expiring March 31, 2027. The
interviewed DMHCA reported providing clinical supervision for non-licensed mental health
professionals, distributing the weekly group schedule, and preparing a monthly fidelity
monitoring calendar. Mental health professionals submit their monthly service calendars,
outlining scheduled individual and family sessions to the DMHCA. In addition, they deliver
individual,family, and group therapy services. They reported communication with clinical staff
occurs daily through both formal and informal methods to promote positive morale, open
dialogue, and the effective functioning of the clinical department.
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 has a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. In addition to the
program’s designated mental health clinician authority (DMHCA), the program has three full
time and one part-time non-licensed therapists, and one recreation therapist. The reviewed
DMHCA’s license was free and clear in the State of Florida with an expiration date of March 31,
2027. The program is licensed under Chapter 397 with the Department of Children and Families
to provide substance abuse treatment to adolescents. The license expires April 1, 2026, and
was displayed in the program’s lobby.
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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 a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program had
three full-time non-licensed therapists and one part-time non-licensed therapist at the program.
The program’s designated mental health clinician authority (DMHCA) shall assure the non-
licensed staff working under their supervision are performing services for which they are
qualified to provide, based on education, training and experience. Reviewed documentation
supported the DMHCA provided on-site face-to-face clinical supervision to the four non-licensed
staff since the last annual compliance review. The supervision was documented on the
program’s form and included all elements on the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form. The program is licensed under Chapter 397 with the Department of Children and Families
to provide substance abuse treatment to adolescents. The license expires April 1, 2026, and
included the program’s physical address. All four non-licensed therapists held a master’s-level
degree. Each reviewed degree was from an accredited university or college in the field of
counseling, social work, psychology, or related human services field. Each non-licensed mental
health clinical staff who conducted Assessments of Suicide Risk completed twenty hours of
training in assessing suicide risk, mental health crisis intervention, and emergency mental
health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a written policy and procedures to establish a system to gather important
treatment and emergent information prior to each youth’s entry into the general population.
Seven mental health and substance abuse records were reviewed, and each contained a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) completed on the date
of the youth’s admission. Each record documented the screener reviewed available information
to include the commitment packet, and reports and/or records for existing documentation of
mental health or substance abuse problems or history of human trafficking. Each MAYSI-2 was
completed in full by a trained screener in the Department’s Juvenile Justice Information System.
All seven reviewed MAYSI-2s indicated the need for further assessment; however, it is the
program’s practice to refer all youth for additional assessment. Each referral documented the
notification to the designated mental health clinician authority (DMHCA). None of the youth were
applicable for being at-risk for suicide or identified as being in crisis. Each youth was referred for
a comprehensive assessment, and the reason for the referral was documented. The reviewed
policy and procedures indicated the facility administrator (FA) is responsible for the
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implementation of a standard admission mental health and substance abuse screening process.
The policy addressed the administration of the MAYSI-2, staff training in administration, and a
standardized referral process. The interviewed FA reported a MAYSI-2 screening is completed
upon intake to identify suicide risk factors, and additional screenings include the Substance
Abuse Subtle Screening Inventory (SASSI), Assessment of Suicide Risk (ASR), and Beck’s
Depression Inventory. The interviewed DMHCA reported once the MAYSI-2 is completed, a
referral form is completed and given to the mental health professionals during the intake
process. ASRs are completed for all youth at the time of intake, regardless of MAYSI-2 results.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a written policy and procedures to establish assessment and evaluation
processes to guide the development of the youth’s individualized treatment plan. It is the
program’s process to complete a new combined mental health and substance abuse evaluation
for all newly admitted youth. A review of seven mental health and substance abuse records
indicated each contained an evaluation completed within thirty calendar days of admission.
Each record contained documented consent for substance abuse services. All seven
evaluations were completed by a non-licensed staff working under the direct supervision of a
licensed professional and were signed by the licensed staff within ten calendar days. Each new
evaluation documented the youth’s identifying information, reason for evaluation, relevant
background information including home environment and family functioning, history of physical
abuse, sexual abuse, neglect, witnessing violence and other forms of trauma, behavioral
functioning, physical health, mental health and substance abuse history, and education
functioning. Each assessment documented the completion of a Mental Status Examination,
interview procedures administered, discussion of findings, diagnostic impressions, patterns of
alcohol and drug abuse, impact of alcohol and drug abuse on major life areas, risk factors of
continued alcohol and other drug abuse, and recommendations. The interviewed designated
mental health clinician authority reported the mental health department provides individualized
treatment through individual, family, and group therapy services to address the mental health
and substance abuse needs of the youth. Additionally, the intake process includes classification,
and problem areas are discussed with the youth and parent/guardian.
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 has a written policy and procedures to establish individualized treatment planning
processes which guide service delivery. A review of seven mental health and substance abuse
records indicated each had an initial treatment plan created within seven days of the initiation of
treatment. Each plan was documented on the program’s form and included all elements on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each of the seven
plans were signed by the clinical staff completing the form, the youth, treatment team leader,
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program management, education staff, and other pertinent parties. Each documented the
participation by telephone, or the attempt to solicit telephone participation from the
parent/guardian, and the assigned juvenile probation officer (JPO). All seven plans were
completed by a non-licensed staff working under the direct supervision of the licensed staff and
were signed the same day by a licensed staff. All seven plans were applicable for individualized
treatment plans and plan reviews. Each individualized plan was applicable and included
psychiatric services, including psychiatric medication and frequency monitoring. Individualized
plans were completed on the program’s form and included all elements of the Department’s
form. The plans were applicable for forty-five reviews, which were all completed at least every
thirty-days as required. All seven individualized plans and all plan reviews included signatures
from the clinical staff completing the forms, the youth, treatment team leader, program
management, living unit representative, education staff, and other applicable team members.
Each documented the telephone participation or the solicitation of telephone participation from
the parent/guardian, and the assigned JPO. All seven individualized plans were completed by a
non-licensed staff working under the direct supervision of a licensed staff and were signed by a
licensed staff the same day. When applicable, plans documented the signature and review of
the individualized plan by the psychiatrist. Each youth’s individualized plan contained goals and
objectives which were individualized, and each plan prescribed a minimum of two monthly
individual sessions, one monthly family session, and four weekly group sessions.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a written policy and procedures to establish individualized treatment planning
processes which guide service delivery. Additionally, the program has a policy and procedures
to establish discharge and transition planning processes for mental health and substance abuse
treatment services. A review of seven mental health and substance abuse records showed each
youth was assigned to a treatment team upon arrival to the program. Reviewed treatment team
assignment forms and treatment team documents verified the youth, program administration, a
living unit representative, medical staff, and mental health staff attended treatment team
meetings. Additionally, treatment team plans and reviews documented the parent’s/guardian’s
telephone participation or attempts to solicit their telephone participation. All seven reviewed
records contained a properly executed Authority for Evaluation and Treatment (AET) and a
signed Youth Consent for Substance Abuse Treatment form. All mental health and substance
abuse treatment notes were documented on the program’s form and contained all elements in
the Department’s Counseling/Therapy Progress Notes form. Mental health and substance
abuse therapy included individual counseling and psychosocial skills training for all seven
reviewed youth. Reviewed progress notes verified each youth received services as stipulated in
their individualized treatment plans. Three mental health and substance abuse records were
reviewed for discharge plans. Each record contained a discharge plan completed on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. No youth
were applicable for being released on suicide precautions. Each discharge plan included future
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needed services. Reviewed documentation supported the discharge plans were discussed with
the youth’s parent/guardian and assigned juvenile probation officer (JPO) during the exit
conference and a copy of the plans were provided to the youth, parent/guardian, and assigned
JPO. The program’s practice is to obtain the parent’s/guardian’s signature upon release, and to
provide them with a copy at release. Additionally, the discharge summary is sent by email and
by mail to the assigned JPO after release.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a written policy and procedures to establish service delivery protocols for the
delivery of Substance Abuse Treatment Overlay Services (SAOS). The program’s specialized
treatment service is SAOS. The program provides substance abuse treatment through group
therapy, individual therapy, and family therapy. Seven youth were interviewed and reported
participating in group, family, and individual counseling at the program. Seven staff were
interviewed and reported the mental health staff facilitate clinical groups. An interview was
conducted with the designated mental health clinician authority (DMHCA) who reported, after
completing the comprehensive assessment, mental health professionals assist youth in
identifying problem areas, including substance abuse, and develop an individualized treatment
plan within twenty-five days. Treatment plan reviews are conducted monthly and reviewed by
the clinical director or designee. Any necessary adjustments are documented using a treatment
addendum. The interviewed facility administrator confirmed SAOS groups are conducted. The
program’s counselor to youth ratio shall not exceed sixteen youth, and a review of caseload
assignments confirmed caseloads were between ten and twelve youth for the program’s four
non-licensed staff. A review of staff credentials confirmed all non-licensed clinical staff held a
master’s-level degree. Youth plans and progress notes verified the program was conducting
individual therapy sessions at least every two weeks, family sessions at least once each month,
and the psychiatrist was on-site at least every two weeks. A review of group video recordings
verified groups were conducted as documented. Documentation supported four SAOS groups
were scheduled each week. There were no documented instances where services were missed
due to medical quarantine since the last annual compliance review.
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 a written Suicide Prevention Plan. The Suicide Prevention Plan describes the
essential components and provides guidelines for the identification, management, and
assessment of a potential suicide or at-risk youth. Potential suicide risk or at-risk youth refer to
youth who have a history of or demonstrate behaviors which indicate they are thinking about or
contemplating suicide, however, are not acutely suicidal. The acutely suicidal youth who attempt
suicide or present an imminent threat of suicide must be treated as an emergency and the
program’s emergency plan shall be implemented. The written plan included identification and
assessment of youth at-risk for suicide, 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 is to include the
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circumstances surrounding the event, program procedures relevant to the incident, relevant
training received by involved staff, pertinent mental health and medical services involving the
victim, possible precipitating factors, recommendations, if any, for changes in policy, training,
medical or mental health services, and/or operating procedures. The plan was reviewed
annually and was last signed on November 11, 2024, by the designated mental health clinician
authority and the facility administrator.
3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a written Suicide Prevention Plan which details the methods for identification,
assessment, and supervision of youth at-risk for suicide. The program’s practice is to screen all
newly admitted youth for suicide risk and to then complete an Assessment of Suicide Risk
(ASR) regardless of the screening results. Seven youth mental health and substance abuse
records were reviewed, and only one was applicable; therefore, two additional mental health
and substance abuse records applicable for suicide risk were requested. A review of each of the
three events indicated the youth were placed on suicide precautions after staff completed
behavior observations. Each ASR was completed in full by a licensed staff and the youth
remained on constant supervision in each instance. Each event documented the notification to
the parent/guardian and the assigned juvenile probation officer (JPO) of the youth’s status.
Subsequent Follow-Up ASRs were completed until the youth were deemed appropriate for close
supervision. The youth’s step down to close supervision only occurred after a documented
conference between the licensed clinical staff and the facility administrator (FA) or designee.
The discontinuation of close supervision in each of the three events was documented in
accordance with the program’s Suicide Prevention Plan. A suicide risk alert was appropriately
placed and removed in the Department’s Juvenile Justice Information System and the
program’s logbook in each instance. The Suicide Precautions-Observation Logs were
completed in their entirety for the duration each youth was on precautionary observation. The
program did not have any youth on suicide precautions in the past thirty days; therefore, a
review of supervision through video was not possible.
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 has a written Suicide Prevention Plan which details the methods for identification,
assessment, and supervision of youth at-risk for suicide. There were three documented
incidents requiring a youth to be placed on precautionary observation since the last annual
compliance review. A review of Suicide Precautions-Observation Logs for the three applicable
incidents were reviewed. Reviewed logs confirmed they were maintained for the duration youth
were on suicide precaution status and the supervision observations were documented in real
time, not exceeding thirty-minute intervals. All three youth were applicable for warning signs
observed, and the logs documented the warning behavior and consultations and reviews with a
licensed mental health staff. Each log was signed by a mental health staff and a supervisory
staff as required. Each log documented the youth’s supervision level instructions and safe
housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a written Suicide Prevention Plan detailing the training requirements for staff.
All staff having direct contact with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk. All staff having direct contact with youth shall be trained on the
supervision procedures and documentation which must be completed on youth identified as at-
risk. The program will offer a minimum of six hours of training annually on suicide prevention
and implementation of suicide precautions. A review of training records for seven in-service and
seven pre-service staff confirmed each had the required six hours of training in suicide
prevention and implementation of suicide precautions. The program has two suicide response
kits located in master control. The kits are co-located with first-aid kits and contain a rescue tool,
wire cutters, and needle nose pliers. The program conducts mock suicide drills no less than
quarterly on each shift for all staff who come into contact with youth. The program’s practice is
to review drills during the monthly all staff meetings allowing staff who were not present to have
the opportunity to review each drill scenario and procedures to understand the process and
receive the necessary training to respond to an incident of a suicide attempt or incident of
serious self-inflicted injury. The interviewed facility administrator reported drills occur monthly on
each shift and are facilitated by the designated operation, mental health, and medical staff. Five
interviewed staff reported, medical emergency and suicide drills are conducted monthly on each
shift. A video review of a mock suicide drill confirmed drills were simulated. Drills were
documented as occurring monthly alternating between the program’s three shifts and drills were
in response to a suicide attempt and/or incident of simulated self-inflicted injury. Program youth
were not used in drill simulations. Reviewed drills confirmed the program’s practice of
completing monthly drills alternating by shift. Each drill included details regarding staff and
applicable emergency contacts and life saving measures used.
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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 a written Crisis Intervention Plan to ensure the program differentiates between
youth in mental health crisis and those requiring suicide precautions or emergency treatment. A
review of the Crisis Intervention Plan showed it included details regarding a 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 a written Crisis Intervention Plan which details the procedures regarding the
completion of a Crisis Assessment and a follow-up Mental Status Examination. The program
had three incidents requiring the completion of a Crisis Assessment since the last annual
compliance review. Two of the three assessments were completed the day the youth was
determined to be in crisis and the third assessment was completed within twenty-four hours.
Each of the three reviewed Crisis Assessments included the reason for the assessment, a
Mental Status Examination and interview, determination of danger to self and/or others,
including imminence of behavior, intent of behavior, clarity of danger, and lethality of behavior,
initial clinical impressions, supervision recommendations, treatment recommendations, and
recommendations for follow-up or further evaluation. None of the reviewed events were
applicable for notification to the parent/guardian regarding follow-up treatment. An informal
interview with the clinical staff reported if there is no additional change in supervision, the
parent/guardian and assigned juvenile probation officer (JPO) does not need to be notified.
Each Crisis Assessment was completed by a licensed staff. All three youth were applicable for
being maintained on precautionary observation and the appropriate alerts were made internally,
documented in the logbook, and entered in the Department’s Juvenile Justice Information
System. Each youth remained on alert until a follow-up Crisis Assessment and a Mental Status
Examination was completed. Supervision observations for each youth were documented as
required. All Crisis Assessments were completed on-site.
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3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written Emergency Response Plan to outline the mental health and
substance abuse emergency procedures and to ensure youth who are believed to be an
imminent danger to themselves or others because of mental illness or substance abuse
impairment receive emergency mental health or substance abuse services. A review of the plan
showed it included processes for immediate staff response, notification, communication,
supervision, authorization to transport for emergency mental health or substance abuse
services, transportation for emergency Baker Act or Marchman Act, documentation, training,
and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program has a written policy, procedures, and plan regarding Baker and Marchman Acts.
The purpose of the plan is to outline mental health and substance abuse emergency procedures
and ensure youth who are believed to be an imminent danger to themselves or others because
of mental illness or substance abuse impairment receive emergency mental health or substance
abuse services. The program had a total of two Baker Acts during the annual compliance review
period. Reviewed documentation indicated there was one incident of self-harm and suicidal
ideation, and one attempted suicide. Each event resulted in a Baker Act and the youth were
placed on constant supervision at the time of discovery. Each youth was placed on one-on-one
supervision by the mental health staff and taken out of the program. Mental health staff and the
facility administrator authorized transportation. Upon return to the program each youth was
maintained on constant supervision until an Assessment of Suicide Risk (ASR) and a Mental
Status Examination were completed. Each reviewed youth’s ASR was completed by a licensed
mental health staff. An informal interview with the designated mental health clinician authority
(DMHCA), confirmed the program’s practice for referring and assessing youth who appear
acutely suicidal, and the immediate safety measures taken to ensure the youth’s safety.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a written policy and procedures to establish a planning process designed to
identify areas affecting the youth and incorporate trauma responsive practices. A review of
seven mental health and substance abuse records showed each record contained a Safety Plan
created on the date of admission. Each plan was jointly prepared with the youth,
parents/guardians, and the program’s clinical staff. Each Safety Plan incorporated applicable
recommendations from previous and current clinical assessments and incorporated trauma
responsive practices. Each plan was updated monthly as part of the monthly treatment plan
review process. One youth’s plan required an update outside of the routine reviews as a result
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of a significant behavioral or mental health event, and the appropriate updates were made. All
seven Safety Plans included the youth’s identified warning signs, baseline behaviors, crisis
recognition, jointly developed coping strategies, the youth’s preferred intervention strategies,
and a debriefing process. The interviewed designated mental health clinician authority reported
Safety Plans are kept in the administration office and maintained in youths’ records and are
accessible to all staff. Seven youth were interviewed and reported contributing to the
development and review of their Safety Plans. The interviewed facility administrator reported
Safety Plans are updated monthly or 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.
The program has a written policy and procedures stipulating the requirements of clinical
responsibility for the medical care of all youth at the program. The program contracts with a
licensed medical doctor (MD) with specialty training in pediatrics to serve as the designated
health authority (DHA). The DHA holds an unrestricted license and meets the requirements for
independent and unsupervised practice in the State of Florida. The DHA has a clear and active
license in the State of Florida, which expires on January 31, 2026. The DHA is a current
member of the American Board of Pediatrics and has no disciplinary cases and/or public
complaints on record. The program has an advanced practice registered nurse (APRN), who
has been utilized since the last annual compliance review on August 13, and September 3,
2025. The DHA was on-site at least once a week, with a week defined as the seven-day period
beginning on Sunday and ending on Saturday. A review of the DHA sign-in sheets since the last
annual compliance review indicated the DHA was on-site for a minimum of two hours each week
and at no time did more than nine days pass between on-site visits. The program has a back-up
DHA who is a licensed physician with a clear and active license in the State of Florida which
expires on July 31, 2026; however, the back-up DHA was not utilized since the last annual
compliance review. An interview with the DHA confirmed their role in the program is to conduct
Comprehensive Physical Assessments (CPAs), physical exams, periodic evaluations, and
focused evaluations for sick complaints. Additionally, they develop, review, and edit of all
medical policies procedures, and all nursing protocols. The DHA is to examine every new youth
intake, and perform routine check-ups on all youth, and follow-up exams to youth with chronic
medical illnesses or conditions. The DHA is responsible to ensure all youth to have a completed
immunization record in accordance with health department standards.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program’s contract with the Department outlines the requirements for a health service
administrator (HSA) and one additional full-time registered nurse (RN). The program has one
HSA who is a full-time RN, one full-time RN, and one part-time RN on-site. A review of nurse
licensure credentials for nurses who provided services during the annual compliance review
period confirmed licenses were clear and active. Each held a current certification in
cardiopulmonary resuscitation (CPR) and first-aid. The required on-site hours for nursing staff
was forty hours for RNs and forty hours for the HSA weekly. A review of the nursing schedule
confirmed the HSA and full-time RN are both on-site for forty hours a week. The schedule
confirmed the part-time RN is on-site twenty hours every other weekend or fills in as needed.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The designated health authority (DHA) is solely responsible for
an annual review of all health-related policies, procedures, and protocols. Reviewed policies
and procedures confirmed the DHA signed and dated all respective treatment FOPs and the
psychiatrist reviewed and signed on October 14, 2025. The facility administrator (FA) signed on
October 16, 2025. The nursing staff reviewed, signed, and dated the cover page of all FOPs,
healthcare protocols, and other procedures on October 2, 2025. On October 14, 2025, the
annual review of medical FOPs and protocols was conducted. All newly employed healthcare
personnel received a comprehensive clinical orientation to the Department’s healthcare policies
and procedures, given by a registered nurse or designated licensed healthcare professional.
The treatment protocols or standing procedures were written and approved by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures requiring the completion of the Authority for
Evaluation and Treatment (AET) for all youth admitted into the program. The program utilizes a
separate form for youth eighteen years of age or older providing consent for release of specific
information as noted on the Release of Information Authorization for Youth Eighteen Years of
Age and Older form and to whom the information can be released and shared. Seven youth
Individual Healthcare Records (IHCRs) were reviewed for an AET, and each included a valid
and legible copy of an AET and the word “Copy” was clearly stamped on each AET. Each
applicable AET form was signed by the youth’s parent/guardian. None of the reviewed IHCRs
were applicable for an additional court order filed. Each applicable reviewed AET form was
signed by the youth’s parent/guardian and by a Department representative. Reviewed
documentation confirmed there were no parent/guardian refusals to sign the AET. One youth
was applicable for turning eighteen while at the program and there was a signed Authorization
for Youth Eighteen Years of Age and Older form in the IHCR. One additional youth was
applicable for having parental rights terminated while admitted to the program and a court order
was within the IHCR authorizing treatment. An interview with the nurse indicated the policy for
obtaining a new or current AET is for the clinical manager or designated staff member to
immediately contact the youth’s assigned juvenile probation officer (JPO) to request one. The
nurse indicated the policy for documenting consent for youth eighteen years of age or older is
for the youth to sign the consent themselves. An interview with the program’s registered nurse
(RN) confirmed the program’s practice.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures requiring the parent/guardian to be informed
of significant changes in the youth’s condition and consent to be obtained when new
medications and treatments are prescribed. Seven youth Individual Healthcare Records
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(IHCRs) were reviewed for parental/guardian notification. One youth was in the care of the
Department of Children and Families (DCF), where there was a termination of parental rights,
and the court authorized all treatment and procedures; however, rights were terminated after
admission. Each of the seven-youth reviewed IHCRs were applicable for consent from the
youth’s parent/guardian for all new medications, over-the-counter medications beyond those
covered by the Authority for Evaluation and Treatment (AET), or new psychotropic medications
prior to administration. Parent/guardian consent was provided for each applicable youth and
written notifications were sent utilizing the Department’s Parental Notification of Health-Related
Care form. Six youth were prescribed psychotropic medications upon admission and one youth
was prescribed psychotropic medications after admission. One youth turned eighteen while in
the program and no longer required consents, and one youth record contained a court order
authorizing treatment. Each of the six applicable reviewed records confirmed whenever a new
psychotropic medication was prescribed or discontinued, or the drug dosage was significantly
changed, a parent/guardian provided verbal consent for psychotropic medication which was
documented on the Clinical Psychiatric Progress Note (CPPN). Written notifications were sent
to each applicable youth’s parent/guardian utilizing the Department’s Parental Notification of
Health-Related Care form. A review of documentation confirmed staff witnessed all telephone
call attempts and conversations for psychotropic medications for one of the applicable youth. All
seven reviewed IHCRs documented vaccinations were verified within thirty days of the youth’s
admission. An interview with the nurse confirmed timeframes for reviewing records are prior to
intake and again during the intake process. The nurse indicated the process for documenting
exemption from immunization is to document the exemption form, which is signed by the
parent/guardian, and is placed on file at the local health department. Parent/guardian
notifications are made in real-time and if the nurse is unable to contact a parent/guardian,
another attempt is made, documented, and logged in the youth’s IHCR. Records are reviewed
by the designated health authority (DHA) during the Comprehensive Physical Assessment and
the initial visit. Additionally, the nurse explained the process for obtaining parent/guardian
consent for medications not covered by the AET.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures outlining youth healthcare admission
screening and rescreening each time the physical custody of a youth changes. The program’s
practice is to complete a rescreening and complete the Department’s Facility Entry Physical
Health Screening (FEPHS) form anytime a youth is admitted into the program and each time the
physical custody of the youth changes with subsequent return or readmission to the program. A
review of seven youth Individual Healthcare Records (IHCRs) showed all seven youth had a
FEPHS completed on the date of admission. Each form was completed by a registered nurse
(RN). None of the FEPHS were completed by direct care staff. None of the youth were
applicable for a change in custody greater than twenty-four hours. The interviewed RN reported
the nurses complete the FEPHS form.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures requiring each youth admitted into the
program to receive a healthcare orientation on the general process of the healthcare services
the youth will receive at the program. The orientation is to address the topics of sick call, access
to medical care, medication process including side effect monitoring, what constitutes an
emergency and when to notify staff, the right to refuse care and how it is documented, the non-
disciplinary role of the healthcare providers, and standard universal precautions. A review of
seven youth Individual Healthcare Records (IHCRs) confirmed each contained documentation
the youth received a general healthcare admission orientation. Each youth’s orientation topics
included access to medical care, sick call, what constitutes an emergency and when to notify
staff, medication process to include side effect monitoring, the right to refuse care and how it is
documented, what to do in the case of a sexual assault or attempted sexual assault, the non-
disciplinary role of the healthcare providers, and standard universal precautions. A review of the
Health Education sign-in sheets and each youth’s IHCR confirmed various healthcare topics
were discussed with the youth. The program maintains an education/orientation binder for youth
who refuse to sign the orientation sheet; however, none of the reviewed youth refused. Each
youth was provided health education on seatbelt usage, alcohol and drug related problems,
sexually transmitted disease/infections, tobacco products, including smoking, dental and basic
personal hygiene, immunizations, infection control, prevention of sexual and other physical
violence, nutrition, physical fitness, testicular self-examination, and chronic conditions monthly.
At the time of the annual compliance review two youth were applicable and received education
for parenting skills.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures requiring the designated health authority
(DHA) to be notified of all youth admitted into the program with known or suspected chronic
health conditions or in need of emergency care. A review of seven youth Individual Healthcare
Records (IHCRs) showed six youth were admitted with a chronic condition and a referral to the
physician was made. The DHA was notified within twelve hours for each applicable youth.
Reviewed documentation confirmed the program’s practice is to notify the DHA of all newly
admitted youth regardless of the youth’s status. Six reviewed youth were taking psychotropic
medication at the time of their admission and the psychiatrist was notified. An interview with the
nurse was conducted and revealed healthcare staff must notify the DHA at admission of any
youth with serious or chronic conditions. Notifications made to the DHA are documented in the
admission progress note.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. A review of seven youth Individual
Healthcare Records (IHCRs) indicated each HRH was completed within seven calendar days of
admission and each contained an HRH completed by a registered nurse (RN). Each HRH was
reviewed by the designated health authority (DHA) as indicated by a checkbox on the CPA. An
interview with the nurse confirmed the practice of completing the HRH upon admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring the completion of the Department’s
standardized Comprehensive Physical Assessment (CPA) form for all youth admitted into the
program. A review of seven youth Individual Healthcare Records (IHCRs) showed each
contained a new CPA completed by the designated health authority (DHA) within seven days of
admission. Each of the CPAs documented the appropriate Medical Grade for the reviewed
youth. There was no indication of any missing or incomplete elements on any of the reviewed
CPAs, which were completed on the Department’s form. All sections of the CPA were marked
with an “O” or an “X”. Each of the seven-youth refused part of the examination, and each CPA
documented the refusal and included the youth’s signature by the applicable portion of the CPA.
Each youth had at least one verified Tuberculosis Skin Test (TST) within the last year which was
documented on the Infectious and Communicable Disease (ICD) form. A review of
documentation confirmed the Department’s Problem List was updated as needed. An interview
with the nurse reported the DHA completes a new CPA within seven days of admission and
Tuberculosis screenings are conducted at intake. The TST is completed within seventy-two
hours of admission.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures requiring all admitted youth to be clinically
screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). The policy reflected HIV test results may only be disclosed to the
youth and entities approved by Florida Administrative Code. A review of seven youth Individual
Healthcare Records (IHCRs) confirmed each youth was clinically screened and evaluated for
STIs; however, none of the reviewed youth required further screenings or evaluations. When
applicable, youth would be tested, and screening results, clinical evaluations, and applicable
diagnoses would be documented on the Infectious and Communicable Disease (ICD) form and
filed in the lab section of the IHCR. A review of seven youth IHCRs found each youth was
offered the opportunity to receive counseling and testing for HIV. All seven-youth documented
consent, and the HIV results were filed confidentially in a sealed envelope marked
“Confidential,” and included a documented review by a practitioner on the sealed envelope.
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Each of the youth had documentation of pre/post-test counseling in their progress notes. Each
applicable youth’s confidentiality was protected by not including the youth’s HIV status or any
other STI diagnosis on the program’s internal alert system. Seven youth were interviewed and
reported they can request a HIV test if needed. An interview with the nurse confirmed the
screening process and access for HIV testing. The health service administrator (HSA) indicated
the program utilizes the medical doctor and the local health department to provide testing and
pre- and post-test counseling services. The DHA is notified immediately of results for treatment.
It was reported the STI screenings, evaluations, referrals, and test results are documented in
the IHCR. The nurse reported youth have a urine drug screen if they have been out of the
program’s/Department’s physical custody for more than thirty days and/or symptoms are
present.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures requiring all youth to be able to make sick call
requests and have their complaints treated appropriately through the sick call system. Sick call
care is to be provided by licensed healthcare professionals pursuant to their scope of practice
and according to protocols approved by the designated health authority (DHA). When a licensed
healthcare professional is not on-site, the shift supervisor is to review all sick call requests within
the required timeframe. A review of seven youth Individual Healthcare Records (IHCRs) showed
two of the seven youth were applicable for having submitted a sick call request; therefore, one
additional applicable youth record was requested for review. None of the three applicable youth
presented with a similar sick call complaint three or more times within a two-week period. A Sick
Call Request form was completed for each of the sick call requests reviewed. Each of the
reviewed Sick Call Request forms were completed by a registered nurse (RN). All sick calls
were documented on the Sick Call Index, the program’s Sick Call Referral Log, and filed within
each youth’s IHCR in reverse chronological order. None of the reviewed sick call instances were
for youth in restricted housing, as the program does not utilize restricted housing. A review of
the posted daily schedule, and nursing interview showed sick call is conducted daily, pursuant to
contract requirements. Sick calls are provided seven days a week, twice daily at 10:00 a.m. and
2:00 p.m. The sick call hours are posted in both living units and only licensed nurses can
conduct sick call. The program has a procedure whereby the shift supervisor reviews all sick call
requests as soon as possible and within four hours after the request is submitted when there is
not a licensed nurse on-site. All sick call request forms are available to youth and an exam table
and equipment is used to perform sick calls. Seven youth interviews were conducted, and each
youth reported they can see a doctor or dentist if needed. Seven youth were asked how quickly
they can see a nurse once the youth make a sick call request and each youth responded they
could see a nurse within one day. The nurse reported the process for referring youth to the DHA
when the youth have repeated complaints is to place them on the DHA log. During the week of
the annual compliance review, there were no sick call requests submitted; therefore,
observations were not completed.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures regarding the provision of episodic and
emergency care. A review of seven youth Individual Healthcare Records (IHCRs) showed four
were applicable for episodic care encounters. Each of the applicable reviewed IHCRs
documented first-aid/episodic care was provided by a licensed healthcare staff and was
documented in the progress notes under the notation of episodic care. All notes were completed
in subjective, objective, assessment, and plan (SOAP) format. The program has five first-aid kits
located in master control, medical, the kitchen, and one in each of the two transport vehicles.
The program’s process for ensuring contents are maintained and stored in accordance with
guidelines to prevent expiration or deterioration, includes documenting first-aid kit contents in a
binder, checking kits weekly, and replenishing the kits as needed. A review of documentation
indicated the nurse checks the first-aid kits weekly. Two observed first-aid kits were fully stocked
with DHA approved contents. The reviewed first-aid kit binder showed the first-aid kits were
being monitored as required. The program has one automated external defibrillator (AED)
located in master control, and AED procedures are maintained on both living units as well as
inside the AED. Nursing staff check weekly to ensure the AED batteries and pads are operable.
During the annual compliance review week, the nurse conducted a self-test of the AED in front
of the Monitoring and Quality Improvement (MQI) regional monitor with no issues noted.
Reviewed documentation showed the AED batteries expire on October 31, 2028, and the pads
expire on March 4, 2027. The batteries were last changed on May 30, 2023, and the pads were
changed on August 18, 2025. The AED provides audible step-by-step instructions when in use.
Written AED procedures are attached to the AEDs. A list of emergency numbers was posted and
accessible for non-licensed and licensed staff and these numbers were inaccessible to all youth
in the program. A review of seven staff training records confirmed each completed episodic,
first-aid, and emergency care training. A review of the program’s emergency medical drills
conducted since the last annual compliance review confirmed medical drills were conducted on
each shift monthly. Emergency medical drills included the demonstration of cardiopulmonary
resuscitation (CPR), first-aid, and AED use at least quarterly. The emergency medical drills
consisted of both announced and unannounced drills and were conducted at least monthly on
each shift. A review of drill documentation indicated direct care staff had the opportunity to
participate in at least one emergency “man down” drill annually. Video observations confirmed
the conducted drills simulated episodic care events which called for immediate first-aid care
and/or administration of CPR techniques. During an informal interview, the health services
administrator (HSA) and designated mental health clinician authority (DMHCA) reported staff
who are not present during medical emergency drills can review each drill scenario during staff
meetings. Additionally, reviewed documentation showed staff signed drill review sign-in sheets
to confirm they were provided the opportunity to review the scenario. During the annual
compliance review week, there was no observation of an episodic care event. The program
maintains a written policy and procedures for the use, access, and inventory of NARCAN® by
licensed healthcare staff and non-healthcare staff trained by the registered nurse (RN) to
administer medication. The program stores the NARCAN® in a locked box behind a locked
door. The program’s inventory process of NARCAN® is for weekly counts to be conducted by
medical staff. Seven staff were interviewed, and each reported they are personally allowed to
call 9-1-1 if needed. Seven youth interviews were conducted, and each youth reported they may
see a doctor or dentist if needed. An interview with the nurse reported the program has a total of
five first-aid kits which are located in the kitchen, medical clinic, each of the two vans, and
master control. Youth who are sent off-site for emergency care are tracked through a transport
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log. The nurse reported drills are conducted monthly on each shift. The nurse reported non-
healthcare staff providing first-aid or episodic care document the encounter on the non-
healthcare staff form, and it is reviewed by the nurse the next day.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a written policy and procedures requiring the provision of timely referrals,
coordination, and documentation of medical services provided to youth by off-site healthcare
providers. The designated health authority (DHA) reviews, signs, and dates the received off-site
care findings and information. A review of seven youth Individual Healthcare Records (IHCRs)
showed three youth required off-site care. Each Summary of Off-Site Care Consultation Report
form was utilized and filed in the IHCR. Each reviewed IHCR confirmed the off-site emergency
care was documented on the Episodic Care Log. Each documented parental notification. Each
IHCR documented the DHA reviewed and signed/initialed all off-site care instructions,
information, and findings. Only one of the three applicable reviewed youth required follow-up
testing, referrals, and appointments. At the time of the annual compliance review the program
only had one additional applicable youth. The follow-ups were completed November 2024, and
September and July of 2025 for the two youth. Each applicable referral was tracked, and youth
received appropriate, timely follow-up care as needed. An interview with the nurse indicated
youth who are sent off-site for emergency care or first-aid care are tracked on a planner and the
transport log. Additionally, the nurse reported all hospital orders are reviewed and documented
by medical staff and the DHA to ensure tracking. The nurse confirmed medical staff track the
referrals, follow-up testing, and appointments on the DHA log.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures requiring youth with chronic illnesses to
receive regularly scheduled evaluations and the required follow-up. A review of seven youth
Individual Healthcare Records (IHCRs) confirmed one youth was applicable for having been
admitted with a chronic condition; therefore, two additional youth IHCRs applicable for chronic
conditions were requested for review. None of the youth were identified as having a
communicable disease. Each of the reviewed youth were taking prescribed medication on an
on-going basis and undergoing treatment for physical health conditions. Three reviewed youth
were classified with a Medical Grade of two through four. Each applicable youth was placed on
the chronic illness list and periodic evaluations were conducted when applicable every ninety
days. None of the reviewed youth were taking anti-Tuberculosis medications and none were
applicable for a periodic evaluation prior to renewing a prescription medication which expired.
An interview with the facility administrator (FA) reported the healthcare staff review important
youth medical concerns and issues during daily management meetings with the leadership
team. The designated health authority (DHA) reported chronic evaluations are conducted every
ninety-days and are tracked utilizing a calendar. Periodic evaluations were conducted prior to a
prescription renewal, change, or expiration. Each of the three reviewed youth were applicable
for an off-site evaluation, and the DHA followed up with the youth and signed off on the off-site
care documentation. There were no indications of lapses in care or missed periodic evaluations
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in each of the reviewed records. The Department’s Problem List for each youth was updated in
accordance with policy. The nurse reported healthcare staff track referrals, follow-up testing, and
appointments through the use of a calendar.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a written policy and procedures which detail the process for the receipt,
storage, inventory and administration of medication in a safe and effective manner. A review of
seven youth Individual Healthcare Records (IHCRs) showed all seven were applicable for taking
medication during the annual compliance review period. Six of the youth were applicable for
having been admitted to the program with medication. A review of documentation indicated
youth medication was confirmed prior to being accepted into the program. Each applicable
youth’s prescription verification was documented in a chronological progress note.
Documentation confirmed the designated health authority (DHA) and/or psychiatrist was
contacted to obtain an order to resume/continue the specified medications prescribed prior to
admission. The DHA placed an order on the Practitioner Order form for all continued
medications. Each Medication Administration Record (MAR) clearly indicated medication start
and stop dates. One youth was applicable for trained non-healthcare staff assisting in the
delivery of medication when licensed healthcare staff were not on-site, and the staff initialed
each administered medication entry, as required. There were no undocumented explanations for
a lapse or errors in medication administration. The program utilizes a pre-printed MAR to
document all medication and treatment. Each reviewed MAR documented all required elements
to include youth name, Department of Juvenile Justice identification number (DJJID), date of
birth, youth allergies, precautions, Medical Grade, medical alerts, current picture of the youth,
and youth’s initials. A review of documentation confirmed nursing staff documented weekly side-
effect monitoring on the MARs. Six of the seven youth were applicable for a refusal of
medication and each signed the Refusal of Treatment form. Each applicable MAR clearly
documented the refusals. None of the reviewed youth were applicable for parenteral medication.
The program’s practice is to provide each youth an Initial Diagnostic Psychiatric Interview within
fourteen days of admission. There was no indication of any type of standing orders for
psychotropic medications, any emergency treatment orders for psychotropic medication, or
indication of any pro re nata (PRN) orders for psychotropic medications. At the time of the
annual compliance review, one medication administration was observed with no issues noted.
The youth was escorted to the medical office by the Right Interactions (RI) certified registered
nurse (RN) providing the medication. The Six Rights of Medication Administration were verified
by the RN. The RN administered the medication as required and did not pre-pour any of the
medications. The nurse reported all medication is verified and the DHA is notified for continued
use of medication. The nurse was knowledgeable regarding the process for administering
medication and completing the MAR. Seven youth interviews were conducted. Four youth
reported the nurse gives them their medication and were able to explain the process, and the
other three reported they did not take medication. An interview with the nurse confirmed the
preprinted pharmacy MAR is used, and non-healthcare staff do not provide medications when
healthcare staff are on-site. The nurse reported medication pass times are daily at 8:00 a.m.
and 5:30 p.m. and medications are procured through a vendor.
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4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a written policy and procedures for the provision of psychiatric services within
the program and maintains a contract with a psychiatrist who is responsible for providing
psychiatric services. The psychiatrist had a clear and active license with the State of Florida,
expiring January 31, 2026. The psychiatrist is available for emergency consultation twenty-four
hours a day, seven days a week. The psychiatrist provided psychiatric services by telephone
briefly as a representative of treatment team and psychiatric recommendations for youth are
incorporated into evaluations and planning at the program. The program did not utilize a back-
up psychiatrist during the annual compliance review period. Psychiatric sign-in logs were
reviewed and confirmed the psychiatrist was on-site biweekly, as required. A review of
documentation showed the psychiatrist actively participated, managed, and supervised
psychotropic medication services in the program. Approved tele-psychiatry services were
provided as needed. A review of seven youth Individual Healthcare Records (IHCRs) indicated
six youth were admitted with prescribed psychotropic medications and one youth was
prescribed medication after admission. Each youth was referred for a psychiatric interview, and
each youth received a Diagnostic Psychiatric Interview within fourteen days of admission. Each
of the reviewed youth were placed on psychotropic medications as a result of the interview.
Each reviewed youth’s Initial Diagnostic Psychiatric Interview was documented on the
Department’s Clinical Psychotropic Progress Note (CPPN). Psychotropic medication and
changes to the youth’s existing and psychotropic medication regimen, were documented on the
CPPN. Each of the youth’s reviewed Initial Diagnostic Psychiatric Interviews included all
required elements. Documentation showed each youth was seen by a psychiatrist at least every
thirty days and all were applicable for psychiatric medication reviews. Each of the seven
reviewed records were applicable for a new psychiatric evaluation. Each instance where page
three of the CPPN was used, the psychiatrist documented the identifying data, diagnosis, target
symptoms of each medication, effects of the medication, medication dosage, dosage range,
frequency, route of administration, side effects, adherence to the medication regime, height,
weight, laboratory findings, and whether there was telephone contact with the youth’s
parent/guardian. Reviewed documentation showed each CPPN was signed and dated by the
psychiatrist. Each of the seven reviewed youth were applicable for monitoring of Tardive
Dyskinesia, which was documented as required. Each youth received and consented to tele-
psychiatry during the annual compliance review period. An interview with the psychiatrist and
designated mental health clinician authority, verified the psychiatric treatment processes at the
program.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures stipulating the requirements for the tracking of
inventory for all medication and medical equipment. The program’s policy requires all medical
equipment to be classified and perpetually inventoried. An observation was conducted of the
medical office and showed controlled medications were secured behind a locked door, and
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locked in a secure medical cart, inside of another locked box. Observations confirmed the
medication cart was clean and organized, with stock items separated from youth-specific
medications. The medical equipment classified as sharps included scissors, syringes, suture
removal kits, and needles. All were secured and inventoried utilizing a routine perpetual
inventory. At the time of the annual compliance review, an observation was conducted for counts
of three controlled medications, three over-the-counter (OTC) medications, and three sharps,
and each inventory count was accurate and coincided with the documented inventory. The
medications were stored in a separate secured area which was not accessible to any youth. The
medications, sharps, and OTC medications were all stored in a designated locked area clearly
labeled. A review of seven staff training records showed the registered nurse (RN) conducted
the training for oversight of medication self-administration and delivery. An interview with the
health service administrator (HSA) indicated if there is discrepancy with the inventory, nursing
staff will do a double check/count of the medication and report the inventory discrepancies to
the HSA. The regional medical supervisor and facility administrator (FA) or designee on-site will
be notified of the discrepancy and an internal investigation will be initiated. Additionally, the
Department's Central Communications Center (CCC) will be contacted. The interviewed HSA
confirmed the program’s disposal process is conducted with the HSA and the pharmacist, and
each signs the medication disposal form. The program maintains a copy of the local pharmacist
license in the medical office. The pharmacist conducts monthly on-site checks of all the
medications and two nurses are required to count the controlled medications shift-to-shift.
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 a written policy and procedures for infection and exposure control. The
program’s policy requires infection control procedures for prevention, containment, treatment,
and reporting requirements related to infectious diseases. The program’s infection control policy
and procedures were signed by the designated health authority (DHA) on October 14, 2025.
The facility administrator (FA) signed to acknowledge review of the policy on October 16, 2025.
The nursing staff reviewed the policy on October 2, 2025. The procedures included common,
infectious diseases of childhood, self-limiting, episodic contagious illnesses, viral or bacterial
infection diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV),
Methicillin-Resistant Staphylococcus Aureus (MRSA), bio-terrorist agents, chemical exposures,
outbreaks of lice, and epidemics. Reviewed documentation confirmed staff have access to
protective equipment and Hepatitis B immunizations are available for program staff. A review of
the facility/occupational exposure book was conducted and showed there were no incidents
where the local health department or the Department's Central Communications Center (CCC)
should have been contacted at the time of the annual compliance review. The Exposure Control
Plan was written in accordance with Occupational Safety and Health Administration (OSHA)
standards. The program maintains a separate record for youth and staff who experienced a
facility/occupational exposure. The health service administrator (HSA) confirmed the program’s
process for needle sticks post-exposure evaluation. Staff will dispose of the needle into the
sharps container, immediately wash the exposed area, notify the supervisor, or facility
administrator (FA), and contact the CCC. An interview with the nurse indicated exposure control
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training is provided by the HSA annually for the staff and new hires. An interview with the FA
confirmed the Exposure Control Plan is reviewed yearly with direct care staff. Additionally,
training is provided to the youth at the time of admission.
4.20 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a written policy and procedures to address proper supervision and youth
counts requiring staff to visually observe each youth under the staff’s direction. The program’s
contract requires staff-to-youth ratios to be one-to-eight during awake hours and one-to-ten
during sleep hours. The ratio for off-site activities, transportation, and visitation is one staff to
five youth. A review of the program’s policy confirmed the staff are to maintain active
supervision of each youth, including any behavior changes, engage in a full schedule of
constructive activities, and consistently apply the behavior management system (BMS). During
the annual compliance review week observations were conducted of youth supervision. The
observations validated staff-to-youth ratios were maintained, as required. Observations included
classroom activities, line movement, school/education, recreation activities, mental health
groups, cleaning duties utilizing Class B tools, kitchen duties, meals, youth searches, vocational
activities, and medication administration. An informal interview with various staff confirmed staff
immediately knew the number of youth they were supervising. A program tour was conducted
and confirmed the daily youth activity schedule was posted on both housing modules. The
program’s policy further states active supervision ensures appropriate supervision of the youth
is always maintained. Staff are to provide effective positioning for optimal sight and sound
supervision of youth. Staff are to communicate with youth and co-workers effectively to ensure
expectations are clearly defined. Video observations of ten-minute checks confirmed youth
supervision continues during sleep hours. A review of the Department's Central
Communications Center (CCC) reports confirmed there were no escapes reported during the
annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a written policy and procedures to address the development, implementation,
and training of the program’s behavior management system (BMS). The BMS is designed to
maintain order and security, fostering compliance with the program rules, teaching youth
alternative pro-social methods of dealing with problems using both rewards, and a system of
progressive discipline. This system, known as the iChoose BMS, is a coordinated system of
promoting, monitoring, recognizing, and rewarding a youth’s progress. It is a program of
incentives and consequences which promotes individualized skill building, appropriate behavior,
and accountability. The policy includes a protocol where staff are trained and provide feedback
regarding the implementation of the BMS. Seven staff records were reviewed, and each
reflected the staff completed training in the program’s BMS, and each job description explained
the expected job functions related to implementing the program’s BMS. The facility administrator
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(FA) ensures all staff who have direct contact with youth, including education staff, are trained
on the BMS. The BMS is posted and outlined within the youth handbook allowing easy access
for youth and includes rules governing conduct, and positive and negative consequences for
behavior including while in the classroom. A review of the youth handbook indicated the BMS is
designed to promote safety, respect, and fairness. Staff use point cards to monitor how well the
youth are progressing in the program. Youth earn points daily for complying with the program
rules. The youth receive rewards based on the number of points earned. All youth enter the
program on orientation level, prior to starting the BMS, and progress their way up to level five.
The five levels of the BMS include orientation, junior, varsity, college, and professional. A review
of seven youth case management records confirmed the youth orientation and handbook
included the program’s BMS. The BMS included all the required elements. The program’s BMS
did not include increased length of stay, denial of youth basic rights, promotion of group
punishment, punishment of youth by other youth, and/or disciplinary confinement. Observations
of staff and youth interactions verified staff were adhering to the BMS by utilizing a ratio of four-
to-one positive rewards to negative consequences when redirecting the youth as indicated in
the program’s policy. The program provides the youth with incentives which include snacks,
later bedtime, games, and access to the “man cave,” which is a rewards and privileges room.
While conducting a program tour, observations found the BMS was posted on each living
module and had not changed during the annual compliance review period. Seven staff were
interviewed and were able to explain the BMS system completely. Each staff indicated youth
basic rights cannot be taken away as a consequence. Each staff stated youth are informed of
the consequences and they can explain their behavior. Seven youth were interviewed, and each
stated the consequences for negative behaviors included level freezes. Each youth was able to
explain the difference between each level and confirmed youth are not allowed to punish other
youth in the program. An interview with the FA confirmed feedback is provided to the staff
during daily staff meetings regarding the implementation of the BMS. The FA also reported
supervisors review the BMS daily to ensure it is being implemented precisely.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
This program does not use room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a written policy and procedures to ensure staff observe youth at least every
ten minutes during sleeping hours or any time a youth is in the room. Staff observations are to
be completed and documented in real time, ensuring the safety and security of each youth. The
program has a total of seventy-one video cameras capable of recording thirty-days of video.
During the annual compliance review week, the program reported all cameras were operational.
A video review of ten-minute checks from the overnight shift and from each living unit, for a total
of nine samples, verified staff were conducting checks every ten-minutes, and documenting
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findings on the Ten-Minute Check Logs. Staff were situated where they were able to see any
movement within the living unit and moved throughout the unit during the checks. In addition,
the Ten-Minute Check Logs since the last annual compliance review were reviewed. A sample
of various days, times, and shifts indicated the ten-minute checks were completed within the
required frequencies. Documentation confirmed staff who completed the checks either initial or
sign the check sheet. Seven staff were interviewed and reported checks are conducted in eight
to ten-minute intervals. An informal interview with the facility administrator (FA) confirmed the
program’s practice.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a written policy and procedures to ensure the staff are aware of the location of
all youth at all times through active supervision and the implementation, monitoring, and use of
an accounting system of scheduled, unscheduled, and emergency counts. A review of the
Continuity of Operations Plan (COOP) verified program staff must always account for the
whereabouts of the youth in the care and custody of the program. The program maintains a
chronological record of events, incidents, and activities in a logbook documented by the master
control staff. A logbook review for twelve randomly selected dates and times, for census counts
and tracking was conducted during the annual compliance review period. Documentation
validated head counts and movements were conducted at the beginning of each shift, after
outdoor activities, after transfers, during emergency situations such as program disturbances,
and during actual and/or simulated drills. The logbook documentation included youth who were
temporarily away from the program, transferred, admitted, and released. Additionally,
observations confirmed the program staff conducted a physical head count during school and
before and after each movement. Seven staff were interviewed and reported counts are
conducted before movement. Two staff reported counts are conducted every hour. All staff
confirmed the emergency count procedures in the event a youth count cannot be reconciled and
each staff confirmed when emergency counts are to be conducted.
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 written policy and procedures regarding logbooks and shift reports. The
program maintains a chronological record of events, incidents, and activities in a logbook
documented by the master control staff. The program’s policy requires the program to maintain
one logbook in master control and all program staff are to be briefed when coming on-duty. A
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review of the logbooks since the last annual compliance review confirmed all errors were struck
through and initialed by staff, the logbooks were bound with numbered pages, and there were
no loose or missing pages found. Logbook entries included shift briefing, population counts,
youth movement, head counts, emergency drills and situations, program checks, perimeter
checks, and law enforcement data. Internal incidents reported to the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC) were documented. Reviewed
logbooks showed recreation was conducted. All entries included the dates and times of events,
when education was scheduled, documented when a youth arrived or departed, and logbook
entries contained the names of the staff and youth involved. Logbook entries indicate adherence
to the daily schedule with minimal interference. Reviewed documentation confirmed staff sign
the logbook and shift report to acknowledge receiving the information. A review of various shift
reports since the last annual compliance review confirmed each report was completed on a daily
basis. A copy of the shift report was made available to staff for at least forty-eight hours.
Reviewed documentation and a review of the CCC reports indicated there were no instances of
escapes or attempted escapes during the annual compliance review period.
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 written policy and procedures to ensure program safety and security and the
safety of staff, youth, and the public by implementing and maintaining a system to govern the
control and use of keys in the program. The program’s policy includes key assignment and
usage including restrictions, inventory and tracking of keys, secure storage of keys not in use,
procedures to address missing or lost keys, and reporting and replacement of damaged keys.
Observations found all program keys are kept within the master control area, which is located at
the entrance of the program. Program keys are maintained inside a locked box on the wall with
the corresponding tracking number, and personal keys are maintained in a separate lock box
within the master control room, only accessible by the master control staff, and administration.
The distribution and collection of keys was observed and confirmed all visitors and staff
surrendered their personal keys upon entering the program and keys were stored within the
master control office. Staff surrender their personal keys and in return staff received a chip
and/or work keys. Staff sign the key logbook, enter the date, key ring number, and time the keys
were signed out. The program maintains a master inventory list of program keys. The log
indicates the number of keys on the key ring, name of staff, and what type of key they are to be
assigned according to their position. Permanent keys are kept to a minimum and must be
authorized in writing by the facility administrator (FA). A review of the signed acknowledgment
forms indicated each staff signed for the use of permanent keys. Medical staff, case managers,
therapists, and kitchen staff, receive their restricted keys from master control after their personal
keys are collected. Three staff were informally interviewed, and were able to identify the
assigned key number, the number of keys on the key ring, and each key’s function. A random
check of five different sets of program keys compared to the inventory list indicated the keys
were accounted for and staff knew which area each key was assigned. An informal interview
with master control staff confirmed random key inventory checks are conducted throughout the
day. The staff were able to explain the program’s method of daily tracking and reconciliation of
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keys. A review of the Department’s Central Communications Center (CCC) reports verified there
were no incidents relating to key control reported to the CCC since the last annual compliance
review. Seven staff were interviewed and were able to explain the program’s key control
process. Each staff was able to explain the process for tracking missing keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a written policy and procedures to address safety and security and to control
the introduction of materials considered contraband into the program. The program’s youth
handbook and policy included a specific list of items considered to be contraband and informs
youth of the consequences if found with contraband. All staff are to be trained to properly
identify contraband items and the steps required for removal of contraband. Search practices
and observations are to be conducted throughout the program and are to include searches of
youth, staff, visitors, property, program grounds, and the searching of incoming and outgoing
mail and the program’s physical plant. The program’s policy specifies the manner in which any
unauthorized or contraband item is to be disposed of, to include return to the sender, mailed to
the youth’s home, returned to the youth upon release, or, in the case of illegal contraband,
turned over to law enforcement. The program’s policy identifies the items considered to be
contraband including sharps, escape paraphernalia, tobacco products, lighters, electronic or
vaporless cigarettes, and unauthorized food or clothing, any intoxicating beverages, any
controlled substance, any prescription or non-prescription drug, any firearm or weapon, any
explosive substance, non-program issued keys, unauthorized currency, non-program issued
cellular telephones and/or equipment or electronic devices capable of taking pictures or video
recordings, and smart watches. Observations made of the program’s lobby found the program
has a contraband sign posted with the contraband attestation statement on it. A review of the
program’s visitor’s log in the main lobby confirmed the log includes a contraband attestation
statement. Reviewed documentation found new program staff sign attestation forms regarding
contraband. Twenty staff were hired since the last annual compliance review, and
documentation verified each staff signed attestation forms. The contraband statement
addresses consequences for any staff who is found in possession of contraband and the
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provision for law enforcement to be notified if there is evidence of unlawful activity. A review of
the program’s logbooks, daily incident reports, and search reports verified searches and
program checks are conducted daily on each shift. Unannounced room searches are conducted
at least weekly at irregular and unpredictable times and common area searches are conducted
daily. A review of the Department’s Central Communications Center (CCC) reports since the
last annual compliance review indicated there were two instances of contraband found at the
program. Reviewed documentation confirmed the contraband was turned over to law
enforcement. Seven staff were interviewed about the program’s process for searching youth
rooms, and all seven staff confirmed the youth rooms are randomly searched daily. An interview
with the facility administrator (FA) confirmed the program’s strict procedures for preventing,
detecting, and removing contraband.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures to ensure searches, and full body visual
searches, are conducted in accordance with Florida Administrative Code. The program’s policy
requires searches to be conducted throughout the program including searches of youth, visitors,
property, staff, and the program’s physical plant. An intake letter is sent at the time of each
youth’s admission notifying parents/guardians of searches during visitation. Youth are searched
before entering and prior to leaving the classroom, after outdoor recreation activities, after work
detail, and upon all movement. During the annual compliance review week youth searches were
observed. Youth were searched in the main hallway leaving class, departing from the cafeteria,
after outdoor recreation and work detail, when leaving the medical office, and after completing
groups. Observations throughout the annual compliance review week confirmed youth are
provided instructions regarding the search, searches were conducted by staff of the same
gender as the youth, staff conducted each search in a manner as not to degrade the youth, and
were based on the Right Interactions (RI) training manual. In-person observations and a video
review of five staff and/or visitors confirmed searches were conducted as required. Logbook
documentation and video review verified youth were being thoroughly searched before and after
each movement. The program did not have any new admissions, transports, visitations, and
there were no youth returning from off-campus activities during the week of the annual
compliance review; therefore, searches for those activities could not be observed. Seven staff
were interviewed and all reported youth are searched after every movement throughout the
program. Seven youth were interviewed, and all seven reported searches occur after outdoor
activities, after returning from off campus, when items are missing, after meals, after visitation,
and after work detail.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a written policy and procedures regarding vehicles and maintenance. The
program’s policy requires each vehicle to have a safety inspection annually. The program has a
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total of three vehicles. Two are used to transport youth and one is for the program’s use. Each
of the three vehicles, had an annual safety inspection conducted by a certified automobile
mechanic. Observations of the vehicles confirmed each vehicle was locked when not in use. An
observation of the two vehicles used to transport youth, confirmed the vehicles had the
appropriate number of seatbelts, a seatbelt cutter, a window punch, an up-to-date fire
extinguisher, and a first-aid kit with items approved by the designated health authority (DHA).
The first-aid kits are not kept in the vehicles and are brought to the vehicle by the staff during
the transport. The door to the youth’s passenger area could not be opened from the inside. The
program is moderate-risk; therefore, did not require a safety screen. A random check of five
staff personal vehicles during the annual compliance review week was conducted to ensure
vehicles were locked and secured when not in use and each vehicle was secured.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures to ensure an appropriate minimum staff to-
youth ratio is maintained while youth are transported off program grounds ensuring the safety
and security of youth, staff, and the public. The policy further outlines all transporting staff are to
have a valid Florida Driver’s License and an acceptable driving record. Any staff whose driving
record is deemed unacceptable are not permitted to operate a program vehicle for the purposes
of transporting youth. The program did not have any transports and there were no youth
returning from off-campus activities during the annual compliance review week; therefore, those
activities could not be observed. An informal interview was conducted with the assistant facility
administrator (AFA) regarding the program’s practice for transporting youth. The AFA reported
staff are required to use the vehicle checklist to ensure all safety items are present for the
transport, search the vehicle, search the youth, bring an authorized cellular telephone, and a
photo is taken of the youth prior to departure. Staff and youth are required to always wear
seatbelts and one staff drives and the other sits in the back with the youth to ensure the one-to-
five ratio is followed. Additionally, the AFA reported human resources (HR) staff track driver’s
licenses and driving record information to ensure the approved staff can continue completing
transports. A list of authorized drivers is posted in the master control area and updated monthly.
Youth are not permitted to drive program or staff vehicles. Seven staff were interviewed
regarding the program’s transportation process. All staff reported seatbelts are required to be
worn. Three staff reported youth are handcuffed and shackled. Each of the seven interviewed
staff confirmed the safety equipment in the transport vehicles included a first-aid kit, suicide
response kit, seatbelt cutter, and fire extinguisher. All seven staff stated they use the program’s
cellular telephone during transports. All seven staff stated prior to conducting a transport, the
youth and vehicles are searched for contraband. Each interviewed staff confirmed they are not
allowed to use personal vehicles to transport youth.. All seven staff indicated in the case of an
emergency, they would call 9-1-1, and/or contact the program. Each staff knew the staff-to-
youth ratio during transport. An interview with seven youth confirmed none of the youth have
ever been handcuffed to any part of the vehicle and have never seen anyone place contraband
in a transport vehicle. An informal interview with the facility administrator confirmed the program
is not a high-risk program and does not require safety screens in the program’s transportation
vehicles.
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a written policy and procedures to ensure safety and security of the physical
plant, grounds, and perimeter. The program’s policy requires weekly safety and security audits
to be conducted by the facility administrator (FA) or designee and documented on the Safety
and Security Audit Inspection form. A review of the program’s Safety and Security Audit
Inspection forms during the annual compliance review period confirmed weekly safety/security
inspections were completed. Any identified deficiencies were noted in the reports, including the
status, due date of any needed corrective action, and were added to the program's tracker form.
A review of the program’s logbook confirmed the perimeter checks were documented daily. A
review of deficiencies entered in the Department’s Juvenile Justice Information System (JJIS)
verified there were no deficiencies assigned regarding safety and security audits during the
annual compliance review period. A review of the program’s Preventative Maintenance
Checklist verified the maintenance schedules and repairs were conducted as required. An
interview with the FA confirmed the weekly safety and security checks are reviewed by the
assistant facility administrator (AFA).
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 written policy and procedures to ensure program tools are properly
controlled and secured to minimize the risk of tools and equipment being used as weapons,
used as a means of escape from the program, or other security breaches. The policy addresses
equipment and tool issuance, inventory, and control. The program’s facility operating
procedures require the staff and youth to be trained in the intended safe use of tools to prevent
injuries. A review of the Tool Inventory Sheet confirmed all tools including sharp-edge and
pointed tools are inventoried daily prior to being used for work and following work activities. The
policy states prohibited tools at the program include machetes, bowie knives, and other long
bladed knives. The maintenance staff are responsible for conducting the inventories and
securely maintaining all Class A tools and equipment. The maintenance staff completes a tool
inventory list which documents each tool in inventory. All maintenance tools were inaccessible
to youth and were observed to be secured in the maintenance room. Class B tools including
mops, brooms, and buckets are maintained in a locked closet on both modules inaccessible to
the youth. The items are used by staff and youth when performing daily cleanup activities. Staff
are required to complete a sign-out and sign-in log when items are taken and are returned to the
designated storage room. An observation and inventory of ten tools was conducted. Five tools
were inventoried from the kitchen and five tools from the maintenance room, and observations
confirmed all tools were secured with the correct markings for easy identification and inventoried
correctly. If a tool is missing or lost, the program's practice is to complete an incident report,
stop all movement, review the camera footage, conduct searches to locate the missing tool, and
call the Department’s Central Communications Center (CCC).
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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 written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy requires the staff and youth to
be trained on the intended safe use of tools. Program youth are allowed to use Class B tools
and non-hazardous tools only. A Youth Risk Assessment is completed by the case manager for
youth to use Class A and Class B tools. Activities involving tools require a ratio of one staff to
five youth. During the annual compliance review week, youth were observed cleaning the
hallway, restroom, and cafeteria with brooms and were observed mopping the floor with no
issues noted. No additional tool usage was observed. A review of seven youth case
management records confirmed the youth signed and acknowledged the rules and regulations
regarding tool usage. Seven youth were interviewed, and each stated they can use mops and
brooms. Seven staff were interviewed and indicated youth are allowed to use mops and
brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. The program procedures state when an outside
contractor enters the program all vendors will sign-in the visitor’s logs, and the vendor is to be
searched electronically and physically. All tools and equipment brought into the program will be
searched and inventoried on the Outside Contractor On-Site Worksheet. The contractors will be
escorted by the maintenance staff. Reviewed documentation for three project invoices
confirmed the vendors signed contractor agreements. Documentation for the outside contractor
forms verified the forms were completed and all requirements were met. A review of the work
project logs since the last annual compliance review reflected the contractors signed the log
confirming notification of what items are considered unauthorized. If any unauthorized items are
needed by the contractor while in the program, approval is obtained by the facility administrator
(FA) or designee.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a written policy and procedures to ensure youth and staff are prepared for fire,
safety, and evacuation emergencies. The program has a written Continuity of Operations Plan
(COOP) which was approved by the Department on March 14, 2025. The program's COOP
addresses fire, safety, evacuation emergency processes, and the frequency of conducting drills
randomly and under varied conditions. Reviewed documentation validated fire, escape, and
COOP drills were conducted for all shifts each month, as required. Reviewed drill
documentation included the type of drill, date and time, participants, a brief scenario description,
deficiencies identified during the drill, and applicable corrective actions. Observations and an
informal interview with the maintenance staff confirmed there were fifteen annually inspected
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fire extinguishers and egress plans were posted throughout the program. Seven staff were
interviewed, and all reported they have participated in fire drills, mental health, and medical
drills. Seven youth were interviewed and reported they have been instructed on what to do the
event of a fire. Five youth reported participating in drills monthly. Two youth reported completing
drills on each shift. The facility administrator reported drills are conducted on a monthly basis.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a written policy and procedures to provide for the safety of the youth, staff,
and public including in the event of an emergency or disaster. The program maintains a
Department approved Continuity of Operations Plan (COOP) which is available for all staff to
review. The COOP is located in the administration hallway and master control. A review of the
COOP validated the plan was submitted on March 13, 2025, and approved by the Department
on March 14, 2025. The COOP addresses phases of a disaster plan, emergency management,
including preparedness, response, and recovery. The COOP addresses emergencies including
fire prevention, severe weather, riots, bomb threats, hostage situations, chemical spills, flooding,
and terrorist threats. In addition, the COOP includes staff roles and responsibilities, equipment
and supplies needed, youth information, provisions for continuity of care and custody of youth,
and provisions for public protection. A review of the plan indicated alternative housing has been
identified should the program require evacuation due to an emergency or disaster. Observations
of the administration office found the program maintains a blue bin with equipment and supplies
to ensure a continuous operation of services during emergency or disaster situations.
Additionally, food and drinks are kept in a secure area in the kitchen. The program maintains an
administrative hard copy record for each youth in case of an emergency. A review of seven
youth hard copy records confirmed each contained the youth’s name, Department identification
number, admission date, date of birth, gender, and race. The records documented the name,
address and telephone number of the parent/guardian, emergency contact, community judge,
state attorney and public defender, circuit judge, victim notification information, physical
description of youth, overall health status, and personal physician. An interview with the facility
administrator confirmed the COOP is in master control and the administrative hallway.
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5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a written policy and procedures for storage and inventory of all flammables,
toxic, poisonous, and caustic materials. The program’s policy is for all flammable, poisonous,
and toxic items to be stored in a secure area not accessible to youth. The program maintains a
list of all staff members who are authorized to handle the materials, including the facility
administrator (FA), maintenance manager, assistant facility administrator (AFA), and shift
supervisor. Observations of the maintenance area found toxic items are stored outside the
program in a locked cabinet in a secure area. A Safety Data Sheet (SDS) binder is located
inside the storage area, and a picture of each material corresponding to the SDS is shown. A
perpetual chemical inventory list is maintained, and the chemicals are checked daily. A review
of the inventory list verified this practice. Chemicals used to clean the program are stored in
locked closets located in the main hallway of the program and in a secured closet. An inventory
sheet is maintained and documents the daily use. A review of the storage closet verified the
number and type of chemicals were maintained on the inventory list. A random sample of ten
chemicals verified the actual count matched the inventory logs. A random sample of ten
chemicals verified chemical counts matched the inventory logs and each included an SDS. In
addition, the program maintains a written policy and procedures to ensure all flammable, toxic,
caustic, and poisonous items are disposed appropriately. During an informal interview, the
maintenance manager reported the program tries to use up all chemicals. Any unused
chemicals are taken to a local bio-hazardous waste contractor. The maintenance manager and
AFA reported there were no chemicals disposed of during the annual compliance review period.
Used mop water, liquid waste, and used beverages are disposed down the plumbing drains.
Kitchen liquid waste, except for grease, is disposed of in the kitchen drain. Grease is placed in a
separate container for disposal by an outside vendor. The program’s policy requires chemical
spills to immediately be reported to the FA, AFA, shift supervisor, and maintenance staff. The
staff will shut down the air handlers and ventilation systems, close all windows and doors at the
direction of the FA, and the FA decides to contact outside assistance if needed. An interview
with the FA confirmed disposals are made off-site at the county or city disposal sites.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items, or materials. Program youth are strictly prohibited
from using, handling, or cleaning with dangerous or hazardous chemicals, responding to
chemical spills or cleaning, handling, or disposing of any biohazardous material, bodily fluids, or
human waste. Youth are strictly prohibited from the maintenance area where toxic items and
chemicals are stored. Observations during the annual compliance week found youth completing
cleanup details with staff. None of the observed youth were handling chemicals or cleaning
products. Seven youth were interviewed and reported they are prohibited from using any
chemicals or cleaning products.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a written policy and procedures for allowing visitation and communication for
youth at the program. The program’s policy requires the program to provide opportunities for
communication and engagement with the youth and family. The program's visitation policy
indicated consideration for requests for alternative visitation arrangements with
parents/guardians are available, if needed. The program has a posted visitation schedule and
rules at the entrance to the program. The visitation schedule was found on both modules in the
main hallway. The visitation and communication procedures are covered in the youth handbook,
parent/guardian handbook, and addressed on the orientation checklist. Visitation is held three
days a week on Wednesdays from 6:00 p.m. to 8:00 p.m. and Saturdays and Sundays from
1:00 p.m. to 3:00 p.m. Youth are allocated opportunities to communicate with their family in
person, by telephone, and by mail. Each youth is provided with an opportunity to correspond on
a regular basis with identified individuals on their Approved Correspondence List and legal
representatives. A review of the logbooks and visitation sign-in sheets verified the program
allows visitation for approved family members. A review of telephone chronological notes
confirmed youth have regular telephone communication with family members. Youth can write
to their parents/guardians at least once each week and are encouraged to correspond with their
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assigned juvenile probation officer (JPO) and committing judge. All outgoing and incoming mail
is searched by the case manager. A review of the mail logs showed the youth were receiving
and sending mail to approved family members. It is the program’s practice for the assigned case
manager to follow-up with the JPO regarding human trafficking victims to determine whether the
parent/guardian should be permitted to communicate with the youth; however, there were no
youth applicable for a history of human trafficking during the annual compliance review period.
An interview with the facility administrator (FA) reported the program offers interpreter services
provided by video remote services. Seven youth were interviewed, and each confirmed they can
call and/or send letters to their parent(s)/guardian(s).
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities. The program has a daily
activity schedule, which reflects each youth receives at least one hour of recreation each day for
leisure activities, including indoor and outdoor large muscle activity. A review of the staff roster
confirmed the program has one recreation therapist, who met all requirements for the position. A
review of the activities confirmed they promoted social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. Logbooks
were reviewed for the annual compliance review period, and recreation was documented each
day for at least one hour, as required. Observations made throughout the annual compliance
review week validated youth are provided with at least one hour of indoor or outdoor recreation
and leisure time. Seven youth were interviewed, and each youth indicated they are provided at
least one hour of indoor and outdoor activities. Seven staff were interviewed, and each reported
the youth received one hour of indoor and outdoor activities such as board games, listening to
music, exercising, and playing sports.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practices confirm the program does not use controlled
observation room; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practices confirm the program does not use controlled
observation room; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 66 (Revised August 2025)
5.25 Controlled Observation Safety Checks Release 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 practices confirm the program does not use controlled
observation room; 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

program_name_raw: Broward Youth Treatment Center