state: FL

facility_name: Orlando Intensive Youth Academy

summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Orange Youth Academy/Orlando Intensive Youth Academy
Youth Opportunities Investments, LLC
(Contract Provider)
3150 39th St.
Orlando, Florida 32839
Review Date(s): May 20 - 23, 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:
Sandra Thompson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Melissa Johnson, Office of Accountability and Program Support, Central Regional Supervisor
(Standard 3)
Tamara Mahl-Adkins, Office of Accountability and Program and Support, Regional Monitor
(Standard 4)
Jefferey Williams, Orange Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Belinda Alexander, Office of Education, Southwest Region Education Coordinator (Standard 6)
Teresa Andersen, Office of Accountability and Program Support, Central Region Deputy
Supervisor (Lead Reviewer)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Co-Lead,
Standard 6)
Nick Johnson, Office of Education, Deputy Chief DJJ Education (Standard 6)
Gus Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Orange Youth Academy/Orlando Intensive Youth Academy
MQI Program Code: 1127/1166
Provider Name: Youth Opportunity Investments Contract Number: 10758
Location: Orange County / Circuit 9 Number of Beds: 56
Review Date(s): May 20 - 23, 2025 Lead Reviewer Code: 220
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, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 71 (Revised September 2022)
A ll in d ic a to rs h a ve b e e n ra te d
O v e
S a tis
ra ll R a tin g S u m
fa c to ry a n d n o c o
m a
rre c
ry
tive a c tio n is n e e d e d a t th is tim e .
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 71 (Revised September 2022)
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
1 .1 1
1 .1 2
1 .1 3
1 .1 4
1 .1 5
1 .1 6
1 .1 7
1 .1 8
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g *
F iv e -Y e a r R e s c re e n in g /R e n e w a l
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t *
M a n a g e m e n t R e s p o n s e to A lle g a tio n s *
In c id e n t R e p o rtin g (C C C ) *
P ro te c tiv e A c tio n R e s p o n s e (P A R ) a n d P h y s ic a l In te rv e n tio n R a te
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts *
In -S e rv ic e T ra in in g
G rie v a n c e P ro c e s s
In te rv e n tio n s a n d F a c ilita to r T ra in in g
L ife S k ills T ra in in g P ro v id e d to Y o u th
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th
In te rn a l A le rts S y s te m a n d A le rts (J J IS )*
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t)
A d v is o ry B o a rd
S ta ff P e rfo rm a n c e
S p e c ia l C o n tra c t C o n d itio n s
D a ta T re n d A n a ly s is
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 71 (Revised September 2022)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
2 .1 2
2 .1 3
2 .1 4
2 .1 5
2 .1 6
2 .1 7
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n
Y o u th O rie n ta tio n
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y )
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S )
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls a n d T ra n s m itta l *
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s )
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T )
E x it P o rtfo lio
E x it C o n fe re n c e
Y o u th In p u t
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 71 (Revised September 2022)
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
3 .1 8
3 .1 9
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff *
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t*
T re a tm e n t a n d D is c h a rg e P la n n in g *
S p e c ia liz e d T re a tm e n t S e rv ic e s *
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
C ris is A s s e s s m e n ts *
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s *
B a k e r a n d M a rc h m a n A c ts *
S a fe ty P la n n in g P ro c e s s fo r Y o u th
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
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 71 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 71 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
5 .0 1 Y o u th S u p e rv is io n *
5 .0 2 C o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
5 .0 3 U s e o f R o o m R e s tric tio n N
5 .0 4 T e n M in u te C h e c k s *
5 .0 5 C e n s u s , C o u n ts , a n d T ra c k in g
5 .0 6 L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
5 .0 7 K e y C o n tro l*
5 .0 8 C o n tra b a n d P ro c e d u re
5 .0 9 S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
5 .1 0 V e h ic le s a n d M a in te n a n c e
5 .1 1 T ra n s p o rta tio n o f Y o u th
5 .1 2 W e e k ly S a fe ty a n d S e c u rity A u d it
5 .1 3 T o o l In v e n to ry a n d M a n a g e m e n t
5 .1 4 Y o u th T o o l H a n d lin g a n d S u p e rv is io n
5 .1 5 O u ts id e C o n tra c to rs
5 .1 6 F ire , S a fe ty , a n d E v a c u a tio n D rills
5 .1 7 D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
5 .1 8 S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
5 .1 9 Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
5 .2 0 E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t * N
5 .2 1 V is ita tio n a n d C o m m u n ic a tio n
5 .2 2 R e c re a tio n a n d L e is u re
5 .2 3 S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m N
5 .2 4 C o n tro lle d O b s e rv a tio n N
5 .2 5 C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s N
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n
o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e
S a tis fa c to ry
S a tis fa c to ry
o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
o n -A p p lic a b le
o n -A p p lic a b le
o n -A p p lic a b le
tio n if a p ro g ra m
s e in d ic a to rs .
n tia l, p ro b a tio n ).
Standard 6: Educational Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 71 (Revised September 2022)
6 .0 1
6 .0 2
6 .0 3
6 .0 4
6 .0 5
6 .0 6
6 .0 7
6 .0 8
* T h e D e p a rtm e n
o p e ra te s b e lo w D
F a ilu re to d o s o w
In d ic a t o r R a t in g s
S ta n d a r d 6 - E d u c a tio n a l S e r v ic e s
C o n tra c t S p e c ific C T E S e rv ic e s (R e s id e n tia l C o n tra c t)
E d u c a tio n a l A c c e s s (R e s id e n tia l C o n tra c t) *
E d u c a tio n a l A c c e s s (E d u c a tio n C o n tra c t) *
C a re e r E d u c a tio n (E d u c a tio n C o n tra c t)
E d u c a tio n T ra n s itio n P la n (E d u c a tio n C o n tra c t)
Q u a lifie d In tru c tio n a l P e rs o n n e l (E d u c a tio n C o n tra c t)
F lo rid a Y o u th C o lle g e (E d u c a tio n C o n tra c t)
F lo rid a Y o u th C o lle g e (P o s t-S e c o n d a ry C o n tra c t)
t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a
e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th
ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
S a tis fa c to ry
tte n tio n if a p ro g ra m
e s e in d ic a to rs .
s id e n tia l, p ro b a tio n ).
Program Overview
The Orange Youth Academy/Orlando Intensive Youth Academy is a 56-bed program, for
fourteen to twenty-one year old males, for the Orange Youth Academy and twelve to eighteen
year old males in the Orlando Intensive Youth Academy, located in Orlando, Florida. The
program is operated by Youth Opportunities, LLC, through a contract with the Department. The
program provides the following services: Substance Abuse Treatment Overlay Services
(SAOS), Mental Health Overlay Services (MHOS), Intensive Mental Health (IMH) treatment
services, Comprehensive treatment services for co-occurring disorders, Borderline Intellectual
Functioning (BIF) Borderline Developmental Disability (BDD) services, Developmental Disability
(DD) Treatment services, Medical Complex Residential Overlay services, and Juvenile Sex
Offender Treatment Services.
In addition, the program fosters each youth by providing. Impact of Crime (IOC), Thinking for
Change (T4C), SkillStreaming the Adolescent, Passport Program, Dialectical Behavioral
Therapy (DBT) Skills, Aggression Replacement Training (ART), and Cannabis Youth Treatment
(CYT). Additional treatment services provided includes family and individual therapy,
recreational therapy. Program administration is comprised of one facility administrator and one
assistant facility administrator. Case management services are provided by one case
management director (DCM), three case managers, two transitional services managers, and
one CTE program manager. Mental health staff at the program includes one director of clinical
services, four licensed mental health therapists, and two recreational therapists, a psychologist
and a psychiatrist. Medical services are offered from 7:00 a.m. to 7:30 p.m. daily and are
provided by one health services administrator, three full-time registered nurses and one
licensed practical nurse. Educational services are provided by Florida Virtual Schools and
Florida Youth College. The layout of the program includes multiple buildings, one larger, three
smaller, and two portables. The main building is the largest and houses administration, staff
offices, master control, and all youth modules. One of the smaller buildings is used as the dining
hall and kitchen. The remaining two portables and two smaller buildings are for the teachers,
divided into offices and classrooms. The program has eighty-nine functioning cameras with two
of them non-functional. At the time of the annual review, the facility administrator reported the
non-functional cameras would be repaired by a contracted company. At the time of the annual
compliance review, the program had seven vacant positions. Of those seven vacancies, one
position is a case manager position, one transporter position, one safety and security specialist
position, three safety and security level one positions and one safety and security specialist
level three position.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 71 (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 policy and procedures outlining the process of conducting initial background
screening for new hires, volunteers, and contracted staff. Since the last annual compliance
review, the program hired twenty-one new staff. The program has a total of seventy-eight staff,
three contracted staff, and one volunteer. The volunteer works less than ten hours a month and
is not with youth without supervision from a trained staff.
Each of the twenty-one reviewed new staff were found to have an eligible background screening
in the Agency for Healthcare Administration (AHCA) Clearinghouse system and the
Department’s Background Screening Unit (BSU), which was completed prior to each staff’s hire
date or before they had contact with the youth. The program added each staff to the
Clearinghouse employee roster. Each staff’s criminal history report was reviewed in the
Department’s Staff Verification System (SVS) report. One of the twenty-one reviewed staff had
a break in service and a new background screening completed. The volunteer and three
contracted hires are not required to take the pre-employment assessment tool. Twenty-one staff
completed and passed the pre-employment assessment tool. Each of the staff signed a
contraband attestation form.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures outlining the process of conducting five-year
rescreening on staff meeting the criteria. A review of the staff, volunteer, mentor, and intern
roster found the program had one staff applicable for a background rescreening during the
annual compliance review period. The staff was found to have a completed and eligible
background rescreening in the Agency for Healthcare Administration (AHCA) Clearinghouse
system and the Department’s Background Screening Unit prior to their five-year anniversary
date.
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1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures outlining the provision of an abuse-free environment
for both staff and youth. During the program tour, the week of the annual compliance review,
observations confirmed information for the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC) were posted throughout the facility. Of the seven staff reviewed
each signed a code of conduct during orientation. The program completed the Trauma
Responsive and Caring Environment (TRACE) self-assessment. The facility administrator (FA)
reported the TRACE was completed May 5, 2025. Since the last annual compliance review,
seven incidents were documented to be related to physical, psychological, or emotional abuse.
One of these incidents was found to be substantiated since the last annual compliance review.
The facility administrator, when asked about the code of conduct, reported the standards are
categorized in three levels: major, minor, and critical offenses. Failure to follow a standard of
conduct may result in disciplinary action, from a verbal warning to termination of employment.
The severity of the penalty depends on the frequency and nature of the offense. These
standards are a minimum expectation for acceptable work performance and workplace
behavior.
Seven staff were interviewed. Each interviewed staff reported knowing the telephone number or
knew where the telephone number for the Florida Abuse Hotline and CCC were posted
throughout the facility. All seven staff reported they would notify the facility administrator and
allow the youth to make the call. Four of the seven staff reported the supervisor would make the
call and one of the seven reported staff are permitted to make the call. All seven staff reported
they have never observed another staff telling a youth they could not call the Florida Abuse
Hotline. Four of the seven staff reported they have never heard another staff use profanity when
speaking to the youth. One of the staff reported hearing a staff use profanity once and two of the
staff reported they have heard staff use profanity while speaking to youth occasionally.
Seven youth were interviewed, and all seven reported they feel safe in the program, have never
been stopped from reporting abuse of any kind and no staff had ever used cursing type
language toward them at any time. All seven youth reported at no time did any staff exchange
any personal information with them or disclose social media information.
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1.04 Management Response to Allegations (Critical) Satisfactory Compliance
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 has a policy and procedures outlining the process of how management responds
to allegations of physical, psychological, and emotional abuse. Since the last annual compliance
review seven incidents were documented indicating abuse or neglect, of which five were
reviewed. Three of the incidents were related to the same allegation resulting in two staff being
suspended, pending the outcome of the investigation. In one of the five incidents, the staff was
suspended pending the outcome of the investigation. The facility administrator reported three
staff had received disciplinary actions, placed on no youth contact and leave without pay due to
the allegations of abuse toward youth since the last annual compliance review.
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 has a policy and procedures outlining the process of reporting incidents to the
Department’s Central Communications Center (CCC). Since the last annual compliance review
twenty-eight CCC incidents have been reported.
Five reports were reviewed and were documented in the logbook as required. All five were
reported within the two-hour time frame from the incident and there were no additional internal
incidents or grievances which should have been reported to the CCC.
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.
The program has a policy and procedures outlining the use of Right Interactions (RI). The facility
administrator (FA) reported during an interview, RI are reviewed during morning management
meetings, a video review is conducted, and monthly RI summary reports are reviewed and
submitted to the Department for tracking in the Morning Meeting Database. Monthly the RI
Summary report is completed and reviewed for trends and submitted to the Department for
tracking. Seven staff were interviewed and six reported knowing the process of RI and one staff
reported he is not a direct care staff and has no interaction with the youth.
During annual compliance review period, eighteen RI incidents were reported. Monthly
summaries were maintained by the program of all RI incidents and submitted to the
Department’s regional office by the fifteenth of each month with no discrepancies. The RI Plan
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was updated on November 25, 2024, and approved by the Department on December 16, 2024.
The program’s PAR rate during the annual compliance review period was 1.42 for Orange
Youth Academy which is below the statewide Residential PAR rate of 2.41 and the PAR Rate
for Orlando Intensive Youth Academy was 5.93 which is above the statewide rate of 2.41. Five
RI Reports were reviewed and all were completed by the end of each staff’s workday and
reviewed by an RI certified instructor/supervisory staff. All incident reports were reviewed by the
FA or designee within seventy-two hours, and a copy was placed in the program’s centralized
file within forty-eight hours of approval by the FA. Each of the five reports included statements
from all staff involved.
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 policy and procedures for ensuring staff satisfy the pre-service training
requirements within 180 days of hire. Staff must complete a minimum of 160 hours of required
training in the pre-service period. Program staff are shared between the two programs. Training
documentation was available for review in the Department’s Learning Management System
(SkillPro). Each of the reviewed seven staff completed the required training prior to having any
contact with youth to include cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), Right Interactions (RI), ethics, facility operating procedures, child abuse
recognition, reporting, and prevention, suicide awareness and prevention, emergency
procedures, child abuse reporting, and Prison Rape Elimination Act (PREA). Additional trainings
were completed by each staff for active shooter preparedness, adolescent development and
behavior, restorative justice, incident reporting, civil rights, diversity, Department of Juvenile
Justice History, equal employment opportunity, gang awareness, infection control, information
security awareness, the Department’s Juvenile Justice Information System (JJIS), mental health
and substance abuse, motivational interviewing, report writing, supervision of youth, human
trafficking, standards of conduct, and trauma responsive practices. Each of the five reviewed
staff completed more than 120 training hours within 180 days of hire. Documentation review
confirmed all instructors were qualified to facilitate CPR, AED, and RI trainings. The provider’s
contract required additional training, which all seven reviewed staff completed. The contract
included two additional training requirements which are captured in the provider’s on-the-job
(OJT) training for the discipline in which it is required. A review of the provider’s OJT Training
Plan for the included disciplines, the therapist, registered nurse and case manager, confirmed
training for each discipline. The seven staff completed the specialized service trainings, as
required. All trainings were captured in SkillPro for each staff. One supervisor was applicable
for pre-service training, who completed forty-two hours of supervisory training, including
coaching, leadership and personal accountability.
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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 policy and procedures outlining annual in-service staff trainings. There is an
annual training calendar which is maintained and updated by the program as changes occur.
The training calendar was approved by the highest official at the program, the assistant
secretary of the Department’s Office or Residential Services and the director of the
Department’s Office of Talent, Leadership and Culture, as evidenced by their signatures. Seven
staff training records were reviewed for in-service training, of which one was a supervisory staff.
Each record included all updated annual certifications in cardiopulmonary resuscitation (CPR),
first-aid, automated external defibrillator (AED), and /Right Interactions (RI). Reviewed
documentation confirmed all instructors were qualified to facilitate CPR, AED, and /RI trainings.
All seven staff training records reflected training completion in all the required topics. All
completed trainings were entered into the Department’s Learning Management System
(SkillPro). The program provides enhanced specialized treatment services, and each staff
completed the training in the required enhanced treatments. The supervisory record included
documentation of the required eight hours of management and supervisory training, which
includes coaching, leadership, and personal accountability.
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 policy and procedures outlining the grievance process. The process
includes staff training with specific time frames, the phases of grievances, appeals, and
orienting youth on the grievance process, upon admission to the facility. The program uses a
Communication Request Form for informal grievances. The youth complete the Communication
Request Form declaring the concern and a desired solution or suggestion. Once turned in, the
grievance will be discussed. Should the grievance go unresolved, then it goes to the Formal
Phase. The facility administrator (FA) was interviewed and advised the grievance process is to
ensure youth are treated fairly, respectfully, and without discrimination. Youth who file a
grievance will not be subject to retaliation or barriers to services. The FA also outlined the
grievance process, to include the informal, formal, and appeal phases, emphasizing there is no
time limit for the youth to file a grievance, and there is no requirement prohibiting a youth from
filing a grievance without first using the informal complaint and resolution steps. Seven
interviewed staff were asked to explain the program’s grievance process. The seven staff
reported there are grievance forms placed throughout the facility and the youth can request
assistance to complete it. All seven reported the grievance process has three phases and the
supervisor and facility administrator review all grievances. Seven youth were interviewed, and
all seven reported the grievance forms are accessible throughout the facility. Three of seven
youth reported there are three phases to the grievance procedures. All seven youth reported
there are time frames for each phase. All seven youth reported they can ask for assistance in
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filling out the forms. Since the last annual compliance review, five grievance incidents were filed
in the Formal Phase. All five grievances were addressed within twenty-four hours and resolved.
The program’s practice correlated to the program’s process. the program maintained a copy of
all grievances since the contracted started September 1, 2024.
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 policy and procedures describing what type of delinquency interventions
shall be provided to the youth. A review of the provider’s contract confirmed the non-clinical
group provided is Impact of Crime (IOC). The program’s daily activity schedule confirmed the
program is providing structured, and planned programming. The IOC group is a sixteen-week
closed group, held two times a week for one hour, by a trained facilitator. Group sign-in sheets
were reviewed for IOC. None of the groups had less than eight youth and no more than eleven
youth. Groups were held as noted on the program’s activity schedule.
The program’s daily activity schedule confirmed the program is providing structured, planned
programming, for at least sixty percent of the youth’s awake hours by trained therapists.
The facility administrator (FA) reported the therapists use Cognitive Behavioral Therapy (CBT)
and trauma informed care to provide therapeutic group and individual services. The designated
mental health clinician authority reported the therapist and one transition service manager
provide interventions. The services include Aggression Replacement Training (ART),
Skillstreaming the Adolescent, Dialectical Behavioral Therapy (DBT), and Cannabis Youth
Treatment (CYT), all of which are clinical and primary groups. The focus of the curriculum is to
help youth understand the harm they have created by committing crimes and helping them take
personal accountability.
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 has a policy and procedures to determine how services are provided. The program
provides daily therapeutic activities which are facilitated by the mental health clinical staff. Life
skills groups are considered primary services. Upon admission, youth participate in a hygiene
course. The program utilizes a life and social skills assessment tool for each youth to assist in
determining any specific interests. The results are incorporated into each youth’s performance
plan and used to assign activities. The life-skills curriculum includes cardiopulmonary
resuscitation (CPR)/first-aid, Occupational Safety and Health Administration (OSHA) training,
mock interviews, career day and the group Skillstreaming the Adolescent. The program
maintains a Brag Book documenting all activities. Each month there are multiple social and life
skills activities in which the youth participate. Activities include ball games, coalition for the
homeless, youth graduation ceremonies , an outreach event for a local non-profit, and town hall
meeting with the youth. Seven youth were interviewed and each reported receiving life-skills
group and mental health and substance abuse classes. Each youth reported participating in
streaming Skillstreaming the Adolescent, Living in Balance, self-esteem, shame and guilt
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groups, and sexual abuse groups. In an interview with the facility administrator, he reported all
youth participate in groups, as stated in the student handbook. The program offers processing
groups and therapists can identify specific needs of each youth. The program provides each
youth with personal items, allowing for personal gender expression and includes meeting youth
needs, who identify with the opposite gender. The designated mental health clinician authority
(DMHCA) reported youth are provided an opportunity to practice learned skills in recreation
therapy and daily interactions with peers and staff.
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 has a policy and procedures regarding restorative justice awareness services. The
program provided Impact of Crime (IOC) groups to address restorative justice services.
Although activities were not during the annual compliance review week, documents were
provided indicating IOC and community service activities with a local non-profit were conducted
from November 2024 through February 2025. IOC is provided Monday through Friday and
restorative justice activities are provided and sign-in sheets, fidelity checks activity flyers and
photos were available and reviewed. The facility administrator reported youth being able to
participate in a variety of restorative justice groups and projects such as IOC, school backpack
giveaways, community cleaning, car washes, helping set up for car shows and cancer walks. All
seven youth reported learning how to control anger using verbal skills, practicing deep breathing
exercises, learning coping skills and meditation, encouraging youth to talk to one another to
work out their differences, and practicing these skills in group and throughout their daily activity.
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 policy and procedures to address the programs utilization of the internal
alert system to include an alert roster and alert board, detailing all applicable youth alerts,
including dietary, security, mental health, medical and the like. Any change in the youth’s alert
status is updated on the board as well as documented in the shift logbook. When alerts are
identified, they are documented, updated, and communicated to staff through the program's
internal alert system and alerts entered in the Department's Juvenile Justice Information System
(JJIS). During the annual compliance review week, it was noted the alert board was in the
program’s conference room. Observed was information which included an internal alert board
displaying an overview listing of alerts for each applicable youth. The alert board is accessible to
staff; however, not to the youth and all youth with medical and/or dietary allergy alerts are
posted in respective departments, including medical and kitchen areas, for staff access. A total
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of sixty alerts were entered for the seven reviewed youth. Each alert was entered, updated, and
removed by the appropriate staff. Each current internal alert correlated with the JJIS dates and
matched the alerts in JJIS.
The facility administrator stated the outgoing shift supervisor will brief the incoming shift of any
new or changed alerts. Additionally, any changes or new alerts are discussed during morning
management meetings. Each department head is responsible for managing alerts applicable to
their department. The internal communications board displays current, open, and applicable
alerts and is updated as needed. Internal trackers are also maintained by department. All
internal trackers are reviewed on a weekly basis during the Monday Morning Management
Team meeting for fidelity monitoring. According to the nursing staff, they are responsible to
update medical alerts and close them out as needed. Seven youth individual mental health,
case management, and healthcare records were reviewed during the annual compliance review
week. Each applicable youth record is comprised of current and updated appropriate alerts
entered with the staff’s name and credentials in JJIS. All alerts related to medical conditions,
medications, diet, Prison Rape Elimination Act and allergies were entered in JJIS upon the
youth’s admission or when verification of a health condition was confirmed.
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 policy and procedures requiring youth records to be separated into
individual case management and Individual Healthcare Records. The healthcare records are
divided into health and mental health/substance abuse records. Seven youth records were
reviewed, and all had individual case management, healthcare, and mental health records.
Each record contained the youth’s name, Department identification number, date of birth, county
of residence, and committing offense. Each record also included legal information, demographic
and chronological information, correspondence, and case management and treatment team
activities. All youth records were marked ‘Confidential.’ The case management records are
stored in locked cabinets within the case managers offices and are marked ‘Confidential.’ The
healthcare and mental health/substance abuse records are kept in a locked office in the medical
department, with no youth accessibility.
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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 policy and procedures addressing implementation and maintaining a
community advisory board. A review of the community advisory board binder included sign-in
sheets, meeting agendas, and minutes. The facility administrator (FA) solicits active
involvement from partners from law enforcement, the judiciary community, the business
community, the faith-based community, school board district and LGBTQIA+, which was
confirmed by supporting documentation in the community advisory board binder. Confirmed
meetings were held on November 20, 2024, and March 31, 2025. Both meetings permitted
members to meet in person or by Zoom. The requirement of the board meeting at least every
ninety to 120 days was not met, as there was a twenty-one-day delay.
The FA stated he maintains the Community Advisory Board requirements. Once the Board has
met, the meeting minutes are shared with all board members to inform those who may not have
been present. Recruitment letters are mailed out periodically to solicit new members and ensure
each position on the board is properly represented.
A board member was interviewed during the annual compliance review week and stated the
board meets quarterly. He stated he will often go to the program to assist, when he can. He
reported being a part of the advisory board to be a very pleasant experience.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures addressing the evaluation of all staff’s performance
within the completion of the first ninety days of hire and then annually thereafter. Reviewed job
and position descriptions ensured each staff’s performance standards were clearly identified for
each of the seven job descriptions reviewed. The reviewed performance evaluations ensured
evaluations were completed as outlined in the policy at least annually. All seven of the reviewed
position descriptions included the Behavior Management System(BMS) responsibilities for the
staff. The records of the recreational therapist showed she has a Bachelor of Science in Leisure
Studies from an accredited university.
In interviews with seven staff, six reported receiving annual performance reviews and one staff
reported receiving a review after six months of employment. The Facility administrator stated
within ninety days of hire, staff are evaluated for job performance duties. They are provided with
feedback and counseled on areas in need of improvement and then annually thereafter. The
program has experienced significant turnover in the past year, in each department. The trend
appears to be staff moving into an elevated position. There has also been a turnover of staff in
direct care. Overall, the focus will be to fill the vacancies and maintain current staff, emphasizing
staff morale and engagement by hosting weekly luncheons, on campus socials and other team
building events.
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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 with the Department includes a Memorandum of Negotiation (MON),
Summary of Negotiated Points, or Secretary’s letter. The items listed as special contract
conditions include the provider to offer regular faith-based opportunities and quarterly
documentation attempts to provide religious services and education which encompasses all
faiths. The program maintains photos and sign-in sheets for all faith-based opportunities. The
program had the conducted both on campus and off campus faith-based activities. The program
provides weekly faith based opportunities for all youth every Thursday. A review of visitor sign-
in/sign-out logbooks confirmed the youth participated in faith based opportunities, as well as
other recreational activities throughout the annual compliance review period.
The provider shall maintain certified trainers for specialty areas which include first-aid/
automated external defibrillator (AED), Right Interactions(RI), Motivational Interviewing, Impact
of Crime(IOC), and Research Assessment for Youth and Performance Planning. Reviewed
training documentation confirmed thirty-three staff were trained in the identified topics.
Management staff shall receive an additional sixteen hours of training in the areas of
management, leadership, personal accountability, employee relations, communications and
fiscal management. Provided training documentation confirmed the training is part of the
provider’s on-the-job training for pre-service supervisors and is provided to all newly promoted
supervisory staff.
The provider shall employ a regional director of clinical services who serve as a certified Train
the Trainer in Aggression Replacement Training (ART) and Cannabis Youth Treatment (CYT)
and ensure ongoing needs are met. The program employs a regional director of clinical
services; however, does not conduct ART and CYT curriculum. An updated Designation and
Request to Change Primary, Intervention, and Treatment Services form was completed and
ART & CYT were removed from their primary, intervention and treatment services when the
contract was assumed by the current provider.
Staff clothing must be distinctly different from the youth’s clothing and must have the word staff
on all issued uniforms. During observations the week of the annual compliance review staff
were observed wearing uniform shirts with the word staff clearly indicated on the right sleeve.
Comprehensive healthcare training is to be provided monthly and staff must be trained in
emergency evacuation procedures for youth with a medical alert. Groups for staff addressing
comprehensive health education and emergency evacuation procedures for youth with a
medical alert, were conducted in November 2024, December 2024, January 2025, February
2025, March 2025, April 2025, and May 2025, which was evidenced by reviewed sign-in/sign-
out sheets.
Each youth shall participate in the development of a community-based Safety Plan, providing a
clear plan in the event home, school, or other location becomes unsafe, giving the youth
alternate safe locations and communication alerts to notify others of the youth’s potential safety
concerns. The program maintains safety plans for each youth which are maintained in the
Individual Healthcare Record (IHCR).
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The facility administrator stated he is aware of all contract negotiated items to include integrated
substance abuse groups, Impact of Crime (IOC), pre-vocational and vocational services,
education and all additional agreed to contract agreements.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures to review data trends for utilization in decision-making
practices. The provider has implemented an internal database and dashboard system allowing
for daily data entry by every program. A review of three months of incident trackers confirmed
they were distributed to the programs with documented described trends. The program’s
practice in sharing information with providers and stakeholders is to report on a quarterly basis
of all monitoring and verifications conducted by the provider’s compliance team. They formulate
a report and provide support, technical assistance and coaching to promote improvement,
professional development, and implementation of assurances of corrective strategies.
Documents supporting this practice showed no discrepancies.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures which require they notify the youth’s parent/guardian
by telephone within twenty-four hours of the youth’s admission in addition to notifying the
committing court and assigned juvenile probation officer (JPO) in writing within five working
days of any admission. Seven youth case management records were reviewed, and all
contained documentation which confirmed the program notified the parent/guardian, committing
court, and JPO on the day of admission. The program also notified each youth’s
parents/guardians in writing within twenty-four hours of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures which require they provide each youth an orientation
to the program’s rules, expectations, goals, and services. Orientation begins on the day of
admission. Seven youth case management records were reviewed, and each contained an
orientation form verifying orientation was conducted on the day of admission. The orientation
included services available, daily schedule, expectations and responsibilities of youth, an
overview of the behavior management system, availability and access to medical, mental
health, and substance abuse services, access to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC), the program’s zero-tolerance regarding
sexual misconduct, the right to be free from sexual misconduct, contraband, performance plan,
dress code and hygiene, visitation, telephone, mail, expectations for release and successful
complete of individual performance plan goals, grievance procedure, facility tour, and
assignment to a room. Seven youth were interviewed, and all were able to describe the topics
discussed in orientation. All seven said the orientation was conducted on the day of admission.
There were no admissions during the week of the annual compliance review; therefore, an
observation of orientation was not completed.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures which require they obtain 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 any information related to the youth’s
physical or mental health screenings, assessments, or treatment with the parent/guardian.
Seven youth case management records were reviewed and only two were applicable for being
over the age of eighteen; therefore, the program provided an additional applicable youth case
management record. All three applicable records contained a written consent, signed by the
youth before providing or discussing information related to physical or mental health screenings,
assessments, or treatments with the parents/guardians.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures governing youth classification. This requires they
establish a classification system, in accordance with Florida Administrative Code, which
promotes safety and security, as well as effective delivery of treatment services for youth.
Classification is used to assign each newly admitted youth to a living unit, sleeping room, youth
group or staff advisor. All youth admitted must be screened for vulnerability to victimization and
sexually aggressive behavior prior to the room assignment. The screening is completed in the
Department’s Juvenile Justice Information System (JJIS). If the program is 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 for a youth, a reassessment and reclassification is
required. The program’s classification form was reviewed, and included physical characteristics,
age and maturity level, special needs, history of violence, gang affiliation, criminal behavior,
sexual aggression or vulnerability to victimization, history of potential or verified human
trafficking, suicide risk, medical risk, escape risk, for each youth. Seven youth case
management records were reviewed, and all contained a completed classification form, which
had all the required elements. Three of the seven youth were applicable for a reclassification,
and each of the three had a reclassification completed. Two of the reclassifications were for a
security level change, and one was due to activity restrictions. A review of the program’s policy
regarding reassessments indicated staff reclassify youth when warranted based upon changes
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in the youth’s supervision status, new or updated alerts, behavioral concerns, and relevant
information to the treatment team to ensure safety and security of the youth and program. The
facility administrator (FA) was interviewed and advised youth are assessed during admission.
Youth medical, mental health, suicide, security alerts, and perception of vulnerability are among
some of the factors used to determine an appropriate living area is assigned to the youth by the
treatment team.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures which outline they gather information on gangs and
share this information with law enforcement. Seven youth case management records were
reviewed and one was applicable for gang identification and affiliation. The program provided
two additional applicable youth records. Each of the three applicable youth records contained
documentation confirming local law enforcement was notified of suspected gang activity, and
these notifications were made prior to the seven day notice of the annual compliance review.
Each of the applicable youth’s residential placement was not in their home county; therefore,
notification of law enforcement in the county of the program was made. In each of the three
applicable youth, gang alerts were entered into the program’s internal alert system, as well as in
the Department’s Juvenile Justice Information System (JJIS). Information of each youth’s gang
status was also shared with the educational provider and the juvenile probation officer.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures requiring the implementation of gang prevention and
intervention strategies. Seven youth case management records were reviewed, and one was
applicable for being identified as a member or affiliated with a gang. The program provided two
additional applicable youth records. A review of the gang intervention log and binder verified two
of the three applicable youth were participating in gang prevention and intervention strategies.
The third youth was recently admitted to the program and his case management record
contained documentation which confirmed he signed the acknowledgement to participate in
these interventions the week before the annual compliance review. The program uses Gangs,
Fifty Plus Stories of Fractured Lives as their gang intervention group. A review of sign-in sheets
verified the groups are delivered as designed. The facility administrator (FA) was interviewed
and advised a review of youth history and alerts is conducted during admission to identify if a
youth is gang affiliated. If a youth is identified as having gang involvement, membership, or
affiliation, they will be issued a gang intervention goal on their individualized performance plan.
Youth will be provided with various materials to educate them on the risks of being involved in a
gang throughout the duration of the commitment. The FA confirmed, identified youth also attend
an intervention called, "Gangs, Fifty Plus Stories of Fractured Lives. A gang binder is
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maintained which contains each youth’s goals, security threat, group questionnaires and any
notifications made to law enforcement and juvenile probation officer.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures requiring an initial assessment of each youth is
conducted within thirty days of admission. The program utilizes the Residential Assessment for
Youth (RAY) tool. Documentation of the initial assessment process is maintained in the
Department’s Juvenile Justice Information System (JJIS). The program completes
reassessments on each youth at least every ninety days from the date of the initial assessment.
Other updates or reassessments are to be completed when deemed necessary by the
intervention and treatment team to effectively manage each youth. Seven youth case
management records were reviewed, and all contained a RAY which was completed within thirty
days of admission. These assessments were all maintained in JJIS, as required. Each youth
had reassessments completed within ninety days of the initial RAY. The program maintained all
reassessment documentation in each youth’s case management records.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures which require they ensure a Youth Needs
Assessment Summary (YNAS) is completed within thirty days of each youth’s admission. A
review of seven youth case management records confirmed a YNAS was completed within thirty
days of admission for six of the seven youth. One YNAS was completed one day late. Each
YNAS was documented in the Department's Juvenile Justice Information System (JJIS) and
included the top three criminogenic needs for each youth.
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a policy and procedures requiring the intervention and treatment team,
including the youth, to meet and develop a performance plan within thirty days of admission.
These plans are developed after the Residential Assessment for Youth (RAY) and the Youth
Needs Assessment Summary (YNAS) are completed. The performance plan shall specify the
target date for completion of each goal, to include the youth’s responsibilities to accomplish the
goal, and the program’s responsibilities to enable the youth to complete the goal. Upon
completion, the program must 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. Seven youth case
management records were reviewed. Six had a performance plan developed within thirty days
of admission. One was developed four days late. All the performance plans were developed
after the RAY and YNAS, and all were signed by the intervention and treatment team leader, the
youth, the facility administrator (FA), a living unit representative, treatment staff, education staff,
and all other parties who had significant responsibility in goal completion. One youth was under
the supervision of the Department of Children and Family Services (DCF), and the DCF
caseworker participated in the development of the performance plan. The remaining six youth
had their parent/guardian participate in the development of the performance plan by telephone,
and signature sheets were mailed for the parent/guardian to sign and return to the program.
Two of the parent/guardians returned the signature sheet, which were filed in the youth case
management record and attached to the original performance plan. All performance plans
included goals which were based upon the prioritized needs identified during the initial
assessment, and the top three criminogenic needs for each youth. Delinquency interventions,
target court-ordered sanctions, transition activities, youth and program staff responsibilities for
goal accomplishment, as well as target dates for goal completion were listed on the
performance plans. All seven youth records contained documentation verifying a copy of the
plan was sent to the committing court, JPO, parent/guardian, and DCF counselor, where
applicable. Seven youth were interviewed, and all said they participated in the development of
their performance plans.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures in place requiring each youth’s performance plan to
be revised as needed for completion of the program. The program completes revisions to
performance plan every ninety days, after the Residential Assessment for Youth (RAY)
reassessment is completed. Seven youth case management records were reviewed, and five
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were applicable for a performance plan revision due to having a RAY reassessment completed.
Two of the youth also required a revision to the performance plan to facilitate transition activities
during the final sixty days of their stay at the program. All revised performance plans
incorporated treatment and academic plans, with references included in the revisions .
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures governing performance summaries and transmittals.
This requires the intervention and treatment team to prepare a performance summary at ninety-
day intervals, beginning ninety days after the youth’s performance plan is signed, or sooner if
requested by the youth’s committing court. The intervention and treatment team must also
prepare a performance summary prior to the youth’s release, discharge, or transfer from the
program. Seven active youth case management records were reviewed, and all had a
performance summary prepared every ninety calendar days, following the signing of the
performance plan. Each of the summaries included the status of each youth’s performance plan
goal, the overall treatment progress of each youth, their academic status, behavior, level of
motivation and readiness to change, interactions with other youth and staff, and any positive
and negative events. Documentations confirmed the youth were allowed to read and add
comments prior to signing. Each youth was provided a copy of the summary, and the original
was maintained in the case management record. All performance summaries were signed by
the youth, treatment team leader, staff who prepared the summary, and the facility administrator
(FA). A copy of each transmittal was sent to the committing court, the juvenile probation officer
(JPO), and the parent/guardian, or DCF caseworker, if applicable. Three closed youth case
management records were reviewed for performance summaries prepared prior to the youth’s
release, discharge, or transfer from the program. All contained the original summary, along with
the justification for release, then sent to the JPO with the pre-release notification (PRN). All
youth were direct discharges and had been at the program over forty-five days and had the
release summaries and PRNs sent at least forty-five days prior to release. A signed copy of the
discharge summaries was maintained in each youth’s case management record. Once the
discharge was approved by the court, the program provided written notification to the
parent/guardian regarding the planned release for each youth. The program completed a
Residential Assessment for Youth (RAY) exit assessment for each reviewed youth.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures which encourage and facilitate the youth’s
parent/guardian to play an active part and be involved in the case management process. This
includes involvement in the assessment process, participation in the development of the
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performance plan, participating in progress reviews and treatment teams, and transition
planning. If a parent/guardian is unable to attend in person, the program gives an opportunity to
participate by telephone and provide verbal input, or they may provide written input. During the
annual compliance review week, treatment team meetings were observed for four youth. The
parents/guardians participated by telephone on two of the four treatment team meetings
observed. The parents/guardians were not available for the remaining two treatment teams. The
transition services manager advised they contact the parents/guardians who were unable to
attend later in the day to review the treatment team information, then follow-up with an email
and mailed copy. The program reaches out to parents/guardians to facilitate involvement by
allowing for an admission call, letters, telephone availability during performance plan
development and treatment team. The facility administrator (FA) was interviewed and advised
the program encourages parent/guardian involvement in case management beginning with a
telephone call during admission, where the assigned case manager and youth advise of the
process. In addition, a parental assessment, family counseling sessions, parent/guardian
involvement in treatment team meetings is encouraged. The program also provides weekly
visitation and youth telephone calls to keep the parent/guardian updated regarding the case
management progress. Seven youth were interviewed regarding the involvement of their
parent/guardian in case management. Five youth said their parents participate in all treatment
teams. One youth was in the custody of the Department of Children and Family (DCF) and
advised their DCF caseworker participates in treatment team. One youth was over the age of
eighteen and advised they did not want their parent to participate. Three youth also said their
parents/guardians visit regularly.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures describing the members of treatment teams, in
addition to outlining the intervention and treatment teams meeting bi-weekly, alternating formal
and informal reviews, and to review the performance of youth at the program. Seven youth case
management records were reviewed, and all contained documentation which confirmed formal
reviews were conducted at least every thirty days. The documentation on the formal treatment
team meetings included the youth’s name, date of review, attendance of all required attendees,
comments from team members, a synopsis of the youth’s progress, any performance plan
revisions, positive and negative behavior, treatment progress, and Residential Assessment for
Youth (RAY) reassessment results. In addition, each youth was provided an opportunity to
demonstrate skills acquired in the program. Documentation was also in each youth case
management record which confirmed informal reviews were held bi-weekly each month,
alternating with the formal treatment team meetings. The informal treatment team meetings also
documented all the information contained in the formal treatment team meetings. The juvenile
probation officer (JPO), parent/guardian, and other pertinent parties were invited and
encouraged to attend through advance notification by email, mail, and telephone calls. They
were also given an opportunity to provide verbal or written input. During the annual compliance
review week, treatment teams were observed for four youth. The parents/guardians participated
by telephone on two of the four treatment teams observed. The parents/guardians were not
available for the remaining two treatment teams. The transition services manager advised they
contact the parents/guardians who were unable to attend later in the day to review the treatment
team information, then follow-up with an email and a mailed copy of the treatment team notes.
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Seven youth were asked if staff talk to them about their performance, to include progress on
performance plan goals, positive and negative behavior, and treatment progress, and all seven
said they do so on a regular basis.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures to ensure the intervention and treatment team
properly plans for the youth’s successful transition to the community when they are released
from the program. Three closed youth case management records were reviewed, and all had
documentation confirming each youth had a transition conference at least sixty days prior to
their targeted release date. The transition conferences were attended by each youth, the
treatment team leader, the facility administrator (FA), additional team members, and education
staff. The juvenile probation officer (JPO), and each youth parent/guardian attended by
telephone. During each conference, the team reviewed the transition activities on the
performance plan, made revisions, identified any additional transition activities,, set target
completion dates, and assigned responsibilities. The treatment team leader obtained signatures
from appropriate parties, indicating their acknowledgement of the transition goals and
accountability for each reviewed youth. A copy of each plan with a request for return with
signature was sent to anyone not in attendance. A copy of the electronic acknowledgement
email from the JPO was printed and filed with the plan for each youth. In addition to the
transition conference, each youth attended a community re-entry team (CRT) meeting prior to
their release from the program. These meetings were attended by each youth and case
manager. Each record had documentation confirming an electronic invitation, to participate in
the CRT meeting, was sent and received by the program.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures requiring the assembly of an exit portfolio for each
youth to assist them once they are released. Three closed youth case management records
were reviewed and all contained an exit portfolio which was discussed and initiated for the youth
during the transition conference. Each exit portfolio included a state-issued identification card,
the transition plan, a calendar with dates, times, and locations of community appointments,
social security card, birth certificate, education and vocation certificates, school transcripts, a
resume, and completed samples of employment applications. Documentation confirmed each
youth’s exit portfolio was verified during the exit conference, completed, forwarded to the
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juvenile probation officer (JPO) and provided to the youth upon release. A review of the
program’s contract indicated no additional requirements for the exit portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures requiring for an exit conference to be conducted, in
addition to a formal or informal meeting to review the status of any goals developed during the
transition conference, and to finalize release plans prior to releasing a youth from the program.
Three closed youth case management records were reviewed and all contained a completed
Exit Conference form. The conference was conducted after the juvenile probation officer (JPO)
was notified at least fourteen days prior to each youth being released. The documentation
indicated the date of the exit conference, signatures of those in attendance, and names of those
who attended by telephone for each youth. A review of the Department’s juvenile justice
information system (JJIS) confirmed the youth’s date of admission and date of termination
documented in the case management record coincided with JJIS for each youth. During the exit
conference, the status of transition activities established during the transition conference,
provision for continuation of education and/or employment, and documentation the JPO and
parent/guardian were aware of any vocational plan was included for each youth. The exit
conference was attended by each youth, the treatment team leader, parent/guardian by
telephone, education representative, JPO, youth and other pertinent parties. The exit
conference was held separate from the transition conference and the community re-entry team
(CRT) meeting for each youth.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures which require they have a formal process to promote
constructive input by youth. The program provides youth with Let's Talk forms which allow youth
to request to meet with any staff member concerning non-grievance issues. The youth are also
able to submit a grievance when applicable. Youth are also provided survey forms, which are
reviewed by program leadership. In addition, the program has youth advisory board meetings
twice a month. During the annual compliance review week, the program provided the youth
advisory board binder, grievance log and Let's Talk form log as evidence of their efforts to solicit
input from youth. The youth advisory board meets twice a month. Youth surveys are also
provided monthly to youth. The assistant facility administrator keeps the Let’s Talk forms for
reference and follow up to ensure youth questions, concerns, and suggestions are considered
and addressed. Seven youth were interviewed regarding program input; all reported they can
speak with the facility administrator (FA), access to Grievance forms, participate in the youth
advisory board, complete youth surveys, and attend weekly meetings. The FA stated the
program solicits input from youth the youth advisory board, Request to Speak forms, grievance
forms, youth surveys, youth meetings with the FA and assistant FA, and by encouraging youth
involvement.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a policy and procedures stating the facility administrator is responsible for the
administrative oversight and management of the mental health and substance abuse services in
the program. The program provides specialized treatment services and must have a single
licensed mental health professional serving as the designated mental health clinician authority
(DMHCA) who is responsible for the coordination and implementation of mental health and
substance abuse services in the program. The program has a full time licensed mental health
counselor (LMHC) who serves as the DMHCA. The DMHCA’s license is clear and active, with
an expiration date of March 31, 2027. The DMHCA is on-site weekly Monday through Friday, to
ensure appropriate coordination and implementation of mental health and substance abuse
services. Documentation of the DMHCA’s position description was reviewed for accuracy to the
program’s requirements, and no issues were noted. The program has two licensed mental
health counselors (LMHCs), each holding an active license, valid through March 31, 2027, who
serve as backup when the DMHCA is unavailable. An interview with the DMHCA revealed they
are responsible for daily mental health and substance abuse group scheduling, and every
admitted youth undergoes a comprehensive screening process, including a review of prior
records, evaluations, assessments, and Juvenile Justice Information System (JJIS) alerts
followed by an admission interview conducted by a therapist who administers the
Massachusetts Youth Screening Instrument-Second version (MAYSI-2), Assessment of Suicide
Risk (ASR), and Victimization and Sexually Aggressive Behavior (VSAB) assessments. The
process concludes with an admission classification meeting, involving key staff and the youth, to
review findings and identify needed referrals.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures requiring all substance abuse and mental health
services to be provided by licensed and/or non-licensed clinical staff. The program’s licensed
mental health and substance abuse clinical staffing is in accordance with the current contract
and Florida Administrative Code. During the annual compliance review week, copies of the
licenses of all mental health professionals were examined, with no issues noted. Observations
of the Chapter 397 license confirmed it was posted at the entrance of the program. A review of
documentation confirmed the program has three licensed mental health counselors (LMHCs),
with one serving as the clinical director and the remaining two as the back-up DMHCAs, all
holding clear and active licenses. A review of job descriptions and an informal interview with the
DMHCA confirmed the clinical supervisor(s) ensure the licensed clinical staff, under their
supervision, provide services aligned with their education, training, experience, and the licensed
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mental health and substance abuse clinical staffing is in accordance with the current contract
and Florida Administrative Code.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures detailing requirements for qualified professionals
delivering mental health and substance abuse services, with the clinical director serving as the
designated mental health clinician authority (DMHCA) responsible for supervising all on-site
clinical staff. The clinical supervisor ensures non-licensed clinical staff under their supervision
perform services aligned with their education, training, and experience, verified through position
description reviews and an informal interview with the DMHCA. Documentation confirmed each
non-licensed mental health clinical staff member received a minimum of one hour a week of on-
site, face-to-face direct supervision from a licensed mental health professional, which is
recorded using the program’s form containing all required elements from the Department’s
Direct Supervision Log. The program holds a valid Chapter 397 license, displayed outside of
master control, with an expiration date of October 10, 2025. All non-licensed clinical staff hold a
master’s degree in psychology or related human services field from an accredited institution.
They are licensed under Chapter 397, have completed twenty hours of training and supervised
experience in assessing suicide risk, mental health crisis intervention, and emergency mental
health services before conducting Assessments of Suicide Risk (ASR) or Crisis Assessments
onsite in the physical presence of a licensed mental health professional. All training was
documented on the Department’s Non-Licensed Mental Health Clinical Staff Person’s Training
in Assessment of Suicide Risk form. The program reported no Non-Licensed Mental Health and
Substance Abuse Clinical Staff vacancies.
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’s a policy and procedures require a comprehensive screening process to identify
the mental health and substance abuse needs of each youth, ensuring timely referrals when
concerns such as substance use, mental health disorders, or suicide risk are present. During an
interview, the facility administrator reported the Assessment of Suicide Risk (ASR) is conducted
upon intake, to determine whether a youth poses a risk of self-harm. Youth identified as such
are placed under precautionary observation. The Massachusetts Youth Screening Instrument,
Second Version (MAYSI-2), is utilized to evaluate suicidal ideation, substance abuse, mental
health symptoms, and trauma history. Results from the MAYSI-2 inform the necessity for further
assessments, which may include the Trauma Symptom Checklist for Children (TSCC),
Reynolds Adolescent Depression Scale, Second Edition (RADS-2), or Structured Assessment
of Violence Risk in Youth (SAVRY). All youth undergo the Adolescent Psychopathology Scale
(APS), while those with identified substance abuse concerns complete the Substance Abuse
Subtle Screening Inventory (SASSI). These comprehensive evaluations facilitate the
development of individualized treatment plans tailored to each youth’s needs. The program’s
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Comprehensive Plan for Mental Health and Substance Abuse Services outlines the procedures
for implementing a standardized screening process during admission. This process includes the
review of commitment documents, relevant reports, and records, as well as administration of the
MAYSI-2 through the Department’s Juvenile Justice Information System (JJIS). Personnel
trained in mental health and substance abuse, administer all five MAYSI-2 assessments to
ensure accuracy and reliability. When additional evaluation or immediate intervention is
required, such as hospital admission or placement in a Baker Act or Marchman Act facility,
referrals are initiated without delay. A review of seven mental health youth records confirmed
each record contained a completed Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2). In each case, the screener reviewed available information, including the
commitment packet and reports, to identify any documented history of mental health concerns,
substance abuse, or human trafficking. All seven MAYSI-2 assessments were completed in JJIS
on the day of admission by trained staff. Five of seven youth records indicated a need for further
assessment, and referrals were made for each.. In each of the five, a referral was made for
further evaluation or immediate attention. Two of the youth required an Assessment of Suicide
Risk (ASR), which was completed as required. The remaining three required a comprehensive
evaluation.
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 policy and procedures describing the process for delivering mental
health and substance abuse assessments and evaluations. The designated mental health
clinician authority (DMHCA) reported the results from evaluations, assessments, and
information in the Department’s Juvenile Justice Information System (JJIS) are reviewed as part
of the comprehensive mental health and substance abuse assessment process. Mental health
services include group counseling four days a week, individual counseling on a bi-weekly basis,
and family therapy provided monthly. A review of seven youth mental health records showed
each included a combined mental health and substance abuse evaluation completed within
thirty calendar days of admission. Each evaluation contained all required elements. Initial
Mental Health/Substance Abuse (MHSA) Treatment Plans and Initial Treatment Notes were
completed within seven days of initiating treatment and using the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. All reviewed records contained signed consents
for substance abuse services. Individualized treatment plans and treatment plan reviews
address psychiatric services, including the use of psychotropic medication when applicable, and
the frequency of psychiatric monitoring for five youth who were prescribed medication.
Individualized treatment plan reviews were completed on the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan Review form for all five youth. The substance
abuse assessments include relevant background information; home environment and family
functioning, with any history of physical abuse, sexual abuse, neglect, witnessing violence, or
other forms of trauma, behavioral functioning, physical health, mental health and substance
abuse history, educational functioning, behavioral observations, methods of assessment, and
patterns of alcohol and other drug use. The assessments also address the impact of substance
use on major life areas, risk factors for continued use, clinical impression, including a Diagnostic
and Statistical Manual (DSM-5) diagnosis, and recommendations.
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3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures requiring the designated mental health clinician
authority (DMHCA), mental health and substance abuse clinical staff, and other multidisciplinary
treatment team members, to ensure each youth’s treatment plans are individualized and
relevant to each youth’s needs. The DMHCA indicated the treatment team assists the primary
therapist in developing, reviewing, and updating plans, as well as the individual mental
health/substance abuse treatment plans. Ongoing reviews of the treatment plan occur on at
least a bi-weekly basis with formal revisions and modifications occurring monthly. Seven youth
mental health records were reviewed, and an initial treatment plan was developed for each
youth within seven days of initiation of treatment. The program utilizes a program form for the
initial treatment plan which contains all required elements from the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Each of the seven initial treatment plans were
completed and signed by the program’s licensed mental health counselor and were signed by
all treatment team members who participated in the development of the plan.
All seven youth’s individualized treatment plans were developed within thirty days of admission.
The program utilizes a program form for the individualized treatment plan which contains all
required elements from the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan form. Each of the seven individual treatment plans were signed by all treatment
team members who participated in the development of the plan. A combined total of twenty-
seven individual treatment plan reviews were completed for the seven reviewed youth. During
the week of the annual compliance review, observations of surveillance video footage from
three randomly selected groups in comparison to logbooks, sign-in sheets, and facilitator
documentation validated the groups occurred as documented and for the required duration.
The youth’s individualized treatment plans documented each youth’s prescribed services,
including bi-monthly individual counseling, daily group counseling, and monthly family therapy
sessions.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a policy and procedures describing the criteria for mental health and
substance abuse treatment, as well as discharge planning requirements. Seven youth mental
health records were reviewed and confirmed each youth was assigned a treatment team on the
day of admission. Treatment team documentation confirmed participation from each youth,
program administration, residential staff, clinical staff, parent/guardian, education staff, and
medical staff. One of the seven youth reviewed records was applicable and received mental
health and substance abuse treatment services, provided by licensed mental health staff or a
non-licensed substance abuse clinical staff, who work under the direct supervision of licensed
mental health staff. Six of the seven youth mental health records contained a properly executed
Authority for Evaluation and Treatment (AET) form. In the remaining record the youth was in the
care of the Department of Children and Families (DCF) and the court authorized all treatment
and procedures.
All seven youth provided consent for substance abuse services through a signed Youth Consent
for Substance Abuse Treatment form. Each of the seven youth records contained a signed
Youth Consent for Release of Substance Abuse Treatment Records form. The program utilizes
a program form for mental health and substance abuse treatment notes; however, it does not
contain all required elements from the Department’s Counseling/Therapy Progress Notes form.
The program form for mental health and substance abuse treatment does not include youth date
of birth and does not specifically address client participation in each session. The program
updated the form during the annual compliance review week to reflect the required elements of
Department form. Mental Health and Substance Abuse Therapy of the seven reviewed youth
included individual psychotherapy or counseling, which involved one-on-one sessions between
youth with diagnosed mental health disorders and clinical mental health staff. Psychosocial
skills training was also provided. Progress notes confirm youth received these services as
outlined in their treatment plans. Three closed youth mental health records were reviewed, and
each contained a discharge plan which were all documented on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form. Each of the three youth’s Mental
Health/Substance Abuse Treatment Discharge Summaries documented the services needed for
daily maintenance of the positive improvement in behavioral, emotional, and social skills made
by each youth during treatment. A review of chronological notes confirmed the discharge plan
was discussed with each youth, parent/guardian, and each youth’s juvenile probation officer
(JPO) during the exit conference. Each youth’s Release Chronological form confirmed a copy of
the Mental Health/Substance Abuse Treatment Discharge Summary was provided to each
youth, parent/guardian, and each youth’s JPO.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures addressing specialized treatment services. The
program provides clinical groups for mental health treatment services, substance abuse
treatment services, and major disorders such as dual diagnostic/intensive. The program’s
contract required clinical groups are Aggression Replacement Training, Cannabis Youth
Treatment, Skillstreaming the Adolescent, Passport Program, A New Direction, and Dialectical
Behavioral Therapy Skills. The program provides each youth with individual, group, and family
therapy at least five days a week as part of each youth’s individualized treatment plan.
Documentation confirmed the Designated Mental Health Clinician Authority (DMHCA) was on-
site for forty hours each week, and licensed mental health staff were present at least five days a
week. The non-licensed staff held a master’s-level degree or were currently enrolled in a
master’s-level program. The program met required mental health service standards. Individual
therapy was provided at least once every two weeks, or more frequently as needed. Family
therapy was conducted at least monthly, when applicable. A psychiatrist provided services at
least once every two weeks. In addition, licensed psychologists, licensed mental health
counselors, or board-certified behavior analysts were available on-site as needed to provide
services such as psychometric assessment, therapeutic services, complex case consultation,
behavior therapy, treatment planning involvement, and staff training and consultation. Group
therapy included four mental health groups each week for all youth and reviewed documentation
confirm proper counselor to youth ratio for all groups. The DMHCA is on-site forty hours weekly,
and clinical staff were available seven days a week, for the Substance Abuse Treatment
Overlay Services. The DMHCA was interviewed and reported the program provides individual
therapy, group therapy, psychiatric services, Applied Behavior Analysis (ABA) services, and
psychological assessments. The DMHCA stated meetings with the psychiatrist to discuss youth
receiving psychiatric services occur monthly. The facility administrator was interviewed
regarding specialized treatment services and confirmed the program offers specialized services
as identified by contract, including Alcoholics Anonymous/Narcotics Anonymous (AA/NA)
groups and a garden program. Seven youth were interviewed regarding participation in
individual and family counseling, and each reported receiving both individual and family
counseling services. All seven youth indicated individual sessions last between 40 to 60
minutes, and family sessions typically last 30 to 40 minutes. One youth shared the therapist
extends session time upon request. Six of seven direct care staff reported they do not facilitate
mental health or substance abuse groups. One case manager facilitated only Impact of Crime
groups.
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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 has a policy and procedures specific to the psychiatric services provided to the
youth in the program. The psychiatrist is scheduled to be on-site weekly for two hours and
provide medication evaluation and on-going monitoring of psychiatric medications. The
psychiatrist’s license was free and clear and expires on January 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. Psychiatric
services were provided by a psychiatrist or psychiatric APRN, who briefed a representative of
the treatment team on the psychiatric status of each youth scheduled for treatment team review.
These briefings occurred either face-to-face or by telephonic communication. The psychiatrist or
APRN’s evaluations and recommendations were incorporated into the mental health clinical
staff’s assessments and the youth’s individualized mental health or substance abuse treatment
plans. The psychiatric APRN has a Collaborative Practice Protocol in place and provides
psychiatric services. Documentation confirmed the psychiatrist conducted biweekly on-site
supervision of the APRN’s medication management services and was available for additional
evaluation and monitoring of youth as needed. The psychiatrist actively participated in,
managed, and supervised psychotropic medication services within the program. Sign-in/out logs
verified psychiatric visits occurred as required by the contract or agreement during the annual
compliance review period. The program does not utilize tele-psychiatry. A back-up psychiatrist
with equal education to the program’s psychiatrist, a clear and active license, valid through April
30, 2026, was available throughout the annual compliance review period. Although no
psychiatrist interview was available for review, the DMHCA reported meeting with the
psychiatrist monthly to discuss youth receiving psychiatric services. Seven youth mental health
records were reviewed and four entered the program on psychotropic medication, with all youth
referred for a psychiatric interview as part of the intake process. All seven records were
applicable for an initial diagnostic psychiatric interview as the program completes one for each
admitted youth included the youth’s history, medical mental health and substance abuse history,
Mental Status Examination, and a Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis. Each of the seven youth records had a psychiatric interview
completed within fourteen days of admission. A review of each youth’s initial diagnostic
psychiatric interview confirmed all required elements were included. All initial diagnostic
psychiatric interviews were documented on the Department’s Clinical Psychotropic Progress
Note (CPPN). Each initial diagnostic psychiatric interview was clearly identified as an “Initial
Diagnostic Psychiatric Interview”. All the applicable youth receiving psychotropic medication
were seen for medication review by the psychiatrist at a minimum of every thirty days, and
received a follow-up psychiatric evaluation which included all required elements, to include the
date and signature of the evaluating psychiatrist. The psychiatrist and nursing staff documented
monitoring for Tardive Dyskinesia monthly as indicated on each youth’s CPPN. Each
documented diagnosis was consistent with the youth’s treatment plan. Each youth had an initial
diagnostic psychiatric interview documented on the CPPN form. Each CPPN form was clearly
identified as an Initial Diagnostic Psychiatric Interview. Each psychiatric evaluation was
documented on page three of the CPPN. All applicable records documented each youth’s
identifying data, diagnosis, the targeted symptoms of each medication, an evaluation-
description of effects of prescribed medication on target symptoms, the name of the prescribed
psychotropic medication, including the dosage and quantity of the medication, normal dosage
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range, ordered dosage, the frequency and route of administration, and the reason for any
change in medication or dosage.
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 plan outlining suicide prevention procedures. The plan includes
identification and assessment of youth at risk of suicide. Staff training includes six hours of
annual training on suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and the review process. The review
process for suicide attempts and mortality includes circumstances surrounding the event, facility
procedures relevant to the incident, all relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations, if any, for changes in policy, training, physical plant, medical or mental health
services, and/or operational procedures. The Suicide Prevention Plan is reviewed annually. The
last review was on October 15, 2024, by the program’s designated mental health clinician
authority.
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.
Seven mental health and substance abuse records were reviewed and two youth, during the
initial screening process, were identified on the day of admission as being at risk. Both received
an Assessment of Suicide Risk (ASR) during intake, completed by a licensed clinical staff on the
Department’s ASR form. Each youth was stepped down to standard supervision after the ASR
was completed. One more record was requested and was identified as being at risk, based on
staff observation. An ASR was conducted by a licensed clinical staff, and this youth was placed
on one-to-one supervision. Parent/guardian and juvenile probation officer (JPO) notifications
were made for all three youth, with documentation recorded on the Department’s ASR form.
Mental health staff provided supportive services to all three youth. ASRs were completed within
twenty-four hours of screening or concern for each. Each ASR included the date and time a
clinician consulted with the facility administrator (FA) or designee and the licensed mental health
professional, as recorded in the appropriate sections of the form. None of the three youth were
identified as being in crisis. Two transitioned to either standard or close supervision following
the ASR. One youth remained on suicide precautions with one-to-one supervision until a Follow-
Up ASR indicated suicide precautions could be discontinued. Before returning to a normal
routine, this youth was stepped down to close supervision. Close supervision continued until the
Designated Mental Health Clinician Authority (DMHCA) or licensed mental health professional
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determined it was no longer necessary. Documentation confirmed a conference between the FA
and licensed mental health professional regarding the reduction in supervision, including the
date and time the youth was stepped down. Discontinuation of close supervision followed the
program’s Suicide Prevention Plan. A suicide risk alert was initiated in the Department’s
Juvenile Justice Information System (JJIS) for the youth placed on suicide precautions and
closed in accordance with the ASR recommendations. Facility logbook entries confirmed
instructions were provided by administrative or supervisory staff regarding suicide risk
assessment findings and precaution decisions. Video review was not completed during the
week of the annual compliance review due to no youth on Precautionary Observation within the
previous thirty days.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Only two of of seven mental health and substance abuse records were applicable for being
placed on suicide precautions; therefore, an additional applicable youth was requested. For
each applicable youth, Suicide Precaution Observation Logs were maintained throughout the
duration of the precaution period. Safe housing requirements were documented in each record.
Each log clearly identified the level of supervision provided and included real-time observations
of youth behavior at intervals not exceeding thirty minutes. Logs were reviewed and signed by
the shift supervisor and mental health clinical staff. In all three records, warning signs were
observed; therefore, notifications were made to the facility administrator or designee and mental
health clinical staff. These actions were documented on the Suicide Precaution Observation
Logs, which were reviewed and signed by each shift supervisor and by mental health clinical
staff.
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 comprehensive Suicide Prevention Plan outlining suicide prevention
training requirements. Staff who work with youth receive training to recognize verbal and non-
verbal warning signs indicating suicide risk, understand suicide prevention protocols, and
implement suicide precautions. Additionally, all staff with daily direct contact with youth must
participate annually in a drill involving the use of cardiopulmonary resuscitation (CPR). A review
of seven pre-service and seven in-service staff training records confirmed completion of suicide
prevention training without concerns. Each training cycle included simulated suicide drills which
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were conducted at least quarterly on every shift. There was no indication youth were used in
any of the simulations. Documentation of mental health and medical drills since the last annual
compliance review confirmed suicide drills were conducted for all staff in contact with youth. Drill
records demonstrated use of life-saving measures, including CPR and the use of an automated
external defibrillator (AED). According to the facility administrator (FA) staff who were not
present during scheduled drills reviewed each scenario afterward to ensure understanding of
the emergency response process and received the necessary training to respond to suicide
attempts or serious self-inflicted injuries. The program maintains two suicide response kits, each
containing a knife-for-life, wire cutters, and needle nose pliers. These kits are in the copy room
and master control and are co-located with the first-aid kits. An interview with the FA confirmed
monthly training or mock drills are conducted for staff, focusing on emergency response to
suicide attempts or self-harm incidents. Seven staff members were interviewed and six
identified the suicide response kits as being in master control and the break room. One staff
indicated the kits are in the master control and the supervisor's office.
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 has a written crisis intervention plan addressing communication, supervision,
documentation, review, notification, and alert system, as well as means of referral, including
youth self-referral.
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 has a Crisis Intervention Plan, which addresses mental health crisis intervention
services and Crisis Assessments. The program maintains a policy and procedures for crisis
assessments. The procedures indicate a qualified mental health professional shall interview a
youth in crisis and complete a Crisis Assessment immediately or within two hours for
emergencies. The primary goal of crisis intervention at the program is to respond to the youth in
crisis in the least restrictive method possible and protect the personal safety of the youth and
others while maintaining control and safety of the program. A review of seven youth mental
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health records indicated none of the youth were applicable for a Crisis Assessment; therefore,
three additional youth records were requested and provided. All three assessments identified
the date the youth was determined to be in crisis, and the date of the Crisis Assessment. Each
Crisis Assessment was conducted within two hours for emergencies, or within twenty-four hours
based on the needs of the youth. The Crisis Assessments included the reason for the
assessment, Mental Status Examination and interview, the determination of danger to self
and/or others including imminence and intent of behavior, clarity and lethality of behavior, initial
clinical impressions, supervision recommendations, treatment recommendations,
recommendations for follow-up or further evaluation, and a notification to parent/guardian. Each
Crisis Assessment was conducted by a licensed mental health professional.
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 has a written emergency mental health and substance abuse plan which includes
immediate staff response, notifications, communication, supervision, authorization to transport
for emergency mental health or substance abuse services, including Baker Act and Marchman
Act, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth records were reviewed for Baker and Marchman Acts, with no youth applicable.
Three additional records were requested, and the program provided two records, as only two
instances of Baker or Marchman Acts occurred during the annual compliance review period. In
both cases, youth were placed on supervision at the time the situation was identified, and
mental health staff were involved. Transportation from the program by law enforcement for the
Baker Act was authorized by a licensed mental health counselor (LMHC). Upon return, each
youth was placed on constant supervision, and a mental health referral was completed,
indicating the need for a Mental Status Examination (MSE). An Assessment of Suicide Risk or
Crisis Assessment was completed by a non-licensed staff member and reviewed by a licensed
mental health professional. Supervision levels were maintained until an appropriate clinical
assessment was completed and reviewed to ensure the youth’s safety and stability.
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 has established a policy and procedures to guide the safety planning process for
youth. Seven youth mental health records were reviewed, each containing a safety plan
completed within fourteen days of admission. Plans included documentation of warning signs,
baseline behaviors, crisis recognition, youth-identified coping strategies, preferred intervention
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approaches, a debriefing process, trauma-responsive practices, and recommendations from
clinical assessments or screening tools. Each plan was collaboratively developed by the youth,
parent/guardian and clinical staff. Each record also included a letter to the parent or guardian
along with a copy of the completed safety plan. Each safety plan was reviewed and updated as
necessary at least every thirty days or when any significant behavioral or mental health event
identified by the youth’s intervention and treatment team. Safety plans are stored in each
youth’s record and secured in a locked cabinet in the conference room. All seven interviewed
youth confirmed their involvement in the development of their safety plans. The facility
administrator reported safety plans are reviewed and updated monthly. Safety plans are
reviewed by staff who have contact with the youth on a regular basis.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician (MD) who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA’s specialty training is in family practice and internal medicine, and the license
expires on January 31, 2026. The DHA does not have any disciplinary cases/public complaints
on record. The program does not have a physician assistant (PA) or an advanced practical
registered nurse (APRN) and does not utilize tele-health. A review of the DHA sign-in/out logs
for the annual compliance review period confirmed the DHA was on-site between one to four
hours during each visit and at least once a week. The DHA was not on-site for two weeks;
however, there were no more than nine days passed between on-site visits. The program’s
contract does not specify the required number of hours or how often the DHA is to be on-site.
The DHA has a back-up DHA with an equal license and the ability to cover for absences of any
kind. The back-up DHA is an MD who holds an unrestricted license and meets all requirements
for independent and unsupervised practice in Florida. The back-up DHA’s specialty training is in
internal medicine and the license expires on January 31, 2027. The back-up DHA was not
utilized during the annual compliance review period. The interviewed DHA stated the DHA
completes the periodic evaluations every sixty days and the comprehensive physical
assessment (CPA) upon admission and as needed. The treatment protocols are utilized for sick
call unless further evaluation is needed. The DHA reported being on-site weekly and available
for communication with staff through telephone, texting, or during on-site visits regarding youth
medical needs. The DHA provides the clinical services on-site and stated the off-site care
findings, instructions, and information is flagged for review in the Individual Healthcare Records
(IHCR). The important medical issues pertaining to the youth are discussed weekly during the
on-site visit with the healthcare staff and follow-up orders are completed as needed. The DHA
indicated when coverage is needed, a back-up MD is available. The DHA voiced no concerns
regarding the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program’s on-site nursing coverage is provided by four full-time registered nurses (RN) and
one full-time licensed practical nurse (LPN). One of the four RNs is the health services
administrator (HSA). A review of the nurse licensures indicated all had clear and active licenses,
three expiring on July 31, 2026, one April 30, 2027, and the LPNs on July 31, 2025. The LPN
was receiving direction from, and medical cases were reviewed by a RN or higher, including on-
call consultation. All five nurses had a current cardiopulmonary resuscitation (CPR) certification,
three expiring in February 2027, one in March 2027, and one May 2027. The provider’s
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contractually requirement of forty hours a week for the HSA, 120 hours a week for three RNs
and forty hours a week for the LPN were met.
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 designated health authority (DHA), the facility administrator (FA), and the psychiatrist
signed and dated all applicable treatment facility operating procedures. The DHA signed on
September 4, 2024, the psychiatrist on January 7, 2025, and the FA on January 14, 2025. The
nursing staff reviewed, signed, and dated a cover page on which all FOPs, healthcare protocols,
and other procedures were listed, which confirmed all were reviewed. Three signed in January
2025, and one in March 2025. The remaining one nurse is a new hire and has not yet finished
her on-the-job training which includes review and signature of the FOPs/healthcare
protocols/procedures. The program has not had any new or changes in policies since the start-
up monitoring. All newly employed health care personnel received a comprehensive clinical
orientation to the Department’s health care policy and procedures, given by a registered nurse
(RN) or designated, licensed health care professional. The approval of treatment protocols or
standing procedures were written and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of seven Individual Healthcare Records (IHCRs) found six contained a legible copy of
the original Authority for Evaluation and Treatment (AET) form with the word “COPY” stamped
on the form. All six AETs were valid, and were signed by each youth’s parent/guardian, and a
Department representative. In the remaining one record the youth was in the care of the
Department of Children and Families (DCF) and the court authorized all treatment and
procedures. Three of the seven youth turned eighteen while in the program and each IHCR
contained a release of information form. The nurse interview stated an AET is obtained from the
Department's Juvenile Justice Information System (JJIS). If a youth is admitted without an AET
the program reaches out to the juvenile probation officer (JPO) and case manager to obtain a
new AET. The nurse stated eighteen-year-old consent forms are available for applicable youth
and all youth eighteen and older can consent to their own treatment.
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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.
A review of seven Individual Healthcare Records (IHCRs) found two youth were not applicable
for parental notifications or consent due to being eighteen years of age. Two of the remaining
five IHCRs included parental notification for over-the-counter (OTC) medications beyond those
covered by the Authority for Evaluation and Treatment (AET) and consent was provided by each
parent/guardian, the remaining three were not applicable. All five applicable IHCRs contained
documentation of attempted contact to the parent/guardian when a new medication was
ordered. Written notifications were sent utilizing the Department’s Parental Notification of
Health-Related Care: General, or Parental Notification of Health-Related Care: Medications
forms, or the Acknowledgement of Receipt of the Clinical Psychotropic Progress Note (CPPN) in
all five IHCRs. Four of the five youth were taking psychotropic medications at admission. Staff
witnessed all telephone call attempts and conversations related to psychotropic medications. In
three of the four applicable IHCRs, whenever a new psychotropic medication was prescribed or
discontinued, or the drug dosage was significantly changed the parent/guardian verbal consent
for psychotropic medication was documented on page three of the CPPN or on a chronological
progress note. One of the five applicable youth was in the care of the Department of Children
and Families (DCF) and the court authorized all treatment and procedures. In all seven IHCRs,
immunization records were obtained and verified within thirty days of the youth’s admission.
None of the youth received any vaccinations while at the program and none were exempt from
immunization. The nurse interview stated verbal and written consent is obtained from the
parent/guardian for any new medication or treatment ordered, dosage changes, and
discontinuation of medications. Parental notifications are made in real time. Notifications and
attempts are documented and when unable to reach, continuous attempts are made to contact
the parent/guardian. The nurse stated when a youth's illness or injury requires emergency
medical services or is life threatening 9-1-1 is called immediately, the nurses notify the
designated health authority (DHA) and the parent/guardian. For new orders, changes, and
discontinuation of psychotropic medications, a telephone call is placed to the parent/guardian
and consent is witnessed. The nurses also send written consent, including page three of the
CPPN. The nurse indicated flu vaccinations can be provided on-site. When a parent/guardian
refuses immunizations, they will fill out the religious exemption form provided by the Department
of Health. The nurse stated immunizations are verified through Florida Shots and school records
prior to youth arrival and at intake.
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.
A review of seven Individual Healthcare Records (IHCRs) found all contained a Facility Entry
Physical Health Screening Form (FEPHS) completed on the date of admission by a nurse. None
of the seven youth had a change in physical custody greater than twenty-four hours. The nurse
interview stated during the orientation process the newly admitted youth visits the clinic on the
day of arrival. The admission screenings are conducted by a nurse. In case a non-healthcare
staff conducts the admission screening the FEPHS is utilized. The nurses are notified of new
youth being admitted through email, as well as management meetings. If a change in physical
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custody occurs since the youth's admission to the program the FEPHS is completed again, and
a new drug screen is performed.
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.
All seven reviewed Individual Healthcare Records (IHCR) maintained documentation confirming
each youth received a general care admission orientation, which included access to medical
care, sick call, what constitutes an "emergency" and when to notify staff, medication process to
include side effect monitoring, the right to refuse care and how it is documented, what to do in
the case of a sexual assault or attempted sexual assault, the non-disciplinary role of the health
care providers, and standard Universal Precautions. All seven youth signed an orientation
acknowledgment form confirming the review of the above topics. The program’s contractually
required frequency of Health Education is monthly in recurring cycles. The Health Education
topics covered seatbelt usage, alcohol and drug related problems, sexually transmitted
disease/infections, tobacco products, smoking cessation, dental hygiene and dental care, basic
personal hygiene, immunizations, infection control, prevention of sexual and other physical
violence, nutrition, physical fitness, breast and testicular self-examinations, and parenting skills.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Seven Individual Healthcare Records (IHCR) were reviewed, and five youth were admitted with
a known or suspected chronic conditions and a referral to the physician was documented in
each IHCR. None of the youth were identified as needing of emergency care upon admission. In
all seven IHCRs the notification to the designated health authority (DHA) on the same day of
admission was documented in the Chronological Progress Notes. In four of the seven IHCRs,
each was taking psychotropic medication upon admission and the psychiatrist was notified. The
nurse interview indicated the DHA is immediately notified by the nurses upon admission of any
youth with serious or chronic conditions and this is documented in the admission progress
notes.
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.
A review of seven Individual Healthcare Records (IHCR) found all contained a Health-Related-
History (HRH) form completed within seven calendar days of each youth admission. Each HRH
was completed prior to the Comprehensive Physical Assessment (CPA), as evidenced by
signature and date and the designated health authority (DHA) reviewed all HRH forms. The
nurse interview indicated the nurses complete the HRH form on the day of each youth’s intake.
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4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
A review of seven Individual Healthcare Records (IHCR) found all youth received a physical
assessment conducted by the designated health authority (DHA) and documented on a
Department Comprehensive Physical Assessment (CPA) form within seven calendar days of
admission. Each CPA documented the youth’s Medical Grade, had no missing or incomplete
elements, and all sections of the CPA were marked with an “O” or an “X”. Six of the seven youth
refused the genital exam, which was noted on the CPA, and a refusal form was completed,
documenting the refused part of the exam. In six of the seven IHCRs the Department’s Problem
List was updated, as required. The remaining one IHCR did not require any updates. In all
seven IHCRs at least one verified Tuberculosis Skin Test (TST) was documented in each IHCR
within the last year. The results of the TST were noted on the CPA and the Infectious and
Communicable Disease (ICD) form and they matched. The nurse interview stated the DHA
completes a new CPA within seven days of each youth admission, and annually for Medical
Grade two and higher, and every two years for Medical Grade one. Each youth is screened
within seventy-two hours of intake for tuberculosis.
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 reflecting human immunodeficiency virus
(HIV) test results are only disclosed to the youth and the youth’s legally authorized
representative, health care providers during the course of consultation, diagnosis, or treatment
of the individual, the Department of Health for purposes of reporting and controlling the spread
of disease, health facility staff committees conducting program monitoring, evaluation, and
service reviews, medical personnel who have been subject to a significant exposure, and health
care facility personnel or agents for the healthcare provider who have a need to know in the
course of patient care activities or administrative operations. A review of seven Individual
Healthcare Records (IHCR) found six youth were sexually active; however, all seven were
clinically screened and evaluated for Sexually Transmitted Infections (STI) on the day of
admission. All seven required further evaluation and each youth was referred to the designated
health authority (DHA), which was documented on the STI screening tool. In all seven, testing
was ordered and performed on the day of admission. All applicable testing, screening results,
clinical evaluations, and diagnosis were documented on the Infectious and Communicable
Diseases (ICD) form, excluding HIV results, and filed in the lab section of each IHCR. None of
the youth were out of the Department’s physical custody or presented symptoms. In all seven
IHCRs there was evidence each youth was offered counseling, testing, and if indicated,
treatment/referral for HIV. Three of the seven youth received an HIV test and each IHCR
contained a youth consent for testing. All three had the HIV results filed confidentially in a
sealed envelope marked “Confidential” consistent with Florida Administrative Code, and there
was proof of review by the DHA on the sealed envelope. All three had pre/post-test counseling
documented on the Individual Health Education Record. Each youth’s confidentiality is protected
by not including the HIV status and any other STI diagnosis on the program’s internal alert
system. The DHA provides HIV pre and post-test counseling services. An interview with seven
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youth indicated all stated they could ask for an HIV test. The nurse interview stated youth are
screened for STIs upon intake and when a youth requests to be tested. If screening indicates a
need for further evaluation, the DHA is immediately notified. All STI screenings, evaluations,
referrals, and tests are documented in the IHCR behind the communicable disease tab and the
progress note tab. If a youth is out of the program’s physical custody for more than thirty days
or exhibits symptoms, the youth is rescreened, and a new urine drug screen is completed. The
HIV test results are maintained in the lab results tab. HIV consent is obtained on the day of
intake; however, a youth can ask for an HIV test at any time. The HIV consent is signed by the
youth and once the test is completed the DHA signs the HIV form and the results.
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 addressing sick call being conducted only by
a licensed nurse; however, if there is no licensed nurse on-site, the shift supervisor reviews all
Sick Call Request forms as soon as possible, or within two hours after the request is submitted.
Any complaint of severe pain, including dental pain is treated as an emergency and referred
immediately to a nurse or designated health authority (DHA). A review of seven Individual
Healthcare Records (IHCR) was conducted. None of the seven youth presented with similar sick
call complaints three or more times within a two week period or had been in restricted housing.
All seven youth and a nurse completed each Sick Call Request form. In five of the seven IHCRs
at least one sick call was conducted by a licensed practical nurse (LPN) and the sick call was
reviewed daily with a registered nurse (RN), which was documented on the Sick Call Request
form. Each Sick Call Request form was filed in each youth’s IHCR in reverse chronological
order and was documented in accordance with Health Services Rule. All sick calls were
documented on the Sick Call Index, as well as the Sick Call Referral Log, and the dates listed
on the Sick Call Index corresponded with the completed Sick Call Request forms. A review of
the daily schedule, posted schedule, contract, and nurse interview confirmed sick call is
conducted twice daily. The sick call hours were posted, and the Sick Call Request forms were
available to youth in all modules. The program did not have any sick call event during the
annual compliance review week; therefore, observations could not be conducted. The clinic
does have an exam table and equipment, which is used to perform sick call. Six of the seven
interviewed youth stated they could see a nurse immediately after making a sick call request.
The remaining youth stated they could see a nurse within one day. The nurse interview
indicated when a youth fills out a Sick Call Request form, the youth will place it in the sick call
box, and sick call is conducted twice a day and as needed. All nurses conduct sick call, as well
as the DHA if on-site. If an LPN performs the sick call, the LPN will consult with a RN, who signs
off on the Sick Call Request form. The sick call is conducted in the clinic and is currently
scheduled for 7:45 a.m. and 12:15 p.m. If a youth has a sick call for the same complaint three or
more times within a fourteen-day period, the youth is referred to the DHA. Youth are referred to
the DHA if a nurse thinks they need to be seen earlier or according to protocol. If a youth is in
restricted confinement the youth is assessed daily and always has access to medical services.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a written policy and procedures addressing episodic and emergency care,
including a process to ensure the contents of the first-aid kits are maintained and stored to
prevent expiration or deterioration, and are replenished as needed, as well as the use, access,
and inventory of Narcan. In six of the seven reviewed Individual Healthcare Records (IHCR)
there was an indication each youth required on-site first-aid or episodic care. All episodic or first-
aid care was conducted by a nurse in problem-oriented charting. The program maintains five
first-aid kits, one in the dining hall, one in the copy room, one in master control, and two
additional in master control for transports. Three first-aid kits were checked and all were fully
stocked with designated health authority (DHA) approved contents. A review of the first-aid kit
inventories for the annual compliance review period indicated the first-aid kits are checked
monthly by the health services administrator (HSA). The program has one automated external
defibrillator (AED) located in master control with AED procedures maintainedalongside it . A
review of the AED checks for the annual compliance period indicated the nurses conduct
monthly checks of the AED. A self-test of the AED during the annual compliance review week
showed the AED was in working order. The AED’s batteries expire on August 31, 2029, and
were last replaced on February 6, 2024. The pads expire on May 18, 2027, and were also last
replaced on February 6, 2024. The list of emergency numbers was posted in the clinic
accessible for all staff, and inaccessible to youth. A review of documentation indicated
authorized direct care staff are appropriately trained on the administration of the epinephrine
auto-injector by a registered nurse (RN). All seven pre-service and seven in-service training
records indicated each were trained on episodic, first-aid, and emergency care. A review of drills
since the start-up monitoring was conducted; however, the start-up monitoring was less than
one year prior and not all direct care staff had participated in at least one drill which included the
use of cardio-pulmonary resuscitation (CPR). The program tried to ensure all staff with direct
youth contact on a day-to-day basis have the opportunity to participate in at least one
emergency “man-down” drill annually. Reviewed emergency medical drill documentation
indicated drills simulated an episodic care event which called for immediate first-aid and/or
administration of CPR techniques and the initiation of the emergency procedures to follow when
a life-threatening emergency occurs. The drills were announced or unannounced emergency
medical drills conducted at least quarterly on each shift. The program maintained all emergency
drill documentation. A video review of three drills, during the annual compliance review week,
confirmed they were simulated events. The program did not have any episodic care events
during the annual compliance review week, and observations could not be conducted. The
program has two doses of Narcan in the locked medical cart, and one dose in the medication
storage cabinet, which was inventoried perpetually and weekly. The program trains all staff to
know when and how to use Narcan, which was confirmed by review of training records. All
seven interviewed staff stated they are allowed to call 9-1-1 if a youth has a medical emergency;
however, they do not have any cellular telephones on them and will contact master control to
make the telephone call. One staff also stated medical can make the call, and three staff said
they will also contact the supervisor, and one stated the facility administrator (FA). All seven
interviewed youth stated they can be seen by a doctor or dentist if they ask. The nurse interview
indicated episodic care is documented on the episodic progress note and logged on the
Episodic Care Log. If non-healthcare staff perform first-aid, they utilize the Department’s Report
of On-Site Health Care by Non-Health Care Staff form, and the youth is assessed by a nurse on
their next visit. Youth who are seen for off-site emergency care are tracked on the transport log
and schedule/planner. The nurse stated emergency medical drills including CPR are conducted
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quarterly and drills monthly. The list of emergency numbers is maintained in master control and
the clinic, inaccessible to youth.
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.
Three of the seven reviewed Individual Healthcare Records (IHCR) were not applicable for off-
site care and referrals. In the remaining four there was an indication each youth required off-site
care and the Summary of Off-Site Care Consultation Report form was utilized and filed in each
IHCR. The program documents the off-site care on the transport log. In three of the four
applicable IHCRs each youth was seen by the dental van and youth do not need to be
transported off-site; therefore, the off-site event was not documented on the transport log. In the
remaining one youth the off-site events were documented on the transport log. In three of the
four youth parental notification efforts were documented in each IHCR. The remaining youth
was eighteen years old and parental notifications were not required. All four applicable IHCRs
had the discharge and other applicable documents filed in each record and the designated
health authority (DHA) reviewed and signed/initialed all off-site care findings, instructions, and
information. One of the four youth did not require follow-up testing, referrals, or appointments.
The remaining three youth required follow-up appointments; however, none of the appointments
had been scheduled at the time of the annual compliance review week. In one of the three
IHCRs the program was awaiting parental consent, and the remaining two youth off-site
appointment had occurred a few days prior to the annual compliance review week and no
follow-up appointments have been scheduled. The nursing interview indicated the nurses track
all off-site care and follow-up testing, referrals and appointments on the transport log, medical
tracker, calendar, and DHA log. If a youth has an off-site event the documents are flagged in the
IHCR, and the youth is added to the DHA log to be seen during the next DHA on-site visit. The
nurses review the off-site orders with the DHA and follow through with the hospital orders.
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.
Two of the seven reviewed Individual Healthcare Records (IHCR) were not applicable for
periodic evaluations. The remaining five youth were identified on the Facility Entry Physical
Health Screening (FEPHS) form with a current chronic condition. None of the five applicable
youth had a communicable disease, were taking anti-tuberculosis medications, were pregnant,
or received an off-site periodic evaluation. One of the five youth was taking prescribed
medication on an on-going basis, the remaining four were not. Two of the five were classified
with Medical Grade two through four. The remaining three had a Medical Grade of five. All five
youth were undergoing treatment for a physical health condition, placed on a chronic illness list,
and received periodic evaluations at least every ninety days. Two of the five youth were
applicable for and received periodic evaluations, prior to renewing a prescription medication
about to expire. In none of the five applicable IHCRs were there any indications of lapses in
care or missed periodic evaluations. Four of the five required the Department’s Problem List to
be updated, in accordance with the Health Services Rule, and was completed. The facility
administrator (FA) stated in an interview, he is meeting with the healthcare staff to review
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important youth medical issues during daily morning meetings, and medication management
meetings. The psychiatrist attends clinical supervision. The designated health authority (DHA)
stated in an interview, periodic evaluations are completed every sixty days, for youth with
chronic conditions, and the appointments are tracked by placing them on a medical
tracker/spreadsheet. The interviewed nurse stated the program monitors youth with chronic
conditions, by placing them on a medical alert tracker system.
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.
In four of the seven reviewed Individual Healthcare Records (IHCR) the Facility Entry Physical
Health Screening (FEPHS) form and progress notes indicate each youth was admitted with
medication. In all four applicable IHCRs each youth was taking medication at admission and the
medication was verified prior to each youth being admitted into the program. The prescription
verification was documented on the Chronological Progress Note and the Department’s
Prescription Medication Verification Checklist form. In the four applicable IHCRs the designated
health authority (DHA) and when appropriate, the psychiatrist, was contacted to obtain an order
to resume the specified medications prescribed prior to admission. All seven youth received a
prescribed medication while at the program and all medications had a current, valid order and
were administered as prescribed. The DHA placed an order on the Practitioner Order form when
a current medication was continued, discontinued, changed, or a new medication was ordered
in six of the seven youth. The remaining one was not applicable. None of the youth were in
restricted housing or received parenteral medications, non-healthcare staff did not assist in the
delivery of medications, the youth did not sign the Medication Administration Record (MAR), and
there were no undocumented explanations for a lapse or error in medication administration. In
three of the seven IHCRs over-the-counter (OTC) medications not listed on the Authority for
Evaluation and Treatment (AET) form were administered according to approved protocols or
Practitioner’s Order. The remaining four were not applicable. In all seven IHCRs the standard
Department Medication Administration Record (MAR) or a pre-printed pharmacy MAR with all
the required information was used to document all medication and treatment, each clearly
indicated medication start and stop dates, the nurse initialed each administered medication
entry, and the nurses documented weekly side-effect monitoring. One of the seven youth
refused treatment, the youth signed the Refusal of Treatment form, and the refusal was clearly
documented on the MAR. Each MAR contained all of the required elements. Four of the seven
youth were prescribed psychotropic medication prior to admission and the DHA/psychiatrist
were notified upon each youth admission. The four youth entered the program on psychotropic
medications and the psychiatrist/psychiatric advanced practical registered nurse (APRN)
conducted an initial diagnostic psychiatric interview within fourteen days of admission. Three of
the four youth received a medication monitoring/review every thirty days, as required. In the
remaining one IHCR one of the six medication reviews was conducted seventeen days late.
The program did not have any standing orders, emergency treatment orders, nor Pro Re Nata
(PRN) orders for psychotropic medications. During the annual compliance review week,
medication administration was observed for four youth. During the medication administration it
was the nurse’s sole responsibility to administer the medications to each youth, including
verifying the Six Rights of Medication Delivery. Each youth was escorted to the clinic door by a
youth care worker individually to offer privacy. The nurse had the medication cart placed in the
threshold of the clinic door. The nurse identified herself, and each youth stated the reason he
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was present and the medication name he is to receive. The nurse then verified the medication,
allergy, and alert status on the MARs, retrieved the correct medications from the medication
cart, placed the medication in a small container, and handed the container and a small cup of
water to each youth. Each youth was asked to cough after swallowing the medication, as well as
having the mouth swabbed. The nurse initialed each MAR. None of the medication
administration was conducted by non-healthcare staff and none of the youth received OTC
medications. All seven interviewed youth stated the nurse provides medication. Five of the
seven were able to explain the medication process, and of the two remaining, one stated
medication is provided during medication administration, and another stated during sick call.
The nurse interview indicated when a youth is admitted with medications the DHA and
psychiatrist are notified upon intake. The medications are verified with the physician who
ordered them or the pharmacy which provided them. This is documented on the Department’s
Prescription Medication Verification Checklist form, and the nurse and youth signed the form.
The nurse stated the program utilizes a pre-printed pharmacy MAR with all the required
components. Non-healthcare staff are trained by a nurse in case the nurses are not on-site and
a medication needs to be provided. The list of trained staff is available in master control and the
clinic. The program’s medication administration is scheduled three times a day, 7:00 a.m., 12:00
p.m. and 6:00 p.m. The nurse indicated in the interview the program has a Class II permit and
medications/prescriptions are procured from a local pharmacy and a back-up pharmacy. The
nurse stated the program utilizes a psychiatrist, on-site and telepsychiatry, providing medication
management, participating in treatment team, and being on-call twenty-four hours a day, seven
days a week.
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 for the destruction and disposal or return of
expired or discontinued medications. Observations of the medical clinic were conducted during
the annual compliance review week. The medical equipment classified as sharps, and over-the-
counter (OTC) medications were maintained in locked cabinets, and the locked medication cart.
Controlled substances are secured in a locked box in the locked medication cart inaccessible to
youth. Different stock medications such as injectable, topicals, drops, and liquids are maintained
separate from youth-specific medications. The medication cart and cabinets were clean and
organized. The clinic has a medication only refrigerator housing tuberculosis serum. A review of
the sharp and OTC inventories for the annual compliance review period indicated they were
completed perpetually with descending count, as well as weekly. Two of the OTC medications
had inventory discrepancies, one count was off by one, and another had one weekly inventory
missing. A review of the controlled substances inventories indicated there was a shift-to-shift
inventory count conducted on each youth’s Individualized Controlled Medication Inventory
Record. A review of the delivery and oversight of medication self-administration training
indicated six supervisory-level, non-healthcare staff were trained by a registered nurse (RN).
Observation of the nurse completing counts for three controlled medications, three OTC
medications, and three sharps was conducted. All medication and sharp counts matched the
inventory numbers. The nurse provided the reporting criteria and procedures regarding
inventory discrepancies. The nurse stated in an interview, medications are disposed with a drug
destroyer solution and non-controlled medications are sent back to the pharmacy for credit.
Controlled medications are destroyed in the presence and with the pharmacy consultant who is
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on-site once a month and ensures the nursing staff are compliant with pharmacy regulations. He
inspects medication storage, Medication Administration Records (MARs), labeling,
documentation, and assists in medication destruction. Controlled substances and narcotics are
stored behind two locks, all other medication is stored in the medication cart and medication
storage area. Inventories are conducted weekly and perpetually.
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 addressing infection control procedures
including prevention, containment, treatment, and reporting requirements related to infectious
diseases, in accordance with the Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
policy includes the program’s process for needle stick post-exposure evaluation. The designated
health authority (DHA) reviewed the infection control procedures on September 3, 2024, the
facility administrator (FA) on September 4, 2024, and others reviewed them on September 6,
2024. The infection control procedures include common, infectious diseases of childhood, self-
limiting, episodic contagious illnesses, viral or bacterial infectious diseases, tuberculosis,
Hepatitis A, B, and C and human immunodeficiency virus (HIV) infectious diseases caused by
bloodborne pathogens, other outbreaks or epidemics caused by any other infectious agent,
whether spread directly or indirectly, outbreaks of pediculosis and/or scabies, Methicillin-
Resistant Staphylococcus Aureus (MRSA) and other emerging antibiotic-resistant micro-
organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures in the workplace.
The program provides Hepatitis B immunizations to staff, as well as access to protective
equipment. The program did not have any instances in which the local county health
department, CDC, and/or the Department’s Central Communications Center (CCC) should have
been notified of an infectious disease. The exposure control plan was written in accordance with
OSHA standards and is made available to all staff. The plan was reviewed and signed annually
by the administration of the program and/or designees in September 2024. The FA, in an
interview, stated the exposure control and infection control plan are available for all staff in the
FA’s office if they would like to review it. The nurse in an interview stated the exposure control
plan is available to the nursing staff and is in the clinic and master control. Infection control
training is conducted by a nurse during pre-service training and annually for all staff. The nurses
also provide training on the exposure control plan. The youth receive infection control training
during the intake process and as needed. The nurse stated the program utilizes the county
health department for immunization services.
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 policy and procedures which require staff to 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 programs behavior management system (BMS). The program adheres to a staff to
youth ratio of one to eight during daytime activities and one to eight during hours of sleep.
Observations of staff during the annual compliance review week found staff were actively
supervising youth during school, physical education, medication administration, during breaks
and positive interactions with youth. The program has schedules of activities posted on each
module. Youth were observed following the schedule. Three staff were informally interviewed
and asked how many youth they were currently supervising, and all three staff were able to
identify the number of youth assigned to them. During the facility tour youth room windows were
uncovered, allowing a clear line of sight. Seven staff were interviewed and six provided steps to
take if a youth count could not be reconciled, as the program policy dictates.
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 utilizes iChoose system and has a detailed description of the collaborative
behavior management system (BMS). The program maintains a detailed written description of
the collaborative behavior motivation system which is conspicuously posted and is outlined
within the youth handbook allowing easy access for youth, including rules governing conduct
and positive and negative consequences for behavior including while in the classroom. The
program’s BMS allows for youth and staff to discuss behavior, their behavior’s impact on
themselves and others, discussion of alternate behaviors and peaceful conflict resolution. The
program reviews youth behavior cards during morning management meetings and with youth
during weekly treatment team. The facility administrator (FA) trained the educational staff on the
BMS, and a joint agreement exists between education and the program. The facility
administrators are responsible for initial training of all staff on the BMS. Seven reviewed staff
personnel records confirmed position descriptions included implementation of the program’s
BMS. A review of seven staff training records confirmed each received training in the program’s
BMS. Of the seven reviewed case management records all youth had confirmed signing of the
youth orientation handbook, which includes rules governing conduct and positive and negative
consequences. Posting of the BMS was observed, during the annual compliance review week,
on all four youth modules. The program had not changed the BMS since the last annual
compliance review nor were they in the process of changing it. The program’s BMS includes
maintaining order and security, promoting and protecting youth rights, positive and negative
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consequences, constructive disciplinary actions, opportunities for positive reinforcement,
recognition of accomplishments and positive behaviors at a four-to-one ratio, and promoting
socially acceptable means for youth to meet their needs. The program’s BMS does not include
increased length of stay, denial of a youth’s basic rights or services, promotion of group
discipline, punishment of youth by other youth or disciplinary confinement. During an
observation of a facility administrator speaking with a youth, it was noted the staff member using
the four-to-one ratio of positive affirmations and praise, this was consistent with additional
observations throughout the annual compliance review week; in addition to consistent use of
BMS. The program offers daily and weekly canteen options and food incentives for perfect
behavior on a daily, weekly and monthly basis. The program also has mod incentives when the
youth have no negative behavior over weekly and monthly periods, which include game room
activities and movie nights. The program has birthday celebrations for the youth. All seven
interviewed staff were able to explain the program’s BMS system and identify rewards granted
or issued. All agreed basic rights cannot be taken away from youth. All interviewed staff stated
consequences are discussed with youth and youth can explain their behaviors. All seven
interviewed youth were able to identify behaviors resulting in consequences and rewards; what
the rewards are, levels to achieve, and how to move through the levels (Orientation, Rookie,
Pro, All Star and Hall of Fame). The facility administrator interview relates the program utilizes
an iChoose system compiled of a series of levels. The FA explained how rewards are
monitored, how the program ensures rewards outnumber the consequences, how
consequences are monitored, and how staff are monitored for the implementation of the BMS.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures which require staff to observe youth at least every ten
minutes while the youth are in their sleeping quarters; however, documentation confirmed
checks being conducted every five minutes. Staff are required to conduct the observations in a
manner to ensure the safety and security of each youth. These checks shall be documented in
real time. The program has eighty-nine cameras; however, two were non-operational at the time
of the annual compliance review. The program maintains thirty days of video recording. A
sample of security tapes and corresponding logs was reviewed to verify ten-minute checks. The
sample included five samples of thirty-minute increments from third shift and four samples of
thirty-minute increments from second shift. The reviewed footage represented each housing
module. The review confirmed all checks were conducted at five-minute intervals, exceeding the
ten-minute requirement. All checks were documented in real time. A review of the ten-minute
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check sheets confirmed staff who completed the checks initialed the check sheet. Video review
further confirmed checks were conducted as required, and staff walked by the rooms pausing
for a moment to observe the youth thoroughly enough to guarantee their safety. A review was
conducted of check sheets for the annual compliance review period which reflected checks
were conducted as required. Seven staff were interviewed, and asked how often room checks
were conducted when a youth is placed in their room for sleeping or non-punishment reasons,
and all seven advised checks are conducted every five minutes, one staff related policy states
checks are to be done every ten minutes. The facility administrator interview confirmed they
have eighty-seven operational cameras.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures to address census, counts and tracking. The
program’s census and counts are documented in the master control logbooks with formal and
informal counts completed each shift, each day. The program’s policy states there are to be
three formal counts completed every twenty-four hours and following each outdoor activity.
Observations during the week of annual compliance review found master control calling for and
completing counts. The program’s master control logbook was reviewed during the annual
compliance review period reflecting counts being completed a total of eight times a shift to
include beginning and end of shift counts. A review, since the last annual compliance review, of
a full day for each month was conducted of the logbooks, and each day contained
documentation of total daily census counts, head counts, youth movements, youth admissions
and releases, and youth temporarily away from the program. Seven interviewed staff reported
counts are being conducted every hour on each shift using formal and informal counts. The
seven interviewed staff stated emergency counts are conducted when a count is not accurate, a
youth cannot be accounted for, after a drill or serious incident, major disruption and inclement
weather. All seven staff reported procedures for when a youth count cannot be reconciled,
which includes stoppage of movement, physical head counts and their where abouts, search of
facility.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures to address logbook entries. During the annual
compliance review period it was observed the program uses a bound logbook, writes entries
during each shift, each day and uses only one book a month. Pages reviewed did not have any
entries destroyed or removed. During the review of the logbook’s, errors were documented
correctly, using a single line through the error with staff initials. Reviewed logbook pages had
entries with dates, time, a brief description of event and names of staff making the entry. The
program does not utilize living unit logbooks. Reviewed logbooks documented class start times
and no interference of the educational instruction period. Logbook entries contained all required
applicable information for each month reviewed. The program utilizes shift reports, which have
the census of all living units, incidents, youth out of the facility, youth alerts, gang members,
security alerts, staffing assignments, sick calls, perimeter checks and their findings. Shift reports
are reviewed by the supervisor from the previous shift. Reviewed shift reports during the annual
compliance review period show staff and supervisors signing their review of the shift report.
During the week of the annual compliance review a shift briefing was attended; the program
supervisor verbally briefed staff with the shift report with their supervisor from the previous shift,
staff were given their assignments and a document review of the shift report. Master control
logbooks and shift reports document the Department’s Central Communications Center and/or
Florida Abuse Hotline information.
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 keys are maintained in secured key boxes located in master control. This area is
secured and inaccessible to youth. Staff personal keys are secured in master control in a locked
cabinet. Master control issues keys based on job position. The key boxes located in master
control are not easily accessible while locked. Each set of keys has an assigned number and
corresponding key ring. The shift supervisor checks the key cabinet and log before the
beginning of the shift to ensure all keys have been appropriately signed for and returned at the
end of the previous shift. A review of the key inventory confirmed it matched the actual key rings
in use. Keys are always locked in a cabinet when not in use. During the week of the annual
compliance review, observations of master control issuing keys was completed and key
inventory matched with the correct number of keys assigned to the correlating key set. Program
keys are secured with a padlock in a clear wall cabinet and youth care worker personal keys are
secured in metal key box, located in master control under camera view. Extra vehicle keys were
in a locked box on the wall in the maintenance office. Both key storage boxes were locked while
not actively retaining keys. Five samples of key sets were observed and compared to the
inventory and key log, confirming each correlated accurately. The facility administrator
authorizes and assigns the permanent and restricted keys based on the position. An
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acknowledgment form for permanent keys is completed for each permanent key assigned with
signature, key number, and return date. Restricted keys are stored in a separate locked box
from non-restricted keys, and only assigned staff can access the restricted key box. The
program has a process for reporting broken or damaged keys. In the event of misplaced or lost
keys the facility administrator, assistant administrator and supervisor on duty must be notified
immediately. Broken or damaged keys are given to the maintenance manager, who is the only
one authorized to replace keys. The program did not have any the Department’s Central
Communications Center incidents or program monitoring and management deficiencies related
to key control during the annual compliance review period. An informal interview with the facility
administrator and maintenance manager found they were able to identify which keys were
restricted and to whom they are issued. The program maintains a twenty-four-hour key log,
which the master control operator updates, listing keys issued to, date, time of issue, who
received the key, and what time it was returned. Master control must initial each entry. An
informal interview with the master control operator was conducted and she reported only staff
assigned to specific areas such as medical, case management and maintenance have access
to restricted keys. Three random staff were informally interviewed. Each staff was able to
identify what key set they had and the function of every key on the key set. The key sets were
also verified using the master key inventory. Seven interviewed staff reported the process for
turning in their personal keys and having keys issued to them. The seven staff reported keys are
inventoried, keys are not accessible to youth, and if keys are missing, to whom this is reported,
and how searches of youth and facility would be orchestrated. All interviewed staff reported the
visitor keys are secured and a chit/token is issued.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures in place to prevent contraband from entering the
facility. The policy includes items and materials considered as contraband, as well as
exemptions. The program has procedures providing youth with a list of items considered as
contraband, informing program youth of the consequences if found with contraband, searching
the facility and grounds, and searching of youth, incoming mail, and outgoing mail. The policy
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includes the consequences if any program staff is found in possession of contraband. The policy
also includes contacting law enforcement if any item found is considered illegal as defined in
Florida Statutes, or if there is any evidence of unlawful activities. The program had one incident
related to contraband during the annual compliance review period. A review of the Department’s
Central Communications Center reports showed there was one report of contraband
confiscated. A review of the facility logbooks and youth room search reports for the annual
compliance review period showed the program conducted searches as required. Contraband
items or illegal contraband are documented on the search log and disposed of as required. The
interview with the facility administrator confirmed all contraband is given to the shift supervisor
then chief of security. If necessary, the CCC contacted. If the contraband is illegal, the police
are contacted. If the incident is CCC reportable, the contraband is kept until the end of
investigation then removed and disposed of by administration. Seven interviewed staff reported
room searches are done once a week. The facility administrator related, upon entry into the
facility, staff and visitors are searched in efforts to prevent contraband from entering the facility.
All visitors/staff are notified of the applicable contraband Florida Statue, as it is posted at the
entrance doors of the facility. In addition, a list of items identified as contraband are noted within
the program’s parent/youth handbook and the employee handbook. Weekly room and common
area searches are completed, and findings are documented on the search log. Any
unauthorized item/illegal contraband is documented on the search log and disposed of properly.
Any findings of illegal contraband require notification/reporting to law enforcement and CCC.
Twenty-one were hired since the last annual compliance review and an attestation form was
completed and in each staff’s personnel record. The program’s visitor sign-in log contains an
attestation statement.
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 policy and procedures to address searches and full body visual searches to
ensure no contraband is introduced into the facility. During the week of the annual compliance
review, staff were observed searching youth prior to and after movement, prior to leaving for a
transport. The program did not have any admissions or releases, visitation, or off-campus
activities during the week of the annual compliance review. Youth searches were observed as
youth exited educational instruction. During observed searches youth were treated with dignity
and respect to minimize stress and embarrassment. Observed searches were conducted by the
same gender and with appropriate number of staff. Youth were given instructions and the
reason for the search prior to, which were in line with the facility’s policy. Youth searches were
conducted as required by Right Interactions training. Video review of five staff and visitor
searches were observed during the annual compliance review week and confirmed staff and
visitors have to wait to be thoroughly searched one at a time prior to entering the secure area.
Of the seven interviewed staff all stated youth are searched before and after movements, two
staff state youth are searched when going off grounds. Seven interviewed youth stated
searches are conducted when returning from off campus, after outdoor activities, when items
are missing, after visitation, after meals, after work details, and before and after movements.
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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 practice of ensuring all staff operating a program vehicle have a current
driver’s license. Reviewed documentation revealed the program maintains an approved driver
list, and ensures each approved driver has a valid driver license, checking this monthly with the
Department of Highway and Safety. The program has a policy and procedures to address
vehicles and maintenance. The program utilizes two vehicles for youth transport, both are 2025
Kia Carnival minivans and placed in service October 2024. Neither vehicle’s mileage has
reached its first recommended service. During the annual compliance review week, eight
randomly selected personal vehicles and two facility vehicles were found secured on one day
and six randomly selected personal vehicles found secure on another day.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to address transportation of youth and driver
eligibility. The review of the program’s policy states a program cellular telephone is issued for all
transports, a minimum of two staff to one youth is required, and a staff of the same gender of
the youth be present during the transport. During the week of the annual compliance review
there was only one transport able to be observed. The program staff followed all policies,
including search of youth and vehicle, pre-trip safety inspection, proper safety equipment in the
vehicle and communication devices. During the facility administrator interview he noted the
program is not required to have a safety screen nor have staff ride in the back with the youth.
Five staff were interviewed and five stated the program vehicles do not have safety screens and
a staff member rides in the back. The seven staff stated youth are secured in the vehicles by
safety equipment, the placement of youth in the vehicle, use of seatbelts for all, shackles and
handcuffs. Six of the seven interviewed staff stated the transportation ratio is one youth to five
staff and one staff answered two staff to one youth. Two staff stated the vehicles have safety
screens, while five staff stated they do not; and four staff stated a staff member rides in the back
with youth. Each of the interviewed staff stated the transport vehicles are equipped with fire
extinguishers, glass breaker, a seatbelt cutter, and a first-aid kit. Each stated a cellular
telephone and two-way radio is used for each transport and the transport vehicle is searched
prior to each use. Each of the interviewed staff knew the emergency response process during a
transport. All seven staff stated staff are not permitted to use a personal vehicle to transport
youth. Of the seven interviewed youth, all denied seeing anyone place contraband in the
transport vehicles. Five youth stated they have not been handcuffed to any part of the vehicle
during transport, two stated they have not been on transports.
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining weekly safety and security audits including
program staff being responsible for conducting the weekly security audits and safety
inspections, the development and implementation of corrective actions warranted because of
safety and security deficiencies found during any inspection, an internal system to verify if the
deficiencies are corrected, and existing systems are improved or new systems instituted as
needed to maintain compliance. The facility administrator (FA), assistant administrator, and
plant manager completes the weekly audits. During the annual compliance review period,
weekly inspections were documented every week. There were no safety and security related
deficiencies assigned during the annual compliance review period. The program’s Preventive
Maintenance Checklists were reviewed with the maintenance manager and confirmed
maintenance schedules and repairs were conducted as required. The interview with facility
administrator (FA) revealed the program assistant FA and physical plant manager complete
weekly safety and security audits. Findings are documented on the weekly safety inspection
report and provided to the FA for review. The report details identification of any issue and tracks
the correction of the deficiencies. All efforts are made to correct deficiencies in a timely manner,
dependent on the severity.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing the issuance, inventory, and control of
equipment and tools. The maintenance manager completes a daily inventory checks as well as
a monthly tool inventory which is signed off by the facility administrator (FA). The program’s
policy prohibits machetes, bowie knives, or other long blade knives. The program has
procedures for missing/lost tools and disposal of dysfunctional tools (disposed of and replaced).
Should a tool become lost or become dysfunctional, the program must take immediate
corrective action. In the event a tool is missing or damaged, staff shall notify the FA, and the tool
control officer immediately. A tag is hung on the shadow board until a replacement tool is in
place. The program did not have missing, lost or damaged tools during the annual compliance
review period. The program’s tool inventory records for the annual compliance review period
showed tools being issued and were inventoried following return. Ten tools were randomly
selected from maintenance shop and kitchen, all were secured, had identification and accurately
matched the inventory list. A review of inventory of tools which do not have sharp edges or
points confirmed the program maintained monthly inventory for the annual compliance review
period.
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5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing the supervision requirements when youth
use tools including one staff to five youth ratio, issuing tools to youth and staff, assessment to
determine a youth’s risk to self and others, tool distribution, collection, and search criteria during
work projects. The program does not utilize disciplinary work projects. During the week of the
annual compliance review, no youth were observed being issued tools or work projects. A
review of seven youth case management records confirmed the program provided instruction
and risk assessments for each youth. Each of the seven youth completed training in the
intended and safe use of tools. Of the seven youth and staff interviews, all reported youth only
use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures to address outside contractors which states which
states outside contractors/services personnel shall be accompanied by the maintenance staff or
designee and will receive instructions regarding responsibilities for tool control and prohibition
on bringing in contraband. Contractors shall limit tools to only those necessary. Staff will check
tools upon the contractors’ arrival to and departure from the program. Youth access will be
restricted from the work areas. In addition, facility staff shall supervise outside
contractors/services personnel in areas located by the youth. Ten contractor sign-in sheets were
reviewed, and all had instruction sheets, tool inventory, with dates and signatures; if tools were
missing there was a place for the contractor and staff signature. Tool inventory was documented
for all tools brought in by the contractors. Three days of outside vendor invoices were reviewed
and each matched contractor forms/contractor sign-in sheets. The facility administrator is
advised if contractors need cellular phones or electronic devices capable of taking
pictures/audio recordings.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to address fire, safety, and evacuation drills. During
the annual compliance review period the program conducted fire drills monthly on every shift.
The drills included the type of drill, date and time, participants, a brief scenario, findings and
recommendations. The fire evacuation routes, and egress plans are posted throughout the
facility. The program has twenty-two fire extinguishers, twenty throughout the facility and two in
transport vehicles, inspected annually. Seven staff were interviewed, and all said they
participated in monthly fire drills, as well as monthly emergency drills. Seven youth were
interviewed, and all said they have been instructed on what to do in case of a fire. In addition, all
seven youth said they have monthly fire drills. The facility administrator was interviewed and
reported drills are completed on a monthly basis, on each shift. Drills include disturbances, riots,
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threats, severe weather, evacuation, and escape scenarios. Fire drills are conducted monthly on
each shift. Drills results are reviewed monthly during general staff meeting.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a Continuity of Operations Plan (COOP) and the COOP was last
reviewed and updated on February 11, 2025, by the facility administrator (FA), and submitted to
the Department for approval on March 9, 2025. Copies of the program COOP plan are in the FA
and assistant facility administrator’s office and in master control. The plan addresses alternative
relocation sites approved by the Department’s regional director and the COOP includes all the
required and relevant information for continuous operation during an emergency. Supplies and
equipment required for the COOP are in the plant manager area and food items are stored in
the kitchen. Supplies, for seventy-two hours minimum, viewed were water, dry goods, can
goods, non-perishable items and youth hygiene related items. The program’s COOP includes
delegation of authority, vendor contact list, emergency and staff contact numbers, and county
cooperation checklist. The program’s COOP references: fire, fire prevention, evacuation, severe
weather, disturbance or riot, bomb threats, hostage situations, chemical spills, flooding, terrorist
threats or acts, staff roles and responsibilities, equipment and supplies needed, information
about youth which may need alternate housing arrangements, provisions for continuity of care
and custody as well as provisions for public safety. The program utilizes both the Department’s
Juvenile Justice Information System (JJIS) and hard copies of youth records. In case of
emergency requiring relocation, the program will hand transport medical, mental health and
case management records, logbooks, education records as well juvenile demographics, and
COOP file. Seven youth reviewed records had a demographic card which has: youth’s full
name, Department identification number (DJJID), admission date, date of birth, gender, race,
name, address and telephone numbers for parents or guardians. The cards have the additional
information; name, address, and telephone number of the person with whom the youth resides
and his or her relationship to the youth, person(s) to notify in case of an emergency (and contact
information), juvenile probation officer’s (JPO) name, circuit/unit, and contact information,
names of committing judge, state attorney, and public defender (or attorney of record) with
contact information on each, committing offense and judicial circuit where the offense occurred,
notation of whether or not the judge retains jurisdiction, victim notification contact information, if
notification is required, physical description of youth to include height, weight, eyes and hair
color, any identifying marks, overall health status, including chronic illnesses, current
medications and allergies, personal physician (if known) and photograph of youth. One youth’s
record did not have the youth’s full name, and second youth did not specify whether the judge
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retained jurisdiction. The facility administrator was interviewed and confirmed the COOP is in
master control and available for staff to access.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures regarding the storage and inventory of flammable,
poisonous, and toxic items. The program stores all bulk flammable, poisonous, and toxic items,
and materials in a secured caged area, which is in the maintenance area and kitchen area,
located away from the housing unit. Items are maintained and inventoried in this area. Youth do
not have access to these areas. When items are depleted, a replacement bottle is removed
from the bulk storage, the inventory is adjusted, and the item is replaced. Inventories were
maintained for all reviewed flammable, poisonous, and toxic items, with the exception of one
item, a disinfectant cleaner, which was found in the game room. The program immediately
removed the item from the area. The program maintains a list of positions authorized to handle
flammable, poisonous, and toxic materials including the facility administrator (FA), assistant
facility administrators, maintenance staff, shift supervisors and kitchen support. The program
maintains safety data sheets for materials on site. Ten chemicals were randomly selected, all
items matched the inventory, were secured, and have safety data sheets present, with no
discrepancies noted. The program did not have during the time of the annual compliance review
period, any hazardous waste to dispose of. An informal interview was conducted with the
maintenance manager who stated the disposal practice is items are disposed with the city
Waste and Disposal Department. Last disposal was prior to November 15, 2024. Since then, the
maintenance manager purchases only what is needed to cut down on waste. In an interview
with the FA it was stated the City of Orlando, waste and disposal department will dispose the
flammable, toxic, caustic, and poisonous items on the first Saturday of the month. The program
has a Bio-Hazard Waste Contractor. The program did not have any chemical spills during the
annual compliance review period.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handling and supervision of
flammable, poisonous, and toxic items. The program maintains strict control over all flammable,
poisonous, and toxic items. The policy prohibits the use, handling, or cleaning dangerous or
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hazardous chemicals. Youth were not observed during the week of annual compliance period
conducting cleaning activities. Seven youth were interviewed, and all stated they do not 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.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation and communication, youth
correspondence, and use of telephone by youth. The visitation schedule is included on the
activity schedule which is posted in the lobby and dorm areas. According to the program policy
youth telephone calls are facilitated by the shift supervisor or designee. All youth will have the
opportunity to make at least one telephone call each week and multiple attempts shall be
initiated if unable to reach an identified individual on the approved correspondence list. All
program youth shall be provided opportunities to send and receive mail to promote
communication which fosters family reunification and community connections. Each youth shall
be provided with writing materials, designated times to draft correspondence as well as
envelopes and postage as needed for mailing. There is not a scheduled time for sending or
receiving mail. Youth may send or receive mail at any time. The mail log was reviewed for two
youth, as well as staff who opened/reviewed mail with youth. It was confirmed the director of
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management checks all outgoing youth mail. All program youth shall be provided opportunities
to promote communication and engagement which fosters family reunification and community
connections. The program has visitation on Saturday and Sunday from 1:00 p.m. to 3:00 p.m.
Each youth's assigned case manager (CM) makes telephone calls with youth when seen
throughout the day. The facility administrator (FA) reported the CM makes calls with youth
during 10:00 a.m. and 12:00 p.m. school breaks, after school, and during and after recreation.
Reviewed youth telephone logs verified this process. Case managers are present seven days a
week. All seven interviewed youth relate they can call their parent/guardian or send a letter. The
FA reported the program utilizes google translate for youth whose English is not their primary
language. During video review, visitation was observed taking place on May 3 and 4, 2025. The
FA indicated alternative visitation arrangements for the parent/guardian is made available when
needed.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities for the youth. The program
activity schedule includes at least one hour of supervised and structured indoor and outdoor
recreation and leisure activities, to include large muscle activity, for youth each day. A review of
the logbook for the annual compliance review period confirmed recreation and leisure activities
occurred as scheduled. Outdoor large muscle and outdoor recreational activities were observed
during week of annual compliance review confirming the program takes precautionary measures
to prevent overexertion, heat stress, and dehydration. The program employs recreational
therapists, and a review of credentials found no discrepancies. The program activities promote
social and cognitive skill development, creativity, teamwork, healthy competition, mental
stimulation, and physical fitness.
Seven reviewed youth records contained recreational therapy included in each youth’s
individual performance and/or treatment plan. Seven youth were interviewed, and all said they
have at least one hour of outdoor recreation daily. During this time, they are allowed to play,
participate in football, basketball, four square, yoga, walking around and ping pong.
Seven staff were interviewed, and all said youth have at least one hour of football, basketball,
yoga, walking around, indoor activities to include puzzles, trivia and board games.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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Standard 6: Educational Services
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 program’s contract requires career and technical education (CTE) services which include
certifications in ServSafe and/or Food Safety Management, first-aid/cardiopulmonary
resuscitation (CPR)/automated external defibrillator (AED), Florida Ready to Work Soft Skills,
Occupational Safety and Health Administration (OSHA)-10 and high school equivalency diploma
(GED) preparation. As a result of the CTE services offered at the program, forty-one youth have
received first-aid/CPR/AED services, fifty-one youth participated in OSHA-10, and fifty-six youth
participated in ServSafe food handler training program, forty-nine youth participated in Digital
Skills certification, and twenty-nine youth participated in Florida Ready to Work Soft Skills. A
review of documentation confirms the number of youth who have completed a certification or
received a certificate of completion for CTE services are forty-one in first-aid/CPR/AED, fifty-one
in OSHA-10, fifty-six in ServSafe, forty-nine youth in Digital Skills, and twenty-nine in Florida
Ready to Work Soft Skills. According to the program’s schedule, eligible youth can receive CTE
services Monday through Friday between 8:30 a.m. to 2:45 p.m. for graduates, Monday through
Friday, after 3:00 p.m. or as available for youth working towards their high school diploma, and
periodically on weekends for all youth. The vocational program manager provides career and
technical education services to the youth which include the coordination and implementation of
CTE assessments, placement and monitoring of youth in training or workforce programs and
providing job search skills training. The vocational program manager is a level one health and
safety institute instructor. An informal interview with the instructional leader indicated three
youth are currently enrolled in coursework towards earning an industry certification. A review of
the schedule and interviews during the annual compliance review week confirmed CTE services
are available. OSHA-10 serves as a base level certification which can lead to multiple industry
certifications from the American Welding Society and the National Center for Construction
Education and Research both of which are identified on the master credentials list. Seven youth
were interviewed, and all seven youth indicated educational services are being provided to them
at the program. The interview with the facility administrator confirmed CTE services such as
first-aid/CPR/AED, OSHA-10, and ServSafe are being provided to youth according to the school
schedule. A review of seven youth records confirmed all seven youth completed first-
aid/CPR/AED and OSHA-10 as required and none of the seven youth are applicable for
completion of the Florida Ready to Work Soft Skills as part three remains in progress for all
youth.
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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 has a written policy and procedures to provide for educational access. The
program integrates education into the daily schedule. A sample of three videos and three
logbook reviews showed youth are going to and from class on time. In addition, randomly
selected logbook entries for seven months of the annual compliance review period were
reviewed and youth were moved accordingly. Seven youth were interviewed and all stated there
are no interruptions during school.
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 through a contract with Florida Virtual School (FLVS) which
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 and was approved by the Department
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 classes were facilitated appropriately for majority of the
classrooms. The video reviewer noted one teacher left thirty-seven minutes early from the
classroom. An informal interview with the instructional leader confirmed 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.
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
the length of stay and classification of youth in the program. The education program includes a
contracted minimum length of stay of nine months allowing time for the education provider to
provide CAPE courses. The career education program does include Type 1 through Life
Management Skills, Personal Finance and Money Management courses. The career education
program also includes Type 2 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 3 through CTE course offerings which provide
content and competencies for those specific careers. A career strengths and interest
questionnaire are completed by each youth upon entry. Each CTE course offering by the
education provider includes soft skills for those specific careers, such as communication,
interpersonal and decision-making skills. The interview with the facility administrator confirmed
youth at this program are provided with ServSafe, Ready to Work, first-aid/cardiopulmonary
resuscitation (CPR), and Occupational Safety and Health Administration -10 courses. The
interview with the lead educator indicated digital information technology and finance in
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transcripts career education services are provided at the program and filed in the youth’s case
management record.
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.
Per the contract, the contracted educational provider is required to develop an Education
Transition Plan for each youth. Three closed youth records were reviewed; none of them
contained an Education Transition Plan. Many youth entered the program before July 1, 2024,
when the new education provider Florida Virtual School (FLVS), began their contract, so they
would not have had an education transition plan developed by the provider. Although seven
youth were interviewed, four stated they had participated in their transition plan and three stated
they had not started their plan yet. In the lead educator interview, it was reported educational
transition forms are completed with the student, and they make a post-secondary plan most of
which choose technical college.
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.
The contracted educational provider has procedures in place to provide for qualified
instructional personnel. After a review of the six teachers, and fifteen flex teachers, it was
verified four teachers and fifteen flex teachers hold active credentials as listed on the
Department of Education (DOE) website. Two teachers have Status of Eligibility (SOE) which
the contracted educational provider furnished. No prior teachers’ certifications were reviewed,
as they were requested; however, not provided. A review class schedulesconfirmed all teachers
were accurately listed and found three courses were being taught out of field. After a review of
three youth records for out-of-field parent notification letters, it was noted no notifications were
sent out prior to October 7, 2024, and none of the letters accurately reflect 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.
Three closed case management records of youth identified with employability as a goal at the
time of release were reviewed. Each record contained a referral to the Florida Youth College
(FYC). Seven youth were interviewed and none of the seven youth indicated they were currently
participating in post-secondary education. The interview with the lead educator indicated all
youth are referred to FYC upon completion of their high school equivalency diploma (GED) or
high school diploma to work with a career navigator on postsecondary courses. The interview
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with the instructional leader for the Florida Scholars Academy indicated when a youth
graduates, a request is submitted to FYC for the youth to pursue further education.
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.
Three closed case management records of youth identified with employability as a goal at the
time of release were reviewed. Each record included documentation to support the day, date,
and time of their orientation to Florida Youth College (FYC). All three youth records contained a
career plan based on the interests and aptitude of each youth. Two of the three records
included youth’s admission and registration to a postsecondary program, the remaining youth
was removed from the FYC post-secondary program due to several behavioral issues indicated
by the lead instructor. Reviewed documentation revealed none of the reviewed records were
applicable for thirty-day, sixty-day, ninety-day, or 180-day follow-ups. One youth was a direct
release from the residential program, one youth was released from the FYC post-secondary
program prior to release due to behavioral issues, and the remaining youth had not been out of
the residential program long enough to require follow-up. The interview with the instructional
lead indicated all youth are referred to FYC upon completion of their high school equivalency
diploma (GED) or high school diploma. Additionally, the instructional lead indicated teachers
monitor youth in the classroom and are there for student support. Seven youth were
interviewed and stated they were not participating in post-secondary education.
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source: DJJ