state: FL

facility_name: Tampa Bay Girls Academy - Moderate

summary: QI Residential - FY25-26 - 12 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Tampa Bay Girls Academy-Moderate
Wayne Halfway House
(Contract Provider)
9506 E Columbus Drive
Tampa, Florida 33619
Review Date(s): July 29-August 1, 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:
Cheryl Francis, Office of Accountability and Program Support, Lead Reviewer (Standard 1])
Belinda Alexander, Office of Education, Central Education Coordinator (Education Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Kara Brown, Office of Accountability and Program Support, Central Region Deputy Supervisor
(Standard 2)
Jamie Franz, Office of Postsecondary and Workforce Education, Deputy Director (Education
Standard 1)
Melissa Johnson, Office of Accountability and Program Support, Central Regional Supervisor
(Standard 3)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Co-Lead)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Meloney Rhynie, Office of Education, Central Education Coordinator, (Education Standard 1)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Tampa Bay Girls Academy-Moderate MQI Program Code: NA
Provider Name: Wayne Halfway House Contract Number: 10889
Location: Hillsborough County / Circuit 13 Number of Beds: 25
Review Date(s): July 29-August 1, 2025 Lead Reviewer Code: 219
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 Quality Improvement Report
Office of Program Accountability Page 3 of 69 (Revised January, 2012)
2.19 C
5.18 S
T h e fo llo w in g lim ite d a n d /o r fa ile d in d
Lim ited R atings
1.06 P re-S ervice/C ertification R equirem ents *
1.16 S pecial C ontract C onditions
2.16 E xit C onference
2.17 Y outh Input
ontract S pecific C areer and Technical E ducation S ervices (R esidential C ontract P rovider)
3.13 S uicide P revention Training *
5.13 Tool Inventory and M anagem ent
torage, Inventory, and D isposal of Flam m able, P oisonous, and Toxic Item s and M aterials
5.21 V isitation and C om m unication
ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n .
Failed R atings
5.07 K ey C ontrol *
5.12 W eekly S afety and S ecurity A udit
5.16 Fire, S afety, and E vacuation D rills
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 69 (Revised August 2025)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
L im ite d
S a tis fa c to
S a tis fa c to
N o n -A p p lic a
S a tis fa c to
N o n -A p p lic a
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
L im ite d
S a tis fa c to
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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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 69 (Revised August 2025)
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
L im ite d
L im ite d
S a tis fa c to
r) L im ite d
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
ryryryryryryryryryryryryryryry
ry
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 69 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
le
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff * Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education 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 7 of 69 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 69 (Revised August 2025)
5555555555555555555555555 .0 1
C .0 2
.0 3
.0 4
.0 5
.0 6
.0 7
.0 8
.0 9
.1 0
.1 1
.1 2
.1 3
.1 4
.1 5
.1 6
.1 7
.1 8
.1 9
.2 0
.2 1
.2 2
.2 3
.2 4
.2 5
* T h e D e
p ro g ra m o
in d ic a to
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l *
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
F a ile d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
F a ile d
L im ite d
S a tis fa c to ry
S a tis fa c to ry
F a ile d
S a tis fa c to ry
L im ite d
S a tis fa c to ry
N o n -A p p lic a b le
L im ite d
S a tis fa c to ry
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
m a re a (d e te n tio n ,
Program Overview
The Tampa Bay Girls Academy Moderate Risk is a twenty-five bed program, for twelve to
twenty-one year old females, located in Tampa, Florida. The program is operated by Wayne
Halfway House, through a contract with the Department. The program provides the following
services: Borderline Intellectual Functioning/Developmental Disability services or
Developmental Disability, Intensive Mental Health Treatment, Medically Complex Residential
Overlay services and Juvenile Sexual Offender Treatment. In addition, the program fosters each
youth by providing career and technical education to include employability and career-themed
courses addressing business education, career planning through Choices, ServSafe Food
Handler certification, Occupational Safety and Health Administration (OSHA) certification, and
cardiopulmonary resuscitation (CPR)/first-aid certification. In conjunction with the Children’s
Home Society, youth shall participate in the Supporting Partnerships to Assure Ready Kids
(SPARK) thirteen-week program. The program assists youth with job training placement and
biannual Career Days with various agencies in the local and surrounding areas. The youth are
offered self-sufficiency planning. Curriculums used by the program include, Dialectical
Behavioral Therapy Skills Manual for Adolescents, Skillstreaming for the Adolescent, and
Impact of Crime, all of which are primary services. Additional treatment services provided
include family therapy, individual therapy, and recreational therapy. Program administration is
comprised of a facility administrator, assistant facility administrator, director of clinical services
who serves as the designated mental health clinician authority (DMHCA), designated health
authority (DHA), health services administrator, and a director of case management. Case
management services are provided by the director of case management, one case manager,
one transitional case manager, and one recreational therapist. Mental health staff at the
program includes the clinical director, a licensed mental health counselor who serves as the
DMHCA, one licensed therapist, and one non-licensed therapist. Medical services are provided
by a health services administrator (HSA) who is a registered nurse (RN), and two full-time RNs.
The program also has two additional RNs which the program uses pro-re-nata, if needed, which
meets contract requirements. The program has an agreement with a medical doctor to serve as
the DHA. The DHA is responsible to oversee the medical services provided at the program and
is on-call for emergency consultation twenty-four hours a day. The DHA is on-site weekly. The
program has a contracted psychiatrist who provides psychiatric services and medication
management at the program weekly. Educational services are provided by the Florida Scholars
Academy and Florida Youth College. These educational services offer a tailored education
system which accommodates the unique needs of each youth by providing multiple pathways to
success. Florida Scholars Academy helps youth attain a high school or high school equivalency
diploma, receive industry-recognized credentials, and enroll in a postsecondary program of
study at a Florida college, university, or technical college. The layout of the program is one
building which includes an administration area, master control, a multipurpose room, two
classrooms, a medical clinic, two dormitories and one portable classroom. The program has
forty-six operating security cameras providing coverage. At the time of the annual compliance
review, the program had one vacant youth care worker position.
.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 69 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures in place regarding initial background screenings. The
program also has a policy and procedures for volunteers, mentors, and interns who work with
youth less than ten hours a month requiring sight and sound supervision. The program’s policy
requires a staff, who is background screened, to always be in the presence of and within the line
of sight of the volunteer who is not background screened. A review of the program’s staff,
volunteers and contractor rosters found twenty-nine direct care staff were applicable for an initial
background screening during the annual compliance review period. There was documentation
to support each staff received a completed and eligible background screening as required, prior
to contact with youth, and confidential youth records. None of the staff were applicable for an
exemption and reviewed documentation validated a criminal history report was reviewed for
each staff. Each staff was added to the program’s roster in the Clearinghouse system. Of the
twenty-nine staff, twenty-two did not pass their pre-employment assessment; however, the
program indicated staff who score less than the ideal range on the pre-employment assessment
tool are being monitored during the training process to identify any areas of concern and are
also closely monitored through on the job training to address any perceived deficiencies. In
addition, the program indicated they are working with the pre-employment assessment tool
company regarding re-calibrating assessment tool scores. All pre-employment assessment
results were placed in each staff’s personnel record. Two out of the twenty-nine staff had a
break in service which was documented in the Department’s Staff Verification System module
(SVS) and a new background screening was completed for each. The program did not have any
volunteers, mentors, or interns who required a background screening during the annual
compliance review period. An Affidavit of Compliance with Level 2 Screening Standards was
submitted to the Department on December 19, 2024. A signed contraband attestation form was
completed for all twenty-nine staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
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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 policy and procedures addressing five-year background rescreening for
staff. There were no staff, volunteers, or contracted providers applicable for a five-year
background rescreening during the annual compliance review period.
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 policy and procedures outlining the provision of an abuse-free environment
for both staff and youth. The program has a zero-tolerance policy regarding any abuse. All staff
shall immediately report any knowledge or suspicion regarding an incident of abuse which
occurred in the program by calling the Florida Child Abuse Hotline, the Department’s Central
Communications Center (CCC) and the program’s facility administrator or supervisor on duty as
soon as possible. The program had six incidents alleging staff physically, psychologically, or
emotionally abused a youth in the program’s care during the annual compliance review period.
Program management reported each applicable incident to the Florida Abuse Hotline and/or the
CCC, as required, and took applicable corrective action to the staff by placing them on no youth
contact pending the outcome of the investigations. None of the allegations were founded and
none of the involved youth were a potential victim of human trafficking, child sexual exploitation,
or labor trafficking. A review of five staff personnel records indicated each staff signed a
document acknowledging a review of the program’s code of conduct. The program had the
Florida Abuse Hotline and the CCC telephone numbers posted throughout the facility for youth
and staff access. The program had six incidents related to physical, psychological, or emotional
abuse since the last annual compliance review period. The program completed a Trauma
Responsive and Caring Environment (TRACE) self-assessment dated May 16, 2025. Five youth
were interviewed and none reported ever being stopped from calling the Florida Abuse Hotline
or CCC. All five youth stated they can find the reporting numbers throughout the facility. Four of
the five youth stated staff are respectful when talking with youth, the remaining youth stated
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some staff curse youth out. Four youth indicated they have never heard staff use curse words
when speaking to youth, the remaining youth stated staff often use curse words when talking to
youth. This was addressed with program administration. The program indicated staff will be
addressed during their next all staff meeting regarding appropriate communication with youth.
None of youth reported having exchanged emails, telephone numbers, or social media contact
information with staff. Five staff were interviewed, and each were able to explain the process of
reporting abuse, which included who to notify. Each staff reported never observing a co-worker
telling a youth they could not call the Florida Abuse Hotline or CCC. All five staff indicated they
have never heard another staff using profanity while speaking with youth. The facility
administrator (FA) was interviewed and was able to provide information regarding the code of
conduct and administrative actions taken should staff act in a prohibited manner. The FA
confirmed the program’s response process to allegations of abuse, and how the program
ensures staff and youth have access to the Florida Abuse Hotline and the CCC numbers
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 policy and procedures for notification to the Department’s Central
Communications Center (CCC) of reportable incidents. The program had a total of seventy-eight
reportable incidents during this annual compliance review period; the required minimum sample
of eight incidents were reviewed. Each of the eight reviewed incidents were reported within the
required two hours from the time the reporter became aware and all eight of the incidents were
documented in the logbook as required. There were no additional reportable internal incident or
grievances located during the annual compliance review which should have been reported to
the CCC and was not. The program did not have an annual compliance review last year;
therefore, the program was not applicable for experiencing an increase of reportable incidents to
the CCC since the last annual compliance review. The facility administrator (FA) was
interviewed and indicated this was the program’s first annual compliance review.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a policy and procedures requiring Right Interactions (RI) as the Department
approved Protective Action Response (PAR) curriculum. A RI Incident Report will be completed
and filed in agreement 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). The program had seventy RI incidents
during the annual compliance review period; the required minimum sample of seven incidents
reports were reviewed. All seven RI reports were completed by the end of the staff’s workday;
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however, one of the seven RI reports did not include statements from all staff involved and two
of the seven forms were not completed as required. Mechanical restraints were not utilized in
any of the RI incidents. None of the RI reports resulted in allegations of abuse. All seven RI
reports were reviewed by a supervisor, a RI instructor, and the facility administrator within
seventy-two hours of the incident. Two of the seven post-RI interviews indicated the need for a
RI medical review and both were completed in the required time frame. Reviewed email
documentation confirmed monthly summaries of all RI incidents were submitted to the
Department’s regional office by the fifteenth of each month and are maintained by the program.
The program’s RI plan was updated and approved by the Department on October 3, 2024. The
program submitted a newly updated RI plan on July 24, 2025, and is pending approval by the
Department. The intensive mental health program had a 15.46 RI Rate, and the borderline
intellectual functioning/borderline intellectual disability/developmental disability program had a
56.60 RI Rate for the previous quarter which is above the statewide Residential RI rate of 2.41.
Five staff were interviewed and two were able to articulate the program’s RI process, two staff
were not able to articulate the RI process, and one staff was not direct care staff and is not
trained in RI. The facility administrator was interviewed and confirmed the program’s practice.
1.06 Pre-Service/Certification Requirements (Critical) Limited 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 policy and procedures outlining the pre-service training and certification
requirements for all new staff. The program considers youth care workers, shift supervisors,
recreational therapist, facility administrator (FA), and assistant FA, to be direct-care staff and
can be counted in the staff-to-youth ratio. A review of supporting documentation indicated the
program’s instructors were qualified to deliver training in cardio-pulmonary resuscitation, first-
aid, automated external defibrillator and Right Interactions. The program submitted a pre-
service training plan on October 25, 2024, prior to implementation. The training plan was
approved by the highest ranking official at the location, the assistant secretary for residential
services, and the director of the Department’s Talent, Leadership, and Culture. A review of five
staff pre-service training records indicated all five pre-service staff, who were past the first 180
days were missing multiple trainings. All five pre-service staff were applicable to have
completed 120 hours of training in the first 180 days. The five staff were missing the following
trainings. One staff was missing eleven pre-service trainings: DJJ Legacy, Equal Employment
Opportunity, Gang Awareness, Human Trafficking Intervention, Juvenile Justice Information
System, 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. The second staff was missing Human Trafficking and Effective
and Respectful Treatment of Youth; the third staff was missing Effective and Respectful
Treatment of Youth; the fourth staff was missing Effective and Respectful Treatment of Youth;
and the fifth staff was missing Gang Awareness, Effective and Respectful Treatment of Youth,
and Communication not all training was documented in the Department’s Learning Management
System (SkillPro) as required or any other training documentation. Three additional pre-service
staff records were selected for staff who are within their 180 days of hire and documentation
confirmed all three staff completed their eight essential skills trainings prior to being in the
presence of any youth. The program had two staff members who were applicable for
supervisory training. Both supervisors completed four of the sixteen hours of required
supervisory training in the required topics.
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1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures outlining the in-service training requirements for staff.
There were no staff applicable for in-service training due to all staff being new hires during the
annual compliance review period. The program maintains an annual in-service training calendar
which is updated as changes occur and was submitted on October 25, 2024. The training plan
was approved by the highest ranking official at the location, the assistant secretary for
residential services, and the director of the Department’s 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 policy and procedures which includes training requirements for the
grievance process, as well as the informal, formal, and appeal phase. The program’s informal
phase indicates when a youth feels they are being treated unfairly or their rights have been
violated, the youth should first speak to the staff or the peer the youth is having a problem with
or utilize the What’s Tea form at the time the grieved situation occurs and try to work out the
situation informally. A youth can submit an informal request anytime as an alternative to filing a
formal grievance. This form is placed in the grievance box and reviewed by the facility
administrator. The program maintained a grievance binder which contained all grievances for
each month of the annual compliance review period. A review of documentation indicated the
program’s practice correlates with their process. The program only had four applicable
grievance forms for review. Of the four grievances reviewed, two were handled within twenty-
four hours of receipt during the formal phase and were resolved, one reviewed grievance was
applicable for requiring an appeal, the program responded and resolved the grievance within the
specified time frames, and the remaining grievance was resolved at the informal phase. Five
youth were interviewed and each indicated they knew where to find a grievance form and each
youth knew what to do with the form upon completion. All five youth stated they could ask for
assistance in completing a grievance form. Five staff were interviewed and all five were able to
accurately describe the grievance process along with the phases and each staff indicated
grievance forms are placed throughout the program. All five staff indicated the supervisor
reviews the grievances. Three of the five interviewed staff indicated the facility administrator
also review grievances. Three of five staff stated youth can request assistance in completing the
grievance forms. An interview with the facility administrator confirmed the program’s grievance
practice.
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1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures ensuring the program provides instruction to youth
focusing on developing life and social skill competencies. The interventions include Living in
Balance, Dialectical Behavior Therapy, and Skillstreaming the Adolescent which are considered
primary services. In addition to these services, the health education record of five youth
confirmed the program incorporates additional life skill interventions to include dental hygiene,
nutrition basics, personal hygiene, and physical fitness, provided by medical staff. Additionally,
documentation supports the program works with each youth to create a portfolio to include a
resume, cover letter, practice job applications, support with choosing a career path, finances,
and budgeting. Non-clinical staff/direct care staff model pro-social behaviors through daily
interactions with youth to help youth function responsibly and successfully in everyday life
situations. Five youth were interviewed and each youth was able to provide examples of groups
and/or activities they have participated in while at the program. The facility administrator
interview confirmed youth receive skills to address their identified needs. The designated mental
health clinician authority (DMHCA) interview results indicate the youth have the opportunity to
practice skills learned in group during daily programing with the behavior modification system.
1.11 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures ensuring the provision of activities and instruction
intended to increase youth awareness and empathy for crime victims/survivors and to increase
personal accountability for youth’s criminal actions and harm to others. The program provides
restorative justice awareness to youth through the Impact of Crime (IOC). IOC is designated as
a Standardized Program Evaluation Protocol primary service at the Tampa Bay Girl’s Academy
Moderate program. For details related specific to IOC delivery, please refer to the annual SPEP
report.
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1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to determine how new alerts are identified,
documented, updated, and communicated to staff. All alerts will be entered and updated in the
Department’s Juvenile Justice Information System (JJIS). Any staff can identify and place a
youth on alert status; however, suicide alerts will be updated or closed by the mental health
clinical staff or a licensed mental health professional. The program maintains an internal alert
board in the administrative office area and an internal alert binder in master control and alerts
are reviewed daily. Additionally, the program utilizes a shift briefing and logbook to help
communicate alerts to staff. The program had a minor deficiency for logbooks for missing
entries of movements, alerts, and population census which was closed on April 28, 2025;
therefore, logbook alerts were only reviewed for May, June, and July 2025. Five youth records
were reviewed to confirm the program was entering alerts into JJIS, and each were applicable
for alerts. Documentation reflected a total of fifty-four alerts were entered into JJIS, updated
and/or closed if required. Two of the fifty-four alerts were entered into JJIS after the alert start
date, one alert was entered in JJIS three days late and the second alert was entered in JJIS two
days late. Five staff were interviewed, each were able to describe ways alerts are shared with
staff including shift briefings, alert board, and logbook. The nursing staff interview indicated the
registered nurse, the clinical director and the health service administrator are responsible for
updating the medical alert system. An interview with the facility administrator confirmed the
policy and procedures for entering and removing alerts.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains an official case records for each youth, which consists of three separate
records for each program area to include, individual case management, individual healthcare,
and individual mental health and substance abuse services. All reviewed individual
management records contained the youth’s name, Department of Juvenile Justice identification
number, date of birth, county of residence, and committing offense. Each individual youth case
management record contained the required sections to include legal information, demographics
and chronological information, correspondence, case management and treatment team
activities, and a miscellaneous section. All youth records were labeled “Confidential” and
secured in a locked room or file cabinet also labeled “Confidential” and inaccessible to youth.
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1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures ensuring the program has a community advisory
board (CAB) meeting at least once every ninety to 120 days. The program had two virtual CAB
meetings; one on March 17, 2025 and one on April 14, 2025. The program’s CAB is combined
with the Wimauma Youth Academy program. Transcribed meeting minutes and agendas
confirmed both programs were discussed, and all required board members were invited or in
attendance. During the annual compliance review week, the review team was unable to conduct
an interview with a board member, despite multiple outreach attempts by telephone calls and
emails, which were not returned. An interview with the facility administrator confirmed the
program’s CAB’s practice and their efforts to maintain current memberships and recruit new
members.
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 policy and procedures to ensure staff are evaluated, at least annually, on
established performance standards. A review of four position descriptions to include, youth care
worker, shift supervisor, case manager, and therapist found the duties and responsibilities were
clearly identified for each staff and whose job function included implementation of the program’s
behavior management system. The program has maintained all contractually required positions
including the recreational therapist. A review of documentation for the recreational therapist
indicated all requirements were met. The program indicated annual performance evaluations
were not available due to this being a new program; therefore, performance standards could not
be reviewed. The facility administrator was interviewed and confirmed the program’s
performance evaluation process for staff. Five staff were interviewed and three indicated they
haven’t had a performance evaluation yet or did not know how often they are performed, one
staff stated they have been at the program for four months and have had one evaluation, and
the remaining staff indicated it depends and provided no further explanation as to how often a
performance evaluation is performed.
1.16 Special Contract Conditions Limited 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 has several additional services or items which were negotiated and outlined in the
provider’s contract with the Department. These special contract conditions are: providing three
snacks to the youth daily; have a sensory room; staff utilize a four-to-one positive reinforcement
to redirection with the youth; applicable youth should participate in Supporting Partnerships to
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Assure Ready Kids (SPARK) thirteen-week program or receive six months of mentoring; hold bi-
annual career day events at the program; applicable youth in transition can earn home passes;
all youth should receive a self-sufficiency and independent living skills assessment within thirty
days of admission; each youth have a community-based safety plan and a relapse prevention
plan developed prior to discharge; all transitioning youth should receive the Overcoming
Obstacles curriculum; and youth involved with the dependency system, the transition staff will
assist with the transition to foster care or independent living. All youth at the program have
received three snacks daily, have access to use the sensory room, and the self-sufficiency
assessment at admission; the staff are utilizing the positive reinforcement to redirection ratio
with all youth; one youth is currently participating in the SPARK program; four youth have been
released with a community-based safety plan and a relapse prevention plan; and the only
dependency youth, currently in the program, is utilizing the additional services and assistance.
The contract has been active and operational for eight months without holding a bi-annual
career day. The facility administrator (FA) stated in an informal interview, the program has been
operational under one year; therefore, the bi-annual career day had not taken place. The
program is not utilizing the Overcoming Obstacles curriculum and stated a request for a contract
amendment to remove this was being sought. An interview with the FA indicated the contract
has been reviewed and no special terms or conditions have been noted. During the week of the
annual compliance review, the FA was directed to the special conditions listed in the contract.
Additionally, the FA indicated if any questions arise regarding the contract’s conditions, they will
consult corporate staff for resolution.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures to review and analyze data in decision making
practices. The program tracks various operation and safety and security data to include Right
Interactions, incident reports, grievances, fights and assaults, and staff turnover rate. This
information is shared weekly during supervisor meetings, monthly staff meetings, and daily
corporate meetings and ways to fix any issues noted are discussed. The program also shares
data with the Department on a monthly basis and with the community advisory board.
Documentation of supervisor staff meeting minutes and emails to the Department confirmed this
practice. All staff meeting agenda documentation covers various data topics. The program has
utilized data trend analysis to assist with determining hiring strategies, youth supervision
practices, and policy and procedures. The program management team uses data to inform and
educate staff, providers, and stakeholders on a minimum of a quarterly basis. The collected
data from the feedback from staff, youth, and stakeholders are incorporated to refine services
and adjust programming, and overall program effectiveness to improve their process.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures ensuring each youth’s parent/guardian, committing
court, assigned juvenile probation officer (JPO), and post-residential services case manager are
notified of the youth’s admission to the facility. Five youth case management records were
reviewed, and each record included documentation of the youth’s parent/guardian being notified
by telephone within twenty-four hours of the youth’s admission and in writing within forty-eight
hours of admission. Each youth’s committing court, JPO, and post-residential services
counselor, if applicable, were notified within five working days of the youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures indicating each youth will receive an orientation to the
program’s rules, expectations, goals of the program, and services applicable to youth. Five
youth case management records were reviewed, and each youth received an orientation
beginning on the day of admission. An admission was not observed during the week of the
annual compliance review, as no admissions took place throughout the week. A review of youth
orientation documentation found the program’s orientation included all required topics. Five
youth were interviewed, and each youth indicated their orientation began within twenty-four
hours of admission and included program rules, procedures, and schedules.
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 policy and procedures stating they will obtain written consent of any youth
eighteen years of age or older before providing or discussing with their parent/guardian any
information related to physical or mental health screenings, assessments, or treatment. Five
youth case management records were reviewed for written consent of youth eighteen years of
age or older. Only one record was applicable, and the program did not have any other youth
applicable for being eighteen years of age or older. The applicable youth record contained
written consent, which was signed before providing or discussing information related to the
youth’s physical or mental health screenings, assessment, or treatment with their
parent/guardian.
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2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures outlining their classification system, which is in
accordance with Florida Administrative Code. The program’s policy and procedures clearly
outline the classification process and include a classification system which promotes safety and
security, as well as effective delivery of treatment services, based on determination of each
youth’s individual needs and risk factors. The program’s classification system includes all
required elements. Five youth case management records were reviewed for classification and
none of the youth were identified with a medical, escape, or security risk. Four of the five youth
were identified as having other risk factors or special needs, and alerts were immediately
entered into the program’s internal alert system and the Department’s Juvenile Justice
Information System (JJIS) for each. Documentation of a review of the youth’s alerts in JJIS for
any issues affecting classification was in each record. All five reviewed youth were classified for
purposes of being assigned to a living area, sleeping room, and youth group or staff advisor.
The program’s policy indicates the treatment team will reassess and reclassify each youth as
necessary throughout their commitment 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-site
activity. None of the reviewed youth were considered for an increase in privileges or freedom of
movement or participation in any work projects or activities involving tools. Reclassifications
were completed prior to considering participation in off-site activities for each youth. The facility
administrator (FA) was interviewed and indicated the clinical director, or designee, will complete
a classification worksheet on each youth at intake based on the commitment packet, discussion
with the juvenile probation officer (JPO), observation of the youth throughout the intake process,
and collateral information from involved staff. Nursing staff and a supervisor determine group
placement. The FA indicated mental health, substance abuse, physical health, and security risk
factors or special needs are determined during or subsequent to the classification process. All
information is immediately entered into the program’s internal alert system and JJIS.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures for gathering information on gangs and sharing this
information with law enforcement. Five youth case management records were reviewed and
none of the youth were applicable for gang identification or notification. The program did not
have any additional youth applicable for gang identification or notification. The program’s policy
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and procedures indicate staff complete a body chart on each youth while conducting a strip
search of the youth. Any notable markings, including gang marks and tattoos are documented
on the body chart. All gang information is to be communicated to the case manager, facility
administrator (FA), education provider, and shift leader to be disseminated to staff. If a youth is
identified as a potential and/or actual gang member or has any gang activity, it will be
documented in the program’s internal alert system and in the Department’s Juvenile Justice
Information System (JJIS). Gang information on each youth is shared with local law
enforcement, the youth’s juvenile probation officer (JPO), the youth’s home school, and home
law enforcement.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures ensuring they implement gang prevention and
intervention strategies. Five youth case management records were reviewed, and none were
applicable for gang prevention or intervention activities. The program did not have any
additional youth applicable for gang prevention or intervention activities. The program utilizes
Arise Gangs as their gang intervention curriculum. Upon admission, each youth is given a Gang
Questionnaire to identify gang membership or affiliation. Each youth is also provided a Guide to
Gangs and sign a receipt indicating they received it. The program’s policy indicates they will
develop a plan for any youth who are identified as a gang member to address their desire or
intent to disaffiliate with a criminal street gang. The facility administrator (FA) was interviewed
and indicated the program will implement gang prevention and intervention strategies when a
youth is identified as a criminal street gang member, are affiliated with any criminal street gang,
or are at high-risk of gang involvement. Identification is based on information obtained through
the screening, assessment, and classification process or when gang related behaviors are
observed.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures indicating an initial Residential Assessment for Youth
(RAY) is completed within thirty days of admission. Reassessments must be completed for each
youth at least every ninety-days from the initial assessment. Five youth case management
records were reviewed, and each youth had an initial RAY completed within thirty days of
admission. A RAY reassessment was completed for each youth at least every ninety-days after
completion of the initial assessment. No other updates or reassessments were completed by the
intervention and treatment team to effectively manage any of the youth’s cases. The program
maintained all reassessment documentation in the Department’s Juvenile Justice Information
System (JJIS) for each youth.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures ensuring a Youth Needs Assessment Summary
(YNAS) is completed for each youth within thirty days of admission. Five youth case
management records were reviewed, and each youth had a YNAS completed within thirty days
of admission and documented in the Department’s Juvenile Justice Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a policy and procedures outlining performance plan development. A review of
five case management records found each youth had an Individualized Performance Plan
developed after the Residential Assessment for Youth (RAY) and Youth Needs Assessment
Summary (YNAS), and within thirty days of admission. All required intervention and treatment
team members were present during the development of each youth’s Individualized
Performance Plan and had the opportunity to sign the plan. The signature sheet was filed in the
youth’s case management record for each youth. Each youth’s Individualized Performance Plan
included individual goals based upon prioritized needs reflecting risk and protective factors
identified during the initial assessment process, delinquency interventions, target court-ordered
sanctions which could be reasonably initiated/completed while in the program, transition
activities targeted for the last sixty days of the youth’s anticipated stay, youth responsibilities to
accomplish goals, program staff responsibilities to enable youth to complete goals, and target
dates for goal completion. Four of the five Individualized Performance Plans included the
youth’s top three criminogenic needs, while the remaining plan was missing one of the youth’s
top three criminogenic needs. A transmittal letter and copy of each youth’s Individualized
Performance Plan was sent to the committing court, juvenile probation officer (JPO), and
parent/guardian within ten working days of completing the plan. Five youth were interviewed,
and each youth indicated they participated in the development of their performance plan.
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2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures indicating each youth’s performance reviews shall
result in revisions to their performance plan when determined necessary by the intervention and
treatment team. A review of five youth case management records found revisions were
completed for each youth when the Residential Assessment for Youth (RAY) reassessment
results warranted, newly acquired or revealed information warranted, or the youth demonstrated
progress toward completing a goal. One reviewed youth demonstrated lack of progress toward
completing a goal and a revision was completed. None of the reviewed youth were within their
last sixty days of stay; therefore, revisions were not needed to facilitate transition activities
during the last sixty days of stay. Each reviewed youth had additional plans, including academic
and treatment plans, and each youth’s performance plan referenced or incorporated the
applicable plans.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures regarding Performance Summaries. Five youth case
management records were reviewed, and a Performance Summary was completed every ninety
calendar days following the signing of the Individualized Performance Plan, as required, for
each youth. Each Performance Summary included the youth’s status on each performance plan
goal, youth’s overall treatment progress, youth’s academic status, grades, and credits earned in
the program, including performance and behavior in school, level of motivation/readiness to
change, interaction with peers, interaction with staff, overall behavior adjustment to the program,
and significant positive and negative events. Each youth was provided a copy of their
Performance Summaries and allowed to read and add comments prior to signing. Each
Performance Summary was filed in the youth’s record for each youth. Each youth’s
Performance Summaries were signed and dated by all required parties and were sent to the
youth’s committing court, juvenile probation officer (JPO), and parent/guardian within ten
working days.
Three closed case management records were reviewed for release summaries. Each youth’s
original release summary included justification for release and was sent to the JPO with the Pre-
Release Notification at least forty-five days prior to release. A copy of each youth’s release
summary was maintained in their case management record. The court did not object to the
release of any of the three youth. The parent/guardian was not provided written notification of
the youth’s planned release in any of the three records. An exit Residential Assessment of
Youth (RAY) was completed for each youth. None of the reviewed youth were direct discharges,
sexual offenders, or required victim notification.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures ensuring parent/guardian involvement in the case
management process is encouraged and facilitated by the program. A review of five case
management records found the program encouraged and facilitated involvement of each youth’s
parent/guardian in the case management process, including the assessment process,
development of the youth’s performance plan, progress reviews, treatment team meetings, and
transition planning. The program sends a letter to each parent/guardian upon admission which
includes the program’s visitation schedule. A Performance Goal Proposal form is also sent to
the parent/guardian to fill out with input for the youth’s performance plan. Performance plans,
family day fliers, and treatment team meeting reminders are provided to each youth’s
parent/guardian. If unable to attend a treatment team meeting, parents/guardians are given the
opportunity to participate by telephone. Two treatment team meetings were observed during the
annual compliance review week and a parent/guardian participated by telephone in both
meetings. The facility administrator (FA) was interviewed and indicated the case manager
and/or designee will make every effort to have parents/legal guardians participate in youth
assessments, performance plan development, progress reviews, and transition planning. The
FA indicated to facilitate involvement, each youth’s parent/guardian is invited to participate in
intervention and treatment team meetings for the purpose of developing the youth’s
Individualized Performance Plan, performance reviews of the youth’s progress in the program,
and planning for the youth’s transition to the community upon release. The FA confirmed if
unable to attend, the parent/guardian shall be given the opportunity to participate by telephone
or video conferencing, or to provide verbal or written input prior to the meeting. Five youth were
interviewed, and each youth indicated their parents/guardians are involved in their case
management.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures indicating each youth will be assigned to a treatment
team with all required individuals. A review of five youth case management records found three
youth had formal reviews held at least every thirty days. The remaining two youth each had one
formal review held after thirty days, one being ten days late, and one being eleven days late.
Each reviewed youth had informal meetings held biweekly each month. All required individuals
attended each meeting, except for program administration who missed two meetings for three
youth and three meetings for two youth. The program indicated they previously had staffing
challenges and had since resolved the issue. Reviewed treatment team documentation for each
youth was contained in the youth’s record and included the youth’s name, date, attendees,
comments from treatment team members, a brief synopsis of the youth’s progress, progress on
performance plan goals, positive and negative behaviors, behaviors resulting in physical
interventions, treatment progress, and Residential Assessment for Youth (RAY) reassessment
results. Each youth was provided an opportunity to demonstrate skills acquired in the program.
Reviewed documentation found each youth’s juvenile probation officer (JPO), parent/guardian,
and any other pertinent parties were invited through advance notification to participate. If
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participation could not be arranged, the opportunity to provide input was provided. An
observation of two treatment team meetings during the week of the annual compliance review
found all required staff were present. Five youth were interviewed, and each stated staff talks
about their performance to include progress on performance plan goals, positive and negative
behaviors, and treatment progress. All five youth indicated they are given the opportunity to
show skills they learned in the program through avenues such as talking, self-reporting goal
status, and writing down goal achievements.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures for planning each youth’s discharge process. Three
closed youth case management records were reviewed. One youth had the required transition
conference at least sixty days prior to release; the remaining two youth had late transition
conferences, one day and three days late. Each transition conference documentation confirmed
the attendance of the youth, transition team leader, executive director or designee, educational
staff, and medical staff; one of the three conferences also included the youth’s juvenile
probation officer (JPO) and the parent/guardian. The reviewed documentation confirmed at
each conference the transition activities on the performance plan were discussed and identified
each person’s responsibilities. Each attendee of the conferences had signed and dated the
required document acknowledging attendance and non-attendees with responsibilities were
sent a copy of the plan for signature. A return email acknowledgement receipt was not located
for electronically transmitted plans to the JPO in any of the three records. All three reviewed
closed youth case management records contained documentation to confirm a community re-
entry team meeting was held with the youth and case manager prior to release. Each record
contained evidence of invitation to attend provided to all applicable parties.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to ensure all youth have a completed exit portfolio at
the time of release. A review of three closed youth case management records were reviewed
and each contained an exit portfolio. Each youth’s exit portfolio was discussed and initiated at
the transition conference. All three reviewed records had documentation of the program’s
request for each youth’s social security card and original or certified copy of birth certificate; only
one record had a copy of the birth certificate. Without the requested information the program
was not able to assist each youth in obtaining a state-issued identification card. One of the three
portfolios contain a transition plan copy and appointment calendar; the remaining two did not.
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One portfolio had a resume; the remaining two did not. Two of the three portfolios had a
completed sample job application; the remaining one did not as the educational staff did not
complete this task with the youth. All three portfolios contained the educational and/or
vocational certificates earned while in the program, and documentation confirmed the portfolio
was completed and each youth was provided the portfolio at release. Confirmation the exit
portfolio was forwarded to each juvenile probation officer was not located in the three closed
records. The program did not have any additional required elements of the exit portfolio
stipulated in the contract.
2.16 Exit Conference Limited Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure each youth completing the program has an
exit conference at least fourteen days prior to discharge. Three closed youth case management
records were reviewed for exit conference documentation and two had documentation to
confirm an exit conference was held fourteen days prior to release; the remaining record had an
exit conference two days late. None of the reviewed records contained exit conference
documentation to include signature of attendees, conference date, and conference content:
transition activity status, education and /or employment status, review of the exit portfolio, and
vocational plan. Each reviewed record contained dates of admission and discharge which
matched the youth record in the Department’s Juvenile Justice Information System (JJIS) as
required. All three reviewed records contained some documentation of exit conference
attendees. All three conferences were attended by the youth, parent/guardian, juvenile
probation officer (JPO), and other pertinent staff; one included educational staff, and the
remaining two did not. The program was able to provide electronic calendar pages with
meetings and the JPO’s case notes in JJIS confirmed the meetings took place for each record.
Each exit conference was held separately from the transition and community re-entry team
meetings.
2.17 Youth Input Limited Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures outlining a formal process to promote constructive
input by youth through living unit meetings, annual Trauma Responsive and Caring Environment
(TRACE) surveys, and allowing youth to complete grievances or “What’s Tea” forms. The
program completed a TRACE assessment on May 16, 2025. Townhall meetings are held on
each living unit every other Friday. The program has grievance forms and “What’s Tea” forms
available for youth throughout the facility. The program’s “What’s Tea” form allows youth to
request to speak with staff by indicating who they would like to speak with and why. The form
has a section for staff to document the solution and sign after they meet with youth. A review of
“What’s Tea” forms during the annual compliance review period found twenty-four of thirty-one
completed forms were left blank by staff, with no documented solution or signature. The
program held a meeting in June 2025 to establish criteria for youth eligible to participate in a
youth advisory board. Youth were able to sign up for positions within the youth advisory board,
and an election was held on June 23, 2025. A review of youth advisory board meeting minutes
found a meeting was held in July 2025, and three youth attended. The program’s policy and
procedures do not require the program to hold youth advisory board meetings at any specific
time intervals. Five youth were interviewed, and each youth stated they can provide input about
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what happens in the program. Youth indicated they provide input through talking with staff,
townhall meetings, and youth advisory board. The facility administrator (FA) was interviewed
and indicated youth can provide input on a regular basis. The FA stated youth can complete
grievance forms, “What’s Tea” forms, and participate in living unit meetings. The FA also
confirmed annual TRACE assessments are conducted.
2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide for educational access. The
program integrates education into the daily schedule. A review of the program activity schedule
and the education schedule confirmed the times on each matched. A sample of three videos
and three logbook reviews showed youth are being sent to class an average of six minutes late,
returning from break on average seventeen minutes late, and going to lunch on average ten
minutes early. In addition, randomly selected logbook entries over the past seven months were
reviewed, and youth were moved accordingly with little deviation. Five youth were interviewed,
all five youth indicated there are interruptions during the school day due to some youths'
behavioral issues.
2.19 Contract Specific Career and Technical Education
Limited Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program’s contract requires the implementation of all Career and Technical Education (CTE)
services, formerly referred to as pre-vocational and vocational services. CTE instruction is
designed to develop the interests, aptitudes, and skills of participating youth while building upon
their existing strengths in a manner supportive of their individualized employability goals,
promoting workforce readiness, and providing an occupational advantage within the youth’s
community. A review of documentation confirmed cardiopulmonary resuscitation (CPR)
certification was received and verified for seventeen youth; however, no documentation was
provided for Occupational Safety and Health Administration (OSHA) certification or Florida Ready
to Work credentials. The facility administrator interview confirmed CPR certification is being
provided to youth; however, OSHA and Florida Ready to Work certifications are not currently
being provided. The program schedule did not reflect CTE services were being provided. An
informal interview with the facility administrator confirmed the program is not currently offering
CTE services. As a result, observations could not be conducted during the annual compliance
review week due to the services not being in place. Five youth were interviewed, three youth
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indicated they were receiving career or technical education services and the remaining two youth
reported they were not. To fully align with state expectations and maximize employability
outcomes for youth, the program is encouraged to ensure documentation is maintained for all
workforce readiness certifications, including OSHA and Florida Ready to Work.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program’s designated mental health clinician authority (DMHCA) is a licensed mental health
counselor (LMHC) with a clear and active license, which expires on March 31, 2027. The
DMHCA is a full-time staff member at the program, working a minimum of forty hours a week,
Monday through Friday. The DMHCA is also available on-call twenty-four hours a day, seven
days a week for clinical emergencies. The DMHCA provides specialized treatment services and
oversees the coordination and implementation of mental health and substance abuse services
within the program. The program has a licensed mental health counselor who serves as the
back-up DMHCA during the DMHCA’s absences. The back-up DMHCA holds a clear and active
license, expiring on March 31, 2027. The DMHCA was interviewed and confirmed part of the
responsibilities include ensuring documentation is completed in a timely and accurate manner
and meeting the requirements outlined within the program's contract. The DMHCA is
responsible for reviewing the Comprehensive Mental Health and Substance Abuse Assessment
within ten calendar days of completion. Individualized Treatment Plans and Treatment Plan
Reviews are reviewed within five days of completion. Additionally, the DMHCA oversees the
review and approval of various assessments, including suicide risk assessments, Crisis
Assessments, Victimization and Sexually Aggressive Behavior (VSAB), and Mental Status
Examinations. Group sign-in sheets are reviewed daily. Individual, group, and weekly progress
notes are reviewed weekly in an online tracking system to ensure services are provided as
required. The DMHCA provides weekly supervision to non-licensed clinical staff for a minimum
of one hour a week. The DMHCA also attends treatment teams, pre-classification, classification,
needs assessment, transition staffing, and exit conferences to ensure individualized treatment is
consistent across the multidisciplinary team. Additionally, the DMHCA conducts monthly group
fidelity checks to ensure the proper application of services within the guidelines. The DMHCA
utilizes an internal monitoring system, which is updated weekly to ensure fidelity of services.
The DMHCA maintains a caseload as needed, conducting individual and family therapy
sessions. The DMHCA also provides coverage for group therapy and other assessments as
necessary. The previous DMHCAs, who provided services during the annual compliance review
period, were licensed clinical social workers with clear and active licenses, which expire on
March 31, 2027.
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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.
Since the last annual compliance review, the program had four licensed mental health and
substance abuse clinical staff, working under the direction of the designated mental health
clinician authority (DMHCA), responsible for the coordination and implementation of services.
Each of licensed mental health counselors’ (LMHC) have clear and active licenses in the State
of Florida with expiration dates of March 31, 2027. The DMHCA ensured the licensed clinical
staff working under their supervision were performing services for which they are qualified to
provide based on education, training and experience as outlined in the review of the job
description. A review of the program’s contract confirmed the licensed mental health and
substance abuse clinical staff are in accordance as required.
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 policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The designated mental health
clinician authority (DMHCA) must ensure clinical staff working under their supervision are
performing services the staff are qualified to provide based on education, training, and
experience. The DMHCA was interviewed and confirmed the program’s procedures were being
followed. The program has one non-licensed master’s-level therapist who provides mental
health andat the program. The Department’s Licensed Mental Health Professionals and
Certified/Licensed Substance Abuse Professionals Direct Supervision Log was reviewed which
verified the non-licensed mental health clinical staff working under the direct supervision of the
DMHCA received a minimum of one hour a week of on-site, face-to-face direct supervision, by a
licensed mental health professional, for the purpose of overseeing and directing the mental
health services provided in the program during the annual compliance review period. Non-
licensed clinical staff provide mental health services seven days a week, each working for forty
hours a week. A review of credentials of the non-licensed therapist confirmed they hold a
master’s-level degrees from an accredited university or college. The non-licensed mental health
clinical staff provide mental health services in the program. The program does not currently hold
a Chapter 397 license and confirmed all substance abuse services were provided by licensed
staff. Documentation confirmed the non-licensed clinical staff completed twenty hours of training
and supervised experience in assessing suicide risk, mental health crisis intervention, and
emergency mental health services. The training included administration of five Assessment of
Suicide Risk screenings conducted on-site in the physical presence of a licensed mental health
professional.
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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 policy and procedures addressing a standardized process for the screening
and referral of youth identified as needing further mental health and/or substance abuse
evaluation, staff training in mental health and substance abuse issues, and the administration of
the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). All youth are
screened upon intake through the administration of the MAYSI-2, within the Department’s
Juvenile Justice Information System (JJIS). The five reviewed youth mental health and
substance abuse records were not applicable due to a recent deficiency which was closed on
March 12, 2025, so an additional three records were requested. The reviewed documentation in
all three mental health and substance abuse records confirmed assessments were completed
on the day of admission by a trained licensed mental health counselor (LMHC) and entered into
JJIS. The three reviewed youth records all included a completed MAYSI-2. For all three youth,
the MAYSI-2 results indicated further assessment was required. Referrals for additional
evaluations were made. In all three. the MAYSI-2 or other admission information indicated the
need for a comprehensive evaluation or an assessment, and the facility administrator (FA) or
designee was notified, and a referral made to alert the designated mental health clinician
authority. All three youth required an Assessment of Suicide Risk (ASR) and the FA ensured an
ASR was conducted within twenty-four hours. All three documented the reason for referral. The
program’s practice includes conducting further evaluation for every youth admitted, regardless
of MAYSI-2 results. The program ensures an ASR and a comprehensive mental health and
substance abuse evaluation is conducted for all youth. The policy outlines a standardized
screening process, which includes reviewing commitment packet information, reports, and
records, administering the MAYSI-2 within JJIS, providing staff training in mental health and
substance abuse issues, and implementing a standardized referral process for youth identified
as needing further evaluation. This may include a referral to a qualified professional or, when
immediate attention is necessary, to a hospital or Baker Act/ Marchman Act receiving facility.
The FA interview indicated the program utilizes the MAYSI-2 as a screening tool.
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 policy and procedures to ensure youth identified by screenings, staff
observations, or behaviors post-admission as in need of further evaluation will be referred for a
combined Comprehensive Mental Health and Substance Abuse Evaluation. Five youth mental
health and substance abuse records were reviewed and all five were applicable for the
completion of a Comprehensive Mental Health and Substance Abuse Evaluation. Four of the
five applicable youth had a new combined comprehensive evaluation completed within thirty
days of admission. The remaining youth’s evaluation was conducted 103 days late. Each record
contained a substance abuse consent for services signed by each youth. None of the five
applicable youth had a comprehensive evaluation completed by a non-licensed clinical staff.
Each youth’s comprehensive evaluation contained all required elements. None of the reviewed
youth were applicable for needing an updated comprehensive evaluation.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures to ensure youth determined to have a 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/Substance Abuse Treatment
Plan. Five youth mental health and substance abuse records were reviewed and each had an
Initial Mental Health/Substance Abuse Treatment Plan completed on a program form which
contained all required elements. Each plan was completed within seven days of the beginning of
treatment or within seven days of the initial psychiatric interview for youth prescribed
psychotropic medication. Three of the five Initial Mental Health/Substance Abuse Treatment
Plans were signed by all members of the treatment team who participated in the development of
each plan. The remaining two were missing treatment team leader signatures. All five Initial
Mental Health/Substance Abuse Treatment Plans were completed by a licensed mental health
clinical staff, and each was signed. All five Initial Mental Health/Substance Abuse Treatment
Plans addressed each youth’s psychiatric needs, including medication and frequency of
monitoring by the psychiatrist. Each youth had an Individualized Mental Health/Substance
Abuse Treatment Plan completed on a program form which contained all required elements. All
five reviewed youth had the frequency for services listed on the Individualized Mental
Health/Substance Abuse Treatment Plan. Individualized Mental Health/Substance Abuse
Treatment Plan reviews were completed for two youth at a minimum of every thirty days. One
youth’s record indicated one of four individualized treatment plan reviews was six days late,
another youth had one of four treatment plans reviews seven days late, and the final youth had
one of three treatment plan reviews twenty-one days late. Four of five youth had Individualized
Mental Health/Substance Abuse Treatment Plans signed by all required parties. The remaining
youth was missing a living unit signature. Individualized treatment plans were reviewed and
indicated they were completed on the Department’s individualized Mental Health/Substance
Abuse Treatment Plan Review form. Each youth had individualized goals and objectives on their
treatment plan. A review of video camera observation of three groups, compared to logbooks
and sign-in sheets, confirmed one group conducted on July 9, 2025, from 4:40 p.m. to 5:00 p.m.
was under forty-five minutes and one group conducted on July 25, 2025, from 4:40 p.m. to 5:17
p.m. was also under forty-five minutes. The third group was conducted on June 30, 2025, from
1:00 p.m. to 1:49 p.m. and completed as required.
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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 policy and procedures addressing treatment and discharge planning. Five
youth mental health and substance abuse records were reviewed and each was assigned to a
treatment team, which contained all required members, on the day of admission to the program.
All five reviewed youth had a properly executed Authority for Evaluation and Treatment in their
record. Each record contained consent through a signed Youth Consent form for substance
abuse treatment. All five records contained treatment progress notes which contained all
elements of the Department’s form. Documentation confirmed each youth was receiving
individual therapy and psychosocial skills training. All five reviewed youth received all services
as stipulated on their treatment plan. Three closed youth mental health and substance abuse
records were reviewed for discharge planning. Each record included a discharge plan on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form which
documented future services needed. None of the reviewed youth were released while on suicide
precautions/mental health alert. Documentation confirmed the discharge plan was discussed
with each youth, parent/guardian, and juvenile probation officer (JPO) during the exit
conference. A copy of the Mental Health/Substance Abuse Treatment Discharge Summary was
provided to each youth, parent/guardian, and JPO.
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 policy and procedures which requires specialized intensive mental health
treatment services to be provided to youth. The program’s required clinical groups according to
the contract are Dialectical Behavior Therapy Skills Manual for Adolescents, Moral Reconation
Therapy, and Living in Balance Therapy. Five youth were interviewed and all confirmed they
participated in individual and family therapy. Five staff were interviewed and all confirmed only
clinical staff facilitate mental health and substance abuse groups. An interview with the
designated mental health clinician authority (DMHCA) confirmed all youth receive intensive
mental health treatment services and substance abuse services according to their individualized
treatment plan. An interview with the facility administrator (FA) confirmed the program provides
Substance Abuse Treatment Overlay Services and/or Mental Health Overlay Services to youth
admitted to the program based on the youth’s needs. The FA also stated youth may be provided
intensive mental health treatment services, borderline intellectual functioning, and/or borderline
developmental disability services. The DMHCA is on-site forty hours a week and clinical staff
are on-site seven days a week. A review of documentation confirmed the program provides
weekly individual therapy, biweekly family therapy, and the psychiatrist is on-site weekly. The
program has contracted with a licensed psychologist to provide services weekly. Documentation
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confirmed program mental health and substance abuse groups are held five times a week.
Substance abuse treatment groups did not exceed the one licensee mental health counselor to
fifteen youth ratios. The program provided at least one individual therapy every two weeks,
groups four times a week and the psychiatrist providing services once every two weeks. Mental
health overlay services all included individual therapy once every two weeks, family therapy at
least once a month, and the psychiatrist provided services once every two weeks. The licensed
mental health counselor did not exceed the one counselor to ten youth ratios. Borderline
intellectual functioning groups were conducted by a license mental health counselor. This
overlay contained individual therapy at least once every two weeks, family therapy at least once
a month, psychiatric services once every two weeks, and five total mental health and substance
abuse groups a week. These groups did not exceed the one counselor to ten youth ratio.
Developmental disabilities groups were conducted by a license mental health counselor. This
overlay included individual therapy every week or more often than needed, family therapy at
least twice a month and weekly psychiatric services at least once a week, and three total mental
health and substance abuse groups and two life skills groups each week. Intensive mental
health groups were conducted by a license mental health counselor. This overlay included
individual therapy at least once a week, family therapy once every two weeks, psychiatric
services at least weekly, and five total mental health and substance abuse groups each week.
The program did not have any youth applicable for needing services during medical quarantine.
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 policy and procedures ensuring the program follows a suicide prevention
plan to safely assess and protect youth with elevated risk of suicide in the least restrictive
means possible. The program has a suicide prevention plan including identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
referrals, communication, notifications, documentation, immediate staff response, and review
process. The program’s review process for suicide attempts and mortality review includes
circumstances surrounding the event, facility program procedures relevant to the incident, all
relevant training received by involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations. The suicide
prevention plan was reviewed by the previous facility administrator (FA) and the DMHCA on
November 19, 2024. The current FA signed the plan on May 21, 2025.
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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 policy and procedures which govern suicide prevention services. This policy
defines suicide precautions as methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. It requires any youth exhibiting suicide risk behaviors to be placed on
suicide precautions, and a minimum of constant supervision. Five youth mental health and
substance abuse records were reviewed and three were applicable for suicide prevention
services. Each of the applicable youth were determined to be at risk by staff observation. Each
youth had an Assessment of Suicide Risk (ASR) completed on the Department’s form within
twenty-four hours of youth being determined to be at risk. Each youth was maintained on
constant supervision. Each record reflected the parent/guardian and juvenile probation officer
were notified about each youth’s potential suicide risk as indicated on the ASR. Documentation
confirmed each youth was provided supportive services by mental health clinical staff and each
ASR was completed by a licensed clinical staff member. Two of the three applicable youth were
continued on constant supervision after the completion of the ASR. The remaining one youth
was discontinued from precautionary observation and was stepped down to close supervision.
Documentation confirmed each ASR contained the actual date/time clinician conferred with
facility administrator (FA) or designee and licensed mental health professional recorded in the
date/time sections. Both records, for the two youth continued on constant supervision, contained
a Follow-Up Assessment of Suicide Risk (FASR) on the Department’s form completed prior to
the removal of each youth from precautionary observation. Both youth were maintained on
constant supervision until the completion of a FASR and were stepped down to close
supervision once it was determined each youth could be discontinued from suicide precautions.
All three applicable youth were maintained on close supervision until it was determined no
longer necessary by the designated mental health clinician authority (DMHCA) and a
conference was held between DMHCA and FA. Discontinuation of close supervision was
documented for each youth in accordance with the program’s suicide prevention plan. A review
of the Department’s Juvenile Justice Information System (JJIS) reflected a suicide alert was
initiated for each youth and closed upon the recommendation of the ASR or FASR. A review of
the program logbooks indicated administration or supervisory staff provided instructions related
to the suicide risk assessment findings and suicide precaution decisions for each youth. While
on precautionary observation, each “at-risk” youth was allowed to participate in select activities
with other youth in designated safe housing/observation areas of the program. A review of video
footage, which is maintained for thirty days was able to be completed for three youth on
precautionary observation and confirmed staff were always with each youth while youth were on
precautionary observation. Precautionary logs and logbooks confirmed the length of time each
youth was on precautionary observation. The program only had three youth on precautionary
observation in the thirty days available for video camera review.
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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.
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’s Suicide Prevention Plan requires staff to maintain one-to-one or constant
supervision of youth placed on suicide precautions. Five youth mental health and substance
abuse records were reviewed and three were applicable for suicide prevention services.
Documentation confirmed suicide precaution observation logs were maintained for each youth
for the time each youth was on suicide precautions. Each suicide precautionary observation log
documented the appropriate level of supervision and observations of each youth’s behavior in
real time with none exceeding thirty-minute intervals, as well as each log being reviewed and
signed by each shift supervisor and mental health clinical staff. Each log documented safe
housing requirements. Each log documented warning signs observed; and the facility
administrator/designee and mental health clinical staff were notified, which was documented on
the log.
3.13 Suicide Prevention Training (Critical) Limited 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 policy and procedures which ensures 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. Five pre-service staff training records were reviewed for
the completion of suicide prevention training. There were no in-service staff applicable during
the annual compliance review period. All five pre-service staff completed the required training.
The program has two suicide response kits which are co-located with first-aid kits in
administration/master control and the medical station. The suicide response kits each contain a
knife-for-life, a needle nose plier, and wire cutters. A review was conducted of the program’s
mock suicide drills which confirmed the program completed the required quarterly drills on each
shift. An observation of video camera review confirmed the two available drills recorded within
the last thirty days were not being simulated. All mock mental health drills scenarios reviewed
were in response to a suicide attempt and/or incident of serious self-injury; however, were not
simulated in the drill. The program exceeded the required semi-annual training on emergency
response procedures; however, it did not include life saving measures which includes mock
training in emergency response to a suicide attempt or incident of serious self-inflicted injury to
include cardiopulmonary resuscitation. All staff who were not present during a quarterly drill had
the opportunity to review each drill scenario and procedures in an effort to understand the
process and receive the necessary training to respond to an incident of a suicide attempt or
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incident of serious self-inflicted injury in the program. An interview with the facility administrator
confirmed the program has medical and mental health drills for every shift quarterly and drills
are reviewed at the monthly staff meeting. Five staff were interviewed and stated if a youth
expressed suicide ideation they would notify mental health clinical staff, place youth on sight
and sound, document supervision, and search room for sharp objects. All five interviewed staff
stated suicide response kits are located in master control. One of five staff stated a suicide
response kit was also located in the medical station and three stated they are located on the
youth module. One of five interviewed staff stated medical and suicide drills are held quarterly,
two staff stated they never had a drill but experienced real life code white, and the remaining
two staff members stated they were held monthly.
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 for mental health and substance abuse
services, suicide prevention, crisis intervention, and emergency care. The plan includes
notification and alert system, means of referral, communication, supervision, documentation,
and review, as well as addressing youth in need of a mental status examination and the
completion of a crisis assessment. If needed, the program will utilize the Department’s Crisis
Assessment form.
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 policy and procedures to ensure all youth exhibiting acute psychological
distress receive a crisis assessment. The program only had one crisis assessment completed
within the annual compliance review period. The reviewed youth individual mental health and
substance abuse record contained the required documentation and was completed immediately
after the observed distress. The completed crisis assessment was completed by a licensed
mental health professional and contained all the required information, to include reason for
assessment, mental status examination and interview, level of self-danger, initial clinical
impressions, supervision and treatment recommendations, need for further evaluation and
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notification to the parent/guardian and juvenile probation officer. The crisis assessment was a
result a Prison Rape Elimination Act (PREA) event and was an alleged PREA victim. The youth
was offered ongoing mental health treatment services.
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 policy and procedures which governs 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 Florida Administrative Code
and the program’s emergency response plan. The program has a written emergency response
plan which includes immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health and substance abuse services, transport
for Baker and Marchman Acts, 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 policy and procedures to ensure individuals 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. Five youth mental
health and substance abuse records were reviewed. One of the reviewed youth were applicable
for requiring a Baker Act. The program initiated three Baker Acts on one youth and no
Marchman Acts during the annual compliance review period. For each time the youth was Baker
Acted, the youth was referred to mental health clinical staff immediately upon staff determining
youth was at risk. Documentation confirmed the youth was placed on one-on-one supervision at
the time of discovery of risk. The youth was assessed each time by mental health staff and a
Baker Act was authorized by the designated mental health clinician authority (DMHCA) and
facility administrator. The youth was then transported each time to a local receiving facility by
emergency medical services. Upon return to the program, the youth was placed on constant
supervision each time and a referral was completed indicating an assessment for suicide risk
was to be conducted. Supervision was maintained each time until the DMHCA completed an
appropriate assessment.
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 policy and procedures to conduct an on-going safety planning process for
each youth. The safety plan shall be designed to identify stimuli which have both positive and
negative effects on the youth. Five youth mental health and substance abuse records were
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reviewed and all five had a safety plan completed within fourteen days of admission which
contained all required elements. Each youth’s plan was jointly prepared by the youth,
parent/guardian or family member, and the program’s clinical staff. Documentation confirmed
each safety plan incorporated any recommendations from previous or current clinical
assessments or screening instruments and incorporated trauma responsive practices. Two of
the five youth had their safety plan reviewed and updated at least every thirty days. One youth
had one safety plan meeting, out of four, which was twenty-nine days late, another youth had
one out of five safety plan meetings which was seven days late, and the last youth had one out
of four safety plan meetings which was twenty-three days late. None required an update
following any significant behavioral or mental health event. Safety plans were located in a binder
in master control for direct care staff to review as well as in each youth’s mental health and
substance abuse record. Five youth were interviewed and each confirmed they participated in
the development of their safety plan. An interview with the facility administrator confirmed safety
plans are updated during formal treatment team meetings monthly which include
multidisciplinary team and the youth, parent/guardian, program, and clinical staff.
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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’s designated health authority (DHA) is a licensed physician who has an
unrestricted license and meets requirements for independent and unsupervised practice in the
State of Florida. The license expires on January 31, 2027. The DHA’s training is in Internal
Medicine with experience in adolescent health. The DHA has no disciplinary cases or public
complaints on record. The program does not utilize a physician assistant (PA) or an advanced
practice registered nurse (APRN). The contract outlines the DHA must be at the program one
time a week. The DHA is on-call for emergencies twenty-four hours a day seven days a week. A
review of the DHA’s sign-in sheets for the annual compliance review period indicated the
requirement was met. If the DHA is unavailable, the program has a written agreement with a
licensed physician for back-up. The back-up physician holds a clear and active unrestricted
license which expires on January 31, 2027; however, was not used during the annual
compliance review period. The program does not utilize tele-medicine/tele-health. The
interviewed DHA confirmed he is on-site a minimum of once a week, scheduled to see youth for
a physical examination, periodic evaluations which are completed every three months based on
an internal tracking system, sick call and makes referrals to specialists if needed. The
interviewed DHA stated they communicate with program staff through written orders, by
telephone, and when on-site. The interviewed DHA stated he is available by telephone and an
answering service when not on-site. The interviewed DHA stated he reviews all off-site care
findings and instructions, which are maintained in a folder for his review. The interviewed DHA
meets quarterly with the clinical director to review important medical issues pertaining to each
youth and stated he has no issues or concerns with healthcare at the program.
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 has three full-time registered nurses (RNs), one of whom serves as the health
services administrator (HSA), and two additional pro re nata (PRN) RNs. The program does not
use a Licensed Practical Nurse. Each of the RNs had a clear and active license in the State of
Florida and a current cardiopulmonary resuscitation certification. The HSA is scheduled to be
on-site forty hours a week and the two RNs are scheduled eighty hours a week for a total of 120
hours a week. The program’s nursing staff and hours on-site are in accordance with contractual
requirements.
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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 (FOP’s) for all health procedures and protocols,
which are part of the procedures used daily by the program. The designated health authority
(DHA), psychiatrist, and the facility administrator signed and dated the health protocols on
November 22, 2024, November 19, 2024, and June 8, 2025, respectively. The nursing staff
reviewed and dated the health protocols on November 17, 2024, and June 8, 2025. The annual
review of medical FOP’s and protocols is required November 17, 2026. All newly employed
healthcare personnel received a comprehensive clinical orientation of the Department’s
healthcare policies and procedures by the health services administrator. The DHA approved
and authorized the written treatment protocols and standing procedures on November 17, 2024.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
Five reviewed youth Individual Healthcare Records (IHCRs) contained the Authority for
Evaluation and Treatment (AET) form. All five youth had a valid legible copy of the AET which
was filled out completely and signed by the parent/guardian and juvenile probation officer. There
were no youth requiring a court order. One youth turned eighteen while at the program and a
release of information was completed as required. None of the five youth were in the care of the
Department of Children and Families. According to the interviewed nursing staff, the program
will obtain a copy of the AET from the Department’s Juvenile Justice Information System if
available or residential services. If a completed AET is not available, the program will contact
the Department’s commitment manager. If a youth turns eighteen, the program will obtain the
required signed documentation by each youth consenting to medical treatment.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures in place for parental/guardian notification when a
youth’s condition changes while in the program. A review of five youth Individual Healthcare
Records (IHCRs) showed all were applicable for the over-the-counter medications beyond those
covered by the Authority for Evaluation and Treatment (AET) forms and consent was provided
by each parent/guardian. Notification was sent on the Department’s Parental Notification of
Health-Related Care form for each youth. Four youth were taking psychotropic medications
upon admission and when a new medication was prescribed or discontinued, or if the dosage
was significantly changed, parental/guardian verbal consent was obtained and placed in the
chronological notes for each youth. Written notification for each youth was then sent to the
parent/guardian on the Department’s Parental Notification of Health-Related Care form and a
copy of the Clinical Psychotropic Progress Note was attached as well. Calls for parent/guardian
consent were made for the four youth on psychotropic medications with a witness present.
There were no youth in the care of the Department of Children and Families. Verifications for
vaccinations were reviewed within thirty days of admission for each of the five reviewed youth
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by the nursing staff. There were no youth applicable for exemption from immunizations.
Immunizations are obtained upon the youth’s arrival at the program. According to interviewed
nursing staff, parental notifications are required whenever a psychotropic medication is
prescribed, discontinued or changed. Parental notifications are also required when a youth is
hospitalized, requires dental services, requires any invasive procedure, requires antibiotic
treatment, needs a new medication or for any changes in healthcare treatment/condition and for
off-site medical treatment. Nursing staff makes the parental notifications as soon as they
become aware any changes. According to interviewed nursing staff anytime a youth’s illness or
injury requires emergency medical services, the facility administrator will contact the
parent/guardian by telephone. The interviewed nurse stated they have ten days to obtain
immunization records, and they use a state of Florida website to do so. The parent/guardian will
need to complete the immunization exemption form from their local health department and have
it signed and authorized by the Department of Health before any immunization exemption can
be upheld.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures requiring youth to be screened upon admission by
use of the Facility Entry Physical Health Screening Form (FEPHS). Five reviewed youth
Individual Healthcare Records included a FEPHS form completed by the registered nurse on the
day of admission. One youth had a change in physical custody greater than twenty-four hours
and had a new FEPHS completed upon returning to the facility. According to the interviewed
nursing staff, they see all newly admitted youth immediately upon arrival to the program to
complete the admission screening and are made aware of a new youth’s admission through the
Department’s Juvenile Justice Information System bed alert.. According to the interviewed
nurse, all youth who re-enter the program following a change of custody will have a new
physical health screening completed by nursing staff or if a nurse is unavailable, a non-
healthcare staff will complete the screening.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures on youth being oriented to the general process of
healthcare delivery services at the program. In all five youth Individual Healthcare Records
(IHCR), each youth was provided a general healthcare orientation by the nursing staff upon
admission and was documented in each youth’s IHCR. All required topics were discussed
including access to medical care, the sick call process, when to notify staff in an emergency and
what constitutes an emergency, the medication process, the side effects of medication, refusal
of care, what to do in case of a sexual assault, the non-disciplinary role of healthcare providers,
and standard universal precautions. Health education was completed monthly as required,
included all minimum requirements, and was documented on the Health Education form.
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4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures in which the designated health authority (DHA) is
notified when youth are admitted or require emergency care. Five reviewed youth Individual
Healthcare Records (IHCRs) indicated three of the youth had a chronic condition and referrals
were placed to the physician and placed in the chronological notes. None of the youth needed
emergency care upon admission. The DHA was notified upon admission for each youth
regardless of chronic condition and the notification was documented in the IHCR. Four of the
youth were admitted with psychotropic medication and the psychiatrist was notified. The nurse
interview indicated an understanding of the registered nurse contacting the DHA upon each
youth admission, and reported all notifications are documented on the IHCR chronological note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures in which the standard Department Health-Related
History (HRH) form shall be used for all youth admitted into the physical custody of the program.
Five reviewed youth Individual Healthcare Records (IHCRs) confirmed an HRH was completed
within seven days of admission for each youth. All five HRHs were completed prior to the
Comprehensive Physical Assessment (CPA) as evidenced by signature and date. In all five
IHCRs, the designated health authority reviewed the HRH forms as evidenced by a checked
box on the CPA and a corresponding note in the admissions documentation. The interviewed
nurse stated a new HRH will be completed within seven days of each youth’s admission to the
program.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the chronic health needs of each youth are
met by completing a Comprehensive Physical Assessment (CPA) within seven days of the
youth’s admission. Five reviewed youth Individual Healthcare Records (IHCRs) confirmed the
program used the Department’s CPA form and a new CPA was completed by the designated
health authority for each youth. All five IHCRs included the youth’s Medical Grade documented
on the CPA and all sections of the CPA were completed in full utilizing “O” and “X” markings.
The Medical Grade for each youth was listed on the front of each record and on the CPA. All
five youth refused a portion of the exam which were documented as “youth refused” on each
CPA. All five youth signed the CPA for the refusal. The Department’s Problem List was updated
for each youth as applicable. All five youth IHCRs confirmed the most recent verified
Tuberculosis Skin Test (TST), which was administered in the last year to determine exposure to
tuberculosis (TB). The results with dates of the TSTs were documented for each youth on the
Department’s Infectious and Communicable Disease (ICD) forms and matched the results
documented on the CPA. Results were filed within each IHCR. The interviewed nurse stated a
new CPA is completed on all youth upon admission to the program and all youth will have an
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annual TB rescreening for symptoms. The interviewed nurse also stated gynecological exams
are not routinely completed.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth are evaluated and treated for
sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). Five reviewed
youth Individual Healthcare Records (IHCRs) indicated all youth were screened and evaluated;
three of the youth were referred for further evaluation to the designated health authority (DHA)
after being screened. The referral was documented on the required STI screening tool. One of
the three referred youth was tested, screened, and the diagnosis was documented on the
Infectious and Communicable Diseases (ICD) form and recorded in the lab section of the ICHR.
Two of three referred youth refused testing, and each had signed a refusal form which was filed
in each IHCR. The one applicable youth received counseling and testing for HIV with
documented consent which was maintained in the applicable youth’s IHCR. The HIV results
were sealed in an envelope marked confidential and filed in the applicable youth’s IHCR. The
DHA signed the envelope as proof of his review of the results. The applicable youth’s Health
Education Record had documentation of pre/post-test counseling. The DHA provides pre/post-
test counseling as well as the testing at the program. The applicable youth’s HIV/STI status was
not placed on the program’s internal alert system. The policy ensures a youth’s HIV results are
only disclosed to a youth’s legally authorized representative, healthcare providers during
treatment, the Department of Health of purposes of recording, health facility staff committees
conducting program monitoring, healthcare personnel exposed, and healthcare facility
personnel with a need to know. Five interviewed youth stated they can ask for HIV testing. The
interviewed nurse stated all youth entering the facility will be screened for STIs during the
admission process and if the screening indicates a need for further evaluation they are referred
to the DHA, who will order testing. If the youth receive the rapid blood test, the test is sent to a
local diagnostic lab for reading. All testing is completed on-site within thirty days. Test results
are documented in the youth IHCR, within a sealed envelope, marked confidential. The
interviewed nurse stated a STI screening is completed on youth who complain of STI symptoms
when returning to the facility after being out of the custody of the program/Department for more
than thirty days. The interviewed nurse stated the DHA speaks to each youth during the
Comprehensive Physical Assessment evaluation about HIV counseling and testing services,
and all youth are encouraged to receive testing upon admission, during their stay, and upon
being discharged from the program.
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 policy and procedures which allows all youth in the program to submit Sick
Call Request forms and have complaints treated appropriately through the sick call system. The
program must respond in a timely manner and document all sick call encounters. Five reviewed
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youth Individual Healthcare Records (IHCR) indicated none of the reviewed youth presented
with a similar sick call complaint three or more times within a two-week period. A total of thirty
Sick Call Request forms were reviewed from the five youth IHCRs. All sick call requests were
completed by a registered nurse (RN) and were documented in accordance with the Health
Services Rule. Each completed Sick Call Request form was filed in each youth’s IHCR in
reverse chronological order and documented on the Sick Call Index and on the program’s Sick
Call Referral Log. None of the five youth were in restricted housing. All dates listed on the Sick
Call Index corresponded to the completed Sick Call Request forms located in the IHCRs. A
review of the daily schedule, posted schedule, and nurse interview confirmed sick call was
conducted twice daily, seven days a week, as required. Sick call is conducted at the program
from 10:00 a.m. to 11:00 a.m. and 3:00 p.m. to 4:00 p.m. Sick call times were posted outside
the medical clinic, above the sick call box and in the housing units. During the facility tour, the
Sick Call Request form box had fallen off the wall. Maintenance immediately re-secured the Sick
Call Request form box. Sick call forms were available next to the sick call form box in the multi-
purpose room. The program has a process in place requiring the shift supervisor to review sick
calls if a nurse is not on-site. The shift supervisor has four hours to complete the review and
notify nursing staff by telephone. The medical clinic contains an exam table and equipment to
perform sick calls. Five interviewed youth said they are seen for sick call within one day. The
interviewed nurse advised youth can submit a sick call at any time by placing in the Sick Call
Request form in the sick call box. Sick call hours are posted outside the medical clinic and
reviewed with each youth during the admission process. The nurse also stated they review the
Sick Call Request and respond as necessary. The nurse stated sick calls are conducted by
nursing staff. The designated health authority (DHA) does not conduct sick calls. The nurse
stated when a youth presents with a repeated sick call compliant an automatic referral to the
DHA or dentist is then completed. The interviewed nurse stated DHA approved treatment
protocols are in place. The nurse confirmed the program does not utilize confinements. An
observation of sick call was conducted. The youth’s verbal consent was obtained prior to
observing the sick call. The youth was escorted to sick call by direct care staff. The nurse
identified herself and stated why the youth was there. The youth was seen in a private area,
with no other youth present to see or hear the examination and was examined by licensed staff.
The direct care staff waited outside the exam room, with the door closed, to maintain privacy of
the youth during the sick call exam.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures which require them to have a comprehensive process
for the provision of episodic and first-aid care. Five reviewed youth Individual Healthcare
Records (IHCR) for episodic care indicated all youth were applicable for having on-site episodic
or first-aid care during the annual compliance review period. On-site care was provided by
licensed healthcare staff, who documented each event in the required subjective, objective,
assessment, and plan format. The program has five first-aid kits, which are kept in master
control, each of the two housing units, classroom, and administration. Each vehicle also has an
assigned first-aid kit, which are in maintained in master control. First-aid kits are checked
weekly by nursing staff. The check consists of a visual observation of each first-aid kit to ensure
the security seal is in intact. If not, a report is submitted to the facility administrator, the kit is
replenished, and resealed. The program has a policy in place to send first-aid kits to medical if
used for replenishment and resealing. Nursing staff also conducts thorough inspections on all
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first-aid kits monthly by breaking the seal, inspecting contents, replenishing deteriorated or
expired items, and resealing each kit. Three first-aid kits were observed, in master control,
administration and dorm one. Each seal was broken in order to review the items, and all items
were compared with the inventory list. All items were accounted for, with current dates, and
properly sealed. All reviewed first-aid kits were then re-sealed by nursing staff. All were fully
stocked with designated health authority (DHA) approved items. A review of First-Aid Kit
Inspection forms during the annual compliance review period was conducted and confirmed
first-aid kits were inspected monthly by nursing staff. The program has one automated external
defibrillator (AED), located in master control. Procedures are kept inside the AED case and a
copy is maintained in the medical clinic. Nursing staff check the AED monthly to ensure the
batteries and pads are operable. This is a new program, and it is unknown when the AED
batteries and AED pads were last changed. The current battery expires June 15, 2026, and the
pads expire November 25, 2025. The green light was flashing on the AED indicating the AED
was operational. The program maintains a list of emergency numbers, including the Poison
Control Center, in a cabinet in the medical clinic, which is inaccessible to youth. Authorized
direct care staff have been appropriately trained on the administration of the epinephrine auto-
injector by a registered nurse. Five reviewed pre-service staff training records indicated all staff
were trained in episodic, first-aid, and emergency care, as required. There were no applicable
in-service training records to review, as this is a new program. A review of emergency drill
documentation, which is maintained in the medical drill binder in medical, confirmed the twelve
required monthly drills, one on each of the two shifts, which exceeds the quarterly requirement
was conducted. The emergency drills indicated cardiopulmonary resuscitation (CPR)/AED
demonstration were practiced at least quarterly, with at least one drill being conducted on each
shift with CPR and/or AED administration. Drills also simulate episodic care events which call
for immediate first-aid and/or administration of CPR techniques and the initiation of the
emergency procedures to follow when a life-threatening emergency occurs. There were no
episodic or first-aid events during the annual compliance review week; therefore, no events
were observed. The program has a specific policy for the use, access, and inventory of Narcan.
Narcan is to be used only by trained staff in the event of an accidental overdose, for youth in the
care of the program. Narcan is stored in the locked medical supply cabinet and can only be
accessed by nursing staff and staff who have been trained to dispense Narcan, if needed. Each
staff with access to Narcan have been trained by the registered nurse. Narcan is inventoried
weekly, along with all other over-the-counter medications, controlled medications, sharps, and
medical equipment. Four of five interviewed staff stated they are allowed to call 9-1-1 if a youth
has a medical emergency. One staff stated they are not permitted to call; however, a follow-up
with administration confirmed staff can call 9-1-1. Five interviewed youth confirmed they can see
a doctor and dentist as needed. The interviewed nurse stated the program has one AED located
in master control. The procedures are located with the AED in master control and in the medical
clinic. The nurse also stated nursing staff check the AED batteries and pad to ensure they are
operable. It is unknow when the AED pads and batteries were last changed due to the AED
already being in the building. The nurse stated emergency medical drills are conducted
quarterly on each shift by nursing staff, critiqued by the health services administrators (HSA)
and facility administrators (FA). Emergency numbers are maintained in master control, HSA
office and the FA’s office.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures in which they provide timely referrals and
coordination of medical services to an off-site healthcare provider, both emergent and non-
emergent, and document such services, as required by the Department. Five reviewed youth
Individual Healthcare Records (IHCRs) indicated three youth required off-site care. The
Summary of Off-Site Care Consultation Report form was utilized in all three cases; however, the
discharging doctor did not complete the required sections, nor did the facility nurse document a
statement referring to the attached discharge documentation. All three off-site care events were
documented in the Episodic Care Log. All three of the youth had parental/guardian notification
efforts documented. The discharge documents and other applicable documentation were in
each youth’s record and the designated health authority (DHA) signed off on each youth’s
findings, instructions, and information. None of the youth required a follow-up appointment. The
interviewed nurse indicated each encounter for off-site first-aid or emergency care is
documented in the Emergency Care Log and off-site log. If a youth is admitted to the hospital,
admission is documented in the youth’s IHCR, the facility administrator is notified, and the nurse
is responsible to provide daily updates. The interviewed nurse stated to ensure hospital orders
are followed, they review the notes and orders and notify the DHA immediately. The interviewed
nurse stated off-site summaries with attachments are placed directly in a binder for the DHA to
review, sign, and date before seeing the youth. The interviewed nurse stated all tracking for
follow-up testing, referrals and appointments are documented on a spreadsheet.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures requiring youth who have chronic conditions to
receive regularly scheduled evaluations and necessary follow-up. Five reviewed youth Individual
Healthcare Records (IHCR) indicated two were applicable for chronic conditions. An additional
youth identified with a chronic condition was reviewed. Each of the three applicable youth were
identified as having a chronic condition on the Facility Entry Physical Health Screening (FEPHS)
form. None of the reviewed youth had a communicable disease. All three of the youth were
taking prescribed medication on an on-going basis. All three applicable youth had an identified
chronic health condition. Each youth was classified with the correct Medical Grade and was
placed on the program’s Chronic Illness List. None of the three applicable youth were pregnant.
Provided documentation reflected all three of the applicable youth received periodic evaluations
at least every ninety days. On-site periodic evaluations were conducted prior to renewing an
expired prescription medication for one of the three reviewed youth; the remaining two were not
applicable. There were no evaluations conducted off-site. The Department’s Problem List was
updated in accordance with Florida Administrative Code for each youth. The interviewed facility
administrator stated youth who have chronic illnesses receive regularly scheduled follow-up
care as needed. Upon arrival to the facility any youth with allergies, disabilities of any kind, or
chronic medical conditions shall be indicated on the FEPHS form. The interviewed designated
health authority (DHA) stated periodic evaluations for youth with chronic conditions are
conducted every three months and the program uses a tracker to ensure evaluations are
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conducted as required. The interviewed nurse confirmed youth with a chronic condition are
monitored by the DHA and receive a periodic evaluation every ninety days.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures which require for medication to 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. Five reviewed
youth Individual Healthcare Records (IHCR) indicated all youth were taking prescribed
medication upon admission. The five youth IHCRs included a Prescription Medication
Verification Checklist form, which indicated the prescriptions were verified. This verification was
also included in the chronological progress notes. The designated health authority (DHA) and
psychiatrist, when applicable, were contacted to obtain the order to resume the specified
medications prescribed prior to admission. All medications had a current, valid order and were
given pursuant to a current prescription, and any medications which were continued,
discontinued, newly ordered were documented on the Practitioner Order Form. All five youth
were applicable for over-the-counter (OTC) medications not listed on the Authority for
Evaluation and Treatment and all OTC medications were administered in accordance with
approved protocols. The Medication Administration Record (MAR), which includes all
information required by Florida Administrative Code was included in each youth’s IHCR. None
of the reviewed youth had medication given to them by non-licensed staff. Each of the MARs
contained documentation reflecting staff and youth initialed each administered medication.
Nursing staff documented weekly side-effect monitoring on each of the youth MARs. All five of
the youth refused medication and each youth signed a Refusal of Treatment form, which was
filed in the youth’s IHCR. In addition, the refusal was clearly documented on the MAR for each
youth. All the MARs contained each youth’s name, Department identification number, date of
birth, allergies, precautions, Medical Grade, and medical alerts. A review of policy and
procedures indicated standing orders for psychotropic medications, emergency treatment orders
for psychotropic medications, and pro re nata (PRN) orders for psychotropic were not allowed.
. During the annual compliance review, an observation of medication administration for
one youth was conducted. Program policy states medication delivery shall be the sole
responsibility of the nurse during the administration of the medication, which was observed. The
youth was escorted to medical individually by direct care staff and approached the nurse. The
nurse identified herself and stated why the youth was in medical. The same nurse who
administered the medication prepared it. The nurse verified each youth’s allergy and alert
status. The nurse and youth both initialed the MAR. Non-healthcare staff did not provide the
medications. The nurse observed the youth while the youth took the medication to ensure the
medication was swallowed. The medications were not pre-poured. The Six Rights of Medication
Delivery/Administration (right youth, right medication, right dosage, right time, right route, and
right documentation) were verified for each youth taking medication. Five interviewed youth
stated the nurse gives them medication. The interviewed nurse stated a nurse will verify
medications when a youth is admitted to the program by checking the previous MAR, call the
past prescriber, call the parent/guardian or the pharmacy who prescribed the medication. The
nurse stated they use a pre-printed pharmacy MAR. The nurse stated staff are trained to
provide medications by the health services administrator and the approved list is sent to the
compliance officer, director of nursing and facility administrator. The nurse confirmed medication
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pass is seven days a week from 8:00 a.m. to 8:30 a.m. and 5:00 p.m. to 5:30 p.m. The nurse
confirmed they have a class two permit and gynecological exams and not routinely completed.
The nurse stated all medications are procured through a contracted pharmacy. The nurse will
fax the medication order to the pharmacy and the medications are delivered within twenty-four
to forty-eight hours. The nurse stated they contract with a psychiatrist who is on-site every
Tuesday, for medication management and a separate fee is not generated for each youth.
Satisfactory
4.17 Psychiatric Services
Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a policy and procedures indicating psychiatric services, including psychiatric
evaluation, psychiatric consultation, medication management, and medical supportive
counseling, will be provided to youth with a diagnosed Diagnostic and Statistical Manual of
Mental Disorders Fifth Edition (DSM-5) mental disorder and to each youth receiving
psychotropic medication in the program. Psychiatric services in the program are provided by a
psychiatrist with a clear and active license, which expires on January 31, 2026. The program
does not utilize a psychiatric advanced practice registered nurse. The psychiatrist’s contract
indicates they will be available for emergency consultation twenty-four hours a day, seven days
a week. A review of treatment team meeting minutes found the psychiatrist briefed a
representative of the treatment team regarding the psychiatric status of each youth receiving
psychiatric services who was scheduled for a treatment team meeting. A review of
Individualized Treatment Plans found the psychiatrist’s evaluation and recommendations for
youth were incorporated into their treatment plans. A review of sign-in/out logs found the
psychiatrist was on-site at least once every two weeks, as required. A review of treatment team
meeting minutes and thirty-day medication reviews forms found the psychiatrist actively
participates in, manages, and supervises psychotropic medication services in the program. A
back-up psychiatrist was not utilized during the annual compliance review period; however, the
program has identified a back-up psychiatrist with equal education to the psychiatrist with a
clear and active license, which expires on January 31, 2026. The program’s contract does not
include tele-psychiatry. The interviewed psychiatrist indicated he is on-site, every Tuesday each
week. He stated he briefly meets with the designated mental health clinician authority on
Tuesdays to discuss each youth seen for the week and to discuss any other clinically relevant
issues. He sees youth for assessment and follow up and works with the therapist and nursing
staff to provide Individualized Treatment Plans. The psychiatrist indicated he evaluates each
youth admitted. Those youth on medications are seen every thirty days. He works with the
therapist and nursing staff to provide holistic care and safe prescribing of medications. He
stated nursing staff discuss any medical issues, youth being non-compliant with medications,
medication side effect issues or other medical issues. The psychiatrists stated he conducts
face-to-face communication with representatives from the treatment team. Five reviewed youth
Individual Healthcare Records (IHCRs) indicted each youth was referred for a psychiatric
interview, as the program’s practice is to refer each youth. Four of the reviewed youth were
admitted with psychotropic medication, one was prescribed psychotropic medication during the
psychiatric interview. All five youth received a diagnostic interview, documented on the
appropriate form which clearly identified it as an Initial Diagnostic Psychiatric Interview, within
fourteen days of admission. Each youth’s psychiatric interview included the youth’s history, a
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mental status examination, DSM-5, documentation of DSM diagnosis and treatment
recommendations. The interviews also included the prescribed medications, explanation of the
need for psychotropic medication related to the youth’s diagnosis, target symptoms, potential
side effects, risks and benefits of taking the medication, and frequency of medication
monitoring/management for the four applicable youth. The initial psychiatric interview resulted in
the prescription of psychotropic medications or changes to the youth’s psychotropic medication
regimen for each of the four applicable youth and page three of the Department’s Clinical
Psychotropic Progress Note (CPPN) was completed for each. A review of thirty-day medication
reviews found all four youth who received psychotropic medications at the program were seen
for medication reviews by the psychiatrist at least every thirty days. Each thirty-day medical
review included documentation of identifying data, diagnosis, target symptoms of each
medication, evaluation and description of effect of prescribed medications on target symptoms,
prescribed psychotropic medication names, dosage and quantity, normal dosage range, ordered
dosage, frequency and route of administration, reason for changes in medication and/or
dosage, side effects, adherence to the medication regimen, height, weight, blood pressure,
most recent serum levels or laboratory findings, as appropriate, telephone contact with the
parent/guardian to discuss medication, the psychiatrist’s signature, the date, and monitoring for
Tardive Dyskinesia. The program does not use tele-psychiatry.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures requiring any medical equipment classified as sharps,
as well as stock medications, to 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 keeps sharps in a locked cabinet in the medical clinic behind a
locked door. A review of sharps inventory during the annual compliance review period confirmed
they are utilizing a perpetual inventory with descending counts as each sharp is used and
disposed. Medications are kept in a locked medication cart separately from other medications,
which is stored in medical. The medication cart is clean and organized with stock items separate
from youth-specific medications. All controlled substances had a perpetual inventory and were
stored separately from other medications, in the locked medication cart behind two locks, and a
locked door. The program does not have any youth requiring refrigerated medication. They do
have a refrigerator in the medical clinic, which was empty at the time of the annual compliance
review. Discontinued and expired medications which needs to be disposed are stored in the
secured medication cart and disposed of by use of a chemical compound specifically created for
destruction and disposal of expired or discontinued medications. A review of medication
inventories during the annual compliance review period confirmed the medical staff is utilizing a
perpetual inventory with descending counts as each medication is issued. In addition, medical
staff conduct a weekly count and documented this on each youth’s Individualized Controlled
Medication Inventory Record as required. In accordance with Board of Pharmacy regulatory
requirements, a shift-to-shift inventory count of all controlled substances was documented on
each youth’s Individualized Controlled Medication Inventory Record. Three supervisory level,
non-healthcare staff were trained by the registered nurse in the delivery and oversight of
medication self-administration in the event medication needs to be administered when nursing
staff are not on-site. Three controlled medications, three over-the-counter medications, and
three sharps were reviewed and counted during the week of the annual compliance review. All
the counts listed on the inventories matched the observed counts, with no discrepancies. If the
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count is off, the nurse will notify the facility administrator who is responsible for notifying the
Department’s Central Communications Center. The interviewed nurse confirmed two nursing
staff dispose of all expired and discontinued medications, and all controlled substances are
locked in the medication cart, which is behind a locked door, and the key for the controlled
substance portion of the medicine cart is not accessible to non-healthcare staff. The nurse
stated they have a contract with a local consultant pharmacist whose license is current and
maintained on-site.
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 policy and procedures for infection control procedures including prevention,
containment, treatment, and recording requirements related to infectious diseases, according to
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control and Prevention guidelines. The designated health authority (DHA) reviewed
and signed the policy on November 22, 2024, and the facility administrator (FA) reviewed and
signed the policy on June 8, 2025. Education for each youth is provided at the time of intake
and when the need is identified. The control procedures include common diseases, contagious
illnesses, viral or bacterial diseases, tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus, other outbreaks, lice and/or scabies, Methicillin-Resistant
Staphylococcus Aureus, foodborne illnesses, bio-terrorist agents, and exposures in the
workplace. Hepatitis B shots are available to staff and the staff have access to protective
equipment. There were no exposures during the annual compliance review period. The
exposure plan is written in accordance with OSHA standards and the plan is available to all staff
at the program. The exposure control plan was reviewed and signed by the DHA on November
22, 2025, and by the FA on June 8, 2025. According to the program policy and the exposure
control plan any needle stick exposure must immediately be reported to the FA by the chain of
command. There were no instances in which the Department’s Central Communications Center
or county health department were contacted for infectious diseases. The interviewed FA stated
the program has an exposure control and infection control plan, staff are trained during
administrative meetings and quality improvement meetings. The interviewed nurse confirmed a
copy of the exposure control plan is available to them and training is completed by the health
service administrator to both staff and youth. The interviewed nurse stated the only county
health department service routinely used is dental care.
4.20 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has a policy and procedures requiring they provide access to prenatal care for all
pregnant youth. In addition, health education shall be provided to both youth and staff. Five
reviewed youth Individual Healthcare Records (IHCRs) indicated none of the youth were
pregnant at the time of the annual compliance review. The program advised they have not had
any pregnant youth during the annual compliance review period. A review was conducted of
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training sign-in sheets which confirmed non-healthcare staff receive in-service education on
girl’s healthcare.. This training is provided by a registered nurse. The training curriculum
included observation and monitoring of emergency care needs/symptoms of possible
miscarriages. The program has nursing protocols and treatment plans for pregnant youth. The
interviewed nurse stated the services provided to a pregnant youth are, pregnancy education,
prenatal care, and a plan of care through post birth include psychological and physical care. The
interviewed nurse stated the designated health authority provides routine monitoring of pregnant
youth every two weeks in the first eight months and weekly thereafter. The interviewed nurse
stated youth are provided a special diet and education is provided to both staff and youth by the
health service administrator. The education topics include alcohol and drug usage, smoking,
nutrition, sexually transmitted infection, contraception, prenatal care, birthing process, post-
partum care, basic baby care, child development, and parenting skills.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures addressing how they will maintain active supervision
of youth at all times, positively interact with youth, and provide thorough observation of youth
behavior. Staff must be able to always account for the whereabouts of youth under their
supervision. The program’s contracted supervision ratio is one staff for every five youth during
daytime activities, and one staff to every six youth during evening hours. Each day of the annual
compliance review week, program staff were observed supervising youth in school, during
recreation, taking restroom breaks from school, cleaning, and before and after a youth transport.
Staff were always properly supervising youth and were within the contractually required ratio.
Interactions were observed to be positive. Three staff were informally interviewed during these
observations, and all staff immediately knew the number of youth they were supervising. The
program’s procedures reflect active supervision as the effective positioning of staff in an area
suited for optimum sight and sound supervision of youth. Staff are to position themselves in a
manner to supervise and interact with all youth they are supervising. The daily schedule is
posted in both dormitories for youth to review, and during the annual compliance review week,
youth were observed to be engaged in a full schedule of activities. Video camera review
confirmed youth were actively observed by staff in their rooms while sleeping. Observations
conducted during the annual compliance review week confirmed youth windows were not
covered by any means which would affect the direct line of sight of the youth. The program did
not have any escapes during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the development, implementation, and
on-going maintenance of the behavior management system (BMS) by all appropriate parties,
including education. Policy did not include a protocol where staff are provided with feedback
regarding the implementation of the BMS. The program stated the policy would be updated to
include this requirement. A review of the program’s contract, policies, and BMS confirmed all
appropriate parties, to include education, were involved in the development, implementation,
and on-going maintenance of the BMS. The program and education provider have a joint plan
related to the utilization of the BMS in the classroom. Documentation confirmed the facility
administrator (FA) trained education staff on the combined BMS plan. A review of five youth
case management records confirmed each youth’s orientation included a review of the BMS. All
requirements of the BMS are also included in the youth handbook. Four staff position
descriptions were reviewed for staff whose job functions include implementation of the BMS,
and all position descriptions included a requirement for the implementation of the BMS. Five
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staff training records were reviewed which confirmed each staff member received training in the
BMS. A review of the youth handbook confirmed documentation of the BMS to include the rules
governing conduct and positive and negative consequences. Observations during the week of
the annual compliance review confirmed the BMS was seen posted in both dormitories and in
the multi-purpose room which is accessible to youth and included the rules governing conduct
and positive and negative consequences. The program’s BMS has not been changed nor was in
the process of being changed during the annual compliance review period. The program’s
written BMS includes five levels which contain all required elements. Observations made during
the annual compliance review week confirmed positive interactions between staff and youth and
adherence to the requirements of the BMS. Documentation confirmed the program’s BMS
includes a process wherein staff explain to the youth the reason for any sanction imposed prior
to the end of the staff’s workday, the youth is given an opportunity to explain his or her behavior,
and staff and youth discuss the behavior’s impact on others, reasonable reparations for harmed
cause to others, and alternative acceptable behavior. The program provides a variety of
rewards/incentives to include spa days, extra telephone calls, extra snacks, and movie days.
Five staff were interviewed and three were able to articulate all required elements of the BMS,
one staff member could not remember the BMS, and the remaining staff member stated they do
not utilize the BMS. One staff member also stated they felt youth are not always held
accountable for their actions. Four of five interviewed staff were able to verbalize rewards
provided as part of the BMS to include snacks, movie nights, and spa days. The remaining staff
member stated they do not utilize the BMS. All five interviewed staff confirmed basic rights
cannot be taken away from youth as a consequence. Results of the staff interviews were
discussed with the facility administrator who stated all interviewed staff have been trained and
implement the BMS; however, they may be confused on the terminology. The facility
Administrator stated they will review the BMS during their next staff meeting. Five youth were
interviewed regarding the implementation of the BMS and all were able to articulate rewards,
consequences, and the individual levels of the BMS. Four of five interviewed youth stated staff
are consistent in their implementation of the BMS. The remaining youth stated staff treat some
youth differently when implementing the BMS. All five youth confirmed youth are not allowed to
punish other youth. The FA interview confirmed the program’s practice.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program maintains a policy and procedures to ensure youth are observed at a minimum of
every ten minutes when youth are in their rooms. The program has forty-six video cameras, and
all were operational during the annual compliance review week. Video coverage is stored for
thirty days. The program’s practice is to conduct checks of youth in their rooms every eight
minutes. A random sample of ten-minute check sheets for each month of the annual compliance
review period found no more than ten minutes passed without the staff actively observing each
youth. Staff completing the checks initialed the check sheet; however, not all of the check
sheets listed the dorm location of the checks. A random review of video recording and ten-
minute check sheets included nine samples of thirty-minute increments, at different times of the
evening, covering all shifts was conducted and confirmed checks were being conducted within
the required ten-minute time frames and in real time as required, except for one check which
was completed three minutes late. The check which was completed three minutes late was
recorded on the check sheet as having been completed within eight minutes of the previous
check instead of thirteen minutes from the previous check. The annual compliance review team
notified the facility administrator (FA) and program’s statewide compliance manager of the
discrepancy, and the statewide compliance manager reported the findings to the Department’s
Central Communications Center. Five staff were interviewed and three stated youth are
checked every eight minutes while in their room and the remaining two staff stated checks are
completed every ten minutes. The FA was interviewed and confirmed the program has forty-six
cameras, all are operational, and video cameras store recordings for thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures which address population census, counts, and
tracking of youth. Policy requires counts to be conducted at minimum at the beginning of each
shift and several times daily to include after each outdoor activity and during any emergency
situations. The program tracks daily census information including at minimum, daily census
count, new admissions, releases, transfers, and youth temporarily away from the program.
Observations during the annual compliance review week confirmed head counts were
conducted throughout the day. The program utilizes a master control logbook to document
youth counts, movements, and daily census. A review of program logbooks for one day each
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month of the annual compliance review period reflected headcounts are being conducted by the
shift supervisor at the beginning of each shift, after recreation, and randomly throughout the
day. The program documented all census, counts, and tracking activities as required, except, for
one instance where the program census count went down by one youth without documentation
as to where the youth went and another instance where five youth were temporarily transported
away from the program; however, the logbook did not indicate the destination of the transport.
Five staff were interviewed, and each staff confirmed head counts are conducted either hourly
or after each movement. Each staff member could verbalize the procedures for when a youth
count cannot be reconciled. Four of five interviewed staff could provide examples of when
emergency counts are conducted. The remaining staff was unsure when emergency counts are
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 policy and procedures addressing logbook entries. The program maintains
one master control logbook. The program does not use shift reports or living unit logbooks.
Each staff member prior to beginning their shift reviews the master control logbook information
from the previous shift and signs in the logbook confirming this information was reviewed. The
program had a minor deficiency for logbooks for missing entries of movements, alerts, and
population census which was closed on April 28, 2025; therefore, a full day of logbooks for only
the months of May, June, and July 2025 were reviewed. The program maintains logbooks which
are bound with numbered pages. None of the logbooks reviewed had any entries removed or
destroyed. Each reviewed month did contain errors which were not struck through with a single
line and initialed by staff as required. All reviewed entries included the dates and times of
events, the names of staff and youth involved, brief descriptions of the events, and the names
and signatures of the staff making the entries. There were three incidents reported to the
Department’s Central Communications Center (CCC) of which two of the three incidents were
documented in the logbook. The remaining CCC incident was not documented in the logbook.
Logbook entries included emergency situations, incidents, special instructions for supervision
and monitoring of youth, population counts at the beginning and end of each shift, and any other
population counts conducted during a shift, perimeter security checks and other security checks
conducted by direct care staff, transports away from the facility, including the names of the staff,
youth involved, and the destination, requests by law enforcement to access any youth, removal
of any youth from the mainstream population, admission and releases, including the name,
date, and time of anticipated arrival or departure and mode of transportation. The program had
one instance where five youth were transported temporarily away from the program; however,
the logbook did not indicate the destination, or names of staff involved in the transport. All other
out of program transports were documented as required. The program does not utilize room
restriction or controlled observation. The program did not have any escape or escape attempts
during the annual compliance review period.
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5.07 Key Control (CRITCAL) Failed Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a policy and procedures addressing key control. The program’s policy
and procedures include key assignment and usage, restrictions on usage, inventory and
tracking, secure storage of keys when not in use, procedures for missing or lost keys, and
reporting and replacement of keys. The program’s policy lists the position titles who can be
issued permanent keys with written authorization of the facility administrator (FA). Each staff
issued permanent keys must sign the Key Responsibilities form prior to being issued permanent
keys. The policy details which staff can have access to restricted keys and which areas those
keys can access. Restricted keys are locked in a separate black lock box inside the main key
lock box and master control maintains control of the key to unlock the restricted key box. An
informal interview with the assistant facility administrator (AFA) confirmed the access to
restricted keys is only authorized for those on the approved list and are kept in a separate lock
box in master control. Policy states any damaged keys should be reported to the shift supervisor
to complete a maintenance request form and damaged keys will be given to the physical plant
manager. Any extra replacement keys will be kept secured in the restricted key box and shall
only be issued with authorization from the FA. Only the FA or designee can make duplicate or
replacement keys. A review of program incidents reported to the Department’s Central
Communications Center reflected one incident report where a staff member left their program
key ring on the podium in one of the dormitories and youth took the staff’s key ring and the key
ring was later found on the recreation yard. The staff member involved in the incident received a
written warning for this incident. It was determined through observations, the program uses a
sign in/sign out log for daily tracking and reconciliation of keys. The program’s key storage is in
a locked key box, which is not accessible when locked, with hooks and labels for each key ring
which corresponds to the key inventory. Staff and visitor’s personal keys are given to master
control which are then locked in the locked key box. The program’s key storage area is located
master control. The restricted key box is a black locked box located inside of the main key lock
box. A separate red lock box inside master control is used for the emergency key box. An
observation of key distribution was unable to observed during the annual compliance review
week. A review of the key inventory and a sample of five staff key rings revealed the key
inventory did not correctly match the keys on any of the five reviewed key rings. The inventory
reflected the incorrect number of keys or keys which were incorrectly labelled. The AFA’s key
ring also contained a damaged key which had not been replaced or given to the physical plant
manager. Key inventory does not contain a key reference indicating what each key unlocks. An
informal interview of three staff revealed none of the three staff could correctly list the number of
keys they had on their key rings. Two of the three informally interviewed staff did not know the
function of each key on their key ring. The remaining staff member could verbalize the function
of each key of their key ring. Five staff were interviewed and all could articulate how staff and
visitor personal keys are stored and how program keys are assigned. One of the five
interviewed staff could articulate the procedures for any missing keys. The remaining four staff
could not provide the process for missing keys. None of the five interviewed staff could detail
the process for the replacement of damaged keys.
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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 policy and procedures which address contraband procedures. The program
has a system in place to prevent contraband from entering the facility and clearly delineates
those items considered to be contraband. The program’s system and policy include all required
elements. The program’s policy specifies law enforcement will be contacted if any found item
would be considered illegal as defined by Florida Statutes or if there is any suspicion of unlawful
activity. The program’s facility visitor log contains a contraband attestation statement. All newly
hired staff are required to sign contraband attestation forms upon hire. A review of twenty-nine
staff personnel records confirmed each staff member signed an attestation form upon hire. The
program’s policy did not address staff found in possession of contraband in a program are
subject to disciplinary action up to and including dismissal and outlined in Florida Administrative
Code. The program’s statewide compliance manager stated policy would be updated to reflect
this requirement. A review of documentation confirmed the program documents the confiscation
and disposition of any contraband. The program had one incident of illegal contraband during
the annual compliance review period. The program followed all required protocols to include
calling the Department’s Central Communications Center, notifying law enforcement, and
locking up the contraband item until law enforcement took possession of the item. A review of
search reports confirmed any non-illegal contraband found was discarded by staff and
documented on the search report. A review of logbooks, incident reports, and search reports
confirmed the program completes searches of program areas daily. An interview with the facility
administrator confirmed the program’s practice. Five staff were interviewed and four stated
searches are conducted daily, the remaining staff member stated searches are conducted three
to five times a week. Two staff also stated searches are conducted if there is any suspicion of
contraband or after any major incidents.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures to ensure the program performs searches and
full body visual searches. The program conducts searches as a method to prevent the
introduction of contraband and unauthorized items into the facility. The policy indicates full body
visual searches of youth are conducted after off-site transports. Searches are completed after
visitation, before and after every movement, before moving youth from an outside area into the
building, and prior to moving youth from the building to an outside area. The annual compliance
review team was able to observe an off-site transport during the week of the annual compliance
review. The review team observed a properly conducted search and full visual searches before
and after the transport. The program did not have any admissions during the annual compliance
review week. The review team also observed several youth searches during the week of the
annual compliance review week including transition to school, to group, to recreation, and back
to the dormitories. A review of video camera recording confirmed youth were searched before
and after visitation as was the multi-purpose room where visitation was conducted. Youth were
not observed utilizing tools during the annual compliance review week as no youth are currently
allowed to utilize any tools, to include class B tools. Search procedures and expectations were
properly explained to all youth before searches were conducted. Searches were conducted by
staff of the same gender as the youth, while a second staff member assisted with supervision.
Searches were thorough and done in a manner which did not degrade the youth. Searches
were conducted as required by the Right Interactions training manual. The annual compliance
review team was electronically searched, and frisk searched every day of the annual
compliance review week. A video camera review of five staff and visitor searches found all staff
and visitors were electronically searched as well as frisk searched. One staff member’s bag was
not searched; however, all other staff and visitor bags were searched. Five staff were
interviewed, and all confirmed youth are searched before and after every movement. Five youth
were interviewed, and all youth confirmed youth are searched before and after every movement.
Two youth stated they are also searched when returning from off campus activities and three
youth stated they are searched after outdoor activities.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures addressing vehicles and maintenance. The
program utilizes one van for youth transports; however, the program will occasionally borrow
another van assigned to a different program on the same campus. A random check of five staff
vehicles and the one program assigned van was completed to ensure vehicles were locked
when not in use. All vehicles were locked except for one staff vehicle. This was brought to the
program’s attention and staff locked the unlocked vehicle. Both vans utilized to transport youth
during the annual compliance review period passed their annual inspections and documentation
confirmed regular maintenance was completed. The program is not a high/secure program;
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therefore, a safety screen is not required. A member of the annual compliance review team
observed the program assigned van, and all required equipment was identified, which included
a seat belt cutter, window punch, fire extinguisher, and first-aid kits. The program was notified
the first-aid kits should not be retained in the vehicles to preserve the integrity of the supplies.
The other van which is assigned to a different program on the campus, was unable to be
observed during the annual compliance review week due to being off-site. All seatbelts in the
van were in proper working condition.
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 policy and procedures addressing transportation of youth. The program’s
policy includes all requirements outlined by the Department relating to transportation of youth
and driver eligibility except the program’s policy does not include the requirement for staff to
notify the program for all driver violations outline by the Department. Current program policy
only requires staff to notify the program if their driver’s license is suspended or revoked. The
program stated they will update their policy to reflect notification for all required driver violations.
A review of the program’s policy and procedures, and interviews and observations completed
during the annual compliance review week, confirmed the program provides a program issued
cellular telephone for all transports. A transport was observed during the annual compliance
review week, and transport staff were found to abide by the transport policy and procedures,
and ratio was two staff to one youth, of which one staff was the same gender as the youth.
During the observed transport, all staff and youth wore seatbelts and the youth was not attached
to any part of the vehicle by any means other than the proper use of a seatbelt. The program is
not a secure program, nor was the observed youth being transported determined to be at
greater risk; therefore, a safety screen was not required. The program’s practice is human
resources completes driver’s license checks on all newly hired staff and subsequent checks
monthly to ensure all staff operating a program vehicle has a current driver’s license and
documentation confirmed this practice. Youth are not permitted to drive program or staff
vehicles. Five staff were interviewed and two had never completed a youth transport; therefore,
they could not articulate the procedures relating to youth transport. The remaining three staff
stated youth are secured within the vehicle by seatbelts and are handcuffed during transport
and the program provides radios and cellular telephones for all transport. The remaining three
staff also stated emergency equipment to include first-aid kit, window punch, and seatbelt cutter
are in the transport vehicles. All five interviewed staff stated staff cannot use their personal
vehicles to transport youth and all transport vehicles are searched for contraband prior to and
after each use. The three staff who had participated in transports were able to detail the
emergency response during vehicle transport and the required staff to youth ratio during vehicle
transport. Five youth were interviewed, and each youth confirmed they have never been
handcuffed to any part of the vehicle during transport, nor have they seen anyone place
contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Failed Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures which designates the facility administrator (FA) or
their designee as the person responsible for conducting weekly safety and security audits and
the implementation of any corrective action warranted as a result of any deficiencies found
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during the weekly audits. The program’s policy meets the requirements outlined in Florida
Administrative Code. The weekly safety audits are kept in a binder in the FA’s office. Findings
are discussed and a corrective action plan is implemented to fix any deficiency noted. During
the annual compliance review period, the program was missing weekly safety and security
audits for the last week of January 2025, the entire month of February 2025, and all except for
one week in March 2025. The completed audits documented safety repairs needed and the date
and time the repairs were completed, or due to be completed. All forms were reviewed and
signed by the FA. The forms include checks of radios, cameras, keys, telephones, mechanical
restraints, the generator, flashlights, fire safety equipment, alarms, anchor points, youth rooms,
recreation area, facility grounds, correction action needed, and corrective action completed. The
program could not provide a Preventative Maintenance Checklist for any weeks during the
annual compliance review period. A review of program deficiencies related to safety and
security during the annual compliance review period reflected a minor deficiency closed in April
2025 for logbooks. The interview with the FA confirmed the weekly safety audits are conducted
in accordance with program policy and procedures.
5.13 Tool Inventory and Management Limited Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing tool inventory and management. The
policy addresses the issuance, inventory, and control of equipment and tools. The policy
prohibits machetes, bowie knives, or other long blades from the facility. The program does not
keep any class A tools on-site; therefore, there is no inventory for sharp edged or pointed tools.
All class A tools are kept in a locked shed at a different program on the same campus. The
program does not have a kitchen on-site; therefore, the program does not have any kitchen
tools. The program’s policy for missing/lost tools includes logging incidents in the logbook,
stopping all youth movement, and conducting a search of facility and youth. The program has
not had any dysfunctional tools which needed to be disposed of and/or replaced; however,
policy states staff would report any dysfunctional tools to their immediate supervisor and the
supervisor would notify the physical plant manager and facility administrator (FA). The physical
plant manager is responsible for replacing and disposing of any dysfunctional tools. A review of
the program’s tool inventory was conducted. The inventory listed six types of tools kept at the
facility which are kept in a locked storage closet inaccessible to youth. Two tool quantities did
not match the inventory, nor were the tools marked for easy identification. The inventory listed
five toilet brushes; however, only two were found. The inventory listed two brooms; however, a
third broom was found in the administration offices of the facility. The remaining four tools
matched the inventory. An informal interview with program’s statewide compliance manager and
FA stated the program will occasionally share tools with another program on the same campus,
which likely resulted in inaccurate documentation on the inventory. Once this was brought to the
program’s attention, the program implemented a new protocol forbidding the sharing of tools or
chemicals with another program. The program is also hiring an inventory specialist who will be
responsible for all tool and chemical inventories. The program also restricted access to the tool
and chemical closet to only the FA and assistant facility administrator until the inventory
specialist is hired.
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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 policy and procedures addressing youth tool handling and supervision.
Policy includes all required elements and ratios. Youth are only authorized to use class B tools;
however, an informal interview with facility administrator (FA) and assistant facility administrator
confirm youth are not currently allowed to use any tools, including class B for cleaning. The FA
stated staff are the ones cleaning the dorms and utilizing class B tools and youth are just picking
up any garbage in the multi-purpose or dormitory rooms. An observation of youth utilizing tools
was unable to be made during the annual compliance review week due to none of the youth
currently being allowed to utilize tools. A review of five youth case management records
confirmed risk assessments were completed allowing youth to use tools for each youth and
each youth was trained on the intended and safe use of tools; however, currently the program is
not allowing youth to use tools. Five staff were interviewed and each staff confirmed youth are
not allowed to use any tools. Five youth were interviewed and three stated youth are not
allowed to use tools and two youth stated they can use mops and brooms only, and only when
they reach higher levels in the behavior management system.
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 policy and procedures addressing outside contractors. This physical plant
manager is responsible for monitoring all tools and sensitive items at the facility. The policy
states outside contractor tools are limited to only those necessary, all tools are checked upon
and prior to exiting the program, youth access to work areas must be restricted, and all
contractors must sign a written notification and attestation form and tool inventory list upon
arrival. The policy also includes a follow up if any tools are missing and restrictions on personal
cellular telephones and/or equipment capable of taking pictures or video recording; however,
the policy does not state who can authorize the use of these devices if required. Contractors are
escorted and supervised by the physical plant manager or designee any time they are within the
facility. The annual compliance review team was unable to observe this process during the
annual compliance review week due to no contractors being on-site during week. Three
contractor agreements and invoices were reviewed to ensure outside contractor agreements
were signed on the date of service. All contractor agreements were signed; however, one
invoice date of service did not match the date the contractor agreement was signed and one
invoice could not be found; however, a contractor agreement was signed. The remaining invoice
and agreement matched the date of service.
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5.16 Fire, Safety, and Evacuation Drills Failed 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 policy and procedures addressing fire, safety, and evacuation drills. A
review of Continuity of Operations Plan (COOP) drills revealed the program was not conducting
monthly drills on a rotational basis as required on each shift during the annual compliance
review period. The program did not complete any drills for February, March, April, and May
2025, and only completed COOP drills on one shift for January and June 2025. The program
completed seven drills to include fire, escape, and/or weather during the annual compliance
review period; however, drill scenarios did not describe what happened during the drill and who
participated. One drill did not include a sign-in sheet for the participants. The annual compliance
review team observed fire evacuation routes and egress plans posted throughout the facility.
The program has seven fire extinguishers which were inspected on November 14, 2024. Five
staff were interviewed, and four stated they had participated in drills in the past twelve months to
include fire, weather, emergency situations, and medical and mental health drills. One staff
member stated they had not participated in any drills. Five youth were interviewed, and each
confirmed they had been instructed on what to do in case of a fire and had participated in fire
drills. One youth stated fire drills are held monthly, two youth stated they are held twice a month,
and the remaining two youth stated they were held frequently. An interview with the facility
administrator reflected fire drills are to be held monthly, and COOP drills are to be conducted at
least semi-annually.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a policy and procedures addressing the Continuity of Operations Plan
(COOP). The program maintains a combined COOP and Emergency Disaster Preparedness
Plan. The policy states the COOP is in the facility administrator’s (FA) office, assistant facility
administrator’s (AFA) office, and master control, and observations during the annual compliance
review week confirmed this practice as well as confirming it is readily available to staff. The plan
addresses alternative housing plans approved by the applicable Department regional
director/designee. The COOP was last approved on March 26, 2025, and submitted to and
approved by the Department on March 28, 2025. The COOP addresses the following: fire
prevention and evacuation, severe weather, disturbances or riots, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The program has food and necessary supplies readily available in case of an
emergency evacuation, which are maintained off-site at another program location located on the
same campus, except for youth medications which are maintained on-site. Emergency
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equipment/supplies include bedding, pillows, extra clothing and undergarments, shoes, hygiene
items, batteries, plastic bags, first-aid kits, and drive away kits. The program maintains an
administrative hard copy file on all youth in case of emergency, with all required information
which are kept in the FA’s office. Five youth administrative hard copy files were reviewed which
confirmed this practice. An interview with the FA confirmed a copy of the COOP is in the FA’s
office, AFA’s office, and in master control.
5.18 Storage, Inventory, and Disposal of Flammable,
Limited 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 policy and procedures for the storage, inventory, and disposal of flammable,
poisonous, and toxic items and materials. The program’s policy does not include procedures for
disposal of chemicals. The program only keeps cleaning supplies on-site which are stored in a
locked storage closet inaccessible to youth. The physical plant manager, facility administrator
(FA), shift supervisors, and dietary workers are the individuals authorized to handle flammable,
poisonous, and toxic items and materials. A binder is stored with the chemicals containing the
Safety Data Sheets (SDS) for the items located in the storage closet. The program has a binder
with a chemical inventory and sign-in/sign-out sheet for any chemical usage. The program does
not have any flammable materials stored on-site; however, policy states any flammable
chemicals would be stored in a metal fireproof safety secured locker. The program did not have
any chemicals which required disposal during the annual compliance review period. An informal
interview with the physical plant manager confirmed if chemicals needed to be disposed of, they
would be returned to manufacturer or disposed of at the county waste disposal site and are in
accordance with the Occupational Safety and Health Administration standards. The program
does not have a kitchen; therefore, there is no kitchen grease needing disposal. The program’s
policy dictates the shift supervisor will be notified, not master control, in the event of a chemical
spill. The shift supervisor or master control would then direct the shut-down of all air handlers
and ventilation systems and close all windows and doors and assistance from outside the facility
would be contacted, as necessary, consistent with emergency procedures. An interview with the
FA confirmed the program’s practice. A review of eight chemicals was compared to the
program’s inventory. The program’s inventory listed only five chemicals on-site; however, a
review of chemicals found three chemicals in the storage closet not listed on the inventory. The
chemicals not listed on the inventory included thirteen bottles of bleach, one bottle of hand
sanitizer, and one bottle of cleaner. Two cleaning chemicals listed on the inventory were not
found in the storage closet. The remaining three chemicals listed on the inventory did not match
the quantities listed. All eight chemicals observed had an SDS sheet located in a binder in the
storage closet, except for one. The program’s statewide compliance manager added the
missing SDS sheet to the binder during the week of the annual compliance review. An informal
interview with program’s statewide compliance manager and FA stated the program will
occasionally share tools and chemicals with another program on the same campus, which likely
resulted in inaccurate documentation on the inventory. Once this was brought to the program’s
attention, program implemented a new protocol forbidding the sharing of tools or chemicals with
another program. The program is also hiring an inventory specialist who will be responsible for
all tool and chemical inventories. The program also restricted access to the tool and chemical
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closet to only the FA and assistant facility administrator until the inventory specialist is hired.
The program corrected the inventory to accurately reflect all chemicals on-site once notified by
the annual compliance review team.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handling and supervision of
flammable, poisonous, and toxic items and materials. The program’s policy prohibits youth
handling, using, or disposing of any dangerous/hazardous chemicals, bio-hazardous material,
bodily fluids, or human waste. All chemicals are stored in a locked storage closet inaccessible to
youth. The annual compliance review team was unable to observe youth during cleaning
activities involving chemicals due to youth not being allowed access to any chemicals, to include
during cleaning activities. An informal interview with the facility administrator confirmed youth do
not have any access to chemicals and even cleaning chemicals are only used when youth are
not in the room. An observation of youth cleaning activities during the annual compliance week
confirmed youth were tidying up the dormitories only and did not use or handle any tools or
chemicals. Five youth were interviewed, and each confirmed they have never handled any
chemicals to include cleaning supplies.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Limited Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation and communication. The
program’s visitation schedule is posted in the lobby of the facility. The program’s policy and
procedures are reviewed during orientation and are communicated to youth and parent/guardian
within seventy-two hours of youth’s admission to the program. Visitation will occur for two hours
unless prior authorization is approved by the facility administrator (FA). Policy states visitation
requests must be submitted to the case manager at least three days prior to visitation; however,
informal interviews with the case manager and FA, confirmed this is not required and will be
removed from program’s policy. Policy states any visitors or communication with youth must be
on the youth’s approved correspondence list which is maintained by the case manager. The
program’s policy also states mail is opened in front of youth and outgoing mail is searched prior
to leaving the facility. The program’s contract specifies the program is to provide visitation every
Saturday and Sunday. A review of the visitation log confirmed the program is only providing
visitation every other Saturday. A review of the program’s telephone log reflected telephone
calls are provided on Mondays and Wednesday for all youth for fifteen minutes. As youth
progress in the program, they can earn additional telephone calls. A review of the program’s
mail log and program policy confirmed mail can be sent any day; however, the program will
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provide postage and writing materials for two letters a week for each youth. Outgoing mail was
logged on the mail log; however, documentation did not indicate the outgoing mail had been
searched prior to leaving the facility. An informal interview with the program’s statewide
compliance manager and case manager confirmed outgoing mail is searched prior to leaving
the facility. Documentation confirmed youth can communicate with family members by mail
and/or telephone. The FA can provide alternative visitation arrangements with parent/guardian if
needed. The program confirms alerts and approved correspondence list for all youth with their
juvenile probation officer (JPO); however, the program is not specifically requesting clarification
from the JPO to verify parent/guardian and/or other family members are not currently or do not
have a history of investigation for human trafficking related charges for those youth who have a
history of human trafficking. The program has an agreement with a third-party language service
to provide translation services. Five youth were interviewed, and each youth confirmed they can
call and/or send a letter to their parent/guardian. An interview with the FA stated the program
does not have services in place for youth whose primary language is not English; however, the
FA clarified in an informal interview the program does have a third party translation agreement.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures to ensure the provision of recreation and
leisure activities to youth. The program’s policy requires recreation activities to be provided for a
minimum of one hour a day. The youth have a variety of recreation and leisure activities posted
on a recreation calendar which promote social and cognitive skill development, creativity,
teamwork, healthy competition, mental stimulation, and physical fitness. The program’s
schedule has structured indoor and outdoor recreation and leisure activities which includes
large muscle activity for a minimum of one hour each day. A review of the master control
logbook during the annual compliance review period indicated recreation was conducted as
scheduled. The program’s contract requires a recreation therapist. A review of documentation
confirmed the recreation therapist has the required credentials and is providing services as
stipulated in the program’s contract. A review of five youth mental health and substance abuse
records confirmed each youth record contained a wellness plan and which was incorporated
into their individualized treatment plan. Five youth were interviewed, and all five stated the
program allows them an opportunity to play outside and participate in physical fitness activities
for at least one hour daily. Five staff were interviewed, and four confirmed recreation is
occurring for a minimum of an hour a day and includes activities such as running, movies, spa
day, arts and crafts, and sports. The remaining staff member has never observed recreation or
leisure. Recreation was observed by the annual compliance review team which confirmed the
program takes precautionary measures to prevent overexertion, heat stress, dehydration,
frostbite, hypothermia, and exacerbation of existing illness or physical injury.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 68 of 69 (Revised August 2025)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 69 (Revised August 2025)

source: DJJ

program_name_raw: Tampa Bay Girls Academy- Moderate

rule: Indicator 1.06

rule: Indicator 1.16

excerpt: Special Contract Conditions

rule: Indicator 2.16

excerpt: Exit Conference

rule: Indicator 2.17

excerpt: Youth Input

rule: Indicator 2.19

rule: Indicator 3.13

excerpt: Suicide Prevention Training (Critical)

rule: Indicator 5.07

excerpt: Key Control (CRITCAL)

rating: Failed Compliance

rule: Indicator 5.12

excerpt: Weekly Safety and Security Audits

rule: Indicator 5.13

excerpt: Tool Inventory and Management

rule: Indicator 5.16

excerpt: Fire, Safety, and Evacuation Drills

rule: Indicator 5.18

rule: Indicator 5.21

excerpt: Visitation and Communication