summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Kissimmee Youth Academy
Youth Opportunity Investment, LLC]
(Contract Provider)
2330 New Beginnings Road
[Kissimmee], Florida [34744]
Review Date(s): January 28-January 31, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Danielle Penn, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Central Education Coordinator, (Standard 6)
Jillian Cumbo, Office of Education, Workforce Education Coordinator, (Standard 6)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Youth and
Staff Interviews)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Donovan Mobley, Bureau of Monitoring and Quality Improvement, (Standard 5)
Acasha Pressley, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Kieara Swan, Bureau of Monitoring and Quality Improvement, Standard 2
Sharon Wong, Office of Accountability and Program Support, Standard 2
Program Name: Kissimmee Youth Academy MQI Program Code: 1468
Provider Name: Youth Opportunity Investment, LLC Contract Number: 10287
Location: Kissimmee County / Circuit 9 Number of Beds: 95
Review Date(s): January 28-31, 2025 Lead Reviewer Code: 218
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and 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
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 72 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 72 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 72 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Satisfactory
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 72 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 72 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Satisfactory
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures 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 8 of 72 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Indicator Ratings
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) 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 9 of 72 (Revised September 2022)
Program Overview
Kissimmee Youth Academy is a ninety-five-bed program for fourteen-to-twenty-one-year-old
males located in Kissimmee, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides services
including high-risk Substance Abuse Overlay Services, high-risk Behavioral/Mental Health
Overlay Services (BHOS/MHOS), and maximum-risk BHOS/MHOS. The program fosters each
youth by providing delinquency intervention, gender specific services, and restorative justice
services. Additional treatment services provided include individual, family, and group therapy.
Program administration is comprised of one facility administrator, three assistant facility
administrators, one director of case management, one human resource/business manager, one
administrative assistant, one health services administrator, one food services manager, and one
clinical director/designated mental health clinician authority (DMHCA). Case management
services are provided by six case managers and one transition service managers. Mental health
staff at the program includes one contracted psychiatrist, one DMHCA, one licensed therapist,
eight mental health /substance abuse therapist, and one contracted behavioral analyst. Medical
services are offered daily and are provided by one health services administrator, six registered
nurses, and a contracted designated health authority who is a licensed medical doctor.
Educational services were being provided by the Osceola County School District for half of the
year until June 30, 2024; however, education services are currently being provided by Florida
Virtual School/Florida Scholars Academy. The layout of the program includes one self-contained
building with two wings separated by a common hallway which houses medical, staff offices, the
staff break room, and the administrative area. The program has 143 cameras providing
coverage, and all were operational at the time of the annual compliance review. At the time of
the annual compliance review, the program had fourteen vacant positions which included two
therapist, one case manager, one transition case manager, one shift supervisor, and nine youth
care specialists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 72 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a written policy and procedures to ensure all newly hired staff and volunteers
receive an initial background screening. The program had fifty-two newly hired staff and no
volunteers since the last annual compliance review. A review of the staff records showed each
of the fifty-two received a background screening prior to contact with youth and confidential
records. The documentation revealed a criminal history report was reviewed and the Staff
Verification System (SVS) module was updated on behalf of each of the fifty-two staff members.
The newly hired staff were added to the Clearinghouse Roster. None of the records reviewed
were applicable for obtaining an exemption prior to working with youth or for a break in services.
The program uses a pre-employment assessment tool for all direct care staff. The reviewed
documentation revealed each of the newly hired staff received a passing score on the pre-
employment assessment tool prior to being hired. All staff hired since the last annual
compliance review have a signed contraband attestation. The program did not have any new
volunteers or interns eligible for a background screening during the annual compliance review.
The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the
Department’s Background Screening Unit (BSU) on January 14, 2025, meeting the annual
requirement. The Department of Education’s annual background screening for the teachers was
submitted on January 18, 2025.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a written policy and procedures in place to ensure all staff and volunteers
receive a background rescreening and renewal every five years from their initial hire date. The
program’s administrator tracks each staff’s hire date and intern/volunteer start dates to establish
when the five-year rescreening should be submitted. The program had six staff applicable for
the five-year rescreening since the last annual compliance review. Each staff’s rescreening was
completed and submitted to the Department’s Background Screening Unit before their
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 72 (Revised September 2022)
anniversary date. Each rescreening was completed at least ten business days prior to each
staff’s five-year anniversary. There were no volunteers or interns applicable for a five-year
rescreening since the last annual compliance review.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a written policy and procedures to ensure an environment free of abuse and
neglect and in which the youth and staff feel safe and secure. The policy reflects youth and staff
have unhindered access to reporting allegations of abuse to the Florida Abuse Hotline. The
policy outlines the reporting procedures for staff to follow when a youth would like to make an
abuse call. The program maintains an employee handbook which outlines the program's code of
conduct. All staff are required to sign and acknowledge receipts of the employee handbook and
code of conduct which outlines the grievance policies and their understanding of the program’s
code of conduct. A review of nine staff records found each record contained documentation of
acknowledgement, receipt, and review of the program’s code of conduct. Observations
conducted during the annual compliance review revealed postings of the Florida Abuse Hotline
and the Department’s Central Communication Center (CCC) throughout the program. The
program’s practice for when a youth request to call the Florida Abuse Hotline is to have the
youth care worker contact the shift supervisor on the radio, and then the shift supervisor takes
the youth to place the call. The program completed the Trauma Response and Caring
Environment (TRACE) self-assessment for Mental Health Overlay Services and Substance
Abuse Treatment Overlay Service programs on August 8, 2024. The program did not have any
reportable incidents since the last annual compliance review. There were no applicable cases
for any potential human trafficking victims, children of sexual exploitation, or labor trafficking
reported at the time of the annual compliance review. Five youth were interviewed, and each
reported never being stopped from reporting abuse to the Florida Abuse Hotline or the CCC.
Each youth knew where the telephone numbers were posted. The four youth reported staff are
respectful when speaking with them and one reported some staff are not respectful. All five-
youth reported they have never exchanged personal contact information with staff. Four youth
reported never hearing staff use profanity when speaking to youth and one reported once. All
five interviewed youth reported feeling safe in the program. Five staff members were
interviewed. The staff explained the process for allowing staff and youth to call the Florida
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 72 (Revised September 2022)
Abuse Hotline or the CCC to report suspected abuse. All interviewed staff reported they either
knew or had access to the numbers for the Florida Abuse Hotline and the CCC. All interviewed
staff reported they never observed a co-worker use profanity when speaking to youth and never
observed a co-worker telling a youth they could not make an abuse call. An interview with the
facility administrator (FA) explained staff alleged of abuse are removed from youth contact
pending an investigation and depending on the severity of the incident, the staff can be
terminated on the first offense. The FA reported the program completed the TRACE
assessment and staff are trained on trauma responsive care. The FA reported when a youth
request to make an abuse call the shift supervisor will take the youth to go and place the call.
1.04 Management Response to Allegations (Critical) Non-Applicable
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had no allegations of physical, psychological, or emotional abuse in the program
during the annual compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a written policy and procedures in reference to the reporting of incidents
in accordance with Florida Administrative Code. The program had thirty-eight reportable
incidents since the last annual compliance review. A review of five incidents found all were
reported to the Department’s Central Communications Center (CCC) within two hours of the
incident or staff becoming aware of the incident. All five incidents were documented in the
program’s logbook. A review of the program’s internal incident reports found there were no
additional incidents which should have been reported to the CCC and were not. The program
has experienced a decrease in the number of reportable incidents to the CCC since the last
annual compliance review. An informal interview with the program’s facility administrator (FA)
confirmed the program has a policy in reference to the CCC and ensures all matters which
require reporting are verbally reported within the two-hour timeframe when the program
becomes aware of the incident.
1.06 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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 72 (Revised September 2022)
The program has a written policy and procedures in reference to the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had three
Right Interactions (RI) incidents since the last annual compliance review. There was
documentation to support a monthly summary of RI Reports was submitted to the Department
each month since the last annual compliance review. A review of the three RI Reports found all
involved staff completed appropriate statements prior to the end of their shift. The RI Reports
were reviewed and processed within seventy-two hours by all required parties. Documentation
supported copies of the PAR/RI Reports were reviewed and placed in the program’s RI binder
within forty-eight hours of each approved incident. The program’s RI Plan was approved by the
Department’s Office of Talent, Leadership, and Culture on December 22, 2023. The program
experienced a decrease in the number of RI Reports compared to the last annual compliance
review period. The program’s PAR/RI rate during the first quarter was zero, which is below the
statewide Residential PAR/RI rate of 1.71. Five staff were interviewed, and all were aware of the
program’s RI practices. An interview with the facility administrator (FA) revealed the staff
completes a RI report and submits the report to the FA for review, All reports are filed in
accordance with Florida Administrative Code.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a written policy and procedures regarding a pre-service training plan for all
new hires. The pre-service training is provided through a combination of instructor-led and web-
based courses. Nine staff training records were reviewed for pre-service certification training. All
nine records documented each staff completed the certification process within 180 days of hire.
Eight staff training records showed documentation to support each staff exceeded the required
120 hours of pre-service training and one staff was previously employed and returned to the
program as a supervisor. The completed trainings included Right Interactions (RI), first-aid,
cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), professionalism
and ethics, suicide prevention, emergency procedures, child abuse reporting, Prison Rape
Elimination Act (PREA), and program operation procedures prior to having any contact with
youth. Additional trainings such as active shooter preparedness, adolescent development and
behavior, balanced approach to restorative justice, the Department’s Central Communications
Center incident reporting, civil rights, communication, confidentiality/Health Insurance Portability
and Accountability (HIPAA), The Department of Juvenile Justice legacy/history, equal
employment opportunity, gang awareness, human trafficking intervention, infection
control/bloodborne pathogens, information security awareness, Juvenile Justice Information
Systems (JJIS), mental health and substance abuse, Motivational Interviewing, quality report
writing, safety, security, and supervision of youth, sexual harassment, effective and respectful
treatment of youth, trauma responsive practices, grievance process, Infection Control/Exposure
Control Plan, behavior management system, intended and safe use of tools, Mental Health
Overlay Services, Substance Abuse Treatment Services, and Substance Abuse Overlay
Services were completed. The program utilizes a specialized training plan and thirty-two hours
of job specific training for safety and security specialists. The program has one staff who
returned as a supervisor with less than one year of separation. Upon the return, the new
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 72 (Revised September 2022)
supervisor completed the active shooter preparedness, CPR/first-aid/AED, human trafficking
intervention, information security awareness, mental health and substance abuse, PREA, RI
update, professionalism, interpersonal communication and ethics, sexual harassment, suicide
awareness and prevention, and trauma responsive practices. The two hired supervisory staff
completed thirty hours of training in
coaching, leadership, and personal accountability. The program considers case managers,
operations managers, and assistant facility administrators (AFA) as direct care staff and they
are included in the staff-to-youth ratio. All the completed trainings were delivered by qualified
trainers and documented in the Department’s Learning Management System (SkillPro).
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written policy and procedures in reference to in-service training for all staff.
Nine staff training records were reviewed for in-service training. All nine reviewed staff training
records indicated each staff exceeded the twenty-four hours of annual in-service training
requirements. The nine staff had current certifications in Right Interactions (RI). Each staff
member had certifications in first-aid, automated external defibrillator (AED), and
cardiopulmonary resuscitation (CPR). Each of the four applicable staff completed the eight
hours of management/supervisory training in the areas of coaching, leadership, and personal
accountability. The program’s therapists completed training in The Seven Challenges, Living in
Balance, Skillstreaming the Adolescent, and Male Healthy Relationships, which are the life skills
groups the program has in place. Additional trainings such as active shooter preparedness and
CPR/first-aid/AED were completed. Additionally, human trafficking Intervention, information
security awareness, mental health and substance abuse, and Prison Rape Elimination Act
(PREA) were completed by the staff. The staff were currently RI certified. The staff all received
professionalism, interpersonal communication and ethics training as well as sexual harassment,
suicide awareness and prevention, trauma responsive practices, emergency response, blood-
borne pathogens, the Exposure Control Plan, Mental Health Overlay Services, Substance
Abuse Treatment Services, and Substance Abuse Overlay Services training. The program’s
emergency drills are conducted quarterly on each shift. The program has a training calendar
which is updated whenever changes occur. All trainings were conducted by qualified trainers
and were documented in the Department's Learning Management System (SkillPro). The
program has a written in-service training plan which was approved and signed by the facility
administrator (FA), the assistant secretary for Residential Services, and the director of Talent,
Leadership, and Culture.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 72 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures regarding their grievance process. Based on
the program’s policy, procedures are in place to confirm each youth’s right to grieve and to
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. The program’s grievance procedures include informal, formal, and appeal phases
with a time frame of two days to provide feedback to the youth and to correct the grieved
situation or condition. The youth are provided with the opportunity to file an alternate informal
request by using a “Request to Speak” form as their first option to voice an objection and
informally resolve a complaint. The grievance and “Request to Speak” forms were available to
the youth and present on each living unit as observed during the program tour. The reviewed
documentation indicated there were no grievance forms submitted by youth since the last
annual compliance review. Nine staff records were reviewed for in-service and pre-service
training. Each staff received the required training on the program’s grievance process and
procedures. Five youth and five staff were interviewed during the annual compliance review. All
five youth and staff were able to explain the grievance process.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program has a written policy and procedures for delinquency interventions and facilitator
training. The program provides Life Skills Training (LST) and Trauma Focused-Cognitive
Behavioral Therapy (TF-CBT) groups to the youth. A review of the program’s activity schedule
and sign-in sheets confirmed youth were participating in the groups. The program has four
group facilitators and all of them had a master’s-level degree or licensed mental health
counselor credentials and were trained to facilitate groups. The program’s activity schedule was
reviewed and verified all contractually required groups were provided as scheduled. A review of
the program’s activity schedule confirmed the program is providing structured, planned
programming, or activities at least sixty percent of the youth’s awake hours. An interview with
the facility administrator (FA) indicated the program provides groups and all youth participate in
daily group sessions which are facilitated by a trained mental health professional. An interview
with the program’s clinical director verified the staff’s education and work experience was
considered when determining staff delivery of intervention services.
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Office of Accountability and Program Support Page 16 of 72 (Revised September 2022)
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures in place to address life skills training for
youth. The program provides life skills training through Life Skills Training (LST) groups and as
well as health and hygiene skills. The life skills group specifically addresses communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
and critical thinking. A review of the program’s activity schedule confirmed the LST group is
provided to the youth once a week by the therapist and all the staff conducting group activities
have received formal training and on-the-job training by a certified trainer to deliver the
curriculum. A review of nine youth case management records and group sign-in sheets
indicated services were delivered as required. Five youth were interviewed and reported they
participate in life skills groups while at the program. All five-youth reported they were able to
demonstrate the skills during role playing activities in groups. An informal interview with the
clinical director indicated youth can practice skills in group, role play activities, learn how to
handle situations in a positive way, and how to interact better with staff and other youth daily
while at the program.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s restorative justice programming includes Impact of Crime (IOC) groups, which is
a primary service. The youth participate in reparation activities at the program. The program
administrators explained youth regularly participate in community service projects, faith-based
activities, making breast cancer ribbons, assisting maintenance staff with cleaning of the
program’s recreation yard, assembling hygiene packages/kits for the local homeless shelter,
and listening to guest speakers as part of their restorative justice activities. The groups and
activities are designed to assist youth in accepting responsibilities for harm they have caused by
their past criminal actions, challenging them to recognize and modify their irresponsible thinking
such as denying, minimizing, rationalizing, and blaming victims, and expose youth to victims’
perspectives through victim speakers. The interviewed facility administrator (FA) reported
restorative justice programming included youth painting living unit rooms, walls, and cleaning
the program of debris. An interview with the designated mental health clinician authority
explained restorative justice is provided throughout the week from different group projects or
activities at the program. The program did not have youth participating in restorative justice
activities during the week of the annual compliance review; therefore, an observation was not
made. Five youth were interviewed, and they reported they participate in restorative justice
groups/activities while at the program.
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Office of Accountability and Program Support Page 17 of 72 (Revised September 2022)
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a written policy and procedures to address youth alerts. The program enters
alerts into the Department’s Juvenile Justice Information System (JJIS) for youth requiring an
alert which may not have been entered prior to the youth’s admission. The program has an alert
board in the main conference room, which identifies each youth’s special alerts, escape risk,
mental health alerts, and/or gang affiliation. The reviewed documentation revealed the
program’s internal alert report is reviewed daily during shift briefings by the program’s
supervisory staff. Observations verified the kitchen staff had access to each youth’s diet and
allergy alerts. Nine youth records were reviewed for case management, medical, mental health,
and substance abuse alerts. All applicable alerts were accurately entered into JJIS. All internal
and JJIS alerts were downgraded or discontinued by a medical staff, the director of case
management, and/or licensed mental health staff. Five staff were interviewed, and each
reported they are informed of youth alerts by reviewing the program’s alert board, during shift
meetings, and by reviewing the medical binder. An interview with the facility administrator (FA)
indicated all internal alerts are entered into JJIS, updated, and provided to the shift supervisor
daily. The program’s FA stated youth alerts are reviewed daily during morning management
meetings and any changes in medical alerts are emailed to all staff. The nursing interview
indicated the nurses are responsible for updating the medical alert system.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, the company philosophy, goals, objectives, and the
legal and contractual requirements. A review of nine youth healthcare, mental health and
substance abuse, and case management records showed each was marked “Confidential” and
each record documented the youth’s name, Department identification number (DJJID), the
youth’s date of birth, county of youth’s residence, date of admission, and committing offenses.
Observations during the annual compliance review week showed all Individual Healthcare
Records, mental health and substance abuse records, and case management records were
secured in a locked room, which was not accessible to youth.
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Office of Accountability and Program Support Page 18 of 72 (Revised September 2022)
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board which meets on a quarterly basis. The reviewed
documentation supported the program’s community advisory board meets at least quarterly.
The reviewed meeting minutes, sign-in sheets, and agendas documented the meetings
occurred on March 6, June 12, September 11, and December 11, 2024. The next meeting is
scheduled for February 6, 2025, and the program’s next family day is scheduled for March 1,
2025. The documentation showed the community advisory board meetings are held virtually,
with a standing conference call in number. The advisory board member consists of a member
from the law enforcement community, a judiciary community member, interested community
partners, a community business member, a school board member, a victim advocate, a
parent/guardian whose child was previously involved in the juvenile justice system, and a faith-
based community member. A review of community advisory board agendas and meeting
minutes documented the program provides the board members with the information regarding
program updates, community updates, and community service activities. An interview with the
facility administrator (FA) reported the program meetings are held quarterly. The program’s FA
reported invitations are sent to community members by mail and email with a calendar invite
and a follow-up call for confirmation is made if a response is not received from the invites. This
practice is a recruitment effort to increase attendance. Two advisory board members were
called during the annual compliance review and messages were left for both members;
however, no one returned the call.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program completes ninety-day performance evaluations for newly hired staff and annual
evaluations for all staff thereafter. Nine staff personnel records were reviewed, and the
performance evaluations were specific to each staff’s job description. All nine reviewed
performance evaluations found each staff’s evaluation was based on the performance
standards for their position. The evaluations rated the staff’s quality of work, modeling of
appropriate behavior, positive reinforcement in a four-to-one ratio, and each evaluation included
ratings on the staff’s job-specific responsibilities. Five staff were interviewed in regard to their
performance evaluations. Three staff have received an annual performance evaluation and two
have received a ninety-day performance evaluation. An interview with the facility administrator
(FA) reported the staff are evaluated after their first ninety days and annually, thereafter, on their
job performance.
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Office of Accountability and Program Support Page 19 of 72 (Revised September 2022)
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract is an older contract and did not clearly identify any special conditions
within the Memorandum of Negotiation (MON) except for an increased budget. A review of the
program’s contract reflected certain conditions specific to the program included special
visitations, religious offerings, resources for expectant fathers, and gas cards for families. The
program conducts special visitations and family sessions through a virtual platform for
parents/guardians who are unable to visit the program. The program partners with a faith-based
organization to come on-site twice a month to provide church services to the youth. Additionally,
when a youth is an expectant father, the program will assist the youth in having an opportunity
to view their child’s birth through video conferencing. The program provided gas cards to
parents/guardians who needed assistance with attending family day due to financial barriers
since the last annual compliance review.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a written policy and procedures which includes data trend analysis
components. The program’s administration and management discussed research efforts to
enhance operations and contribute to the base knowledge of the Department’s practice. The
program’s quality assurance policy is designed to objectively and systematically monitor and
evaluate program outcomes and ensure the program services are consistent and effective. The
provider has development processes, research, and analytics which they incorporate into all
their programs. According to the facility administrator (FA), the program conducts interviews
with families and youth, tracks outcome measures, monitors incident reports, conducts fidelity
monitoring, tracks evidenced-based services, and performs quality improvement audits. The
program has several data collection reports, to include monthly incident report trackers, monthly
key performance indicators, and survey analysis reports. Documentation showed data is shared
through monthly monitoring and verification meetings where the program’s administration
provides response and measure to address any identified trends with the corporate team. The
program staff are made aware of data trend reports monthly during all staff meetings. The
program’s FA is responsible for completing any follow-up needs identified on the data trends
monthly reports and submitting the required update to the corporate team. For example, if
trends are identified on a particular shift, the program’s FA can target those particular time
frames for management to focus more on those areas. Survey results provide opportunities to
target identified areas such as staff morale or youth input.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a policy and procedures ensuring initial contact with parents/guardians
and court notification. A review of nine youth case management records confirmed the program
notified the parent/guardian by telephone within twenty-four hours of admission. Each reviewed
record confirmed the program notified the parent/guardian in writing within forty-eight hours of
the youth's admission. Each record confirmed the court, juvenile probation officer (JPO), and
applicable post-residential counselor 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 maintains a written policy and procedures regarding youth orientation. A review of
nine youth case management records revealed the program provided each youth an orientation
on the day of admission. During the annual compliance review week, an observation of
orientation could not be completed due to orientation occurring early in the morning or late at
night. An informal interview with the compliance director and reviewed documentation verified
the orientation practice included services available, daily schedule, expectations and
responsibilities of the youth, written information on the program's behavior management system,
including rules governing conduct and positive and negative consequences for behavior,
information on how to access medical and mental health services, access to the Florida Abuse
Hotline, or the Department's Central Communications Center (CCC) if the youth is over eighteen
years of age, the program's zero-tolerance policy regarding sexual misconduct, including how to
report incidents or suspicions of sexual misconduct, special accommodations which are
available to ensure all written information about sexual misconduct policies, including how to
report sexual misconduct, the right to be free from sexual misconduct, the right to be free from
retaliation for reporting such misconduct, the agency's sexual misconduct response policies and
procedures, and items considered contraband, including illegal, prohibited items in which
possession may result in the youth being prosecuted. Additionally, the youth orientation
included information on the performance plan process, dress code and hygiene requirements,
procedures regarding visitation, mail, and use of the telephone, expectations for release from
the program, including the youth's successful completion of individual performance plan goals,
recommendation to the court for release based on the youth's performance in the program and
the court's decision to release, community access, grievance procedures, emergency
procedures, including procedures for fire drills and building evacuation, a program tour and a
general layout of the program, which focuses upon areas which are not accessible to youth,
assignment to a living unit, room, treatment team, and a staff advisor or youth group.
Information is conveyed verbally to youth with limited reading skills or who are visually impaired,
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Office of Accountability and Program Support Page 22 of 72 (Revised September 2022)
deaf, or otherwise disabled. Five youth were formally interviewed. All five youth reported the
required orientation information was presented to them.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures to address the written consent of youth
eighteen or older. Nine youth case management records were reviewed for written consent from
youth eighteen or older. Three case management records were applicable and all three youth
case management records included documentation of a written consent which was obtained for
each youth upon entering the program, if already eighteen, or if the youth turned eighteen while
in the program.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program maintains a policy and procedures regarding the classification process for youth
upon admission to the program and completion of reassessments as warranted. A review of the
program's classification form revealed the form included physical characteristics of the youth,
age, and maturity level, identified special needs, history of violence, gang affiliation, criminal
behavior, sexual aggression or vulnerability to victimization, youth's perception of vulnerability,
youth's history of potential or verified human trafficking, suicide risk, medical risk, escape risk,
and security risk. Nine reviewed youth case management records confirmed each contained an
Admission Classification form which included all required elements outlined in the Department's
policy. One youth case management record had suspected risk factors, which included suicide
risk. Four youth had medical risks. There were no escape risks, and three had security risks. A
review of the Department's Juvenile Justice Information System (JJIS) and the program's
internal alerts showed no issues affecting each youth's classification. Each youth was classified
for assignment to a living area, sleeping room, and youth group or staff advisor. Medical, mental
health, substance abuse, security risk factors, and/or special needs identified during or after the
classification process are immediately entered into the program's internal alert system and JJIS.
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Office of Accountability and Program Support Page 23 of 72 (Revised September 2022)
Nine reviewed youth case management records revealed each had reclassifications completed
prior to considering an increase in the youth's 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. No youth were able to participate in off-campus activities. A
review of the program's policy and procedures clearly outlined the classification process and
included a classification system to promote safety and security, as well as effective delivery of
treatment services, based on the determination of each youth's individual needs and risk
factors, which addresses, at a minimum, items outlined in Florida Administrative Code. The
program's policy regarding reassessment states youth may be reclassified at intervals
throughout their stay. Staff shall reclassify youth when warranted based upon changes in the
youth's supervision status, new or updated alerts, behavioral concerns, and relevant information
to the treatment team to ensure the safety and security of the youth and program. Examples
requiring reclassification may include living unit or room assignment change, assignment to
work projects or activities which involve tools or instruments which may be used as potential
weapons or means of escape, and prior to the level change, increase in youth privileges and
advancement or freedom of movement. An interview with the facility administrator reported all
youth participated in an admission classification meeting at intake. All factors, such as mental
health, physical health, age, prior victimization, gang involvement, behavior demonstrated at
intake, and size, are discussed to determine the appropriate room assignment. The admission
classification forms are maintained in each youth’s case management record.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program maintains a written policy and procedures regarding gang identification and
notification to law enforcement. A review of nine youth case management records revealed
three youth were applicable for notification to law enforcement due to suspected gang affiliation.
All three applicable youth records had documentation the program notified local law
enforcement of suspected gang activity. The reviewed documentation confirmed all three youth
records included documentation verifying the youth’s residence. Local law enforcement was
notified of suspected gang affiliation prior to the Monitoring and Quality Improvement (MQI)
seven-day notice. All gang alerts were maintained in the program’s internal alert system and the
Department’s Juvenile Justice Information System (JJIS) and updated as required upon
notification. Each reviewed record confirmed the educational provider at the residential program
and the youth’s assigned juvenile probation officer (JPO) were notified of the youth’s status.
Two of the three youth were applicable for having a post-residential service provider, and each
was notified as required.
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Office of Accountability and Program Support Page 24 of 72 (Revised September 2022)
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a written policy and procedures regarding gang prevention and
intervention strategies. Nine youth case management records were reviewed, and three were
applicable for being identified as a gang member or affiliated. Each case management record
validated the youth participated in gang prevention and intervention strategies. The program
provides Impact of Crime (IOC) groups, Gang Prevention 50+ Stories of Fractured Lives, and
reproductive worksheets. The program maintains sign-in sheets to document youth participation
in gang prevention and intervention activities conducted at least once a month. A review of the
program’s policy and procedures included provisions for developing a plan if youth choose to
disaffiliate from a gang. The interviewed facility administrator (FA) reported gang intervention
activities are implemented when youth are identified as being in a criminal street gang or are at
high-risk of involvement. The FA reported the youth participate in monthly gang and
intervention/prevention services. The curriculum is provided to youth by choice. Youth are
usually given an assignment to complete and submit to the program gang liaison. Additionally,
all youth participate in the IOC groups.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program maintains a written policy and procedures regarding Residential Assessment for
Youth (RAY) and RAY reassessments for youth in the program. The RAY was completed within
thirty days in the nine youth case management records reviewed. Each initial assessment was
maintained in the Department’s Juvenile Justice Information System (JJIS). Each of the nine-
youth case management records showed a RAY reassessment was completed after completion
of the initial RAY; however, three youth reassessments were late. One youth RAY
reassessment was completed twenty-three days late, one was three days late, and one was
completed nineteen days late. Four of the nine youth case records were applicable and
documented the youth’s reassessment had reassessments completed when deemed necessary
by the intervention and treatment team to effectively manage the youth’s case. All reassessment
documentation was maintained in the youth’s official case record.
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Office of Accountability and Program Support Page 25 of 72 (Revised September 2022)
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program maintains a written policy and procedures regarding the completion of the Youth
Needs Assessment Summary (YNAS). Nine youth case management records were reviewed,
and documentation confirmed each youth’s YNAS was completed within thirty days of
admission. All nine youth’s YNAS reports were documented in the Department’s Juvenile
Justice Information System (JJIS). Reviewed documentation verified each youth’s top three
criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program maintains a written policy and procedures outlining performance plan
development, goals, and transmittals. Nine youth case management records were reviewed. All
nine youth case management records documented the Individualized Performance Plans (IPPs)
were developed within thirty days of the youth's admission and developed after the completion
of the initial Residential Assessment for Youth (RAY) and the Youth Needs Assessment
Summary (YNAS). Each reviewed IPP was developed and signed by the treatment team leader,
youth, administrative representatives, living unit representatives, treatment staff, education staff,
the Department of Children and Families (DCF) counselor, when applicable, and all parties
responsible for goal completion. Reviewed documentation confirmed each of the nine
completed IPPs were mailed to the youth's parent/guardian requesting a signature; however,
none were returned to the program. Each of the nine applicable IPPs had the signature sheet
attached to the original performance plan, which were filed in the youth’s official case
management record. Each reviewed IPP included individualized goals based on the prioritized
needs identified during the initial assessment. Nine IPPs addressed the youth's top three
criminogenic needs. Six records specified delinquency interventions, four records included
targeted court-ordered sanctions which could be reasonably initiated and/or completed while in
the program, and seven records were applicable for and included transition activities targeted
for the last sixty days of the youth's anticipated stay. All nine youth records outlined program
staff responsibilities to enable youth to complete goals and target dates to accomplish the goals.
All nine youth case management records reviewed found the IPP’s were mailed to the youth's
committing court, juvenile probation officer (JPO), and parent/guardian. One youth was involved
with the Department of Children and Families (DCF); therefore, the IPP was sent to the youth's
case manager within ten days of completion. Five interviewed youth reported they participated
in developing their IPP, were knowledgeable of their current IPP goals, and reported receiving a
copy of their plan.
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Office of Accountability and Program Support Page 26 of 72 (Revised September 2022)
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program maintains a written policy and procedures regarding revisions to a youth’s
performance plan. Nine youth case management records were reviewed for a Residential
Assessment for Youth (RAY) reassessment and three were not applicable. Six records included
documentation a reassessment was completed due to newly acquired information, and five
youth demonstrated progress towards completing a goal. Each Individualized Performance Plan
(IPP) revision was completed when the Residential Assessment for Youth (RAY) reassessment
results warranted and/or the youth demonstrated progress toward completing a goal. Two of
nine records were applicable for the youth demonstrating a lack of progress toward completing
a goal, and revisions were made. Seven of the nine reviewed IPPs were applicable and had
revisions made when needed to facilitate transition activities during the last sixty days of a youth
stay. A review of nine youth case management records reflected each IPP had incorporated
mental health treatment, recreation, vocation, and academic goals into the plan. Each goal
included the person responsible for assisting the youth to complete the goal successfully. One
of the nine youth records was applicable for being in the custody of the Department of Children
and Families (DCF), and/or Agency for Persons with Disabilities (APD) and documentation
supported the program's incorporation of the case plan into the youth’s IPP.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program maintains a written policy and procedures outlining the completion of Performance
Summaries and transmittals. Nine reviewed youth case management records confirmed
Individualized Performance Plans (IPPs) were completed with documented completion dates.
Six Performance Summaries were completed and three youth were still within the initial ninety
calendar days from admission. One summary was three calendar days late, and one summary
was five calendar days late. Six youth were applicable for a Performance Summary preparation
prior to the youth’s release, discharge, or transfer from the program, and three were not in
transition. The six reviewed applicable Performance Summaries included the youth’s status on
each performance plan goal, youth’s overall treatment progress, youth’s behavior, level of
motivation/readiness to change, interaction with peers, interaction with staff, overall behavior
adjustment to the program, and significant positive and negative events. One of the six records
did not include the youth’s academic status. Each youth’s Performance Summary included
documentation confirming the youth was allowed to read and add comments prior to signing, a
copy of the summary was provided, and the original summary was filed in the youth’s case
management record. Each reviewed summary was signed and dated by the treatment team
leader, facility administrator or designee, and youth. Each summary was sent to the committing
court, youth’s assigned juvenile probation officer (JPO), parent/guardian, and the Department of
Children and Families (DCF) case manager within ten working days.
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Office of Accountability and Program Support Page 27 of 72 (Revised September 2022)
Three reviewed closed case management records confirmed release summaries included a
copy of the youth’s original summary, along with justification for release, sent with the Pre-
Release Notification (PRN) to the JPO at least forty-five days prior to the youth’s planned
release date. A signed copy was retained in each of the youth’s case management records.
None of the three youth were applicable for the court objecting to the youth’s release. Reviewed
documentation confirmed, once approved, the program provided written notification to the
youth’s parent/guardian regarding the planned release. Each was applicable for the completion
of an exit Residential Assessment for Youth (RAY). One youth was missing the exit RAY, which
was acknowledged by the program. None of the youth were applicable for the Sexually Violent
Predator Program (SVPP) or victim notification.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures regarding parental involvement in case
management services. Documentation supported the program's efforts to include the
parents/guardians in the assessment process, participation in the development of the youth’s
performance plan and progress reviews, provided advanced notice of formal treatment team
meeting dates and times, and transition planning. If parents/guardians are unable to attend, they
are given the opportunity to participate by telephone/video conferencing or provide
verbal/written input to the meetings. During the week of the annual compliance review,
observation of a treatment team meeting confirmed the program’s practice of having the
parents/guardians participate by telephone. The program reaches out to parents/guardians to
facilitate involvement through monthly meetings, treatment team invitations, weekly phone calls,
and family days. An interview with the facility administrator revealed the case management
process is explained to the parent during intake. They are provided a parent/guardian/youth
handbook by mail with the parent/guardian notification letter. Monthly treatment team letters are
mailed with the treatment team review and the parent/guardian is provided with the date/time of
the next treatment team. During informal and formal treatment team reviews, an attempt is
made to reach the parent/guardian by phone. When the program is completed, the
parent/guardian is invited to a quarterly family day by letter. Five youth were interviewed and
asked if their parent/guardian was involved in their case management activities. Four youth
reported calling their parents/guardians for treatment team meetings and one reported
participating in family sessions on the phone with the therapist.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program maintains a written policy and procedures regarding treatment team meetings.
Nine reviewed youth case management records confirmed formal treatment team meetings
were held every thirty days for each youth and informal meetings were held bi-weekly, as
required. Reviewed documentation for each of the formal treatment team review meetings
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included the youth’s name, date of review, all required attendees, parents/guardians who
attended by phone, any comments from treatment team members, a brief synopsis of the
youth’s progress in the program, performance plan revisions, progress on performance plan
goals, positive and negative behaviors, and behaviors resulting in physical interventions, if
applicable. Each youth was given the opportunity to demonstrate skills acquired in the program
and treatment progress. Reviewed documentation confirmed nine youth’s formal treatment
review meetings included the Residential Assessment for Youth (RAY) reassessment results.
Reviewed documentation for seven informal treatment team meetings confirmed reviews were
held bi-weekly each month. Bi-weekly informal meetings were alternating formal treatment team
meetings. Seven of nine youth were applicable for the informal treatment team review meetings
which included the youth’s name, date of review, required attendees, any comments from
treatment team members or others, brief synopsis of the youth’s progress in the program,
applicable performance plan revisions, progress on performance plan goals, positive and
negative behaviors, applicable behaviors resulting in physical interventions, and treatment
progress. All informal treatment team meeting documentation was contained in the youth’s
record. The youth’s assigned juvenile probation officer (JPO), parent/guardian, and other
pertinent parties were invited and encouraged through advance notification to participate and if
participation could not be arranged, the opportunity to provide input was provided. During the
week of the annual compliance review, an observation of a treatment team meeting confirmed
all required parties were present. Five youth were interviewed regarding treatment team
meetings. One youth reported speaking with their therapist and going over the information in
treatment team. One reported telling the staff about things and staff asking them questions. One
reported writing on papers about how they are doing and what they are working on. One
reported writing something down on paper and informing the staff they wanted to get their high
school equivalency diploma and work on self-control. One reported speaking about what stage
of change they think they are in at the program and what they have learned.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program maintains a written policy and procedures addressing transition planning,
conferences, and the Community Re-Entry Team (CRT). Three closed youth case management
records were reviewed, and each youth's transition conference was held at least sixty days
before the targeted release date. All required and applicable treatment team members, including
the youth, treatment team leader, and the facility administrator (FA) or designee, attended the
transition conference in each of the reviewed youth case management records. Each reviewed
record documented the youth’s juvenile probation officer (JPO), parent/guardian, education
staff, and other pertinent parties were invited to attend the transition conference. All required
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parties participated either in person or by telephone. None of the reviewed youth were
applicable for the attendance of a human trafficking-specific service provider. Each transition
conference included a review of transition activities on the youth’s performance plan, targeted
completion dates, persons responsible for completion, and other pertinent transition activities.
Reviewed documentation validated the treatment team leader obtained attendees’ dated
signatures representing their acknowledgment of the transition goals and accountability for
completion. A copy of each plan was mailed with a request for return with a signature to the
parent/guardian and JPO. Each record confirmed the CRT meeting was conducted prior to the
youth’s release and both the youth and case manager participated in the CRT meeting.
Reviewed documentation confirmed there was evidence of an invitation to participate in the
CRT meeting by email.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures addressing the assembly of an exit
portfolio to assist each youth once the youth is released back into the community. Three closed
youth records were reviewed, and each youth’s exit portfolio was discussed during the transition
conference. All three reviewed case management records included a state-issued identification
card, a copy of the youth’s transition plan, a calendar with all dates, times, and locations of
upcoming community appointments, and there were no copies of a Social Security card.
According to the case manager, each youth knew their number; however, the parents/guardians
could not locate the document. A copy of each youth’s birth certificate, educational
and/vocational certificates earned while in the program, all educational records/documents,
school transcript, resumé and a completed sample employment application were maintained in
the exit portfolios. Each youth’s exit portfolio was verified during the exit conference, provided to
the youth upon release, and forwarded to the assigned juvenile probation officer (JPO).
Reviewed documentation verified each youth was provided with completed forms and clear
instructions on how to obtain documents for employment. During the transition conference, a
plan was put in place as to whom would be responsible for working with the youth to obtain
those items. A review of the program’s contract did not find any additional requirements.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
A review of three closed youth case management records confirmed the exit conference was
conducted after the program notified the assigned juvenile probation officer (JPO) of the youth’s
release. In three of the closed case management records, the exit conference was conducted at
least fourteen days prior to release. All pertinent parties participated in the exit conference
meeting. The exit, transition, and Community Re-Entry Team (CRT) meetings were conducted
separately in all three records. Each date of admission and termination documented in the case
record matched the Department’s Juvenile Justice Information System (JJIS). The status of
transition activities was established at the transition conference and plans were finalized for the
youth’s release. Reviewed documentation confirmed provisions for continuation of education
and/or employment, documentation the youth, the youth’s parent/guardian, case manager, and
JPO were aware of the vocational plan for the youth, documents, and post-release discharge
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plans. Reviewed documentation confirmed the intervention and treatment team leader,
parent/guardian, education representative, JPO, youth, and other pertinent parties all
participated in the exit conference.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process in place to promote constructive input by youth. The program
has a grievance process, “Request to Speak” forms, and the student council/youth advisory
council. The forms are maintained in the youth’s living units, along with the form drop box. Youth
can submit the form when seeking a discussion with a staff or when requesting any needed
item. During the annual compliance review week, observations confirmed the forms were in the
youth’s living units. According to policy, the program's town hall and youth advisory council
meetings are held bi-weekly. Youth can communicate their concerns during these student
council committee meetings with a board member. A review of the program's sign-in sheets,
agendas, and meeting minutes confirmed these meetings were held as scheduled. In an
interview, the facility administrator (FA) stated the program formally seeks youth input through
student council meetings and town hall gatherings. Additionally, the program utilizes grievance
forms and monthly youth surveys. Five interviewed youth indicated they could provide input by
speaking to staff members and the FA, filing grievances, and participating in town hall meetings.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program maintains a written policy and procedures ensuring a designated mental health
clinician authority (DMHCA). The program has a director of clinical services who serves as the
program’s DMHCA. The DMHCA is full-time an on-site forty hours weekly as required by the
program’s contract to ensure appropriate coordination and implementation of mental health and
substance abuse services are taking place in the program. As a part of the assigned
responsibilities, the DMHCA ensures consistent and appropriate services in addition to being
on-call twenty-four hours a day seven days weekly for emergency consultation. The DMHCA is
a licensed marriage and family therapist. The reviewed licensed confirmed it was free and clear
in the State of Florida with an expiration date of March 31, 2025. The program’s back-up
DMHCA is the regional clinical manager who has a free and clear license in the State of Florida
with an expiration date of March 31, 2025. The interviewed DMHCA stated their role in the
coordination and implementation of mental health and substance abuse includes identifying
youth needs and the therapist which best fits the youth mental health and substance abuse
needs during admission.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures ensuring established requirements for
qualified professionals in the delivery of mental health and substance abuse services. The
program’s licensed designated mental health clinician authority (DMHCA) serves as the
program’s supervisor for on-site clinical staff. The program’s staff listing, and contractual
requirements confirmed there is a licensed assistant clinical director staff beyond the DMHCA.
The assistant clinical director is a licensed mental health counselor with a free and clear license
in the State of Florida, which expires March 31, 2025. Additionally, the regional clinical manager
is a licensed mental health counselor. The reviewed licensed confirmed it was free and clear in
the State of Florida with an expiration date of March 31, 2025. The regional clinical manager
provides support and supervisory services to the DMHCA and on-site clinical staff. The program
is licensed under Chapter 397 by the Department of Children and Families to provide substance
abuse services to adolescents. The Chapter 397 license expires April 1, 2025. The program’s
clinical staffing, based on the contract, requires one DMHCA, one recreation therapist, one
additional licensed therapist and eight non-licensed mental health clinicians.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a written policy and procedures regarding non-licensed clinical staff.
The designated mental health clinician authority (DMHCA) confirmed their responsibility for
ensuring non-licensed clinical staff are working under their supervision and performing services
they are qualified based on education, training, and experience. The program’s practice is to
complete group and/or individual clinical supervision for the non-licensed clinicians and the
recreation therapist. A review of twelve months of clinical supervision logs since the last annual
compliance review was conducted. The clinical supervision was documented on the program’s
form and included all elements on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. Documentation
verified each non-licensed clinical staff received clinical supervision for each week they provided
services. The program is licensed under Chapter 397 through the Department of Children and
Families to provide substance abuse services to adolescents. A review of the license reflected it
was displayed in the lobby with the program’s physical address listed. The reviewed license
expires on April 1, 2025. The program’s contract requires a recreation therapist. Documentation
supported education and service requirements were in accordance with the contractual
requirements. The program had two clinical staff vacancies during the annual compliance
review week for unlicensed therapists, which have been vacant since November 15, and
December 6, 2024. The program had six non-licensed mental health clinicians providing
therapeutic services since the last annual compliance review. A review of the of six non-licensed
staffs’ education documentation reflected each held a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or a related human
services field. Each non-licensed staff providing clinical services was employed by a service
provider which was licensed under Chapter 397. Each of the six non-licensed clinical staff
received training in the administration of the Assessment of Suicide Risk.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a written policy and procedures ensuring staff completes a mental
health, substance abuse, and suicide risk screening, upon a youth’s admission to the program.
A review of nine mental health and substance abuse records confirmed the program completed
a Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) on the day of
admission. Each reviewed MAYSI-2 confirmed the screener reviewed available information to
include the commitment packet, reports, and records for existing documentation of mental
health or substance abuse problems and/or history of human trafficking information. Each
reviewed MAYSI-2 included the date of completion and the name of staff who completed the
screening. Screenings were completed by trained staff. Each screening was completed in the
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Department’s Juvenile Justice Information System (JJIS) on the day of admission and
completed in full. Each reviewed MAYSI-2 confirmed further assessment was required and a
referral was made for further evaluation and/or immediate attention. Each reviewed MAYSI-2
confirmed the need for an assessment and the facility administrator (FA) was notified and a
referral was made to alert the designated mental health clinician authority (DMHCA). One
reviewed MAYSI-2 confirmed the FA ensured an Assessment of Suicide Risk (ASR) was
conducted within twenty-four hours when the MAYSI-2 category “suicide ideation” indicated
further assessment was needed or other information obtained at intake suggested potential risk.
None of the reviewed youth records were applicable for youth being referred for an immediate
assessment or emergency services if the youth was in crisis. One youth was referred for an
Assessment of Suicide Risk and eight youth were referred for a comprehensive evaluation.
Each referral documented the reason for referral. Reviewed documentation confirmed the FA is
responsible for developing a written policy and procedures for the implementation of a
standardized admission and intake mental health and substance abuse screening process. The
policy addresses a standardized screening process which includes the review of the
commitment packet information, reports, and records, administration of the MAYSI-2 on the
Department’s Juvenile Justice Information System (JJIS) ,and referral for youth identified by
screenings as in need of further evaluation or immediate attention, staff training in mental health
and substance abuse issues and administration of the MAYSI-2, and a standardized process for
referral of youth identified as in need of further mental health and/or substance abuse evaluation
to an appropriate service provider/professional or, when immediate attention is needed, to a
hospital or Baker Act or Marchman Act receiving program. An interview with the FA reported the
program has a contracted board-certified behavior analyst who provides additional services for
referred youth who are identified as at-risk for mental health, substance abuse, and suicide.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to establish an evaluation process to
assist in the development of each youth’s individualized treatment plan. The program ensures
the mental health and substance abuse needs of the youth are identified through a
comprehensive mental health and substance abuse evaluation process. The designated mental
health clinician authority (DMHCA) was interviewed and reported the youth will receive a
Massachusetts Youth Screening Instrument, second version (MAYSI-2) screening and the bio-
psychosocial comprehensive assessment will be completed within thirty days of youth arrival.
The youth have treatment team on a monthly basis to review their behavior and progress. Nine
reviewed youth case management records confirmed the program completed a combined
mental health and substance abuse evaluation for the youth. A new evaluation was completed
for each youth within thirty calendar days of admission. Reviewed documentation confirmed
consent was obtained for substance abuse services. Each reviewed evaluation was completed
by a non-licensed staff and reviewed and signed by a licensed mental health professional or,
within ten calendar days after the evaluation was conducted. Each evaluation included
identifying information/demographics, the reason for evaluation, relevant background
information including home environment and family functioning, history of physical abuse,
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sexual abuse, neglect, witnessing violence and other forms of trauma, behavioral functioning,
physical health, mental health and substance abuse history, and education functioning,
behavioral observations, a Mental Status Examination, interview or procedures administered,
discussion of findings, diagnostic impression/formulation including Diagnostic and Statistical
Manual, Fifth Edition (DSM-5) diagnosis, patterns of alcohol and other drug abuse, impact of
alcohol and other drug abuse on major life areas, risk factors of continued alcohol and other
drug abuse, and recommendations.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a written policy and procedures ensuring the program’s mental health
and substance abuse treatment services. Nine reviewed youth records confirmed each had an
initial mental health and substance abuse treatment plan developed within seven days of
admission. Each initial mental health treatment and substance abuse treatment plan was
documented on the Department’s Initial Mental Health/Substance Abuse Treatment Plan form.
Each of the nine initial plans were signed by the licensed designated mental health clinician
authority (DMHCA) within ten days of completion. Each plan was signed by the youth,
parent/guardian, treatment team leader, program management, and other applicable treatment
team members. Each plan confirmed the participation of the juvenile probation officer (JPO),
and parent/guardian was by telephone. Each individualized treatment plan review was
completed on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
Review form. Each treatment plan review was completed every thirty days. Each individualized
treatment plan and review included signatures from the licensed DMHCA on the day of
completion, the youth, parent/guardian, JPO, treatment team leader, program management,
living unit, education, and all other applicable treatment team members. Each treatment plan
prescribed individual, group, and family services. Each treatment plan was individualized with
goals and objectives. A review of video compared to sign-in sheets for groups confirmed groups
were being conducted as required.
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.
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The program maintains a written policy and procedures ensuring treatment and discharge
planning. Nine reviewed youth records confirmed each youth was assigned to a treatment team
upon arrival to the program. Reviewed documentation confirmed the treatment team members
were comprised of the youth, program administration, living unit, education, medical staff,
mental health, and substance abuse staff. Reviewed documentation confirmed mental health
and substance abuse treatment services included individual, group, and/or family counseling
provided by a licensed qualified professional, or a non-licensed substance abuse clinical staff in
accordance with the youth’s initial or individualized substance abuse treatment plan. Each youth
who received mental health treatment had a properly executed Authority for Evaluation and
Treatment (AET) form, unless the youth was eighteen years of age or older. The program is
licensed under Chapter 397 to provide substance abuse services to adolescents. Reviewed
documentation confirmed each youth receiving substance abuse treatment provided consent
through a signed Youth Consent for Substance Abuse Treatment form. All mental health
treatment notes or substance abuse treatment notes were documented on the Department’s
Counseling/Therapy Progress Notes form. Each youth received individual psychotherapy or
counseling, and psychosocial skills training. Progress notes determined youth received services
as stipulated on the treatment plans. Three closed youth records were reviewed for discharge
plans. Each reviewed discharge summary was documented on the Department’s Mental Health
and Substance Abuse Treatment Discharge Summary form. None of the reviewed closed
records were applicable for the youth being released while on suicide alert/precautions. Each
reviewed summary documented the future services needed. Reviewed documentation reflected
the discharge plan was discussed with the youth, parent/guardian, and juvenile probation officer
(JPO) during the exit conference. A copy of the Mental Health/Substance Abuse Treatment
Discharge Summary form was provided to the youth, assigned juvenile probation officer (JPO),
and to the parent/guardian.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a policy and procedures ensuring a delivery protocol for mental health
overlay services (MHOS) and Substance Abuse Overlay Services (SAOS). Required program
clinical treatment groups include Skill Streaming the Adolescent, The Seven Challenges,
Trauma Focused Cognitive Behavioral Therapy, and Life Skills Training. Five interviewed youth
reported they are participating in family and/or individual counseling. Five interviewed staff
reported direct care staff do not facilitate any mental health or substance abuse groups. An
interview with the designated mental health clinician authority (DMHCA) reported the program
provides group, individual, and family counseling services to address mental health and
substance abuse concerns of the youth. The interviewed facility administrator (FA) reported the
program provides specialized treatment services and mental health and substance abuse
services for the youth as identified by contract. Documentation confirmed the DMHCA was on-
site for forty-hours each week and licensed mental health staff was on site at least five days
each week. The program met the required counselor to youth ratio, which is not to exceed one
counselor to sixteen youth. Additionally, each non-licensed staff held a master’s-level degree.
The program met requirements to include individual therapy provided at least once every two
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weeks, or more often as needed, family therapy provided at a minimum of monthly, as
applicable, and psychiatric services at least once every two weeks. The program has a licensed
mental health counselor to provide on-site services, as needed. Group therapy included four
total mental health and substance abuse groups each week for all youth.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a written policy and procedures ensuring psychiatric services within the
program. The program’s psychiatric services are provided by a psychiatrist with a clear and
active license with an expiration date of January 31, 2026. The psychiatrist is available for
emergency consultation twenty-four hours a day, seven days a week. The psychiatrist is a brief
representative of the treatment team and provided information regarding the psychiatric status
of each youth receiving psychiatric services who is scheduled for treatment team review. The
briefing may be accomplished through face-to-face interaction or telephonic communication with
a representative or treatment team. The psychiatrist evaluation and recommendations for the
youth are incorporated into the mental health clinical staff’s evaluations of the youth and the
youth’s individualized mental health or substance abuse treatment plan. The program did not
utilize a back-up psychiatrist during the annual compliance review period. The program does not
use a psychiatric advanced practice registered nurse. A review of sign-in/out logs confirm visits
during the annual compliance review period were conducted as required by the contract. The
psychiatrist actively participates in, manages, and supervises psychotropic medication services
in the program. The program does not utilize tele-psychiatry services. The interviewed
psychiatrist reported services they provided in the program included conducting initial
psychiatric evaluations with youth admitted within fourteen days, monthly medication
management, on call services twenty-four hours a day seven days each week, participating in
quarterly interdisciplinary meetings and conducting evaluations for youth with referrals on an as
needed basis. The designated mental health clinician authority (DMHCA) was interviewed and
reported they meet with the psychiatrist to discuss youth receiving psychiatric services on a
monthly basis. Nine reviewed youth records confirmed none were applicable for psychiatric
services; therefore, three additional records were requested for review. During the week of the
annual compliance review, the program only had two applicable youth with psychiatric services.
Each of the two youth entered the program with prescribed psychotropic medications. Each
youth was referred for a psychiatric interview, and each diagnostic interview was completed
within fourteen days of admission. Each reviewed Initial Diagnostic Psychiatric Interview for
youth on medications included history, a Mental Status Examination, a Diagnostic and Statistical
Manual, Fifth Edition (DSM-5) diagnosis, treatment recommendations, prescribed medications,
explanation for the need of medications, target symptoms, initial treatment goals, potential side
effects, risks and benefits of taking the medication, and frequency of medication management.
Each Initial Diagnostic Psychiatric Interview was documented on the Department’s Clinical
Psychotropic Progress Note (CPPN) form. The CPPN was clearly identified as an “Initial
Diagnostic Psychiatric Interview”. When the Initial Psychiatric Diagnostic Interview resulted in
the prescription of psychotropic medications, page three of the CPPN was completed. Each
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youth received monthly psychiatric medication reviews. All were completed as required. The
reviewed documentation supported each youth was seen for a medication review by the
psychiatrist, at a minimum, every thirty days. Reviewed documentation confirmed the psychiatric
evaluation resulted in the prescription of psychotropic medication and page three of the CPPN
was completed. None of the reviewed records were applicable for a psychiatric evaluation
update. Information documented on page three of the CPPN when psychotropic medication was
prescribed/dispensed/administered by the psychiatrist included the identifying data, diagnosis,
target symptoms of each medication, evaluation and description of effects of prescribed
medication on target symptoms, prescribed psychotropic medication, if any, including the name,
dosage, and quantity of the medication, normal dosage range, ordered dosage, frequency and
route of administration, reasons for changes in medication and/or dosage, side effects,
description of response to medication, both positive and adverse experiences, or documentation
if none were present, youth’s adherence to the medication regime, height, weight, blood
pressure, most recent serum drug levels or laboratory findings, telephone contact with the
youth’s parent/guardian to discuss medication, signature of the psychiatrist, and date. Reviewed
documentation confirmed the psychiatrist, and the nursing staff documented monitoring for
Tardive Dyskinesia on a monthly basis as indicated on the CPPN. None of the reviewed records
were applicable for the use of tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program maintains a policy and procedures ensuring the implementation of a Suicide
Prevention Plan. The plan includes Identification and assessment of youth at risk of suicide,
staff training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and review process. The review process for suicide
attempts and mortality review includes circumstances surrounding the event, procedures
relevant to the incident, all relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, recommendations, if
any, for changes in policy, training, physical plant, medical or mental health services, and/or
operational procedures. The Suicide Prevention Plan was reviewed on October 2, 2024, by the
facility administrator (FA).
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program maintains a written Suicide Prevention Plan outlining all of the program’s suicide
prevention procedures. The Suicide Prevention Plan addresses the program’s suicide
prevention services, suicide precautions and observation logs, as well as suicide prevention
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training. Nine reviewed youth records confirmed none were applicable for an Assessment of
Suicide Risk (ASR); therefore, three additional records were requested for review. During the
week of the annual compliance review, the program had only one youth applicable as being
actively suicidal and requiring interventions since the last annual compliance review. A review of
the ASR completed during the admission screening process determined the youth to be at risk.
Reviewed documentation confirmed the ASR was completed on the Department’s ASR form.
The completed ASR included placement start date, and the ASR referral date. Reviewed
documentation confirmed the youth on suicide precautions was placed on precautionary
observation. Reviewed documentation confirmed the youth’s parent/guardian was notified of the
youth’s potential suicide risk, as indicated by the ASR. The parent/guardian and juvenile
probation officer (JPO) notification was documented on the ASR. Reviewed documentation
confirmed mental health staff provided supportive services. Reviewed documentation confirmed
the assessment was completed by the designated mental health clinician authority (DMHCA).
The ASR was completed within twenty-four hours of the screening and by a licensed staff, in
person. Reviewed documentation confirmed the facility administrator (FA) documented
discontinuation of supervision in the program’s logbook. Documentation of the actual date/time
the clinician conferred with the FA was recorded on the ASR in the date/time sections.
Reviewed documentation confirmed a Follow-Up ASR was completed prior to the removal of
youth from precautionary observation. The Follow-Up ASR was documented on the
Department’s Follow-Up Assessment of Suicide Risk form. The youth was maintained on
suicide precautions and constant supervision until the Follow-Up ASR indicated suicide
precautions could be discontinued. Reviewed documentation confirmed the youth’s Follow-Up
ASR indicated suicide precautions could be discontinued and the youth was stepped down to
close supervision prior to transition to normal routine and standard supervision. Reviewed
documentation confirmed close supervision was maintained until it was determined no longer
necessary by the DMHCA. Reviewed documentation confirmed there was documentation of a
conference held by the FA and DMHCA to reduce level of supervision. The discontinuation of
close supervision was documented in accordance with the program’s Suicide Prevention Plan.
Reviewed documentation confirmed there was a Juvenile Justice Information System (JJIS)
suicide alert initiated for the youth placed on suicide precautions and it was accurately closed
following the recommendations of the ASR. Reviewed documentation confirmed there was
evidence in the program’s logbook indicating administration or supervisory staff provided
instructions related to the suicide risk assessment findings and suicide precaution decisions.
While on precautionary observation, the “at-risk” youth was allowed to participate in select
activities with other youth in designated safe housing/observation areas of the program. There
were no video observations to verify precautionary observations during the annual compliance
review week due to no youth being placed in the past thirty days.
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3.12 Secure Observation (Critical) Satisfactory Compliance
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”.
3.13 Suicide Precautions-Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a written policy and procedures ensuring staff always maintain at least
constant supervision of the youth on precautionary observation and document their
observations of the youth on the Suicide Precautions-Observation Log in intervals which do not
exceed thirty minutes. Nine reviewed youth records confirmed none were applicable for being
placed on precautionary observation; therefore, three additional records were requested for
review. During the week of the annual compliance review, the program had only one youth
applicable for suicide precaution observation since the last annual compliance review. The
Suicide Precautions-Observation Logs were maintained for the duration the youth was under
suicide precautions. Reviewed documentation confirmed the appropriate level of supervision
and observations of the youth’s behavior was documented in real time and not exceeding thirty-
minute intervals. Reviewed documentation confirmed when warning signs were observed, the
notification to the facility administrator and mental health clinical staff was documented on the
Suicide Precautions-Observation Log. Each Suicide Precautions-Observation log was reviewed
and signed by the shift supervisor and mental health clinical staff. The Suicide Precautions-
Observation Logs documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan ensuring details of the suicide
prevention training requirements. Nine reviewed pre-service and nine in-service training records
confirmed staff training records documented completion of suicide prevention training. The
program has two suicide response kits located in both sub controls on the shadow board. The
suicide response kits are co-located with the first-aid kits. The program is required to complete
one mock suicide drill for each shift at least quarterly. A review of suicide drills for the past
twelve months reflected the program conducted the necessary drills on each shift, as required.
Reviewed drills included the use of lifesaving measures to include the use of cardiopulmonary
resuscitation (CPR), first-aid kits, suicide kits, and an automated external defibrillator (AED).
Reviewed documentation confirmed all drills were simulated. Reviewed documentation
confirmed all direct care staff participated in at least one drill which involved the use of CPR
annually. The trainings included mock suicide drills held no less than quarterly on each shift, for
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all staff who come into contact with youth including kitchen and maintenance staff. Video review
indicated drills were simulated and all mock mental health drills were in response to a suicide
attempt and/or incident of serious self-injury. The program youth were not used in drill
simulations related to mental health or substance abuse care. The program provides semi-
annual trainings on emergency response procedures which includes “mock” training in
emergency response to a suicide attempt or incident of serious self-inflicted injury. Staff who
were not present during a quarterly drill can 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 incident of serious self-inflicted injury in the program. The facility
administrator (FA) was interviewed and reported quarterly mental health and suicide drills are
conducted. Five interviewed staff reported medical emergency and suicide drills are conducted
monthly on their shift.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan confirmed it included notification and
alert system, means of referral, including youth self-referral, communication, supervision,
documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. Nine reviewed youth records confirmed none were applicable for a Crisis
Assessment; therefore, three additional records were requested for review. During the week of
the annual compliance review, the program had no youth applicable for a Crisis Assessment
since the last annual compliance review.
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3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be in imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Mental Health and Substance Abuse Services Plan includes immediate staff
response, notifications, communication, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for emergency mental health evaluation
and treatment under Chapter 394, Baker Act, transport for emergency substance abuse
assessment and treatment under Chapter 397, Marchman Act, documentation, training, and
review.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
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 did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated “non-applicable”.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures ensuring an ongoing safety planning
process for each admitted youth. Safety planning is designed to identify stimuli which have both
positive and negative effects on the youth. Nine reviewed youth records confirmed each Safety
Plan was completed within fourteen days upon admission, and jointly prepared by the youth,
parent(s)/guardian(s) or family members, the program’s clinical staff, and behavioral specialist, if
applicable. Each plan incorporated any recommendations from previous or current clinical
assessments or screening instruments and incorporated trauma responsive practices, was
reviewed and updated as necessary at least every thirty days and was reviewed and updated as
necessary following any significant behavioral or mental health event identified by the youth’s
intervention and treatment team. Reviewed documentation confirmed the Safety Plan included
warning signs identified by the youth or collateral contacts, parent(s)/guardian(s) which indicate
a youth is escalating in their behavior(s), the youth’s baseline behavior(s) as gathered from
collateral contacts, parent/guardian, youth’s history, and evaluations, if applicable, crisis
recognition of the youth, and program staff’s perception of verbal and non-verbal stimuli which
have both positive and negative effects on the youth, jointly developed coping strategies, to
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include people and healthy environments as defined by the youth, intervention strategies
preferred by the youth, and a debriefing process. Reviewed documentation confirmed the Safety
Plans were reviewed by staff who have contact with the youth and plans are kept in both sub
controls and in the youth’s record. Five youth were interviewed and reported they contributed to
their Safety Plan. The facility administrator (FA) was interviewed and reported the plans and
results are updated monthly at treatment team reviews.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a written policy and procedures which requires a designated health authority
(DHA) to provide medical care to program youth. The DHA is contracted through the State of
Florida and is a licensed osteopathic physician (DO) with specialty training in family practice. A
review confirmed the license was clear and active with no disciplinary action and an expiration
date of March 31, 2026. The program does not utilize an advanced practice registered nurse
(APRN) or physician assistant (PA). The DHA is contracted to be on-site two hours weekly;
however, is on-call twenty-four hours a day, seven days a week for emergency medical
concerns. A review of the sign-in sheets confirmed the DHA was on-site for the contracted
number of hours weekly. The program does have a back-up designated health authority;
however, the health services administrator (HSA) verified they have not been utilized since the
last annual compliance review. An informal interview with the director of nursing confirmed tele-
medicine services were utilized on October 10, December 25, 2024, and January 1, 2025, for
follow-ups. The DHA and nursing staff interviews confirmed their role in completing program
Comprehensive Physical Assessments (CPA), necessary evaluations, sick-calls, off-site
referrals and follow-ups, and the DHA’s schedule.
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 a written policy and procedures requiring all healthcare services to be
provided to youth at the program. The designated health authority (DHA) is clinically responsible
for all healthcare services, in conjunction with licensed registered nurses, provided to program
youth. A review of the program’s schedule and sign-in logs confirmed the program utilizes six
full-time registered nurses (RN) and one part-time licensed practical nurse (LPN). The health
services administrator (HSA) is a licensed registered nurse and oversees all medical cases. A
review of all credentials confirmed all nurses providing services during the annual compliance
review period held clear and active licenses. A review of the nursing staff schedule and
interviews confirmed on-site coverage for a minimum of forty hours, seven days a week. Each
registered nurse and licensed practical nurse had current cardiopulmonary resuscitation (CPR)
certifications.
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 policy and procedures for all health-related procedures and protocols utilized
at the program. The designated health authority (DHA) is exclusively responsible for reviewing
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the policies, protocols, and procedures for health-related services. A review of the facility
operating procedures and nursing protocols showed they were revised and signed by the DHA
on January 1, 2025. The nursing staff signed an acknowledgement form verifying review of all
procedures and protocols on January 1, 2025. At the time of the annual compliance review,
there were two new hires and the program’s practice is for the health services administrator
(HSA) to provide new employees a comprehensive clinical orientation. Documentation
supported this practice and receipt of the policies and procedures.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures to ensure the completion of the Authorization
of Treatment (AET) form for specific treatment of youth in the custody of the Department. The
program utilizes a separate form for youth eighteen years of age or older. The form labeled
Release of Information Authorization for youth Eighteen Years of Age and Older provides
consent for specific health related information to be shared. A review of nine youth records
confirmed the original AET form was filed in five youth’s Individual Healthcare Records (IHCR).
Three of the nine youth were eighteen years old, and one youth was in the care of the
Department of Children and Families (DCF). The youth eighteen years of age did contain valid
Release of Information Authorization for Youth Eighteen Years of Age and Older forms. The
DCF youth’s record contained a valid court order authorizing treatment at the program. An
interview with nursing staff confirmed when obtaining a new AET the parent/guardian is called
and mailed an acknowledgment consent for the AET. Additionally, youth eighteen years of age
and older have a different consent form.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures to inform parent/guardians of significant
changes in the youth’s condition and obtain consent for new medications and treatment
prescriptions not covered by the Authority of Evaluation and Treatment. A review of four
applicable Individual Healthcare Records (IHCRs) showed each contained parental consent.
Each consent covered parent/guardian notification of new, over-the-counter, or psychotropic
medications on the Department’s Parental Notification of Health-Related Care form. No youth
were applicable for psychotropic medications at the time of the review. One youth was
prescribed an inhaler, and the other three youth were taking medications for dental issues. No
youth records were applicable for new vaccinations or religious exemptions. An informal
interview with the head nurse confirmed the Florida Shots website is utilized to obtain youth
immunization records. Each youth record included vaccination records at the time of admission.
The health services administrator reported to ensure parental notifications are made timely, the
parental/guardian notification is made by phone and verbal consent is obtained. Then, written
notification is sent within twenty-four hours.
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4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures involving youth screening during admission for
healthcare referrals. The program’s process is to complete a Facility Entry Physical Health
Screening (FEPHS) for rescreening anytime a youth enters the program or when there is a
change in physical custody. Nine youth Individual Healthcare Records (IHCRs) were reviewed,
and each contained a Facility Entry Physical Health Screening (FEPHS) form completed by a
licensed practical nurse (LPN) or registered nurse (RN). One youth was applicable for a change
in physical custody and a new FEPHS form was completed by an RN. Nursing staff interviews
confirmed each admission is completed by a registered nurse. If a direct care staff completes an
admission, a registered nurse reviews the FEPHS entry physical form.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures to make sure each youth is provided a
healthcare orientation. Nine youth records were reviewed and included documentation
supporting each youth received a healthcare orientation at admission. The orientation included
access to medical care, sick call access, emergency procedures, medication monitoring, the
right of refusal, sexual assault procedures, health care provider roles, and standard universal
precautions. Each topic was documented on the Department’s Health Education form in the
Individual Healthcare Records (IHCRs). Health Education covered seatbelt usage, alcohol/drug
related problems, sexually transmitted infections, tobacco products including smoking cessation,
dental hygiene, basic personal hygiene, immunizations, infection control, prevention of sexual
and other physical violence, nutrition, physical fitness, breast/testicular self-examinations,
parenting skills, prenatal, post-partum, and parenting education, as applicable.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures regarding notifying the designated health
authority (DHA) when admitted youth required emergency care. Three youth were applicable for
known chronic conditions and documentation supported the DHA notification process was
completed within twelve hours of admission. The applicable youth records included the required
progress notes including parent/guardian notification. None of the youth were applicable for
psychotropic medications. The nursing interviews confirmed the DHA is notified by the
registered nurse at the time of admission and this is documented in the admission progress
note.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures for completing the Department’s Health-
Related History (HRH) form upon admission. The program’s practice is to complete the HRH
form prior to the Comprehensive Physical Assessment (CPA). The nurse interview confirmed
this practice. All nine youth Individual Healthcare Records (IHCRs) contained the required HRH
which was completed by a registered nurse at admission. Each record included supporting
documentation with signatures and dates indicating they were completed and reviewed by the
designated health authority on the day of admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring the completion of a standardized
Comprehensive Physical Assessment (CPA) for youth admitted into physical custody of the
program. The program’s practice is for the designated health authority (DHA) to complete the
CPAs within seven days of admission and yearly thereafter. Nine records were reviewed, and
each contained a current CPA form including the necessary Medical Grade. All nine CPAs were
completed by the DHA within seven days of admission. All CPAs were completed in entirety
containing the “X” and “O” marks for required sections. Each youth refused part of the
examination, which was noted by the DHA. In addition, each record contained a treatment
refusal form signed by the youth and medical staff. Results of each youth’s Tuberculosis skin
Test (TST) were recorded on the CPA and the Infectious and Communicable Disease (ICD)
forms, which coincided documentation. The Department’s Problem List was updated as
required. According to the nursing staff interviews, the TST is administered to the youth annually
and the youth may receive a chest X-ray if determined necessary by the DHA.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a written policy and procedures to ensure all youth are evaluated and treated
for sexually transmitted infections (STIs). The program’s policy states human immunodeficiency
virus (HIV) test results are only disclosed to a youth’s legal authorized representative,
healthcare providers, the Department of Health, health facility staff committees, medical
personnel, and healthcare facility staff or personnel. Nine youth Individual Healthcare Records
(IHCRs) were reviewed and indicated each youth disclosed sexually active statuses which
required the designated health authority (DHA) to refer each youth for evaluation. Each ordered
test and referral was documented on the required STI Screening Tool. All nine youth had tests
ordered on the day of admission, which were signed by the DHA with results documented on
the Infectious and Communicable Disease (ICD) form, excluding HIV results. Documentation
supported offerings for HIV counseling, regardless of testing. HIV testing results are provided in
a concealed envelope in the youth’s IHCR and reviewed by a practitioner. Three of the nine-
youth consented to HIV testing. One was scheduled for testing on January 30, 2025, with the
local health department. Each youth did receive post-test counseling by a certified HIV
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counselor. The remaining youth did not consent for HIV testing. A review of youth and nursing
staff interviews confirmed youth can consent to chlamydia, gonorrhea and HIV screenings at the
time of admission. Nursing staff interviews confirmed confidential STI screenings can be
completed on-site through the DHA’s orders. Each screening, evaluation and referral are
documented in the IHCR, and youth are rescreened if there is a change of custody for more
than thirty days.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures requiring sick call requests and treatment
appropriate to the complaints. Sick call request forms are available to youth in each living unit.
The nursing staff interview confirmed the program conducts sick call requests daily at 8:30 a.m.
and 2:30 p.m., and Saturday and Sundays at 8:30 a.m. Hours are posted throughout the
program, in each living unit, and east/west wing hallways. Request forms are available in each
living unit. Licensed nursing staff handles sick call. None of the nine youth records reviewed
were applicable for similar sick call complaints three or more times within a two-week period.
Five of nine youth were applicable for sick call requests. Each applicable record included a sick
call request form completed by a registered nurse. Only one youth record documented sick call
was completed by the LPN; however, the form was reviewed by the registered nurse and
documented with a signature. Each Sick Call Request form was filed in reverse chronological
order and documented in the progress notes as well as the Sick Call Index. Additionally, the
program maintains a Sick Call Referral Log. The program utilizes an exam table and medical
equipment to assess youth during sick call. A review of youth interviews confirmed the
program’s process. Four of five youth stated seeing a nurse within two days after submitting a
sick call request. One youth revealed seeing a nurse after three days. An observation of sick
call confirmed the program’s practices. The youth was escorted by the direct care supervisor.
The registered nurse identified themself and verified the youth’s reason for sick call. The youth
was interviewed and examined in a private area by a licensed registered nurse while the staff
waited in the medical lobby area.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a comprehensive process for the provision of episodic and first-aid care.
Nine youth records were reviewed and four were applicable for episodic care. Each applicable
youth received care and a follow-up evaluation from a licensed healthcare staff. Each record
contained documentation including subjective, objective, assessment and plan (SOAP)
elements in the medical notes. The program maintains five first-aid kits throughout the program,
which include two in master control, one in west sub control, one in east sub control, and one in
the kitchen. The program possesses two transportation vehicles and first-aid kits are in each
vehicle. An informal interview with the health services administrator confirmed the first-aid kits
are checked monthly by nursing staff and documented in a log. A review of three first-aid kits
and logs confirmed their practice, and the required contents were included. The program’s AED
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is in the staff breakroom along with the procedure’s binder. The on-site nursing staff monitors
the operability of the AED, pads and batteries. A review of the AED confirmed it was in working
condition with a green indicator light. The expiration date of the AED batteries and pads
observed was December 2026. Each were changed March 2024. A list of emergency numbers
was posted and accessible to staff in the breakroom, inaccessible to youth. A review of staff
training requirements verified authorized direct care staff were appropriately trained on the
administration of epinephrine auto-injectors. Nine staff records were reviewed and confirmed
staff requirements were met regarding episodic, first-aid, and emergency care. A review of the
program’s documentation confirmed direct care staff participated in an emergency medical drill
as required quarterly on each shift. Video observations confirmed the simulations utilized
episodic care events with first-aid or cardiopulmonary resuscitation (CPR) techniques. Drills
were both announced and unannounced. During the annual compliance review period, there
were no episodic care events to observe. The program has a written policy and procedures
which describes the access, use and inventory of NARCAN®. The nurse secures NARCAN® in
a locked medical cart and cabinet. The facility administrator and nursing staff maintain access to
NARCAN®. Nurses take inventory of NARCAN® weekly and document it in a log. Once
NARCAN® is received at the program, it is added to the over-the-counter inventory and is
updated perpetually as used in weekly counts. The health services administrator confirmed all
licensed nursing staff are trained on the use of NARCAN®. A review of staff interviews
confirmed the nurses provide care and in extreme cases, 9-1-1 is called. Two staff verified no
phones are allowed in living units, so a supervisor or master control must be contacted for
emergency care. Three staff stated a code blue is called and care is provided as necessary.
Each interviewed youth confirmed floor staff notifies nursing staff for emergencies.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a written policy and procedures for providing timely referrals and
coordination of medical services to an off-site health care provider and documentation of
emergent or non-emergent events. Three of nine Individual Healthcare Records (IHCRs) were
applicable for youth receiving off-site care. All three records included a Summary of Off-Site
Care Consultation Report form. Documentation contained parental notification efforts and
designated health authority signatures. The program documented each event in an Episodic
Care Log. Only one youth required a follow-up appointment for dental care. Documentation
indicated referrals were tracked and received as needed. Nursing staff interviews confirmed off-
site emergency care was documented in the designated health authority weekly logbook and
transport logs.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program maintains a written policy and procedures ensuring youth with chronic conditions
receive regularly scheduled evaluations and necessary follow-up. Nine youth records were
reviewed and three were applicable for chronic conditions documented on their individual
Facility Entry Physical Health Screening (FEPHS) form during admission. None of the youth had
a communicable disease, were undergoing treatment for a physical condition, or a body mass
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index over thirty. One youth had ongoing medication. Since it is an all-male program, pregnancy
evaluations are not applicable. Each youth was placed on the program’s chronic illness list and
received periodic evaluations every ninety days. No youth were applicable for Tuberculosis
medication or off-site evaluations so no follow-up with the designated health authority (DHA)
was necessary. The Department’s Problem List was updated in accordance with Florida
Administrative Code. The facility administrator interview confirmed procedures for youth medical
issues. The program’s procedure is for the medical department to update staff during morning
meetings and daily with youth alerts which are posted in staff locations. The DHA’s interview
confirmed youth with chronic conditions are evaluated every ninety days or less if needed. The
periodic evaluations are placed on a tracker. Nursing staff interviews verified the DHA is notified
of youth chronic conditions at the time of admission by the registered nurse and the notification
is documented in the progress note.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains a written policy and procedures regarding medication management. The
program does not have any standing, emergency treatment or pro-re-nada orders for
psychotropic medications. Nine records were reviewed and only one was applicable for being
admitted with medication. The Facility Entry Physical Health Screening (FEPHS) and progress
notes were documented accordingly in the youth’s Individual Healthcare Record (IHCR). The
prescription verification and progress note included a signature from the designated health
authority. The youth record included a current and valid prescription. The program does not
utilize restrictive housing. Five youth had updates on the Department’s Medication
Administration Record (MAR). The MAR included each youth’s name, Department identification
number (DJJID), date of birth, allergies, precautions, Medical Grade, medical alerts, current
picture, and youth’s initials. Four youth were receiving over-the-counter medications. One youth
was receiving ongoing medication. Each medication entry was initialed by staff. No trained non-
healthcare staff assisted in delivering medications. No lapses or errors were observed during
review of medication documentation. Nursing staff effectively documented weekly side effect
monitoring on each MAR. No youth refused medication, so no refusal forms were included in the
records. No youth were applicable for psychotropic medications during admission at the time of
review. One medication administration was observed during sick call. Youth received over-the-
counter medication administered by the registered nurse after being escorted by direct care
staff. The youth and medical staff both initialed the MAR after the registered nurse explained
what was being received, the reason for medication and the Six Rights of Medication Delivery.
Three youth stated nurses provided medications, the remaining youth stated never having to
take medications. Nursing staff interviews confirmed providing medications and maintaining
inventory of all medications.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures to secure medical equipment, routine
perpetual inventory, utilization and disposal. An observation of the medical area verified the
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proper classification of sharps equipment and medications. The medication cart was in a secure
locked area and was organized with stock items separate from youth-specific medications. All
controlled substances are stored separately and inventoried perpetually. Each medication is
stored separately and securely, inaccessible to youth. An informal interview with the health
services administrator (HSA) indicated the program’s process for destruction and
disposal/return of expired medications is to return for credit, or the use of a medical destruction
agent. The program has a sharps bin which is disposed of by a local vendor. All perpetual and
weekly inventories of sharps and over-the-counter medications were documented in a shift-to-
shift log as well as the youth’s Individualized Controlled Medication Inventory Record, meeting
the Board of Pharmacy regulatory requirements. Nine reviewed records confirmed each non-
healthcare staff was trained by a registered nurse in the delivery and oversight of medication.
During the annual compliance review, three over-the counter medications, and sharps were
reviewed, and no discrepancies were observed. The program only had two controlled
medications during the annual compliance review, and each were inventoried accurately. The
HSA confirmed medical staff notifies the clinical manager who then reports to the director of
nursing and the facility administrator if an inventory discrepancy occurs. An internal investigation
is started, and a Department’s Central Communications Center (CCC) is notified. Nursing staff
complete all inventory of medications and weekly stock medication inventories.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a written policy and procedures for infection control including an Exposure
Control Plan in accordance with Occupational Safety and Health Administration (OSHA) and the
Centers for Disease Control (CDC) guidelines. The infection control policy was reviewed and
signed by the designated health authority (DHA) on January 1, 2025, and the facility
administrator (FA) on January 2nd, 2025. The plan included common infectious diseases,
episodic contagious illnesses, viral/bacterial infectious diseases, Tuberculosis, Hepatitis A, B
and C, human immunodeficiency virus (HIV), infectious diseases caused by blood-borne
pathogens, other outbreaks or epidemics caused by any other infectious agent, outbreaks of lice
or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant
micro-organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. The
program has procedures for staff to adhere to universal precautions and staff access to
Hepatitis B immunizations and protective equipment. The program had no instances where the
local county health department had to be contacted for infectious disease exposures. The
program’s process for needle sticks post-exposure evaluation requires the Department of Health
to oversee the treatment of staff. Needles are to be put into the “sharps” bin. There were no
cases of reportable infectious diseases for staff exposed in occupational hazards. The (FA)
confirmed the Infection and Exposure Control Plan is located in the medical office and is
reviewed annually with staff. Nursing staff interviews confirmed the health services administrator
and director of nursing provide training for infection/exposure control, with the binder kept in the
medical office
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4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a written policy and procedures ensuring the location of all youth, at all times
through active supervision and the implementation, monitoring, and use of an accounting
system of scheduled, unscheduled, and emergency counts. 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, and
consistently applying the behavior management system. The program has a daily youth activity
schedule which was posted on all living units and throughout the program. The shift schedule
ensures a staff-to-youth ratio of one staff to eight youth for Mental Health Overlay
Services/Substance Abuse Treatment Overlay Services (MHOS/SAOS) during day and evening
hours, and one staff to ten youth during sleep hours, which meets the contractually required
ratio. Observations during the annual compliance review week verified staff were actively and
positively engaging with youth during classroom activities, school breaks, head counts, mental
health groups, movement, and outdoor recreation activities. The observations ensured staff-to-
youth ratios were maintained, as required. Interviews with three staff on the living units
confirmed each staff immediately knew the number of youth they were supervising. The
program’s system for accounting of youth requires the physical counting of youth at various
times throughout the day. Staff shall conduct and document counts minimally at the beginning of
each shift, after each outdoor activity and during emergency situations such as escapes or riots.
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 it is practical after order has been
restored. All staff shall monitor the movement of youth into and out of the program. Daily census
information at a minimum shall include the total daily census count, new admissions, releases or
direct discharges, transfers, and youth temporarily away from the program.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a written policy and procedures addressing the implementation and training of
the behavior management system (BMS), which has not changed since the last annual
compliance review. The BMS is posted and outlined within the youth handbook allowing easy
access for youth and includes rules governing conduct and positive and negative consequences
for behavior including while in the classroom. Through observations, the BMS was seen posted
throughout the program. The BMS shall complement the performance and treatment planning
process, including the coordination of individualized behavior plans, as applicable. The facility
administrator (FA) ensures all staff having direct contact with youth are trained on the BMS.
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Youth have access to a youth handbook which clearly outlines the BMS, program rules, and the
progressive disciplinary system for the youth. Observations of staff and youth interactions
confirmed staff were adhering to the BMS by utilizing a ratio of four-to-one positive to negative
consequences when redirecting the youth, as indicated in the program’s policy. All staff
members having direct contact with youth are trained in the implementation of the BMS, to
include the common components which serve as the basis for the BMS, in pre-service training.
Ongoing training is provided as needed and appropriate during shift supervisor and general staff
meetings. A review of nine youth case management records indicated each youth participated in
orientation upon arrival to the program and received a copy of the youth handbook. Nine staff
pre-service training records were reviewed, and all staff were trained in the program’s BMS
system. Five youth were interviewed, and each stated negative consequences include early
bedtime, level freeze, more days added, and confinement. One youth stated youth can be
placed in controlled observation for fighting. Each interviewed youth stated they receive
canteen, “Gotchas”, activities, and different types of incentives as rewards for good behavior.
Five interviewed youth stated staff are consistent in what behaviors they give rewards and
consequences to. Each youth was able to explain the difference between each level and how
you move from level to level. Each of the interviewed youth stated no youth are ever allowed to
punish other youth. Five staff were interviewed, and each was able to describe how the BMS is
used with ratio included. Each staff described “Gotchas”, canteen, and different kinds of
privileges as rewards for good behavior. Canteen is given out every two weeks, while “Phat
Friday’s” are every week. Five of the interviewed staff each stated basic rights cannot be taken
away from youth consequently. Each interviewed staff stated youth are informed of their
consequences through problem behavior reports and they are able to explain their behavior. An
interview with the FA indicated the program BMS uses the iChoose system, which is focused on
modeling, coaching, and incentivizing pro-social healthy behaviors which consists of a point
system used at the program. The youth earn points based on behaviors and points are added
by day to total up to 200. These points are used to purchase canteen. The youth can either earn
or fail to earn their points to "Make Their Day." As the youth earn their points, it progresses the
youth to level up in the program. The FA stated consequences are monitored through treatment
teams and reviewed in the morning meeting. Additionally, the FA stated staff implementation of
the BMS to ensure consistency is monitored through a point system which is reviewed each
shift and calculated by the shift manager. The consequences received are checked to see if any
other actions are needed. The number of youth who made their day is reviewed in the morning
meeting.
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, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
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The program has a written policy and procedures in place to conduct and document ten-minute
checks during sleep hours or at other times, such as during an illness or room restriction. The
program has a total of 143 video cameras capable of recording thirty-days of video footage.
During the annual compliance review week, all cameras were operational. Prior to conducting
checks, staff are positioned where they can see any movement within the living unit. Staff are
required to conduct room checks every ten-minutes and document the time of the check on the
Ten-Minute Check Log when youth are sleeping. A review of six separate video footage
samples of ten-minute checks from each program living unit and log sheets reflected there were
no discrepancies. Documentation confirmed staff who complete the checks initial or sign the
check sheet. Five interviewed staff stated room checks were conducted every ten minutes when
a youth was placed in their room for sleeping or non-punishment reasons.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a written policy and procedures to ensure the continuity of custody and care of
youth and protection of the public in the event of an emergency which prevents occupancy of
the program’s primary building and structure. The program shall maintain an administrative hard
copy file which is easily accessible and mobile in the event of an emergency which results in the
program relocating quickly or in the event any needed information cannot be accessed
electronically. Additionally, the program shall establish and maintain critical identifying
information and a current photograph of each admitted youth which is easily accessible to verify
a youth’s identity, as needed during their stay in the program. The program’s policy indicates
counts are conducted during riots, escapes, power outages, or any other disruptions which may
occur. Head counts are conducted before and after each movement, and during emergencies
and drills. A review of the logbook confirmed the program documented counts during shifts,
emergencies, and before and after each movement. The logbooks also included youth who
were temporarily away from the program, transferred, admitted, and released. Additionally,
observations confirmed the program conducted a physical head count during school and before
and after each movement. Five interviewed staff stated counts are conducted before and after
each movement, during drills, emergencies, and when a program count is 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.
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The program has a written policy and procedures which maintains a master control logbook
which documents a chronological record of events, incidents and activities within the program,
head counts, shift changes and group movement. At a minimum, each logbook entry shall be
legible and include the date and time of the event, the names of staff and youth involved, a brief
description of the event, the name and signature of the person making the entry and the date
and time of entry. No logbook entries shall be obliterated or removed. All errors shall be struck
through with a single line and initialed by the staff correcting the error. All direct care staff and
supervisors shall be briefed when coming on duty. A review of the logbooks and observations
verified since the last annual compliance review, all errors were struck through and initialed by
staff and no loose or missing pages were found. Logbook entries included shift briefing, youth
movement, head counts, emergency drills and situations, program checks, and law enforcement
data. Internal incidents reported to the Florida Abuse Hotline and/or the Department’s Central
Communications Center (CCC) were documented. Reviewed logbooks showed recreation was
conducted. All entries included the dates and times of events, with the names of the staff and
youth involved.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures to ensure program safety and security, safety
of staff, youth, and the public by implementing and maintaining a system of program key control.
All staff shall be provided with guidelines and training on the key control policy and required
procedures on the physical control and use of program keys, while ensuring the provision of
community protection through safe and secure programming for youth. The assistant facility
administrator (AFA) is assigned as the key control manager who is responsible for the security
and accountability of keys and key control systems as well as damaged keys. A master control
operator interview was conducted, and it was reported staff turn in their personal key to receive
their assigned key needed for work. Observations verified when entering the program, staff are
required to sign, date, and list the key number in a logbook. When leaving the program, staff are
required to sign the logbook and key sheet to show the key was returned. Additionally,
observations confirmed the program has a key log sheet for staff assigned permanent keys
which they are required to sign indicating the number of keys issued and the key identification
number. Permanent keys are kept to a minimum and must be authorized in writing by the facility
administrator (FA). An informal interview of three staff confirmed each staff knew the number of
keys and each key’s function. Restricted keys are in master control and only accessible to
authorized staff who are assigned to specific job functions requiring restricted key use.
Designated staff for restricted key use are case managers, supervisors, nurses, teachers,
human resources, therapists, maintenance, and the AFA. Damaged keys are to be reported to
the shift supervisor and returned to the AFA. The AFA will then discard the keys and update
inventories. The AFA conducts quarterly inspections of emergency keys and annual audits to
make sure keys are functioning, verified, located, and inventoried. Since the last annual
compliance review, there were no incidents reported to the Department’s Central
Communications Center (CCC) or Program Monitoring and Management (PMM) deficiencies
related to key control concerns. Master control reported the process for restricted key use is to
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check the log and key cabinet area at the beginning and end of each shift to make sure all keys
are accounted for. Observations verified there was a review of key inventories, and all keys
were accounted for. The key lock box was out of reach and unable to be touched from outside
of master control. Five interviewed staff knew the process of obtaining keys and replacing
damaged ones.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures addressing safety and security and to control
the introduction of materials considered contraband into the program. Search practices shall be
initiated to assist in prevention, detection and removal of all items considered contraband or
unauthorized within the program. All staff shall be trained to properly identify contraband items
and the steps required for removal of contraband. Search practices and observations shall be
conducted throughout the program and shall include searches of youth, staff, visitors, property,
program grounds, and the program’s physical plant. A review of the youth handbook verified
prohibited items include sharps, escape paraphernalia, tobacco products, lighters or matches,
unauthorized currency or coins, non-program issued keys, jewelry, candy, gum, drinks,
flashlights, gang related items, pornography, aerosol cans, ropes, any unauthorized article of
food or clothing, wire, or other items not indicated as approved within the handbook.
Additionally, illegal contraband included any non-program issued electronic equipment or
cellular devices, smartwatches, electronic or vaporless cigarettes, any intoxicating beverage or
any beverage which causes or may cause an intoxicating effect, any controlled substance,
marijuana, hemp, industrial hemp, or any prescription or nonprescription drug which has a
hypnotic, stimulating, or depressing effect, and any firearm or weapon of any kind, or any
explosive substance. The youth handbook states consequences for youth found with
contraband, which is also outlined in the behavior management system. Reviewed
documentation included the procedures for searching incoming and outgoing mail. The policy
reports all illegal contraband will be surrendered to law enforcement, and unlawful activity will be
reported to law enforcement. Observations confirmed the program documented the
confiscations of contraband and disposition while keeping it maintained in the youth case
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record. Since the last annual compliance review, illegal contraband was turned over to law
enforcement and documented in the Department’s Central Communications Center (CCC)
incidents. The facility administrator (FA) stated any contraband which is illegal is turned over to
the local Sherriff’s department to dispose while any contraband which is not illegal is secured in
the FA's office and dated, photographed until the investigation is complete, and then disposed
of off-site. Five interviewed staff all explained the process of youth room searches and
confirmed they are done randomly. Additionally, the staff, FA, and supervisor will all do room
checks.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures to ensure searches, and full body visual
searches, are conducted, as prescribed, or otherwise permitted based upon the Right
Interactions (RI) training manual. Prior to conducting any search, staff shall prepare the youth by
explaining the purpose of the search and what to expect while assuring the youth’s safety. Staff
shall avoid use of unnecessary force and shall treat the youth with dignity and respect to
minimize the youth’s stress and embarrassment. During the annual compliance review week,
youth searches were observed during movement. Youth were not observed being searched
before and after transports, before and after visitation, admission, upon return from off-campus
activities, or following the access or ability to obtain tools or other equipment. Observations
verified all staff and visitors were searched before entering all secure/non-secure areas.
Logbook documentation and video review verified youth were being thoroughly searched before
and after each movement. Additionally, observations confirmed searches were conducted by
staff of the same gender as the youth and conducted in a manner as not to degrade the youth.
Five staff were interviewed, and all were able to explain how and when youth are searched. Five
interviewed youth all stated visual and full body searches occur after each movement, after
outdoor activities, when returning from off campus, after visitation, and school.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a written policy and procedures to ensure all program vehicles used in the
transportation of youth are properly maintained and documentation of use and vehicle service is
maintained. Transporting staff shall have a cellular phone for use in the case of emergency
during the transport. Mechanical restraints shall be used in the secure transportation of use and
all mechanical restraint equipment will be double locked. Youth shall never be restrained to
stationary objects. Each vehicle being used for transportation of youth shall pass an annual
safety inspection. Reviewed documentation confirmed each vehicle received an annual safety
inspection and was maintained. During the annual compliance review week, the program was
only using one of their two vehicles to transport youth. All vehicles were inspected during the
annual compliance week, and both were verified to be equipped with safety screening which
separates the vehicle’s front seat from the back-seat area, which accommodates the high-risk
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youth. Additionally, seat belts, a seat belt cutter, a window punch, a fire extinguisher, and an
approved first-aid kit were observed. Rear vehicle doors cannot be opened from the inside. Ten
vehicles were checked in the program’s parking lot and all vehicles were confirmed to be
locked. Four interviewed youth stated they wear hand restraints, a seat belt, and leg shackles
during transports and have never been handcuffed to the vehicle. One interviewed youth stated
they have never been on a transport. Five staff were interviewed in reference to the program’s
transports for youth. One staff has not participated in a transport and four staff indicated
seatbelts and shackles are used for security purposes and two staff are with each transport.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures to ensure an appropriate minimum staff-to-
youth ratio is maintained while youth are transported off program grounds ensuring the safety
and security of youth, staff, and the public. All transporting staff shall have a valid Florida
Driver’s License and an acceptable driving record. Any staff whose driving record is deemed
unacceptable shall not be permitted to operate a program vehicle for the purposes of
transporting youth. All staff must inform their immediate supervisor of driving violations.
Reviewed documentation verified all active drivers had a valid driver’s license. Human resource
staff shall obtain monthly driving record information from the Department of Motor Highway
Safety and Motor Vehicles (DMHSMV) for all staff. Youth are not permitted to drive program or
staff vehicles. The program uses a minimum staffing ratio of one staff for every five youth;
however, at least two staff shall accompany youth on all transports with one staff present of the
same gender as the youth. Five interviewed staff all stated youth are secured during transports
by a seat belt, shackles, and handcuffs. Each staff stated they are provided with a cellphone
and radio during transports as communication devices and a first-aid kit, window punch, fire
extinguisher, and glass punch as safety equipment. Additionally, each of the interviewed staff
verified transport vehicles are search for contraband before use and they are not allowed to use
their personal vehicles to transport youth. All five interviewed staff were knowledgeable and able
to explain the emergency response process during vehicle transport and knew what the ratios
for transport were. Five interviewed youth each stated they have never seen anyone place
contraband in a transport vehicle. During this annual compliance review week, there was not an
observation of a transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures requiring a safe and secure physical
plant, grounds, and perimeter to be maintained and for weekly safety and security audits to be
conducted. The facility administrator (FA), and program leadership is responsible for conducting
weekly safety and security audits and submitting the findings to the Department. Reviewed
documentation confirmed weekly safety and security audits were conducted and any identified
deficiencies were documented on the reports including the status and due date of any needed
corrective action. A review of the program’s Preventative Maintenance Checklist forms since the
last annual compliance review indicated inspections were completed, as required, and
documented deficiencies and repair updates. An interview with the facility administrator (FA)
reported the program completes a key performance indicator (KPI) report based on the reported
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information from each morning meeting. This information is totaled each month and compared
to the previous month. A meeting with the management team is conducted to plan how to
reduce deficiencies. Internal reviews are completed by corporate staff to verify deficiencies are
being reduced.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a written policy and procedures for tool inventory and management to
ensure youth do not use tools or equipment as weapons or for security breaches. The
program’s policy requires all program equipment and tools to be properly controlled and secured
to minimize the risk of tools and equipment being used as weapons, means of escape from the
program or other security breaches. A review of the program’s inventory list and the tool storage
shed verified tools are securely stored when not in use, easily marked for identification and
inventoried prior to and following work activities. All sharp edged and pointed tools are
inventoried daily when in use, including kitchen tools. There is a monthly inventory of tools
which do not have sharp edges or points. Prohibited tools at the program include machetes,
bowie knives, and other long bladed knives. If a tool is broken or inoperable, the maintenance
manager is responsible for replacing the broken tool. A review of the inventory used to
document issuance and return of tools found no discrepancies. In the event a tool is missing,
staff shall notify either the facility administrator (FA), the tool control officer, the assistant facility
administrator, or maintenance supervisor immediately. A tag is hung on the shadow board until
a replacement tool is in place. If a Class A tool is missing, during a work project or activities
involving youth, the FA or designee is immediately notified and the staff member supervising the
inventory writes an incident report, which is documented in the program’s logbook, and
notification is made to the Department's Central Communications Center (CCC) within the
required timeframe. A review of the CCC reports verified there were no instances of missing/lost
tools since the last annual compliance review.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to staff and youth. A review of the program’s policy
and procedures included supervision requirements, issuing tools to youth and staff, and
activities involving tools. The ratio is one staff for every five youth during vocational training and
tool use. A review of the program’s procedures and documentation verified staff are required to
complete a sign-out and sign-in log when Class B tools are taken and are returned to the
designated storage room. Reviewed documentation confirmed youth were trained on the
intended and safe use of Class B tools. Reviewed documentation confirmed nine youth were
trained on the intended and safe use of Class B tools. Nine youth case management records
were reviewed, and risk assessments were completed prior to youth using tools. Youth are
prohibited from using Class A tools. Five staff were interviewed, and four stated youth can use a
scrub brush, and five reported brooms, mops, and scrub brushes. Five youth were interviewed,
and stated they use mops and brooms.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a written policy and procedures establishing guidelines for outside
contractors who come on-site to complete repairs. When a private contractor or vendor enters
the program, they sign the Outside Contractor On-Site Work Project Log which lists
unauthorized items. An informal interview with the assistant facility administrator (AFA) indicated
when contractors are on-site contractors shall receive written instruction detailing
responsibilities regarding tool management and contraband and shall confine their work to the
authorized area using safety and security precautions. A review of work project logs since the
last annual compliance review verified the contractors signed the log confirming notification of
what items are considered unauthorized. A review of three project invoices showed the vendors
signed contractor agreements and an inventory of tools was completed and documented.
Reviewed outside contractor logs confirmed the program reviewed the inventory or equipment
when the vendor arrived and left. An informal interview with the AFA reported the program’s
practice is to assign a staff in the event the maintenance manager is not available to the
contractor to ensure the work is being completed and all tools are secured. The program's
policy states the facility administrator (FA) is responsible for providing approval and permissions
for personal cellular telephone and/or equipment/electronic devices capable of taking pictures
and audio or video recordings, including smartwatches.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a written policy and procedures to ensure fire safety and evacuation
drills are conducted, and youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. The Continuity of Operations Plan
(COOP) requires the program to conduct unannounced fire drills quarterly for each shift.
Reviewed documentation confirmed fire drills were conducted for all shifts as required. The
program conducted monthly emergency drills on each shift ensuring disturbances, escapes,
bomb threats, chemical spills, medical situations, and severe weather were covered on a
rotating basis. Each reviewed drill included the type of drill, date and time, participants, a brief
scenario description, deficiencies identified during the drill, and applicable corrective actions.
The program’s fire evacuation routes are posted throughout the program. All twenty-two of the
program’s fire extinguishers were inspected annually. Five staff were interviewed, and each
reported they participated in fire drills, medical drills, suicide, weather, and escape drills. All five
interviewed youth stated they participated in fire drills and have been instructed on what to do in
the event of a fire. An interview conducted with the facility administrator confirmed the program
conducts monthly fire and COOP drills on all shifts.
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
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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 regarding safety of the youth, staff, and public
in the event of an emergency or disaster. A review of the Department approved Disaster and
Continuity of Operations Plan (COOP) was available for all staff. An informal interview with the
assistant facility administrator (AFA) indicated the COOP is available to all staff, and is in the
conference room, master control, and the main office. The plan was reviewed, updated, and
approved by the Department on May 15, 2024. The COOP addressed alternative relocation
sites approved by the Department regional director/designee. The program’s Emergency
Disaster Preparedness Plan and COOP is one combined plan. The COOP addresses basic
care and custody of youth in the event of an emergency or disaster, addresses phases of a
disaster plan and emergency management, including preparedness, response, and recovery.
The COOP addresses emergencies including fire prevention, bomb threats, evacuations,
chemical spills, severe weather, and terrorist attacks. The equipment and supplies required for
continuous operation and services during emergencies or disasters are in the administration
office, medical office, and kitchen. An informal interview with the AFA reported the supplies are
batteries, flashlights, radios, canned food, and gloves. The program maintains identifying
information on each youth in the program, and if the program must evacuate the youth record
accompanies the youth to the temporary location. Reviewed documentation confirmed the
program maintains critical identifying information in hard copy binders including case
management, and medical. The program’s hard copy records are easily accessible and mobile
in the event of an emergency resulting in the program relocating quickly or in the event needed
information cannot be accessed electronically for all youth in the program. The facility
administrator (FA) reported fire drills, COOP drills, suicide drills, and medical drills are
completed on all shifts monthly and quarterly. A review of nine youth case management records
confirmed each contained the youth’s name, a photograph, Department identification number,
admission date, date of birth, gender and race, overall health status, address, and
parent/guardian contact information which included name, address, telephone number of the
person with whom the youth resides and their relationship to the youth, and person(s) to notify
in case of an emergency. In addition, the records contained the youth’s assigned juvenile
probation officer (JPO), committing judge, state attorney, and public defender.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
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The program maintains a written policy and procedures to ensure strict control of flammable,
toxic, poisonous, and caustic materials. All flammable, poisonous, and toxic items are stored in
the outside storage area where youth do not have access. A review of the flammable,
poisonous, and toxic items and inventories verified the items were securely stored and
inventories were accurate. The program maintains a list of program staff with position titles who
are authorized to handle the materials, which include the facility administrator (FA),
maintenance manager, supervisors, case managers, and counselors. The program policy
requires only the maintenance or other trained staff who have the safety equipment to dilute,
handle, and dispose of hazardous waste and/or solid waste to be responsible for disposing of
hazardous items and toxic materials. Reviewed documents confirmed the program’s disposal
procedures of chemicals was created in accordance with Occupational Safety and Health
Administration (OSHA) standards. All hazardous chemicals which are no longer used or are
outdated are disposed of by returning them back to the vendor or sending the chemical to the
hazardous waste center in accordance with the Safety Data Sheets (SDS). The program
maintains a SDS Log to track the disposal of such items. A review of the Disposal Logs
indicated the program did not have any chemicals disposed of since the last annual compliance
review. If there are any chemicals in need of disposal, the maintenance staff fill out the Disposal
Log and drop off the chemicals at the bio-hazardous waste station. All liquid waste from work
details is disposed by pouring the liquid in plumbing drains. Kitchen liquid waste, except for
grease, is disposed of in the kitchen drain. Grease is placed in a separate container for
disposal. The program uses a local disposal company to dispose of the grease in the grease
trap every quarter. The program has a procedure in place in the event of a chemical spill. If a
chemical spill occurs, the shift supervisor and maintenance staff are notified, the staff shut down
the air handlers and ventilation systems and close all windows and doors. An SDS binder is
located inside the storage area with a picture of each material corresponding to the SDS. The
program maintains chemicals used daily in a locked storage area inside the program and
outside. The program has a Chemical Daily Usage Log to track all toxic materials when in use
by authorized staff. Observations of the storage area indicated it is clearly marked hazardous
chemicals, securely locked, and has a posted list of authorized staff. In an interview, the facility
administrator (FA)stated the program only purchases what is used and has not disposed of any
items.
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,
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grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Program youth are strictly prohibited to
use, handle, or clean dangerous or hazardous chemicals, respond to chemical spills or clean,
handle, or dispose of any biohazardous material, bodily fluids, or human waste. Youth are
strictly prohibited from the maintenance area where toxic items and chemicals are stored. Five
youth were interviewed, and each reported they do not handle or use any chemicals or cleaning
products.
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.
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5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a written policy and procedures to ensure youth are allowed to receive
visitation and communication with approved family members. The program has a posted
visitation schedule and rules at the front of the program. The program’s policy provides each
youth opportunities to promote communication and engagement which fosters family
reunification and community connections. The program assists youth and families in maintaining
connections in a visitation environment which provides monitoring, control of movement, and
security practices to ensure visitor, youth, staff, and program safety. The program maintains a
list of approved visitors; however, attorneys, representatives of the court, juvenile probation
officers, other agency representatives, and clergy are authorized to visit at any time. Searches
of visitors will be conducted upon entry and all youth shall be searched following visitation
sessions. A review of the logbooks and visitation sign-in sheets verified the program allows
visitation for approved family members. Visitation is held two days a week on Saturdays and
Sundays from 1:00 p.m. to 4:00 p.m. A review of the telephone chronological notes verified
youth have consistent telephone communication with family members. The program’s visitation
policy indicated consideration for requests of alternative visitation arrangements with
parents/guardians, if needed. Youth can write letters or call by telephone at least once a week
to approved family members. None of the reviewed youth had a history of human trafficking. All
incoming and outgoing mail is checked for contraband and then given to the youth. An informal
interview with the regional director of compliance reported mail is sent out as it is received by
the program. The program utilizes a translation service for youth who do not speak English well.
Five youth were interviewed, and each stated they can call their parent/gaurdian or send a
letter.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program offers a diverse range of recreational and leisure activities for each youth. The
program has a daily activity schedule, which reflects each youth receives at least one hour of
recreation each day for leisure activities, including large indoor and outdoor muscle activity. A
review of the logbook indicated recreation was conducted, as scheduled. Logbooks were
reviewed for the annual compliance review period, and recreation was documented each day for
at least one hour, as required. Observations during the annual compliance review week
confirmed outdoor activities. The program's contract requires a recreation therapist. A review of
the staff credentials confirmed they met contractual qualifications. A review of nine youth
Individualized Performance Plans (IPP) confirmed each youth record contained a wellness plan
goal. Five youth were interviewed, and each youth reported the program allows youth the
opportunity to play basketball and football. Additionally, one youth reported video games and
card games. Five staff were interviewed, and each reported the youth received one hour of
indoor and outdoor activities such as board games, sports, basketball, football, and fitness. The
program is currently redoing the fence around the property, so the outside area is limited to the
small recreation yard.
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5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program maintains a policy and procedures to ensure youth searches and room inspections
are conducted prior to placing a youth in a controlled observation room. Youth shall never be left
alone in a controlled observation room until an inspection of the room is conducted, it is deemed
safe and secure, and in compliance with the required room specifications. Reviewed
documentation for eight youth placed in controlled observation was completed and verified each
youth and room was searched prior to placing the youth there. Each room was a minimum of
thirty-five unencumbered square feet and had a solid core metal door with a shatter resistant
observation window which allows for sight and sound observation. Additionally, each room was
equipped with windows which were shatter resistant and had no electrical outlets or switches.
Observations confirmed the program utilizes a controlled observation checklist which
documents youth and room searches. Youth are provided a security rated, fire retardant plastic
mattress suitable for use on the floor or a suicide resistant bed.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy and procedures address controlled observation, which may be used as an
immediate short-term crisis management strategy when a youth’s aggressive, violent or
potentially dangerous behavior substantially threatens the physical safety of others,
compromises program security and when non-physical interventions would not be effective.
Youth demonstrating acute psychological distress shall not be placed in controlled observation.
The facility administrator (FA) shall ensure all use of controlled observation is implemented only
as authorized and in accordance with policy. All program staff shall be sufficiently trained in both
use and documentation of controlled observation. Since the last annual compliance review
period, there were a total of thirty-eight controlled observations. A review of documentation for
eight youth placed on controlled observation verified no youth were suspected of suicide or a
mental health crisis. Each controlled observation was verified by a supervisor or higher-level
staff. Each of the reviewed youth showed active aggression towards others and were physically
out-of-control with less restrictive methods being ineffective, while one youth never physically
made it to controlled observation due to quickly becoming calm and realizing his actions. Six of
the reviewed controlled observations showed the youth were in controlled observation less than
four hours. Three of the youth were in controlled observation longer than two hours with the FA
approving and granting the extensions. Each youth was advised for the reason of placement
and had a health status checklist completed. If complaints or injuries were observed, a
healthcare staff was notified for assessment and treatment of all youth.
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5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
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 maintains a written policy and procedures which addresses controlled observation
safety checks and release procedures. The policy states safety checks of youth will be
completed every fifteen minutes to ensure the youth’s safety and observe the youth’s behavior
while youth is in controlled observation. Staff documenting observations must include the time,
code, explanation of behavior, and staff initials on the Controlled Observation Safety Checks
form. Continuous sight and sound supervision of youth will be maintained as a provision of
continuous, uninterrupted visual and sound monitoring of the youth when demonstrating
physical behaviors which pose a high risk of self-injury and document all safety checks on the
Controlled Observation Safety Checks form. Medical staff will be notified of any illness or
reported injury. Youth shall not be denied meals or dietary needs when in controlled
observation. Once a youth is determined ready for re-integration from controlled observation
into the general population, the facility administrator (FA) or designated supervisory staff must
give written approval prior to the youth’s release from controlled observation. A review of eight
controlled observation safety checks and release procedures verified staff making placement
completed the first page of the Controlled Observation Report and submitted the form to a
supervisor. Staff conducted and documented safety checks at least every fifteen minutes and
observed the youth’s behavior. The FA or designated supervisory staff, approved each youth’s
release from controlled observation, which was based on whether the youth was no longer an
imminent threat to self or others. Each of the eight youth required an internal alert upon
placement and release from controlled observation. The Controlled Observation Report, Health
Status Checklist, and Controlled Observation Safety Check forms were maintained in an
administrative record for each youth.
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Standard 6: Career and Technical Education/Education
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The career and technical education (CTE) services being provided, as contracted, are Florida
Ready to Work Soft Skills, Occupational Safety and Health Administration 10 (OSHA10), and
first-aid/cardiopulmonary resuscitation (CPR). The program’s contracted CTE services do not
include industry certifications from the master credentials list (MCL). The program is contracted
to provide OSHA10, which is a base level certification which can lead to industry certifications
Construction Education and Research (NCCER). The program currently has an instructor to
provide career and technical education services with first-aid and CPR. The instructor is certified
in first-aid and (CPR). Certifications are not required to facilitate Florida Ready to Work - Soft
Skills and OSHA10 as those are certified by each organization upon youth passing the web-
based modules and assessments. Thirty-seven youth are enrolled in coursework towards
earning an industry certification. Nine reviewed youth have completed first-aid/CPR and
OSHA10. The youth are on track to complete the required Florida Ready to Work - Soft Skills
within the contracted time frame. Five youth were interviewed and asked how well you think this
program is preparing you for your high school equivalency diploma (GED), high school,
vocational school, employment, and/or college. Four youth stated very well, and one youth
stated not well. The facility administrator (FA) was interviewed in regard to which career
education services are provided to the youth at the program, and it was reported the youth are
given an Independent Living Skills Assessment following intake to identify deficiencies. The
youth then work with the transition service manager to address their needs. The youth are
provided with a Florida identification card, learn to write a resume/cover letter, and practice
filling out job applications. Graduates have the option of Project Anchor for college courses or
career and technical education (CTE) certifications. The program offers a masonry program,
OSHA 10 and 30, and a construction certification. When asked to confirm which contract
specific pre-vocational and vocational services are provided at the program the FA reported
Florida Ready to Work, Project Anchor, CTE certification, and masonry.
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6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program maintains a written a policy and procedures to provide educational access. The
program integrates education into the daily schedule. A sample of three videos and three
logbook reviews showed youth are being sent to class on time; however, two of the three days
reviewed in the logbook had no notation of when school ended or movement showing school
ended. In addition, randomly selected logbook entries over the past year were reviewed and
youth were moved accordingly with little deviation. Five interviewed youth stated there are no
interruptions during the school day. Five youth were asked how well you think this program is
preparing you for a high school equivalency diploma (GED), high school, vocational school,
employment, and/or college. Two youth responded very well, two youth responded well, and
one youth responded not well.
6.03 Educational Access (Education Contract Provider) Non-Applicable
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.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The contracted education provider ensures the integrity of the required minimum instruction time
distributed over a twelve-month period. The district approved calendar and daily school
schedule were reviewed, which incorporated the required 250 days of instruction, with twenty
days used for teacher planning, and a minimum of twenty-five hours of instruction weekly. The
daily school schedule was approved by the board on April 29, 2024. Youth are enrolled in
academic courses through Florida Scholars Academy and receive credit, as appropriate, when
courses are completed. A sample of three videos and three logbook reviews showed youth are
being sent to class on time, however two of the three days reviewed in the logbook had no
notation of when school ended or movement showing school ended. In addition, randomly
selected logbook entries over the past year were reviewed and youth were moved accordingly
with little deviation. In a review of the lead educator’s interview, the instructional leader reported
the educational schedule is adhered to.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
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the length of stay and classification of youth in the program. The career education program does
include Type One through Life Management Skills and Personal Finance and Money
Management courses. The career education program does include Type Two through career
and technical education (CTE) course offerings which provide exploration and knowledge of
occupations within those specific careers. The career education program does include Type
Three through CTE course offerings which provide content and competencies for those specific
careers. A career strengths and interest questionnaire are completed by students upon entry.
Each CTE course offering by the education provider includes soft skills for those specific
careers. The education contracted provider is responsible for providing Career and Professional
Education (CAPE) courses leading to pre-apprentice certifications and industry certification.
Youth at the program are enrolled in Digital Information Technology and Foundations of
Programming, courses which lead to the CAPE Industry Certification Comp TIA A+. An interview
was completed with the facility administrator (FA) to confirm which career education services
are provided. The FA reported the youth are given an Independent Living Skills Assessment
following intake to identify deficiencies. The youth then work with the transition service manager
(TSM) to address their needs. The youth are provided with a Florida identification card, learn to
write a resume/cover letter, and practice filling out job applications. Graduates have the option
of Project Anchor for college courses or CTE certifications, The masonry program offered
Occupational Safety and Health Administration 10 and 30 (OSHA 10 and 30), and construction
certification. The FA was asked to confirm which contract specific pre-vocational and vocational
services are provided at the program and they reported Florida Ready to Work, Project Anchor,
CTE certification, and masonry. The lead educator interview was completed by the instructional
leader and the interview revealed career education services and assessments are provided to
youth in the program and the students complete a career strengths and interest questionnaire
upon entry. Youth are placed into Digital Information Technology and Life Management CTE
courses. The lead teacher interview revealed how the information is shared with the multi-
disciplinary treatment team members. Progress reports are sent to case management by email
within twenty-four hours of treatment team meetings and the teachers add behavior notes to the
academic progress reports.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The program maintains a written policy and procedures for an education transition plan. After a
review of the closed records provided, all of the youth files were missing Individual Education
Transition Plans (IETP) which would have been provided by Florida Scholars Academy (FSA)
and not the transition plans by the program. During the annual compliance review period, the
program has not received any education transition plans from FSA education staff.
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6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The contracted educational provider has procedures in place to provide for qualified
instructional personnel. A review of six certifications of current teachers and two teachers which
left, as well as fifteen flex teachers, found twenty-two had a valid Florida educator’s certificate.
One teacher’s credentials were not active on the Department of Education (DOE) website. Five
reviewed teaching credentials found personnel were not teaching in their field and there was no
approval obtained by the school board for out-of-field teaching. A review of the three youth
school schedules found two teachers were listed on two of the schedules. These teachers did
have an active teaching certification on the DOE website; however, their teacher’s information
was not provided. After reviewing three youth records for out-of- field parent/guardian
notification letters, it was noted no notifications were sent out prior to October 14, 2024, and
none of the letters accurately reflected the classes, or teaching assignments outside of their
field of expertise.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
Education services are provided by Florida Scholars Academy/Florida Virtual School. This
indicator was reviewed; however, will not be rated until the 25/26 review cycle.
The education contract provider is responsible for referring all youth who receive their high
school diploma or equivalent to Florida Youth College so they can work with a career navigator
on postsecondary courses and/or enrollment in a state or technical college. None of the three
reviewed youth were referred to Florida Youth College. A further review of the youth records
revealed youth were still working towards earning their high school diploma at the time of their
release; therefore, they did not meet the eligibility criteria for a referral to Florida Youth College.
An additional record was reviewed for a youth who did meet the eligibility criteria and was
referred to Florida Youth College. Five youth were interviewed and were asked how well you
think this program is preparing you for your high school equivalency diploma (GED), high
school, vocational school, employment, and/or college. Four youth stated very well, and one
youth stated not well. The lead educator interview was completed by the instructional leader.
The instructional leader was asked what career education services and assessments are
provided to youth and where is this documented. The response indicated students complete a
career strengths and interest questionnaire upon entry and are placed into Digital Information
Technology and Life Management career training and education (CTE) courses. The
information is shared with the multi-disciplinary treatment team members by progress reports
which are sent to case management by email within twenty-four hours of treatment team
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 72 (Revised September 2022)
meetings. Teachers add behavior notes to the academic progress reports. The Florida Scholars
Academy instructor was informally interviewed regarding postsecondary pathways and support
offered to youth. The instructor identified Project Anchor and technical colleges as
postsecondary pathways and stated support is provided through individual teacher assistance
and peer-to-peer.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each referral received by Florida Youth College from the education contract provider is
assigned a career navigator. The career navigator then connects with youth through the
residential contract provider to schedule an orientation session. During orientation, the youth
and career navigator develop a career pathway plan to include postsecondary courses and/or
enrollment in a state or technical college. The career navigator continues to assist youth on their
career pathway plan and have incremental follow-up sessions scheduled through the residential
contract provider. For the sample records reviewed, there were no referrals to Florida Youth
College, therefore a career navigator was not assigned to the youth. An additional record was
reviewed for a youth who was referred to Florida Youth College. There was documentation to
support the date of orientation and the occurrence of a thirty-day and sixty-day follow-up. The
youth’s ninety-day and one hundred eighty-day follow-up will occur in the future. The Florida
Youth College youth record indicated the career interests of youth. A copy of admission to a
postsecondary program was not included as the youth is currently working towards an
Occupational Safety and Health Administration 30 (OSHA30) credential and it is undetermined
at this time if the youth’s career pathway will include enrollment in a postsecondary program. An
informal interview was conducted with the Florida Scholars Academy (FSA) instructor. When
asked which postsecondary pathways can be identified for youth, the response included work-
based learning in careers like construction, automotive, and waste management to include
enrollment in technical colleges with the support of Project Anchor. When asked which options
are offered to youth during their time in FSA, the response included Digital Information
Technology and Foundations of Programming are available for students working towards their
high school diploma and graduates. When asked how FSA instructors offer support to youth
within the classroom to continue academic and credential progress, the response included
individual assistance and small group tutoring are provided by teachers and youth also receive
support through peer-to-peer assistance. Five youth were interviewed. When asked how well
you think this program is preparing you for your high school equivalency diploma (GED), high
school, vocational school, employment, and/or college four youth selected very well, and one
youth selected not well.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 72 of 72 (Revised September 2022)

report_type: QI Residential

program_name_raw: Kissimmee Youth Academy - MHOS