summary: QI Residential - FY25-26 - 29 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Redwood Youth Academy
Wayne Halfway House
(Contract Provider)
14692 NE County Road 199
Raiford, Florida 32083-2519
Review Date(s): August 5-8, 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:
Bradley Taylor, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, North Central Education Coordinator (Residential Education
Standard 1)
Jamie Franz, Office of Education, Deputy Director of Postsecondary and Workforce Education
(Standard 2 and Residential Education Standard 1)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor, North
Region (Standard 4)
Kristine Harshaw, Office of Accountability and Program Support, Regional (Standard 2)
Patrick McKinstry, Office of Accountability and Program Support, Regional (Standard 5)
Ken Phillips, Office of Accountability and Program Support, Regional (Standard 3)
Cloretta Singletary, Right of Passage, Oak Grove (Standard 4)
Andre Watson, Office of Accountability and Program Support, Co-Lead Reviewer (Standard 1)
Program Name: Redwood Youth Academy MQI Program Code:
￼147Provider Name: Wayne Halfway House Contract Number: 10844
Location: Union County / Circuit 8 Number of Beds: 24
Review Date(s): August 5-8, 2025 Lead Reviewer Code:229￼
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 61 (Revised August 2025)
T h
O v e ra ll R a tin g S u m m a ry
is p ro g ra m h a s re c e iv e d a n o v e ra ll p ro g ra m c o m p lia n c e ra tin g o f F a ile d , a fo llo w -u p re v ie w o f th e p ro g ra m s h a ll b e c o n d u c te d w ith in s ix (6 ) m o n th s o f p u b lic
th e p ro g ra m re p o rt.
T h e fo llo w in g lim ite d a n d /o r fa ile d in d ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n .
Lim ited R atings Failed R atings
1.01 Initial B ackground S creening * 1.06 P re-S ervice/C ertification R equirem ents *
2.04 C lassification Factors, P rocedures, and R eassessm ent for A ctivities 2.01 Initial C ontacts to P arent/G uardian and C ourt N otification
2.19 C ontract S pecific C areer and Technical E ducation S ervices (R esidential C ontract P rovider) 2.06 G ang Identification: P revention and Intervention A ctivities
3.03 N on-Licensed M ental H ealth and S ubstance A buse C linical S taff 2.07 R esidential A ssessm ent for Y outh (R A Y ) A ssessm ents and R eassessm ents
3.08 S pecialized Treatm ent S ervices* 2.08 Y outh N eeds A ssessm ent S um m ary (Y N A S )
3.10 S uicide P revention S ervices * 2.09 P erform ance P lan D evelopm ent, G oals, and Transm ittal *
5.02 C om prehensive and C onsistent Im plem entation of the B ehavior M gt S ystem and S taff Training 2.13 Treatm ent Team M em bers and M eetings (Form al and Inform al R eview s)
5.04 Ten M inute C hecks * 2.15 E xit P ortfolio
5.07 K ey C ontrol * 2.16 E xit C onference
5.08 C ontraband P rocedure 3.05 M ental H ealth and S ubstance A buse A ssessm ent/E valuation
5.09 S earches and Full B ody V isual S earches 3.06 M ental H ealth and S ubstance A buse Treatm ent *
5.13 Tool Inventory and M anagem ent 3.07 Treatm ent and D ischarge P lanning *
5.15 O utside C ontractors 3.18 S afety P lanning P rocess for Y outh
5.16 Fire, S afety, and E vacuation D rills
5.18 S torage, Inventory, and D isposal of Flam m able, P oisonous, and Toxic Item s and M aterials
5.21 V isitation and C om m unication
a tio n o f
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 61 (Revised August 2025)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t a n d M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 3
In c id e n t R e p o rtin g (C C C ) * 1 .0 4
R ig h t In te ra c tio n s (R I) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 5
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 6
In -S e rv ic e T ra in in g 1 .0 7
G rie v a n c e P ro c e s s 1 .0 8
D e lin q u e n c y In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .0 9
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 0
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 1
In te rn a l A le rts S y s te m a n d A le rts (J J IS ) * 1 .1 2
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 3
A d v is o ry B o a rd 1 .1 4
S ta ff P e rfo rm a n c e 1 .1 5
S p e c ia l C o n tra c t C o n d itio n s 1 .1 6
D a ta T re n d A n a ly s is 1 .1 7
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
L im ite d
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
F a ile d
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
N o n -A p p lic a
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
S a tis fa c to
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
ryryryry
ryryryrybryryryryryry
le
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Failed
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Limited
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Failed
2.07 Residential Assessment for Youth (RAY) Assessments and Reassessments Failed
2.08 Youth Needs Assessment Summary (YNAS) Failed
2.09 Performance Plan Development, Goals, and Transmittal * Failed
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Failed
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Failed
2.16 Exit Conference Failed
2.17 Youth Input Satisfactory
2.18 Education Access (Residential Provider) * Satisfactory
2.19 Contract Specific Career and Technical Education Services (Residential Contract Provider) Limited
* 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).
Overall Rating Summary for Standard 2
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be
conducted within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 61 (Revised August 2025)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Limited
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Failed
3.06 Mental Health and Substance Abuse Treatment * Failed
3.07 Treatment and Discharge Planning * Failed
3.08 Specialized Treatment Services* Limited
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Limited
3.11 Secure Observation * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Failed
* 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).
Overall Rating Summary for Standard 3
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be
conducted within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 61 (Revised August 2025)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff * Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Psychiatric Services * Satisfactory
4.18 Medication/Sharps Inventory and Storage Process Satisfactory
4.19 Infection Control/Exposure Control Satisfactory
4.20 Prenatal Care/Education 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 61 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Limited
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Limited
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control * Limited
5.08 Contraband Procedure Limited
5.09 Searches and Full Body Visual Searches Limited
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Limited
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Limited
5.16 Fire, Safety, and Evacuation Drills Limited
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Limited
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Limited
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Overall Rating Summary for Standard 5
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be
conducted within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 61 (Revised August 2025)
Program Overview
The Redwood Youth Academy is a twenty-four bed program, for fourteen to eighteen year-old
males, located in Raiford, Florida. The program is operated by Wayne Halfway House, through
a contract with the Department. The program provides the following services: Mental Health
Overlay Services (MHOS) or Substance Abuse Overlay Services (SAOS). In addition, the
program fosters each youth by providing Impact of Crime (IOC), Aggression Replacement
Training (ART), and Cannabis Youth Treatment (CYT) treatment services. Additional treatment
services provided includes Living in Balance, and Dialectical Behavior Therapy Skills Manual for
Adolescents, as well as providing peer to peer mentoring and faith-based services. Program
administration is comprised of a facility administrator (FA), assistant facility administrator (AFA),
a human resources/administrative assistant, a food service manager, and a physical plant
manager. Case management services are provided by the designated mental health clinician
authority (DMHCA), case manager, and transition services manager. Mental health staff at the
program includes two unlicensed clinical therapists and a recreation therapist. Medical services
are offered from 7:00 a.m. to 7:00 p.m. and are provided by the health service administrator and
registered nurse. Education services are provided by the Department’s Florida Scholars
Academy through Florida Virtual School. The layout of the program includes: a main building
which includes administration, staff offices, youth living areas, a dining room/multi-purpose room
and classrooms. The program has thirty-two operating security cameras providing coverage. At
the time of the annual compliance review, a review of the staff roster showed there was one
unlicensed clinical therapist, one youth care worker, and one supervisor position vacant.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 61 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Limited 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.
A review of the staff roster found twenty-five staff were hired during the annual compliance
review period. Each staff received a clear and eligible background screening in the
Clearinghouse system and their criminal history reports were reviewed prior to contact with
youth or confidential youth records. None of the staff required an exemption, and none of the
staff were applicable for a break in service. A review of the twenty-five staff screenings found,
five have not completed a pre-employment assessment tool, three staff passed the assessment,
and eighteen staff records indicated no passing pre-employment assessment score.
Additionally, there was no documentation for any of the eighteen applicable staff showing
additional training was conducted for the staff who did not pass the pre-employment
assessment tool. All twenty-five staff were added to the program’s roster in Clearinghouse and
had a signed contraband attestation form located in their personnel file. The program did not
have any volunteers, mentors, contract staff, or interns who required a background screening.
The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted for the
program on December 19, 2024. The program does not employ teachers who are paid by the
school board.
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 to ensure all staff are administered background re-
screenings every five years of employment. A review of the staff roster found no staff were
eligible for a five-year background rescreening.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 61 (Revised August 2025)
▪ 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 staff adhere to a code of conduct as evidenced by five reviewed staff personnel
records. Each staff signed a receipt indicating they received the program’s code of conduct.
Observations were made throughout the program showing the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC) numbers were posted and available to
staff and youth. The program has a written policy and procedures on abuse reporting process.
All staff are trained as mandatory reporters. The expectation is staff will make a call to the
Florida Abuse Hotline and allow the youth to speak to the operator. The call/incident will be
documented. An additional call to the Department’s Central Communication Center (CCC) will
be made. If the incident is in reference to the Prison Rape Elimination Act (PREA), then law
enforcement will be contacted, along with program administration. The youth will be separated,
if needed, and staff will be placed on a no contact status, if needed. Two applicable incidents for
abuse were reviewed, of which neither was substantiated. One report did have a potential for
human trafficking, Child Sexual Exploitation, or labor trafficking, which was reported to the
abuse hotline and local law enforcement. This incident was closed as unfounded. The Trauma
Responsive and Caring Environment (TRACE) self-assessment was completed on May 13,
2025.
The facility administrator (FA) was interviewed and revealed the program’s staff code of conduct
includes all types of abuse, neglect, profanity, contraband, improper youth supervision, sleeping
on duty, arrests, and several other issues listed in policy. The program ensures accurate
reporting and dissemination of information regarding program incidents, which require
immediate and urgent response, action, or other intervention to ensure the safety and security
of youth in the program’s care. All staff must adhere to the Florida Administrative Code for
reporting incidents as well as the procedures required for internal incident reporting which may
not be required to be called into the CCC. All staff will immediately report any actions of abuse
to administration, who will ensure it is reported within the required two-hour timeframe. The FA
is responsible for ensuring all staff have completed the required training covering child abuse.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of thirty-three reports made to the Department’s Central
Communications Center (CCC) during the annual compliance review period. A review of internal
incidents and grievances was conducted, as a result no additional calls to the CCC were
warranted. A sample of five CCC reports was reviewed for completion requirements. All five
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 61 (Revised August 2025)
documented calls were made to the CCC within the two-hour required timeframe. A review of
the program’s master control logbooks showed three of the five incidents were documented in
the logbook. The program has not experienced an increase of reportable incidents to the CCC
since the last annual compliance review period.
1.05 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had two Right Interactions (RI) incidents during the annual compliance review
period, of which each were reviewed. Both RI incident reports were completed by the end of the
staff’s workday and had all staff statements. Both reports included documentation in which the
reports were reviewed by the supervisor and RI instructor. Both RI reports were reviewed by an
administrator or designee fourteen days late. None of the reviewed reports indicated a need for
a RI medical review, the use of mechanical restraints, or alleged abuse. Each RI report was filed
in a centralized record and submitted to the Department in accordance with Florida
Administrative Code. The program’s RI Plan was last updated on October 23, 2024. The
programs RI plan was approved by the Department on December 12, 2024. The program’s RI
rate during the previous quarter was 0.00, which is below the statewide Residential RI rate of
2.41
The facility administrator was interviewed and reported physical intervention techniques are
used as a last resort and in accordance with the 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 protective action
response (PAR) incident report is completed and filed. Monthly meetings are conducted to
discuss trends and ways to decrease or avoid physical interventions. Five staff were
interviewed, of which each are direct care staff and RI certified. Staff interview results revealed
the process of RI is to notice warning signs, de-escalate the situation, call for a supervisor, and
to complete a report.
1.06 Pre-Service/Certification Requirements (Critical) Failed 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 an approved pre-service training plan/calendar from the highest-ranking
official at the location, the assistant secretary for Residential Services, and the director of
Talent, Leadership, and Culture. Youth Care Workers (YCWs) are the only direct-care staff who
are counted in the staff-to-youth ratio. All instructors are qualified to deliver training provided.
Five staff training records were reviewed for completion of pre-service training. None of the five
staff had completed the required 120 hours of training in the Department’s Learning
Management System (SkillPro), with two missing forty-nine and a half hours, one missing fifty-
one and a half hours, one missing twenty-two and a half hours, and one missing twenty-six
hours of training. Each of the five staff reviewed did have the eight required essential skills
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 61 (Revised August 2025)
trainings completed prior to any contact with youth. One staff record reviewed was applicable for
requiring additional supervisor training. The record showed only one of the three required
courses was completed. No staff were applicable for returning after a separation from the
program or Department. Three of five staff records showed completion of specialized service
training, which consisted of Mental Health Overlay Services/Substance Abuse Overlay Services
one through four in SkillPro. Three staff records were reviewed for staff within their 180 days of
hire. Each of the three reviewed staff records showed a completion of all required training prior
to being in the presence of any youth.
1.07 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has an approved annual in-service training plan/calendar from the highest-ranking
official at the location, the assistant secretary for Residential Services and the director of Talent,
Leadership, and Culture. All instructors are qualified to deliver training provided. Due to the
program not being operational during the complete annual compliance timeframe, no staff were
applicable to review for in-service training.
1.08 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedure in place which includes the training requirements of
the grievance process. The process includes the informal phase, formal phase, and appeal
phase. Documentation showed the program’s practice correlates with their process and copies
of the grievances are maintained for the past twelve months. Only two grievances were
submitted during the annual compliance review period. Each were reviewed which showed both
grievances were reviewed within the required timeframe and resolved in the formal phase. Five
interviewed youth were asked how they would file a grievance if needed. Each of the five youth
stated they would fill out the grievance form and turn them in to either the facility administrator
(FA) or the grievance box. Each youth stated they can ask for assistance in filling out the
grievance if needed. Five staff were asked about the grievance process. Answers ranged from
ensuring forms are accessible to youth throughout the facility, youth can request a grievance at
any time, there are three phases to the grievance process, and a supervisor or program director
reviews the grievances. The FA was asked to explain the program’s grievance process and
stated the grievance process includes three phases including the informal phase in which a
youth should discuss with the staff member he is filing the grievance on. Stage two is the formal
phase in which the assistant facility administrator (AFA) responds. The final phase is the
appeals stage in which the FA conducts a meeting with the youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 61 (Revised August 2025)
1.09 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a policy and procedures which ensure interventions or instruction
focusing on developing life and social skill competencies in youth are provided; however, the
program’s only life skill groups provided are considered primary services. The program does not
provide additional life skills for the youth. Five youth were asked what life skills groups/activities
they have participated in, with all five youth notating participation in Impact of Crime (IOC),
Aggression Replacement Therapy (ART) and Dialectical Behavior Therapy (DBT). The facility
administrator (FA) was asked about what delinquency intervention models have been
implemented. The FA reported the program utilizes intervention models such as ART, DBT,
IOC, Cannabis Youth Treatment (CYT) and Living in Balance (LIB). The designated mental
health clinician authority (DMHCA) was asked how the program provides and implements
interventions to address the needs of the youth. The DMHCA reported evidenced based groups
are provided four times a week. The youth also participate in individual and family therapy with
the utilization of evidence-based practices to include Cognitive Behavior Therapy, Person
Centered, Solution Focused and Substance Abuse Treatment.
1.11 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at theRedwood Youth Academy program. For details related specific to IOC
service delivery, please refer to the annual SPEP report.
1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 61 (Revised August 2025)
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures regarding the alert process which outlines alerts shall
be consistent in the internal alert system and the Department’s Juvenile Justice Information
System (JJIS) and only authorized staff shall update or close applicable alerts. The program
utilizes an alert board in master control to track all internal alerts. A total of five youth records
were reviewed, consisting of ten applicable alerts between them. Each of the ten applicable
alerts were completed on time, by the appropriate staff, and matched the alert board. Each of
the five youth’s alerts were also documented in the logbook. The facility administrator was
interviewed and stated the nurse will ensure all admitted youth receive a preliminary screening
including a review of medical history to assess medical needs. At this time, the nurse will
complete the Facility Entry Physical Health Screening form. If the screening is completed by a
direct care staff, it will be reviewed within twenty-four hours by the nurse. The alerts are then
updated, added, or removed in the JJIS by medical or mental health staff based on results of
assessments. The nursing staff was interviewed and stated the registered nurse is responsible
for updating the medical alert system. Five staff were asked how they are informed of the
youth’s alerts, of which answers ranged from staff debriefing, from a supervisor, or from the alert
board.
1.13 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains an Individual Healthcare Record (IHCR) and an individual case
management record for each youth. Five youth individual case management records were
reviewed, and each contained the youth’s name, Department identification number (DJJID),
date of birth, county of residence, and committing offense. Each record included sections for
legal information, demographic and chronological information, correspondence, case
management and treatment team activities, and miscellaneous information. All youth records
are labeled, “Confidential” and are secured in locked cabinets, which are also labeled
“Confidential” in the medical and case management offices.
1.14 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures in place to ensure the program has a community
support group or advisory board meeting at least every ninety to 120 days. There was
documentation of the facility administrator (FA) soliciting active involvement from law
enforcement, judiciary community, community partners, business community, school board or
district, faith community, a parent/guardian of a former youth involved in the juvenile justice
system, and a victim advocate. The program holds meetings on-site, in person, which was
confirmed by a review of sign-in sheets and agendas from quarterly advisory board meetings.
None of the meetings were cancelled or rescheduled. An interview with the FA confirmed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 61 (Revised August 2025)
meetings are held quarterly and include a review of an agenda detailing program updates and
community advisory board member updates. Two attempts were made to call a member of the
advisory board, without success.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures in place to ensure a system for evaluating staff, at
least annually, based on established performance standards. A review of three position
descriptions confirmed each staff’s performance standards were clearly identified. Two position
descriptions were reviewed for staff whose job functions includes implementation of the
program’s behavior management system (BMS). Both descriptions did not include the use of the
program’s BMS. The program did update the job descriptions once the deficiency was
observed. Due to the program not being operational for a full year, no performance evaluations
were able to be reviewed. A review of the contract confirmed contractually required positions
were maintained and performed as outlined. The program does require a recreational therapist,
of which all employment requirements were met. The facility administrator (FA) was asked what
steps are taken to address turnover and morale issues. The FA stated there is a system in place
to keep staff informed and give them opportunities to provide input and feedback pertaining to
operation of the program. The program provides staff raffles, gives annual evaluation bonuses,
and provides cookouts for the staff. The program also holds daily, monthly, and quarterly
meetings for staff to meet and discuss issues or provide input. The program conducts annual
evaluations for staff, and monthly fidelity checks for the mental health staff. Five staff were
interviewed and two staff reported they would receiv evaluations annually, two were unsure or
haven’t received one, and one staff said every six months.
1.16 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of the program’s contract revealed two special contract conditions are required to be
completed, all of which are being met or are in progress, as evidenced by documentation or
observation by the annual compliance review team. Special contract conditions being met are
peer to peer mentoring and faith-based opportunities. An interview with the facility administrator
(FA) confirmed all contract items are being provided. Documentation, to include sign-in rosters,
e-mails, photographs and event write-ups were provided.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 61 (Revised August 2025)
The program’s practice regarding data trend analysis includes collecting information internally
as requested by the Department. The information is then used to improve systems, training,
provide feedback, and improve services. The information is shared with staff and administration
monthly through meetings, emails, and compliance measures. This information is also sent on a
quarterly basis to the provider and stakeholders. Data is being collected and information is sent
out to receive feedback from providers and stakeholders. Once feedback is received, the
program conducts management meetings daily to see what can be done to continue to improve.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 61 (Revised August 2025)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Failed Compliance
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a written policy and procedures ensuring initial contacts to
parents or guardians and court notifications are completed. A review of five youth case
management records revealed no documentation was maintained by the program documenting
the parent or guardian was notified by telephone within twenty-four hours of admission. Only
one of the five reviewed records confirmed the program notified the parent/guardian in writing
within forty-eight hours of the youth’s admission, and the court, and juvenile probation officer
(JPO) within five working days. Two of the five records did not contain any correspondence to
the parent or guardian, court, or JPO, and two youth records contained undated notifications to
the youth’s parent, judge, and JPO.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program maintains a written policy and procedures regarding youth orientation. The
program’s orientation included services available, daily schedule, expectations, and
responsibilities of the youth. The written behavior management system (BMS) was posted
throughout the program and provided in a handbook to allow easy access for youth. The
orientation included rules governing conduct and positive and negative consequences for
behavior, availability of and access to medical and mental health and substance abuse services,
and access to the Florida Abuse Hotline or if the youth is eighteen years of age or older, the
Department’s Central Communications Center (CCC). Youth orientation included the program’s
zero-tolerance policy regarding sexual misconduct, including how to report incidents or
suspicions of sexual misconduct. Special accommodations are available to ensure all written
information about sexual misconduct policies, including how to report sexual misconduct, is
conveyed verbally to youth with limited reading skills or who are visually impaired, deaf, or
otherwise disabled. Additionally, orientation included the right to be free from sexual
misconduct, right to be free from retaliation for reporting such misconduct, the agency’s sexual
misconduct response policies and procedures, items considered contraband, including illegal
prohibited items in which possession may result in the youth being prosecuted, the performance
planning process involving the development of goals for each youth to achieve, dress code, and
hygiene practices. Furthermore, orientation services include procedures on visitation, mail and
use of the telephone, expectations for release from the program, including the youth’s
successful completion of their Individualized Performance Plan (IPP) goals, recommendation to
the court for release based on the youth’s performance in the program, and the court’s decision
to release, community access, grievance procedures, emergency procedures, including
procedures for fire drills and building evacuation, program tour, assignment to a living unit and
room, treatment team, and if applicable, a staff advisor or youth group. During the annual
compliance review week, the program did not have any youth admitted into the program;
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 61 (Revised August 2025)
therefore, there were no youth observations of the program’s orientation process conducted.
Five youth were interviewed, and each reported their orientation to the program was conducted
on their first day and included a handbook detailing rules, procedures, and schedules.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a written policy and procedures regarding obtaining written consent of
youth who are eighteen years of age or older. Three reviewed youth case management records
confirmed each of the youth were applicable. Each reviewed youth case management record
confirmed a written consent was obtained before release of information related to the youth’s
physical or mental health screenings, assessments, or treatments.
2.04 Classification Factors, Procedures, and Reassessment for
Limited Compliance
Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program maintains a written policy and procedures regarding the classification process for
youth upon admission to the program and completion of reassessments as warranted. A review
of the program’s classification form revealed the form included physical characteristics of the
youth, age and maturity level, identified special needs, history of violence, gang affiliation,
criminal behavior, sexual aggression or vulnerability to victimization, youth’s perception of
vulnerability, youth’s history of potential or verified human trafficking, suicide risk, medical risk,
escape risk, and security risk. The interviewed facility administrator confirmed the classification
policy. Five youth case management records were reviewed. Three of the five records
contained an admission classification form including all required elements outlined by the
Department’s policy. Two of the five records did not contain a classification form. A review of the
Department’s Juvenile Justice Information System (JJIS) alerts and the program’s internal alerts
showed there were no issues affecting each youth’s classification. Each of the three records
containing classification forms reflect youth were classified for the purposes of assignment to a
living area, sleeping room, and youth group or staff advisor. Each of the three reviewed records
confirmed medical, mental health, substance abuse, security risk factors, and/or special needs
identified during or after the classification process are immediately entered into the program’s
internal alert system and JJIS. The remaining two records were absent of any classification form
or documentation confirming a classification meeting was held.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 61 (Revised August 2025)
Five reviewed youth case management records revealed three applicable records had
reclassifications completed prior to considering an increase in the youth’s privileges or freedom
of movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape and were able to participate in
off-campus activities. The program’s policy and procedures clearly outlined the classification
process and included a classification system to promote safety and security, as well as effective
delivery of treatment services, based on the determination of each youth’s individual needs and
risk factors, which addresses, at a minimum, items outlined in Florida Administrative Code. The
program’s policy regarding reassessments states the treatment team, as necessary throughout
the youth’s commitment, will reassess and reclassify, if warranted, prior to considering an
increase in privileges or freedom of movement, participation in work projects, or other activities
involving tools or instruments with the ability to be used as potential weapons or means of
escape, or participation in any off-campus activity.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program maintains a written policy and procedures regarding gang identification including
notification to law enforcement. The program had one youth identified as gang affiliated since
the program’s start-up monitoring. The program’s protocol includes notification by the program
of the youth’s gang involvement to the youth’s home county law enforcement and the program’s
county law enforcement. Additionally, gang alerts are entered in the internal alert system and in
the Department’s Juvenile Justice Information System (JJIS) upon identification. The gang
status is shared with the educational provider at the residential program and the youth’s
assigned juvenile probation officer (JPO). Each of these requirements were completed
regarding the one applicable youth.
2.06 Gang Identification: Prevention and Intervention Activities Failed Compliance
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a written policy and procedures regarding youth’s participation in gang
prevention and/or intervention activities. The program’s policy addresses providing youth an
opportunity, if they desire, to develop a plan to disaffiliate with a criminal street gang. At the time
of the annual compliance review the program had one youth having gang involvement during
the review period. There was no evidence or documentation to support prevention or
intervention activities were utilized with the youth. The facility administrator (FA) stated in an
interview youth identified as having gang affiliation will receive gang educational services and
the Impact of Crime (IOC) curriculum. Each youth’s performance plan is required to include
relevant goals relating to gang intervention strategies, and all staff will be required to have at
least one training yearly on gang awareness. This training includes identification, signs and
symbols, trends, possible gang activity in the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 61 (Revised August 2025)
2.07 Residential Assessment for Youth (RAY) Assessments and
Failed Compliance
Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program maintains a written policy and procedures requiring the Residential Assessment
for Youth (RAY) to be completed for each youth within thirty days of admission. Five youth
records were reviewed. Three of five youth records reflect youth RAY assessments were
completed late, with one being four days late, one ten days late, and one thirty days late. Three
of four applicable RAY reassessments were completed late, one was fifteen days late, one was
thirty-six days late, and one was 121 days late. All other updates or reassessments were
completed when deemed necessary by the intervention and treatment team to effectively
manage the youth’s case. All reassessment documentation was maintained in the youth’s
official case record. All RAY initial assessments and re-assessments were completed and
maintained in the Department’s Juvenile Justice Information System.
2.08 Youth Needs Assessment Summary (YNAS) Failed Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program maintains a written policy and procedures regarding the completion of the Youth
Needs Assessment Summary (YNAS). Five youth case management records were reviewed. In
four of the five youth records, the YNAS was completed between two and thirty-two days late.
One of the five youth YNAS was completed within thirty days of admission. Each YNAS was
documented in the Department’s Juvenile Justice Information System (JJIS). In each of the five
youth case management records, the YNAS documented the youth’s top three criminogenic
needs.
2.09 Performance Plan Development, Goals, and Transmittal
Failed Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program maintains a written policy and procedures outlining performance plan
development, goals, and transmittal. Five youth case management records were reviewed for
individual performance plans (IPP) and four plans were not completed within the required thirty
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 61 (Revised August 2025)
days of admission. These IPPs were developed between eleven and 130 days late. Each IPP
was developed after the initial Residential Assessment for Youth (RAY) and Youth Needs
Assessment Summary (YNAS) were completed. Two of five records contained signatures for
intervention and treatment team leader, the youth, an administrative representative, treatment
staff, and education staff. The three remaining records did not contain signed performance
plans. All five reviewed performance plans had individualized goals and based upon the
prioritized needs reflecting the risk and protective factors identified during the initial assessment
process. Each record contained delinquency interventions on the IPP. Four of five records
addressed the youth’s top three criminogenic needs. One youth’s IPP was missing one of the
top three criminogenic needs. Target court-ordered sanctions which could be reasonably
initiated/completed while in the program, transition activities targeted for the last sixty days of
the youth’s anticipated stay, youth’s responsibilities to accomplish goals, program staff
responsibilities to enable youth to complete goals, and target dates for goal completions were all
listed on the IPP. None of the five youth records contained evidence IPPs were sent, along with
a transmittal letter, to any of the required parties. Five interviewed youth reported they
participated in the development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program maintains a written policy and procedures in place regarding revisions to a youth’s
performance plan. Five reviewed youth case management records confirmed four applicable for
Individualized Performance Plan (IPP) revisions. Each IPP revision was completed when the
Residential Assessment for Youth (RAY) Reassessment results warranted, and/or when the
youth demonstrated progress toward completing a goal. None of the records were applicable for
the youth demonstrating lack of progress toward completing a goal requiring revisions. Three of
the five reviewed IPPs were applicable for revisions needed to facilitate transition activities
during the last sixty days of a youth’s stay, which were included. Each youth was applicable for
education and mental health plans which were incorporated into the IPP. One of the five youth
showed a current case plan through the Department of Children and Families (DCF).
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 in place to ensure performance summaries and
transmittals are completed within required timeframes. At each ninety-day interval, beginning
ninety days from the signing of the youth’s performance plan, the intervention and treatment
team meets to create a performance summary. In addition, prior to the youth’s release,
discharge, or transfer from the program, the intervention and treatment team will meet to create
the performance summary. Five youth records were reviewed for the completion of performance
summaries and three were applicable for performance summaries. Two of the three applicable
summaries reviewed were completed within the required timeframe and contained all the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 61 (Revised August 2025)
required elements. One record requiring a summary did not have one completed. The two
records containing completed summaries also documented the transmittal of the summary to
the court, juvenile probation officer, and the parent/guardian or Department of Children and
Families counselor within ten working days.
Three closed records were reviewed for discharge and release summaries. All three records
contained the original release summary which included the justification for the youth’s release
from the program. One of the three youth was a direct discharge and documentation of the
summary transmittal was observed. All records contained a pre-release notification (PRN),
completed at least forty-five days prior to the youth’s release. All summaries and PRNs were
signed by the appropriate parties and two of the three were maintained in the youth’s closed
case management record. One youth record was missing the signed documents. One of the
three closed records contained documentation supporting the exit Residential Assessment for
Youth (RAY) was completed for the youth following approval of their release. Two youth did not
receive an exit RAY. No youth were applicable for the Sexually Violent Predator Program
(SVPP).
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a written policy and procedures regarding parental/guardian
involvement in case management services. A review of documentation showed the program
makes efforts to include the parent/guardian in the assessment process, development of the
youth’s performance plan, progress reviews, and transition planning. If unable to attend, the
parent/guardian is given the opportunity to participate by telephone/video conferencing or
provide verbal/written input prior to the meetings. During the week of the annual compliance
review, an observation of a treatment team meeting was not scheduled thus unable to be
observed. According to policy, during the intake process, families are mailed the treatment team
and visitation schedules for the year and invitations are mailed to the families in advance for
family days, holiday celebrations, graduations, or any other specialized activities.
The facility administrator (FA) stated in an interview the program recognizes the importance of
family involvement and relationship building between parents, the youth, and their siblings.
Ultimately, the youth are anticipating the return to their homes, communities, and schools.
Beyond providing each youth with the means to write and telephone home on a consistent
basis, it is important to utilize all other resources available to encourage and support family
involvement. The program sends parent notification letters to encourage family participation and
tells the parents when the treatment team meetings are so they can participate with their child
and the team in developing a course of treatment. The family is also encouraged to participate
in transition planning through phone calls and formal transition and exit conference meetings.
The only exception to encouraging family participation will be when the youth is not returning
home post release and will be going to an alternative family or independent living. Five youth
were interviewed, and each report parents, guardians, or Department of Children and Families
case workers are involved in their case management, usually by phone during treatment team
meetings and/or family sessions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 61 (Revised August 2025)
2.13 Treatment Team Members and Meetings (Formal and
Failed Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program maintains a written policy and procedures regarding treatment team meetings.
Five youth case management records were reviewed. One of the five records contained
documentation for treatment teams being completed every thirty days. This record was missing
attendee signatures for three of the five monthly treatment team meetings. Three of the five
youth records were missing documentation for one or more formal treatment teams. One of the
five records did not contain any documents reflecting any treatment teams were conducted and
none of the five records contained documentation for any informal treatment team meetings.
Three of five records did not contain documentation reflecting the juvenile probation officer,
parent/guardian, and other pertinent parties were invited to participate in treatment team
meetings. There was no observation of a treatment team meeting, as there was no treatment
team scheduled for the annual compliance review week. Five youth were interviewed, and each
confirmed program staff talk about their performance to include progress on performance plan
goals, positive and negative behavior, and treatment progress. The five interviewed youth
reported they are able to explain their progress, level of change, and future goals by completing
a document submitted during treatment team.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program maintains a written policy and procedures regarding the transition planning
conference, and Community Re-Entry Team (CRT) meetings. A review of three closed youth
case management records confirmed in two of the three records a transition conference was
held at least sixty days prior to the youth’s targeted release date. One record documented the
transition conference was held thirteen days early. A review of documentation showed the
youth, treatment team leader, facility administrator (FA) or designee, and other team members
attended the transition conference in all three records. Documentation confirmed the treatment
team leader invited and encouraged participation of the youth’s juvenile probation officer (JPO),
parent/guardian, education staff, and any other pertinent parties through advance notification. A
review of documentation confirmed during the transition conference, the participants reviewed
transition activities on the youth’s performance plan, revised performance plans, if necessary,
identified additional transition activities as needed, identified target completion dates, and
identified persons responsible for completion. The treatment team lead obtained attendees’
dated signatures representing their acknowledgment of the transition goals, and accountability
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 24 of 61 (Revised August 2025)
for completion. In two of three records, a copy of the plan was sent with a request for return with
signature to anyone not in attendance who had a responsibility for completion of transition goals
and transition documents were transmitted electronically to the JPO, with a return email
acknowledgment receipt printed and filed with the plan. One record did not contain this
documentation. In each of the three records, documentation revealed a Community Re-Entry
Team (CRT) meeting was conducted prior to the youth’s release with the youth’s and case
manager’s participation and evidence of an invitation to participate in the CRT meeting was
shown.
2.15 Exit Portfolio Failed Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures regarding the requirements for each
youth’s exit portfolio. A review of three closed youth case management records revealed in one
of the three records the exit portfolio was discussed and initiated for the youth during the
transition conference. This one youth’s exit portfolio was discussed during the exit conference
and documentation indicated portions of the exit portfolio were completed; however, there was
no evidence the portfolio was given to the youth upon release. The other two records did not
contain any of the required documentation pertaining to the exit portfolio. None of the three
closed case management records contained a state-issued identification card or social security
card; however, there was a note in the one record containing an exit portfolio explaining why the
identification was not included. The one youth’s exit portfolio contained the youth’s transition
plan, a calendar with all dates, times, and locations of upcoming community appointments,
educational and vocational certifications earned in the program, and a resume. There was no
sample employment application. The youth’s case management record reflected the program
staff forwarded the exit portfolio information to the juvenile probation officer.
2.16 Exit Conference Failed 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 maintains a written policy and procedures regarding completion of an exit
conference. Three closed case management records were reviewed. None of the three records
contained documentation of an exit conference. The evidence exit conferences were conducted
was obtained through the Department’s Juvenile Justice Information System (JJIS) in the
juvenile probation officer’s (JPO) case notes. According to the JPO’s notes, one of the exit
conferences was held four days earlier than required. Some information was available in these
notes, but nothing was maintained by the program. The Community Re-Entry Team (CRT)
meetings for all three closed records were conducted not in conjunction with the exit
conference.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a written policy and procedures regarding written provisions for youth
input. The program’s formal process to promote constructive input from youth is conducted
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 25 of 61 (Revised August 2025)
through youth surveys, living unit meetings, informal and formal treatment team, and Request to
Speak and grievance forms, if necessary. A review of the program’s efforts to solicit input from
youth through avenues such as youth advisory board minutes, were available in the youth
advisory board binder. The youth advisory board meetings are held monthly. A review of the
program’s sign-in sheets, agendas, and meeting minutes confirmed the meetings are being held
as required. Youth unit meeting minutes were reviewed and reflect they are being held weekly.
An interview with five youth indicated they can voice their input through the youth advisory
board, by submitting Request to Speak forms, or by speaking directly to the facility administrator
(FA). In an interview, the FA reported there is a formal process to promote constructive input by
youth. Youth are encouraged to participate in the program’s Trauma Responsive and Caring
Environment (TRACE) Survey. Also, the program has a questionnaire asking the youth about
their satisfaction with the program every thirty days during formal treatment team reviews. The
program has a Rams Club student council to discuss and plan events and each living unit has
suggestion forms for the youth to complete and submit.
2.18 Educational Access (Residential Contract Provide) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The center
provides education services through Florida Virtual School (FLVS) with a 250-day calendar,
which is distributed over twelve months, including twenty days used for teacher training and
planning was reviewed. A review of five random dates in the logbook for the last eight months
showed the daily class schedule was being followed. Further review of logbook entries and
video footage for three days verified the youth were attending school as scheduled.
2.19 Contract Specific Career and Technical Education
Limited Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program’s contract requires the implementation of all Career and Technical Education
(CTE) services, formerly referred to as pre-vocational and vocational services. CTE instruction
is designed to develop the interests, aptitudes, and skills of participating youth while building
upon their existing strengths in a manner supportive of their individualized employability goals,
promoting workforce readiness, and providing an occupational advantage within the youth’s
community. A review of documentation confirmed cardiopulmonary resuscitation (CPR) was
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 61 (Revised August 2025)
received and verified for youth participants. No documentation was provided for Florida Ready
to Work or Occupational Safety and Health Association (OSHA) 10 credentials.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 61 (Revised August 2025)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program’s designated mental health clinician authority (DMHCA) is a licensed mental health
counselor (LMHC). The license date of expiration is March 31, 2027. The program also has a
back-up LMHC who also provided services during the scope of the annual compliance review
period. The back-up LMHC’s active license was also reviewed and has an expiration date of
March 31, 2027. The provider’s contract indicates the DMHCA will be employed as a full-time
position, working forty-hours a week. The DMHCA position description was also reviewed which
indicated the DMHCA will be under the direction of the provider’s cooperate clinical director and
will be primarily responsible for ensuring appropriate coordination, implementation, and
oversight of mental health and substance abuse services and therapeutic services for the
residents at the program, as well as conduct intake assessments, as requested. The DMHCA
was interviewed and stated their role is to provide support and oversight to the clinical
department. They also coordinate and ensure services are being provided as outlined in the
contract. Clinical services provided include individual, group, and family therapy. Daily
communication is conducted to discuss pertinent information. Other forms of communication
with the clinical staff include weekly supervision of the non-licensed staff.
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 licensed mental health counselor (LMHC) who acts as the designated
mental health clinician authority (DMHCA). In addition, the program has another LMHC who
performs clinical duties as needed as the back-up to the DMCHA. The program currently only
has one masters-level therapist who is a non-licensed clinical staff. According to the program’s
human resources department, the program had one vacant therapist positions at the time of the
annal compliance review.
3.03 Non-Licensed Mental Health and Substance Abuse Clinical
Limited Compliance
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 currently has one masters-level therapist who is a non-licensed clinical staff and
one vacancy. At the time of the annual compliance review, the program had an open deficiency,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 28 of 61 (Revised August 2025)
put in place by the Department’s Office of Health Services (OHS) which was the result of a
supplemental monitoring visit to the program by OHS July 22, 2025. A minor deficiency was
assigned at the time as there was no documentation of the program’s Designated Mental Health
Clinical Authority (DMHCA) providing weekly supervision to the non-licensed clinical staff for at
least one hour weekly as required. Verification for this deficiency will be facilitated by the
Department and OHS at a future date.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth records were reviewed for Mental Health and Substance Abuse admission
screening. Three of five youth records contained a completed Massachusetts Assessment
Screening for Youth, Second Version (MAYSI-2) completed on their date of admission. One
MAYSI-2 was completed twenty-eight days late, and one youth did not have a MAYSI-2
completed. For this youth, there was evidence in the record the youth had screening for General
Anxiety and Depression (GAD) and a Substance Abuse Screening Instrument completed upon
his date of admission. All five youth had a completed Assessment for Suicide Risk (ASR),
Generalized Anxiety and Depression (GAD) screening, and Suicide Risk Screening Instrument
(SRSI) completed. The program’s designated mental health clinician authority (DMHCA)
reported an ASR and SRSI are completed for all youth regardless of the MAYSI-2 results. None
of the reviewed youth required crisis assessment or emergency services implemented. None of
the youth required placement on precautionary observation as a result of the initial screenings
completed. . The program had a written policy and procedures which provides implementation
of the standardized admission/intake mental health and substance abuse screening process.
The policy addresses all required elements, which includes a review of the electronic
commitment packet information, training for staff in the administration of the MAYSI-2, and a
standardized referral process for youth identified as in need of further assessment and
evaluation. The facility administrator was interviewed and stated the program conducts a mental
health screening upon the youth’s admission, and when a youth who has been on inactive
status re-enters the program. It is the policy of the program to administer mental health
screening, including suicide risk screening, during a youth’s admission to the program. When
indicated, referrals are made for further evaluation, assessment, and clinical services as
appropriate. The initial intake and screening process ensures equitable treatment, gives priority
to urgent needs and emergency situations, facilitates the identification of youth who have co-
occurring conditions, supports access to an integrated assessment process and results in timely
initiation of services.
3.05 Mental Health and Substance Abuse
Failed 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.
Five youth records were reviewed for mental health and substance abuse assessment and
evaluation. Four of five youth records contained evidence of a completed Massachusetts
Assessment Screening for Youth, Second Version (MAYSI-2). One youth did not have a
MAYSI-2 completed. All five youth had an Assessment for Suicide Risk (ASR), Generalized
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 61 (Revised August 2025)
Anxiety and Depression (GAD) screening, and Suicide Risk Screening Instrument (SRSI)
completed. One youth had a new comprehensive evaluation completed. The assessment was
completed by a licensed staff. One youth did not require completion of a comprehensive
evaluation. The remaining three youth required a comprehensive evaluation based on initial
assessments completed at intake; however, records provided revealed a comprehensive
evaluation was not done as required. All youth were outside of thirty-days from their date of
admission to the program. All five youth records contained evidence of consent signed using the
Department’s Youth Consent for Substance Abuse Treatment form. For the one completed
comprehensive evaluation, there was evidence all required information was included in the
assessment. The designated mental health clinician authority (DMCHA) was interviewed and
stated the comprehensive assessment is completed after twenty-one days of admission to
report baseline behaviors observed and histories reported in youth records. Interviews are done
with the youth and parent.
3.06 Mental Health and Substance Abuse Treatment (Critical) Failed Compliance
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.
All five reviewed youth records contained an Initial Mental Health and Substance Abuse
Treatment Plan completed on the date of the youths’ admission to the program. The Initial
Mental Health Treatment Plans were documented on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. The one applicable youth who was admitted with
psychotropic medications was not noted on the initial plan. There was evidence the initial
treatment plans were signed by a licensed mental health clinical staff completing the form. Four
of five plans were noted as signed by the youth. One plan did not have the youth signature.
Four of five plans were missing a signature from the parent/guardian. For the one remaining
plan, there was a note indicating the plan was mailed to the parent/guardian. None of the plans
noted any further signatures from applicable treatment team members. Individualized Treatment
Plans (ITPs) were completed using the Department’s Individualized Mental Health/Substance
Abuse Treatment Plan form. The five youth records reviewed found evidence of four youth had
a completed ITP. One youth did not have a plan completed as required. Applicable reviewed
ITPs included documentation of psychiatric services as required. ITPs were missing signatures
from the parent/guardian, juvenile probation officer (JPO), education, and living unit
representative. When completed, plan reviews were documented using the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan Review form. Thirty-day
treatment plan reviews were reviewed for the four youth who had an Individualized Treatment
Plan. One was missing three months of treatment plan reviews, and the remaining three youth
records had no treatment plan reviews conducted. Goals and objectives of the ITPs were
reviewed. For one youth’s plan it was noted the youth would participate in group therapy, but
specific services, interventions, and frequency were not indicated. In addition, for this youth it
was noted in the plan the youth was taking 100 milligrams of medication, but the type was
unknown due to the writing being illegible, as noted within the psychiatric services section of the
plan. The designated mental health clinician authority (DMCHA) was interviewed and stated the
DMHCA utilizes a monthly tracker to ensure services are being provided. The youth’s treatment
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 61 (Revised August 2025)
plan is reviewed and updated every thirty-days from the date of completion of the treatment
plan.
3.07 Treatment and Discharge Planning (Critical) Failed 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.
Five youth records were reviewed. Four of five records did not contain documentation a
multidisciplinary treatment team was assigned to the youth. Signatures from treatment team
members were found to be inconsistent in all five records. All five youth had an active Authority
for Evaluation and Treatment (AET) in their medical record as required. All five youth records
had evidence of a signed Substance Abuse Treatment Consent form using the Department’s
form. Treatment notes were documented on the Department’s Counseling/Therapy Progress
Notes form for all five records. At the time of this annual compliance review, services and
interventions for mental health and substance treatment was under an open Outcome Based
Corrective Action Plan (OBCAP) as initially identified on January 29, 2025. The Department
conducted verifications for this open deficiency on May 19, 2025, and June 16, 2025, with the
most recent follow-up completed on July 22, 2025 by the Office of Health Services (OHS), at
which time it was determined by OHS the deficiency remain open, and another verification be
completed at a future date.
Three closed youth records were provided and reviewed for discharge planning and discharge
summary completion. One of three of these records indicated the youth was released from the
program July 3, 2025. The discharge summary was completed and signed by the LMHC on
June 29, 2025; however, it was not signed by the case manager and other treatment team
members until August 4, 2025. The remaining two youth closed records provided did not contain
a discharge summary. The designated mental health clinician authority (DMCHA) was
interviewed and stated therapists meet with the facility administrator daily. Youth collaborate
with the assigned therapist and/or DMHCA to identify treatment plan goals to be addressed in
treatment.
3.08 Specialized Treatment Services (Critical) Limited Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
According to the provider’s contractual agreement, the program provides Mental Health Overlay
Services (MHOS) and Substance Abuse Overlay Services (SAOS) for youth. Primary services
include Impact of Crime (IOC), Aggression Replacement Therapy (ART), and Cannabis Youth
Treatment (CYT). Five interviewed staff reported they do not facilitate any mental health or
substance abuse groups. The program has a licensed mental health counselor who provides
on-site services. In addition, the program has an agreement with a licensed psychiatrist who
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 61 (Revised August 2025)
provided services on-site at least once every two weeks. The facility administrator was
interviewed and stated the program provides specialized treatment services in accordance with
Florida Statute and Administrative Rule. All program youth are prescreened and placed by the
Department of Juvenile Justice based upon identified treatment needs. The focus of treatment
services includes targeting and reducing/alleviating the youth’s risk and needs allowing youth to
improve functioning and reintegrate within the community. The program has therapists who
provide individual, group, and family counseling. A psychiatrist is onsite at least twice a month to
conduct evaluations, medication management, and provide information for the treatment teams.
The program utilizes individualized treatment tools to target the areas identified as high risk,
mental health. All groups are evidence-based and are specific to the needs of the youth. All five
interviewed youth confirmed they are participating in family and/or individual counseling. The
designated mental health clinician authority (DMCHA) was interviewed and stated mental health
and substance abuse treatment services include assessments, individual group, and family
therapy. Psychiatric evaluations and consultations are also conducted. At the time of this annual
compliance review, services and interventions for mental health and substance treatment was
under an open Outcome Based Corrective Action Plan (OBCAP) as initially identified on
January 29, 2025. The Department conducted verifications for this open deficiency on May 19,
2025, and June 16, 2025, with the most recently follow-up completed by the Office of Health
Services (OHS) on July 22, 2025, at which time it was determined by OHS the deficiency
remain open, and another verification be completed at a future date.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written Suicide Prevention Plan which includes all required elements such
as identification and assessment of youth at risk of suicide, staff training, suicide precautions,
levels of supervision, referral, communication, notification, documentation, immediate staff
response, and review process. The review process for suicide attempts and mortality review
included all required elements within the Suicide Prevention Plan. Documentation provided
indicated the Suicide Prevention Plan was reviewed annually by the facility administrator (FA)
and designated mental health clinician authority (DMHCA) on May 29, 2025.
3.10 Suicide Prevention Services (Critical) Limited Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
There is currently an open deficiency generated by the Department’s Office of Health Services
(OHS) resulting from a monitoring visit on July 22, 2025. A major deficiency was assigned for
youth not receiving an Assessment of Suicide Risk (ASR) within twenty-four hours of admission
to the program, ASR’s not being signed off appropriately, youth who were transferred on
constant supervision did not have Precautionary Observation Logs in their records, and suicide
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 61 (Revised August 2025)
risk alerts not being closed within the Department’s Juvenile Justice Information System (JJIS)
when a youth is stepped down from Precautionary Observation supervision status. Verification
for this open deficiency will be reviewed by OHS at a later date.
3.11 Secure Observation (Critical) Satisfactory Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program has a written policy and procedures addressing secure observation which
indicates youth placed on suicide precautions may be maintained on secure observation when
less restrictive means are not effective. An interview was conducted with the program’s licensed
mental health counselor (LMHC) which concluded the program has not used secure observation
for youth for the scope of this annual compliance review.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Five youth records were reviewed for completion of suicide precaution observation logs. Only
one of the five youth was applicable for having been placed on precautionary observation during
their time spent at the program. The program’s licensed mental health counselor (LMHC)
reported they have not had any additional youth placed on precautionary observation for the
scope of this annual compliance review period. For the one applicable youth record, there was
evidence the program utilized Suicide Precaution Observation Logs using the Department’s
form. Youth behavior was documented at thirty-minute increments as required. The logs
indicated a review from each shift supervisor based on signatures provided. Logs were also
reviewed and signed by licensed mental health staff, which also included documentation of safe
housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
A review of five pre-service training records revealed all five staff had completed suicide
prevention training as required. The program has a total of three suicide response kits, each
with a knife-for-life, wire cutters, and needle nose pliers. The kits are located in master control,
medical office, and secured common area closet. The kits were co-located with an approved
first-aid kit as well. The program maintains suicide drills in a binder for the scope of the annual
compliance review. The program currently operates on two shifts. Suicide drills are to be
conducted at least quarterly on each shift. A review of drill documentation found one second
shift drill missing, which was for the quarter consisting of October, November, December 2024.
All other drills were documented. The program provided semi-annual training on emergency
response procedures which included mock training in emergency response to a suicide attempt
or incident of serious self-inflicted injury. A video review of a suicide drill was conducted during
the annual compliance review week. The drill was simulated. Staff were observed responding to
the scene with the suicide response kit and demonstrating cardiopulmonary resuscitation (CPR)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 61 (Revised August 2025)
techniques. A review of sign-in sheets for the drills were compared with the current staff roster.
Eighteen of twenty-one applicable staff documented they participated in a suicide drill for the
scope reviewed, and three staff did not. The facility administrator (FA) reported the program
initially did not have a system in place to address drills for staff who were not present during the
time a suicide drill took place; however, follow-up provided by the FA noted drills will be
reviewed in all staff meetings in the event there is a staff member who was absent for the drill.
The interviewed FA stated the program conducts mock drills to prepare staff for appropriate
responses during emergency situations including mental health, medical, fire, escape, and
Continuity of Operations Planning (COOP). Staff are trained on how to respond to youth in crisis
in the least restrictive means possible to protect the safety of the youth and others, while
maintaining safety, security and control of the program. The staff have been trained to discern if
a youth has an acute emotional problem or serious psychological distress from a youth which
requires emergency services. All staff who work with youth are trained to recognize verbal and
behavioral cues indicating suicide risk, suicide prevention, and implementation of suicide
precautions. The program has a written crisis intervention plan and emergency mental health
and substance abuse plan, which addresses those practices necessary to effectively handle
youth in need of a mental status exam and a Crisis Assessment. Five interviewed staff were
able to summarize what they were responsible for when a youth expresses suicidal thoughts.
Staff gave examples such as notification to mental health staff, providing constant sight and
sound supervision, notify other supervisors, and document supervision provided. Staff stated
suicide response kits are maintained in the modular areas and master control.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written crisis intervention plan which includes all required elements such as
a system of notification and alert, means of referral and self-referral, communication,
supervision, documentation, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program reported having had only two youth, for the scope of the annual compliance
review, who have required a crisis assessment. The two applicable youth records were
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 61 (Revised August 2025)
reviewed and determined in both incidents the Crisis Assessment was conducted timely based
on the needs of the youth. Both Crisis Assessments included the reason for the assessment, a
mental status examination and interview, determination of danger to self and others, initial
clinical impressions, supervision recommendations, treatment recommendations, and
notification to parent/guardian. Both were conducted by the licensed mental health counselor
(LMHC). Neither youth required precautionary observation, or an alert to be entered into the
Department’s Juvenile Justice Information System (JJIS). Neither incident required an off-site or
follow-up assessment to be completed. For one youth who was an alleged Prison Rape
Elimination Act (PREA) victim, there was documentation of referral for notification by the LMHC
forwarded to the clinical director advising to complete the Crisis Assessment process.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse plan which includes
all required elements such as immediate staff response, notifications, communication,
supervision, emergency transportation services, documentation, training, and review process.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Failed Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains youth safety plans in a binder located in the master control room.
According to program administration, all staff have access to the master control area, and ability
to review these plans. Five youth safety plans were reviewed. Each was developed on the date
of the youth admission to the program. Three of five plans included evidence the plans were
jointly prepared with the youth as well as the parent/guardian or family member. Two of five
were not marked indicating the parent/guardian was contacted to assist in plan development.
Four of the five safety plans reviewed had documentation they incorporated recommendations
from previous or current clinical assessments or screening instruments. For one plan, this
section was not checked off. None of the five plans reviewed were documented to have been
consistently reviewed and updated as necessary every thirty-days. One plan was missing five
thirty-day revisions, three were missing three thirty-day revisions, and one was missing two
thirty-day revisions. All five reviewed safety plans included documentation of youth warning
signs, crisis recognition, intervention strategies, and a debriefing process. Four of five notated
youth baseline behaviors. The remaining one plan had this area for baseline behaviors left
blank. All five interviewed youth confirmed they participated in the development of their safety
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 61 (Revised August 2025)
plan. The facility administrator was interviewed and stated the program provides on-going safety
planning for each youth. Each of the safety plans highlight the youth’s warning signs, behavior,
crisis recognition, and coping and intervention strategies. Each plan is developed and updated
each month. The initial planning is complete upon admission to the program for each youth. The
plan is developed with the youth, parent/guardian, and program’s clinical staff. The safety plan
is reviewed and signed by each staff who had contact with each of the youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 61 (Revised August 2025)
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 board-certified physician who is a
licensed physician who has no disciplinary cases on record, with an license expiration date of
January 31, 2026. Documentation of reviewed sign-in/sign-out logs verified the DHA was on-site
once a week during the annual compliance review period. A back-up DHA was not utilized
during the annual compliance period; however, the program does have a back-up DHA who can
be utilized. Telemedicine is not utilized at the program. The interviewed DHA stated his role is
for oversight of clinical operations, acute care, and completing evaluations, assessments, and
periodic evaluations. The DHA verified he is on-site weekly, communicates with program staff
through verbal communications, records, and orders, and is available off-site through telephone
calls, texting, and emailing. To ensure all off-site care findings, instructions, and information is
reviewed, the nursing staff track consultation, off-site care, laboratory results, and x-rays and
will communicate if action is needed, and review documentation when on-site. If needed,
coverage is arranged through the cooperate administration.
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.
A review of all program nurse credentials during the annual compliance review period verified
each nurse has a clear and active license. Each nurse has a current cardiopulmonary
resuscitation (CPR) card. Reviewed documentation verified the nursing staff were on-site for the
required hours and in compliance according to the contract, forty hours for the health service
authority and forty hours for the registered nurse.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPS) for all-related procedures and protocols.
All health-related FOPs were signed by the facility administrator on May 29, 2025, the
designated health authority (DHA) on November 19, 2024, and psychiatrist on January 21,
2025. All approved treatment protocols and standing procedures were written and authorized
by the DHA. The nursing staff signed and dated a cover sheet signifying review of health
protocols during hiring orientation. There have been no new or changes in policies since the
program’s commencement. Documentation review confirmed healthcare personnel received a
comprehensive clinical orientation to the Department’s healthcare and procedures given by a
registered nurse.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 61 (Revised August 2025)
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
Five individual healthcare records (IHCR) were reviewed for completion of the Authority of
Evaluation and Treatment (AET) form. Each youth’s IHCR contained a valid copy of the AET,
signed by a Department representative and parent/guardian. None of the youth were eighteen
of age nor under the care of the Department of Children and Families. The interviewed nurse
was able to explain the AET process and documenting consent for any youth over the age of
eighteen.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
Five individual healthcare records (IHCR) were reviewed for parental notification. Four of five
records were applicable for documentation of parental notification for over-the-counter (OTC)
medications beyond those covered by the Authority for Evaluation (AET) and treatment consent
was provided by the parent/guardian, in which all records had the required notification. New
medication was ordered for one of the five youth, which the IHCR contained documentation of
parent/guardian consent utilizing the Department’s Parental Notification of Health-Related Care:
General or Parental Notification of Health-Related Care. One out of the five youth were taking
psychotropic medication on admission, which the staff contacted the parent/guardian who gave
verbal consent for the medication and was documented on page three of the (CPPN).Two
additional youth were place on psychotropic medication after admission which the
parent/guardian gave verbal consent for the medication and was documented on page three of
the (CPPN) None of the youth were in the care of Department of Children and Families. Each
record contained a verified shot record within thirty days. None of the records were applicable
for administering vaccinations or for refusal. The interviewed nurse was able to explain the
process when it’s required to send parental notification within time frame. The nurse also stated
vaccinations are given on site and records are obtained though Florida Shots Immunization
portal when a youth is admitted.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
Five individual healthcare records (IHCR) were reviewed for Facility Entry Physical Health
Screening (FEPHS) forms. Each FEPHS was completed on admission by a registered nurse.
One youth had a change of physical custody greater than twenty-four hours and a re-screening
was completed after the youth returned to the program. The interviewed nurse was able to
explain what process is required when a youth has had a change in custody greater than
twenty-four hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 61 (Revised August 2025)
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
Five reviewed individual healthcare records (IHCR) showed each youth received general
healthcare orientation which included access to medical, sick call, what constitutes an
emergency, the medication process, the right to refuse care and documentation, what to do in
the case of sexual assault, non-disciplinary role of health care staff, and standard universal
precautions. Each IHCR had an orientation sheet signed by each youth. A review of the
program’s contract determined the frequency of additional health education is in recurring cycles
and includes all health education elements.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Five individual healthcare records (IHCR) were reviewed for notification and referral to the
designated health authority (DHA). It is the program’s policy all admitted youth are referred to
the DHA and all five youth were referred within twelve hours of admission. One out of the five
reviewed youth had documented chronic conditions and were referred to the DHA. No youth
were identified for need of emergency care upon admission. The one applicable youth who were
taking psychotropic medication upon admission had documentation a referral was made to the
psychiatrist. The interviewed nurse relayed the DHA is notified of any youth admitted into the
program by the registered nurse and documentation is noted on the admission chronological
progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
Five individual healthcare records (IHCR) were reviewed for completion of the Department’s
Health Related History (HRH) form. Each IHCR contained a completed HRH within seven
calendar days of admission. All were completed prior to the Comprehensive Physical
Assessment. The designated health authority (DHA) reviewed all five HRH forms. The
interviewed nurse stated the HRH is completed at admission by the registered nurse.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
Five individual healthcare records (IHCR) were reviewed, each had a new Comprehensive
Physical Assessment (CPA) completed by the designated health authority (DHA), with medical
grades documented, within seven days of admission. Each section of the CPA was completed
with the appropriate mark, and each had a valid Tuberculosis (TB) Skin Test result documented.
Each youth refused the genital exam, which the DHA notated on the CPA as either deferred or
refused, and a refusal form was documented in the IHCR if applicable. Each youth’s Problem
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 61 (Revised August 2025)
List was updated as required. The interviewed nurse stated the CPA is completed by the DHA
within seven days of admission as well as annually. TB screenings are noted on the medical
tracker and on front of IHRC, which are then performed annually.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
Five individual healthcare records (IHCR) were reviewed for sexual transmitted infections
(STIs). All five youth admitted to being sexually active, therefore each was clinically screened
and evaluated. All five youth were referred to the designated health authority (DHA) for further
evaluation, which was documented on the STI screening tool. Testing was ordered and
completed for one youth, with results, evaluations, and diagnosis being documented on the
Infectious and Communicable Diseases form. The other four youth refused testing. None of the
youth were out of the Department’s physical custody or had symptoms present, therefore no re-
screenings were applicable. All five youth refused human immunodeficiency virus (HIV) testing.
The program has a policy and procedures reflecting 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 control of 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.
The five interviewed youth were aware HIV testing was available and confidential. The
interviewed nurse was familiar with the STI and HIV testing policy and procedures.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
Five individual healthcare records (IHCR) were reviewed for sick call process. None of the
reviewed youth presented with similar sick call complaints three or more times within a two-
week period. Four of the five youth completed a Sick Call Request form, which were all
completed by the registered nurse (RN) in the appropriate section. Each request form was filed
in the youth’s IHCR in reverse chronological order. None of the youth were in restricted housing.
All sick call forms and progress notes were documented in accordance with the Health Services
Rule. Each sick call was documented on the Sick Call Index and on the program’s Sick Call
Referral Log. The dates listed on the Sick Call Index correspond to the completed Sick Call
forms located in each IHCR. The daily sick call hours are posted in multiple locations throughout
the program and is conducted by licensed nurses. When there is not a licensed nurse on-site,
the program has procedures whereby the shift supervisor reviews all sick call requests as soon
as possible and within four hours after the request is submitted. Sick call request forms are
available to youth in each dormitory. An exam table and equipment are used to perform sick
calls. The interviewed nurse confirmed the RN conducts sick call, or the designated health
authority (DHA). The nurse confirmed the program has DHA-approved protocols. Sick calls are
conducted twice a day at 10:00 a.m. and 3:30 p.m. in the clinic. If a youth presents with the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 61 (Revised August 2025)
same complaint three or more times, the youth is referred to the DHA. There was no sick call
observations completed during the annual compliance review week as no youth put in a sick call
request. One out of five interviewed youth stated they would see the nurse immediately once a
sick call request is submitted, and four youth stated it would be within a day.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
Five individual healthcare records (IHCR) were reviewed and there was no indication any of the
youth required on-site first-aid or episodic care. The program did not have any youth who
required episodic, first-aid, or emergency care during the annual compliance review period.
There were no episodic care events to observe the week of the annual compliance review. The
program’s Episodic and Emergency Care procedures were reviewed and contained all required
elements. The program has a total of eight first-aid kits, with six located in the back hall, kitchen,
master control, multipurpose room, classroom one, classroom two, and one for each of the two
vans. The program maintains an inventory for all first-aid kits, including expiration dates, being
monitoring weekly to ensuring first-aid kits contents are maintained and stored in accordance
with guidelines to prevent expiration or deterioration and replenished as needed. All first-aid kits
are fully stocked with Designated Health Authority-approved contents. The program has one
new automated external defibrillator (AED) with procedures located in master control. The on-
site nurse checks to ensure the AED batteries and pads are operable. The registered nurse
(RN) conducted a self-test of the AED in front a member of the review team and there were no
issues. The AED battery expiration date is October 31, 2029, pads expiration date is August 31,
2026. Reviewed documentation confirmed the program completed one emergency drill a month
on each shift, with at least one drill which included the use of cardiopulmonary resuscitation
(CPR) annually. One drill was reviewed by video which showed the staff simulating the drill and
following all emergency procedures. Reviewed documentation confirmed an effort was made to
ensure all direct care staff had the opportunity to participate in at least one emergency “man
down” drill annually. The interviewed nurse was able to explain the process for documenting on-
site episodic care, as well as knowing the locations and procedures of the first-aid kits and AED.
The nurse verified emergency drills are completed monthly according to policy, and CPR is
included in at least one drill annually. All emergency numbers are posted in medical, master
control, and near alert board. The program has two prescribed non-youth specific naloxone
Nasal Spray kits for emergency purposes of accidental overdose for use for all youth in their
care which is inventoried as required on the inventory form. Narcan is stored in the medication
cart for medical staff and trained floor staff to have access. Five interviewed staff verified staff
are personally allowed to call emergency services if a youth has a medical emergency. Five
interviewed youth stated they can see a doctor and/or a dentist if needed.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Five individual healthcare records (IHCR) were reviewed, four out of five youth required off-site
care. All four youth had the Summary of Off-Site Care Consultation Report form utilized and
filed in thier IHCR. Parental notification efforts were documented in each IHCR. One of the four
was applicable for emergency care which was documented on the Episodic (first
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 61 (Revised August 2025)
aid/emergency) Care Log. The DHA reviewed and signed each applicable discharge off-site
summary with the findings, instructions, and information. Three of the four youth required follow-
up testing, referrals, and/or appointments, which reviewed document indicated was tracked with
the youth receiving appropriate, timely follow-up care, as needed. The interviewed nurse stated
off-site emergency care and any follow-ups are tracked utilizing calendar, travel log, and
episodic log, and hospital orders are relayed to the DHA for phone continuation orders, as well
as faxing medication prescriptions to the pharmacy and updating all necessary forms if
applicable. The off-site orders are then placed in the DHA binder for review and signature on
next visit.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Five individual healthcare records (IHCR) were reviewed and only one was applicable for
chronic conditions. Two additional IHCR were requested and reviewed. All three youth were
identified on the Facility Entry Physical Health Screening (FEPHS) form with a current chronic
condition. No youth had a communicable disease, undergoing treatment for physical health
condition, taking anti-tuberculosis medication, or taking prescribed medication on an on-going
basis for any reason. Each applicable youth was classified with the appropriate Medical Grade.
All three youth were placed on the chronic illness list and their Department Problem List form
was updated in accordance with the Health Services Rule. A review of each IHCR found
periodic evaluations were conducted every ninety days as required. The interviewed designated
health authority (DHA) verified periodic evaluations are completed at least every ninety days,
which is tracked by the program’s nurse. The interviewed facility administrator was able to relay
the policy and procedures in regards to meeting with healthcare staff ito review mportant youth
medical issues. The interviewed nurse confirmed all youth with chronic conditions are seen by
the DHA every three months and is monitored by the nurse on the medical tracker and chronic
clinic book.
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.
Five individual healthcare records (IHCR) were reviewed and three were applicable for being
admitted to the program with prescription medications according to the Facility Entry Physical
Health Screening (FEPHS) form and progress notes. Each youth’s medication was verified prior
to being admitted into the program utilizing the Department’s Prescription Verification
Medication Checklist form. The designated health authority (DHA), and the psychiatrist if
needed, were contacted to obtain the order to resume medications prescribed. All medications
have a current, valid order and administered pursuant to a current prescription for all current
medication, with new, discontinued or changed prescriptions being placed on the Practitioner
Order Form. The program does not have restricted housing. Two youth were applicable for
over-the-counter (OTC) medications not listed on Department’s Authority for Evaluation (AET)
form, which was administered according to approved protocols or Practitioner’s Order form. The
standard Department’s Medication Administration Record (MAR) was used to document all
medication and treatment. The MAR clearly indicated medication start and stop dates. Non-
healthcare staff did not assist in the delivery of medications. The nursing staff document daily
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 61 (Revised August 2025)
side-effect monitoring on the MAR. There were no lapses or errors in medication administration.
Two youth were applicable for refusal of medication and each youth had a signed Refusal of
Treatment form indicating the refusal, which was also clearly documented on the MAR. Each
MAR had all required elements and the youth initialed each provided medication entry. No youth
required parenteral medication. There were no standing orders, emergency treatment orders, or
pro re nata (PRN) orders for psychotropic medications. An observation of a medication
administration was conducted and the delivery was completed by the nurse with all required
procedures followed. The nurse administering medication did not conduct or supervise any
other center activities during this time. The interviewed nurse knew the policy and procedures
for verifying medication upon a youth’s admission, and relayed mediation pass is daily at 8:00
a.m. and 5:00 p.m. The program utilizes the Department’s MAR form and all prescriptions are
procured through a vendor. Five interviewed youth verified the nurse gives medication and were
able to relay the process of receiving medication.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
All psychiatric services are provided by a psychiatrist with a clear and active license which
expires January 31, 2026. The psychiatrist is available for emergency consultation twenty-four
hours a day, seven days a week. The psychiatrist briefs a member of the treatment team with
youth psychiatric services information for treatment team review. All psychiatric evaluations are
incorporated in the mental health evaluations and on all applicable treatment plans. Reviewed
sign-in/out logs during the annual compliance review period verified the psychiatrist visits were
completed as required by the contract. The psychiatrist actively participated in, managed, and
supervised psychotropic medication services in the program. The program only utilizes an
advanced practice registered nurse as back-up to the psychiatrist; however, was not utilized
during the annual compliance review period.
Five youth records were reviewed for psychiatric services. One youth was admitted on
psychotropic medications, but all five received a diagnostic interview within fourteen days of
admission. Three youth were prescribed medications after the initial interview. All five initial
diagnostic interviews included the youths’ history, Mental Status Examination, Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis consistent with the
youth’s treatment plan, treatment recommendations, prescribed medications, explanation of the
need for psychotropic medication related to the youth’s diagnosis, target symptoms, initial
treatment goals, potential side effects, risks and benefits of taking the medication, and
frequency of medication monitoring/management. The initial diagnostic psychiatric interview
was documented on the Department’s Clinical Psychotropic Progress Note (CPPN) form in all
five records reviewed. The CPPN forms were clearly identified as an “Initial Diagnostic
Psychiatric Interview” in all five records. Medication reviews were conducted monthly as
required for the three applicable youth prescribed medication. The psychiatric evaluation was
documented on the Department’s CPPN form and included all three pages. When the
psychiatric evaluation resulted in the prescription of psychotropic medication or changes to the
youth’s existing psychotropic medication, page three of the CPPN was completed in all
applicable records reviewed. None of the youth had an updated psychiatric evaluation
completed; all youth had a new evaluation. When psychotropic medication was
prescribed/dispensed/administered by the psychiatrist, identifying data, diagnosis, target
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 61 (Revised August 2025)
symptoms of each medication, evaluation and description of the effect of prescribed medication
on target symptoms, prescribed psychotropic medication information including the name,
dosage and quantity of the medication, normal dosage range, ordered dosage, frequency and
route of administration, side effects, and reasons for changes in medication and/or dosage were
documented in all applicable records. The youth’s adherence to the medication regimen, height,
weight, blood pressure, most recent serum drug levels or laboratory findings, when appropriate,
telephone contact with the parent/guardian to discuss medication, signature of the psychiatrist,
and date of signature were also documented in all applicable youth records. The psychiatrist
and nursing staff have documented monitoring for Tardive Dyskinesia on a monthly basis as
indicated on the CPPN in all applicable records reviewed. The program did not use tele-
psychiatry with the reviewed youth.
The interviewed psychiatrist stated their role is to evaluate and access all new admissions and
participate in treatment planning by working with therapist and nursing staff to provide
individualized treatment plans and participate in person for treatment team. The psychiatrist is
on-site every two weeks, meet with the clinical staff in person or by phone, and provide
psychiatric evaluations and treatment as needed. The psychiatrist stated clinical staff are good;
however, the program is having trouble following through with a thoughtful, organized behavior
plan for the entire institution due to large staff turnover rate and lack of discipline, structure, and
clear set of consequences and rewards it is negatively affecting the mental health of the youth
and can lead to distress and reinforcement of maladaptive behaviors. The interviewed
designated mental health clinician authority confirmed the psychiatrist is on-site twice a month
for medication monitoring of youth on psychotropic medication.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
A review of the medical equipment classified as sharps confirmed the items were securely
stored and inventoried utilizing a routine perpetual inventory descending count as each was
used and disposed. All medications were identified and secured in a locked medication cart
designated for storage of medications. The medication cart was secured, clean, and organized
with stock items separate from youth-specific medications, as well as different types of
medication, injectables, topical, drops, and liquids, were secured separately. All medications
were stored in a separate, secured area, inaccessible to the youth. All medications had a
perpetual inventory, with controlled substances having a shift-to-shift inventory count and stored
separately from other medication behind double locks. Narcotics are also stored behind two
locks. Refrigerated medication was stored in a secured refrigerator, being only used for
medication. The program’s process for the destruction and disposal of expired or discontinued
medications is using the drug buster liquid. Controlled substances are disposed of monthly
when the pharmacist is onsite. A review of documentation confirmed the program conducts a
perpetual and weekly inventory of all sharps and stock over-the-counter (OTC) medications,
with no discrepancies being reported for the annual compliance review period. The nursing staff
maintained a shift-to-shift inventory of all controlled substances on each youth’s Individualized
Controlled Medication Inventory Record. The number of pills, tablets, or dosages remaining
were documented on the youth’s Individualized Controlled Medication Inventory Record after
each administered dosage. Supervisory-level staff were trained by the registered nurse (RN) in
the delivery and oversight of medication self-administration. Observations conducted of
inventory counts of three OTC medications and three sharps found no discrepancies. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 61 (Revised August 2025)
program did not have any controlled medications at during the review. The interviewed nurse
stated the drug buster is utilized weekly to destroy medication, with two staff confirming, and
monthly with the contracted pharmacy consultant for controlled medication. All controlled
substances are kept in the medication cart, which is doubled locked.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a combined Exposure Control and Infection Control Plan, which is reviewed
and signed annually, is available to all staff, and located in medical office. The designated
health authority (DHA) signed the plan on November 19, 2024, the facility administrator (FA)
signed on May 29, 2025, and the psychiatrist signed on January 21, 2025. The program’s
infection control procedures included prevention, containment, treatment, and reporting
requirements related to infectious diseases, as according to Occupational Safety and Health
Administration (OSHA) federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The plan addresses common childhood infectious, self-limiting, episodic
contagious illnesses, viral and bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C,
Human Immunodeficiency Virus (HIV), infectious diseases caused by blood-borne pathogens,
other outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other antibiotic resistant micro-
organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. Staff have
access to personal protective equipment and the program offers Hepatitis B immunizations to all
staff. The program has a comprehensive process for needle stick post-exposure evaluation. The
program has a separate file to contain documents of any youth or staff who if they experience a
facility or occupational exposure, which has not happened during the annual compliance review
period. The interviewed FA verified the location of the exposure control and infection control
plan, which is reviewed annually or as needed. The interviewed nurse stated the Exposure
Control Plan is available to all staff in the medical office. A registered nurse (RN) conducted
infection control training for all staff, as well as for youth at admission and during health
education class. All medications are stored behind a double lock system in the clinic and
inventoried as required.
4.20 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 61 (Revised August 2025)
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 written policy and procedures addressing youth supervision. The program had
a minor deficiency pertaining to improper supervision, which had been identified June 25, 2025.
Daily observations were made at the program during the annual compliance review week for
supervision, which was also to conduct verification of the deficiency. During the week, youth
were primarily observed in classrooms for education. Other observations made included meals,
snacks, movements, and recreation. During these observations staff to youth ratio pursuant to
contract of one to eight was met. There was one occasion a youth was unescorted from a
classroom, entered the dining area to utilize the restroom. During this time no radio call was
made from the staff to the staff in the dining area. It was observed the staff in the dining area did
not have a radio. During the week, there were positive interactions between staff and youth.
Three staff were asked how many youths they were supervising. Each of the staff were able to
articulate the number of youths they were supervising.
The program considers active supervision to providing safety and security of the youth and staff
and ensure the program’s mission, goals, and outcomes can be achieved, by maintaining active
supervision of youth to include interacting positively with youth, engaging youth in a full
schedule of constructive activities, closely observing behavior of youth and changes in behavior,
and consistently applying the program’s behavior management system. It shall be the policy of
the program to ensure proper staffing ratios as established by the Department of Juvenile
Justice and as set by contract. The program is a secure delinquent juvenile residential program;
staffing shall be one staff to eight youth during awake hours and one staff to twelve youth during
non-awake hours. For off-site activities, the ratio shall be one staff to five youth. A daily
schedule is posted and available to youth in each living dormitory. It appeared youth were
engaged in a full schedule of activities through observations made while on-site. Observations
of youth rooms confirmed windows were not covered by any means. There were no
documented escapes during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Limited Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has written policy and procedures addressing the program’s behavior
management system (BMS). A review of the program’s BMS revealed appropriate parties were
involved in the development and implementation, except for the education staff. An agreement
between the program and school related to BMS was found posted in classrooms; however,
according to education staff none of them had ever received any BMS training. A request for
documentation of training for education staff was made; however, the program never provided
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 61 (Revised August 2025)
any completed training sign-in rosters. Later the program accepted and agreed to set a date to
train education staff. A review of five youth case management records confirmed youth
orientation included the program’s BMS practices. A review of position descriptions for staff
whose job functions includes implementation of the program’s BMS was conducted. None of the
position descriptions included specific BMS implementation. The program contended job
descriptions contain a bullet point which staff will complete other job duties as assigned, which
should be sufficient for BMS Implementation. A review of five pre-service training records
reflected staff have completed training in the program’s BMS. Observations made throughout
the week revealed no specific postings outline the BMS were found in the program. The
program remarks, incentives, expectations, phase sheet, and fourteen values are posted in the
dormitories, which program believes is sufficient to meet the requirements of this indicator. The
rules governing conduct and positive and negative consequences were not found in any area
accessible to youth. The program’s BMS was documented in the youth handbook. No revisions
to the program’s BMS have been required, the program had a start-up monitoring in and around
January 2025. The program’s BMS meets and includes all requirements as outlined within
Florida Administrative Code 63E-7 and contract. A few staff and youth interactions were
observed, each adhered to the elements outlined with the program’s BMS for behaviors
demonstrated.
The program’s BMS allows for a variety of rewards and incentives. Positive consequences are
used to recognize and, ideally, to increase the frequency with which youths do the right thing.
The program recognizes those youths who are following rules and procedures. Positive
consequences can be used to develop self-managed behavior and are most effective when they
target a specific behavior and are applied immediately, with eye contact and genuine
enthusiasm. Rewards and natural consequences will occur; however, in accordance with the
performance of individuals and the group. Consequences are always appropriate to the
violation. This process also develops the motivation and, subsequent to empowerment, the
desire to become involved in problems before they get out of control. The most commonly used
consequence is the loss of a minor privilege or special activity, such as a movie or special
event. The ratio of positive consequences to negative needs to be at a minimum of four to one
for a program’s BMS to be effective. Incentives or rewards which may be earned by individuals,
groups and the community as a result of their acceptance of responsibility and following of
community norms. Privileges in the BMS are weighted in terms of the contribution and effect on
the positive peer community. Privileges are earned when the group members are accepting
responsibility, confronting as well as supporting one another appropriately, and living
consistently according to established norms. Staff and youth will establish privileges. Individual
privileges are based upon weekly point totals obtained as the youth displays positive changes in
thinking errors and in accepting responsibility. An individual’s points may be used in the
established token economy and at the program point store. The program point store stocks
items such as a large variety of greeting cards, candy, and sundries not otherwise available to
youth in the program.
Five staff were interviewed and were able to explain parts of the program’s behavior
management system. Staff agreed, no basic rights can be taken away from youth as a
consequence. Two of the five staff were able to identify ways for youth to be informed about
consequences and ability to explain behaviors. The remaining three staff appeared to not fully
grasp the process and unable to explain allowing youth the opportunity to address behaviors.
Five youth were interviewed and were able to outline consequences and rewards for behaviors
at the program. All youth agreed staff are consistent in applying consequences and rewards for
youth behaviors. The youth had a varying degree of responses pertaining to the difference
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 61 (Revised August 2025)
between moving from one level to the next in the program’s BMS. The youth did agree, no youth
are ever allowed to punish other youth.
The facility administrator (FA) was interviewed and provided the following as it pertains to the
program’s BMS. The program utilizes a BMS in which all youth are held accountable for their
behavior either positive or negative. The rules governing conduct, positive and negative
consequences are posted in the student handbook in which the youth have access to daily. The
FA ensures the BMS is based upon the youth’s status progression, daily progress notes, and
code of conduct. Recognitions of accomplishments and positive behaviors of five to one positive
ratio is documented in the dorms on the wall. All staff have received training on the BMS during
the first phase of their employment. Youth are rewarded for positive behavior. When a youth
consistently display positive behavior, they can earn incentives including off-site trips, restaurant
outings, personal items, and other rewards. Additionally, the FA provided the following
concerning how rewards are monitored: consequences are monitored through the program’s
code of conduct and the BMS; staff are trained in the implementation of the program’s BMS; all
education staff are trained in the jointly combined BMS plans to include use of BMS during
school; the shift supervisors and youth care workers provide feedback regarding the
implementation of the BMS during staff briefings, shift meetings and random conversation
throughout the day; and the youth are informed of their consequences and are allowed an
opportunity to explain their behavior.
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) Limited 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 written policy and procedures addressing the practice for ten-minute checks.
The program, according to maintenance and master control, have thirty-two cameras. One
camera was found to be in-operable; the program has an active work order to address repairing
the camera. The program’s video recording capabilities is for a minimum of thirty days.
Observations of ten-minute checks were conducted to reflect if checks were conducted in the
required frequency and in real time, and to ensure the checks are met with fidelity. Nine
separate checks were completed. Three of the nine checks had a variance of staff completing
timely. The three checks were approximately twenty-six, twenty-six-, and twenty-three-minutes
lapse between required ten-minute checks. The corresponding check sheets were unable to be
verified, as the check sheets were not present. The program does complete ten-minute checks
at a minimum of approximately eight minutes. Staff were seen conducting room checks,
stopping at doors, using flashlights, and recording findings in an eight-minute period. A sample
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 61 (Revised August 2025)
of logs to verify ten-minute checks throughout the annual compliance review period were
reviewed. The samples included one thirty-minute increment from each month while youth were
in their rooms; no issues were discovered. Five staff were interviewed and two of five staff said
checks are completed every eight minutes. The remaining three staff said checks are completed
every ten minutes when a youth is placed in their room for sleeping or non-punishment reasons.
The facility administrator was interviewed regarding operation of security cameras, where the
program has thirty-two cameras with videotaped footage maintained for a total of thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has written policy and procedures regarding youth census, counts, and tracking.
An observation of counts being conducted revealed radio calls made to master control during
youth movement and official hourly headcounts. A deficiency for logbooks was identified
January 29, 2025, which identified logbook entries contained written over entries, erasures,
blacked out entries and the entries were not struck through. The logbooks also contained
instances in which staff failed to initial entries. The deficiency was reviewed and corrected April
16, 2025. A review of four applicable month of logbooks annotated census, counts, and tracking
are captured accordingly with no exceptions. Five staff were interviewed, each identified youth
counts are conducted. Additionally, staff were able to identify practices necessary when a youth
count cannot be reconciled or when an emergency count is required.
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 maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control. The program had been issued a deficiency pertaining to
logbook completeness; and was subsequently corrected in April 2025. A sample review of
logbook entries demonstrates the program has maintained compliance with logbook and shift
report entries with no exceptions. A copy of the program’s reporting practices is maintained and
accessible to staff to review for up to forty-eight hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 49 of 61 (Revised August 2025)
5.07 Key Control (CRITCAL) Limited Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has written policy and procedures addressing key control. The program will
maintain control of keys utilized within the program. The purpose of key control is to keep the
program secure thus preventing escapes and providing continued protection to the community.
Duty keys are issued to staff will provide limited and necessary access around the program. It is
prohibited for youth to possess keys. It is the responsibility of the program administrator to
approve all key assignments, maintaining key inventories and tracking. A key ring reference file
will be maintained, which includes the master key inventory and other documentation relating to
key control. Each key shall be accounted for through this inventory process. The key ring
reference file shall identify which keys are on each individual key ring. All changes in lock
locations, key locations, and key duplications are authorized by the program administrator and
documented in the key ring reference file. Permanent issue keys must be approved and issued
by the program administrator. Inventories and documentation related to permanent issue keys,
restricted keys, and active keys will be maintained through the master key inventory in addition
to the key ring reference file. All keys are to be maintained on secure or braised key rings. The
physical plant manager or designee is responsible for monthly inventories and issuance/return
documentation of active, restricted, and emergency keys in the key room. The physical plant
manager or designee will also be responsible for a quarterly inventory of the main key box
(locked box containing a copy of all keys to the program) and the spare key box located in the
program administrator’s office. Each key is identified with a control code, which distinguishes it
from other keys. Each key ring has a tag indicating the number of keys on the ring and a key
reference number which can be cross-referenced to the Master Key Inventory. All active
keys/key rings maintained in the limited access key boxes are assigned a hook with a
corresponding code. Youth are prohibited from possessing any key for any reason. All program
staff are responsible to ensure no personal keys are allowed in any areas of the program which
youth have access to. Immediate disciplinary action shall be taken on any staff which allows
keys to be handled by a youth. The physical plant manager and shift supervisors will ensure the
limited access key box, visitor key box and restricted key box are kept locked at all times when
not in use. Permanent issue keys must be authorized in writing by the program administrator.
Only department heads, program nurse, and clinicians will have permanent issued keys. Use of
these keys must be limited to those individuals to whom the keys were issued for necessary
security and programming purposes. These keys may be taken off program grounds at the
discretion of the program administrator and are relinquished at the end of employment or by
request of the program administrator. Each employee who is issued permanent keys to the
program will sign a copy of the Key Responsibilities form during orientation which will go in the
key reference file. Restricted keys are clearly separated from active keys maintained in the
restricted key box. Restricted keys will be issued only to employees approved to have access to
those specified areas, unless there is an emergency. Emergency keys are identified as those
necessary for emergency egress from the building as well as to identified “off-limit” areas. All
keys which allow egress from the program can be individually identified by both touch and sight
in the event of an emergency (i.e. smoke-filled room, power outage, etc.) by a groove in the key.
Active-duty key sets will be issued out to employees for the period of time they are on duty. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 61 (Revised August 2025)
staff members/teachers turn personal keys in to the master control operator located in the lobby,
or secure in the staff lockers located at the program entrance. The staff will retrieve their
program keys from the staff on their assigned dorm/unit. Upon completing the shift or leaving
the program the staff member will return their program keys to the master control operator and
enter the time and initialing the entry in the daily key log. This process facilitates inventory of the
keys and allows the master control to know whether a set of keys has been returned or not.
Each key ring includes a tag indicating the number of keys on the ring. Upon receiving their duty
key set the employee will verify the key set and the number of keys on the set. If the key count
is incorrect, staff will immediately notify the shift supervisor of the problem. Request for keys will
be made to the physical plant manager. The program administrator must approve any changes
or additions. To avoid the loss of key sets and possible escape, injury and the tremendous cost
associated with the loss, staff must keep key security at the forefront of their thoughts. It is
imperative all program keys issued to staff be retained on their person at all times. Youth care
workers must carefully protect their keys, never leave them lying around, and never allow a
youth to handle the keys. Key storage box should not be easily accessible and will be secured
when not in use. Security of visitor keys is essential. All staff, visitors, volunteers, and interns
will be asked to relinquish their personal keys to sub control upon entering the program. Visitor
keys shall be collected and affixed to a hook with a number upon entrance to the program. The
visitor will be given a visitor’s badge which corresponds to the number on the hook for personal
keys were affixed to in the secured visitors’ key box located in sub control near the front
entrance to the program. Upon leaving the program, visitors must present the visitor’s badge
given to them to claim their personal keys. In the event of lost or missing keys, the shift
supervisor and program administrator must be notified immediately. A program wide search of
all program areas and youth will take place immediately in an attempt to locate the keys in
question. Staff will ensure during the search; the program is placed on the highest security alert
until the keys are found. Youth will be in their sleeping rooms until the search is completed. The
shift supervisor will document the incident in the program logbook and complete an incident
report outlining how the keys were lost and any investigation details. The program will make
reports to the Department and the Department’s Central Communications Center as necessary.
Staff will be held accountable for the loss of any keys. Progressive discipline shall be enacted in
the event keys are lost/misplaced. Any staff who accidentally takes a key home will be required
to notify the program they have the key and will be required to return it to the program
immediately. Keys which are broken or need to be replaced will be given to the physical plant
manager. Any extra replacement keys will be kept secured in the emergency and restricted key
box and shall be issued only with the authorization of the program administrator. This shall be
reflected in the documentation contained within the Key Log. Only the program administrator or
designee may authorize the making of duplicate keys, if necessary. The key to each program
van or the program truck is kept secured in master control in the main key box when not in use.
While in use the vehicle logbook and key(s) must remain on the possession of the assigned
staff at all times. Upon returning to the program the vehicle keys must be returned to master
control main key box immediately.
The distribution of keys was observed; the master control operator searched visitors and
requested keys, handed out chits for each set of keys. By end of day, chits were turned in and
keys handed back to each person. The provisions for restricted keys were not observed. The
process for reporting and replacement of damaged keys and broken or malfunctioning locks and
keys will be immediately brought to the attention of the shift supervisor and physical plant
manager. Security of doors and mechanical and electronic locks shall be formally checked
during perimeter security checks on each shift. There were no incidents reported to the
Department’s Central Communications Center (CCC) or Program Monitoring and Management
(PMM) deficiencies related to key control during the annual compliance review period. An
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 61 (Revised August 2025)
informal interview was conducted with the master control operator; only staff who are allowed to
have access to medical, mental health, and kitchen, may check out restricted keys. The
program’s method for the daily tracking and reconciliation of keys is active-duty key sets will be
issued out to employees for the period of time they are on duty. Staff members/teachers turn
personal keys in to the master control operator located in the lobby, or secure in the staff
lockers located at the facility entrance. The staff will retrieve their facility keys from the staff on
their assigned dormitory/unit. Upon completing the shift or leaving the facility the staff member
will return their facility keys to the master control operator and enter the time and initialing the
entry in the daily key log. This process facilitates inventory of the keys and allows the master
control to know whether a set of keys has been returned or not. Each key ring includes a tag
indicating the number of keys on the ring. Upon receiving their duty key set the employee will
verify the key set and the number of keys on the set. If the key count is incorrect, staff will
immediately notify the shift supervisor of the problem. Observation of the key storage area was
found located on a wall in master control. The key box is locked with only a few people having
access to distribute/take keys.
The key inventory was reviewed to ensure the inventory matches the actual key rings in use.
The master key control inventory indicates in most instances the number of keys; however,
individual key rings do not mark (indicate) total number of keys on each of the reviewed key
rings. Additionally, two of the five key rings reviewed were not correctly annotated on the master
key control inventory, whereas the total count was incorrect. A review of three random staff key
rings was conducted. One of the three key rings reviewed was medical keys (permanent keys)
which was incorrect. Key ring indicated eleven keys present; however, only nine keys were on
the ring. The medical cart keys are kept locked in medical; however, no inventory present or
noted on the master key control inventory. During on-site observation, a set of keys were left
unattended on the master control desk with no staff present (door open to master control area).
On two separate occasions keys were observed and left in the front door, unattended. Five staff
were interviewed and confirmed key accountability practices within the program.
5.08 Contraband Procedures Limited 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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 61 (Revised August 2025)
The program is currently under an outcome base correction action plan (OBCAP) for
contraband; therefore, this indicator will be preliminary rated “limited”.
A deficiency was identified March 18, 2025, which addressed visitor log containing a contraband
attestation statement. Along with video of staff and visitor searches were reviewed to include
twelve staff and visitors. Of the twelve only three were searched completely to include pat down,
wand and bags searched. Five staff did not have their bags searched, one staff did not receive
a pat down, and three staff were not within camera view to determine if a search was
completed. The facility administrator (FA) advised he would put in corrective action to include a
rug to serve as a location for optimal camera view for searches and a retraining for all staff on
Wednesday, March 19, 2025, for searches. The FA advised he would provide the
documentation for the training and agenda. Documentation was not received as requested. The
deficiency remains open during the annual compliance review.
5.09 Searches and Full Body Visual Searches Limited Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has written policy and procedures addressing search practices. Search practices
observed were not in accordance with programs written procedures and right interactions
training manual. Areas missed during searches of youth included the staff not checking facial
areas, mouth, ears or hair. Staff were not consistent with instructing the youth to empty all
pockets and remove shoes. Staff did not conduct the searches from behind the youth; staff were
observed having the youth turn and face the staff to complete part of the search. Staff were not
consistent with using the same pattern/technique every time. Staff did not frisk at all in the
crotch area
No youth searches were observed before and after transports for no transports were conducted
during the on-site review. No youth searches were observed during admission for no
admissions were completed during the on-site review. No youth searches were observed before
and after visitation as no visitations were during the on-site review. No youth searches were
observed upon return from off-campus activities, there were no off-campus activities during the
on-site review. No youth searches were observed and following access or ability to obtain tools
or other equipment; no youth had access to tools during the on-site review. A video review of
five staff and/or visitor searches was conducted with no exceptions. Five staff were interviewed,
each staff was able to identify when youth searches are conducted; however, none of the staff
articulated the process of how to search youth. Five youth were interviewed and each able to
share when searches take place.
A deficiency was identified on June 24, 2025, whereas a video review of searches was
conducted to include six days of searches. Ten staff entered the building during those dates and
only one search occurred properly.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 53 of 61 (Revised August 2025)
The program has two vehicles used to transport youth. One of the two vehicles had a completed
annual safety inspection. The program was going to take both vehicles in, complete annual
inspections, and send the completed inspection forms in by close of business Monday;
however, only one vehicle was completed. Both vehicles had a fire extinguisher present;
however, neither of the extinguishers were properly anchored. The program vehicle contained a
first aid kit, seatbelt cutter, and window punch. The program has conducted monthly
inspections, which began what appeared to be since the beginning of the year for eight months.
The program was missing monthly inspections for three months.
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 written policy and procedures addressing transportation of youth and met all
requirements outlined within Florida Department of Juvenile Justice written policy and
procedures. A review of three staff records revealed each had a valid Florida State driver’s
license. A cellular telephone or two-way radio is issued to staff while conducting youth
transports. No youth transport was observed during the on-site review. The program human
resource staff completes an approved driver check on a monthly basis and forwards to the
facility administrator to ensure all staff operating program vehicles have a current driver’s
license. There was no indication of youth being permitted to drive a program or staff vehicles.
Five staff were interviewed, and each was able to identify youth use seatbelts and a cellphone
and or radio is carried during transports. Additionally, safety equipment (fire extinguisher and
first aid kit) is in the transport vehicles. All five staff confirmed they are not allowed to use
personal vehicles to transport youth. Staff agreed transport vehicles are searched for
contraband prior to and after each use. Staff were also able to explain the emergency response
process during a vehicle transport if necessary. Five youth were interviewed, and all agree they
have never been handcuffed to any part of the transport vehicle. In addition, none of the youth
have ever witnessed anyone placing contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has written policy and procedures addressing weekly safety and security audits.
Safety and security audits are the responsibility of the facility administrator or designee to be
conducted weekly. Any deficiencies found would be documented on the safety and security
audit tool and reviewed by the facility administrator (FA). The FA will follow-up on a weekly
basis to ensure any corrective action is addressed. The weekly safety and security audit was
observed completed and is sent to the Department’s residential operation staff. Additionally, the
program’s preventive maintenance checklist is reviewed by the Department’s residential
operation staff and facilities services staff at a minimum quarterly according to on-site
maintenance staff. Correspondence with Department residential staff supports the claim the
program consistently turns in safety audits.
The FA was interviewed and provided the following to address process in identifying and
tracking safety and security deficiencies. The program has a policy and procedures in place to
ensure the program maintains a safe and secure physical plant, grounds, and perimeter. The
program’s policy includes completion of a weekly Safety and Security Audit and the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 61 (Revised August 2025)
development and implementation of corrective actions warranted as a result of safety and
security deficiencies found during any internal or external review audit or inspection. If
deficiencies are found, the issue(s) will be discussed during the daily meetings and during all
site meetings when staff from both shifts are present.
The program had two deficiencies pertaining to safety and security. One for improper
supervision and the other for contraband searches. Both were opened on June 24, 2025, and
have not been closed at time of the annual compliance review.
5.13 Tool Inventory and Management Limited Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has written policy and procedures addressing issuance, inventory, and control of
equipment and tools. The procedures for missing or lost tools, should any tool become missing
are the facility administrator (FA) and shift supervisor will be notified immediately. The incident
is to be logged in the logbook. All youth movement shall be halted until a thorough search is
completed or the tool is found. The FA or shift supervisor shall ensure a thorough facility search
takes place as soon as an item is reported missing. The missing tool will be documented in the
facility logbook and on an incident report before the end of the shift. The incident report will be
circulated to all department heads for review and notification. Results of the search shall also be
documented in the logbook and discussed in shift briefings for the purpose of alerting incoming
staff to security concerns, identifying the missing item for continued search, or indicating an item
was missing and then located. In the event a tool is missing, a red tag will be placed on the
shadow board in the tool’s spot until the missing tool is found or replaced. Machetes, bowie
knives, and other long blades are prohibited.
A review of tool inventory for the maintenance area and kitchen was conducted. There was no
inventory or daily tracking of tools maintained in or for maintenance tools since October 2024.
The program had a maintenance bag which was utilized from one of the other programs (which
is no longer used since new tools were brought into the program). The program has started an
inventory of current tools, which began on August 3, 2025. Five tools reviewed in maintenance
did not have any marking for easy identification or inventory. Five tools reviewed in kitchen did
not have any marking for easy identification or inventory. One of the five maintenance tools
were not located on the master tool inventory. One of the five kitchen tools was not accurately
depicted on the inventory; whereas inventory showed nine; however, there were eleven. The
kitchen tool inventory was missing for April and February 2025. A pair of needle nose pliers
were found outside the kitchen doorway (unsecured and not on inventory); these were
subsequently removed by the FA.
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 written policy and procedures addressing the essential components for youth
tool handling and supervision. Youth are only to use class “B” items under the supervision of
staff with a minimum of one staff to every five youth. There was no observation made of youth
with tools during the on-site compliance review; there were no vocational courses or work
project occurring to be observed. A review of five youth records revealed each was trained and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 61 (Revised August 2025)
a risk assessment completed prior to the use of tools. Five staff were interviewed and confirmed
youth only handle mops, brooms, and at times a scrub brush. Five youth were interviewed, and
all confirmed the only tools utilized at the program are mops and brooms.
5.15 Outside Contractors Limited Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has written policy and procedures addressing outside contractors. The program
will maintain strict control of secure storage and the purchase of tools and sensitive items. All
tools are to be considered as possible weapons as they can inflict great bodily harm, no matter
what class they are assigned to. All tools and sensitive items will be strictly under the control of
the physical plant manager. It is the responsibility of the physical plant manager and program
administrator to monitor use of all tools and equipment in the program. All violations or misuse
of tools and equipment are reported to administration and corrective action is initiated. Any tools
brought on-site from the outside, the program shall closely monitor the use of tools when
brought into the facility or onto facility grounds. When a repair person or other worker comes on-
site from the outside community with the tools of their trade, program staff should alert them to
the potential danger of tools used on grounds and request them to limit the tools used to only
those necessary to complete the job. In addition, tools are checked when they arrive and leave,
kept close track of while working on-site, and immediately notify program staff if any tool
missing. The outside worker or repairman will sign an acknowledgment form indicating all tools
must be inventoried upon entry into the program and exit from the program. This
acknowledgment shall be recorded on the appropriate inventory form. When outside workers
are on-site with tools, program staff should restrict youths’ access to the work area to the extent
possible, closely monitor the situation, and vigilantly supervise youth at all times. When the work
is completed, staff shall check the work area to ensure the repair person takes all tools (and
toxic substances, if applicable) with him when they leave. If any tool brought on-site under these
types of circumstances is found to be missing, staff shall take immediate action according to the
program’s facility operating procedure.
A review of outside contractor guidelines included tools checked upon arrival and departure, tool
restrictions, youth restricted from work area, and missing tool follow-up. A review of three
separate project invoices revealed the following: vendor one had no signature in visitation log
(completion of attestation form); vendor two had no signature in visitation log (completion of
attestation form) and missing contractor signature on contractor form, along with date and time
exited on form; vendor three had no signature in visitation log (completion of attestation form)
and missing contractor signature on contractor form, as well as tools were not listed on form,
nor was the box checked indicating no tools were brought on-site.
5.16 Fire, Safety, and Evacuation Drills Limited 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.
A review of the past nine months found the program had a total of nine completed Continuity of
Operations Plan (COOP) drills. The program was missing a total of nine COOP drills between
the two operating shifts. Drills were not conducted monthly for each of the programs two shifts.
The program did not conduct varying COOP drills (with the exception of one drill completed in
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 61 (Revised August 2025)
July which was an escape drill); all other documented drills were fire drills only. A review of
documentation for all of the drills did not consistently contain findings and recommendations.
Fire evacuation routes and egress plans were observed posted throughout the program. A
review of documentation reflected the fire extinguishers were inspected during the program’s
start-up and an annual inspection is not applicable at the time of the of annual compliance
review. The program has thirteen fire extinguishers in the program according to maintenance
staff.
Five staff were interviewed, and each identified having participated at a minimum a fire drill in
the past twelve months. Five youth were interviewed, and each confirmed they have been
instructed on what to do in case of a fire. The facility administrator was interviewed and
elaborated on how often and type of drills are conducted at the program. The program conducts
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. Staff participate in the
following drills: fire, suicide, medical, active shooter, and weather. The program conducts drills
throughout the year. A drill schedule is given to staff to show when and which drills are to be
conducted.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program has a written Continuity of Operations Plan (COOP), addressing the basic care
and custody of youth in the event of an emergency or disaster. The program’s COOP is located
in master control and readily available for staff. The program’s COOP was missing the current
program administrator’s review/signature. The COOP addresses alternative relocation sites
approved by the applicable Department regional director. The COOP was last submitted to the
Department for approval on March 13, 2025. The program’s COOP was inclusive for equipment
and supplies required for continuous operation and services during emergency or disaster
situations. The program’s practice for taking youth records with them during an emergency is to
hand carrythe medical and case management records, facility logbooks, juvenile demographics,
and educational paperwork. A review of five separate youth records confirms this practice which
addresses all COOP components required.
The facility administrator was interviewed and provided the following as it pertained to staff
access to the COOP. The program has a combined coordinated disaster and COOP. The
COOP is in master control, as well as a binder containing youth information in case the program
has to evacuate. The plan addressed alternative housing plans approved by the Department’s
regional director or designee. The COOP is accessible to all staff in a clearly marked binder in
control room.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 61 (Revised August 2025)
5.18 Storage, Inventory, and Disposal of Flammable,
Limited Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has written policy and procedures addressing the storage and inventory of
flammable, poisonous, and toxic items and materials. Observation of flammable, poisonous, and
toxic items (e.g. bleach, gas, cleaners, pesticides, antifreeze) were found to be secured at all
times and inaccessible to youth. The program does not appear to have a list of positions, titles,
or functions authorized to handle flammable, toxic, caustic and poisonous items. The program
does not appear to have a list of positions, titles, or functions authorized to dispose of
flammable, toxic, caustic and poisonous items. A review of ten separate chemicals were
observed. One of the ten were not on any inventory. Three of ten did not have the correct count
documented on the inventory. Five of ten chemicals observed did not have a Safety Data Sheet
(SDS) present. The programs disposal written procedures appear to be in accordance with
Occupational Safety and Health Administration (OSHA) Standard 29. The program has not had
to dispose of any hazardous waste according to maintenance and kitchen staff. The program
has disposed of dirty mop water and or unused beverages (kitchen waste) down drains located
in the kitchen area. The program has not encountered any chemical spills requiring any clean-
up. The facility administrator was interviewed and stated the program has policy and procedures
in place on the disposal of flammable, toxic, caustic, and poisonous items. The plant manager is
authorized to dispose these items. The disposal procedures are in accordance with OSHA.
Disposal of items are taken to the Union County Solid Waste site. When bio-hazardous
materials need to be disposed of, the plant manager will contact a bio-hazardous company, and
they will come and retrieve the items. The plant manager has been trained on disposing
hazardous items and toxic materials.
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 written policy and procedures regarding youth handling and supervision of
flammable, poisonous, toxic items and materials. The program will maintain strict control of
flammable, poisonous and toxic items used in the facility. All chemicals entering into the facility
must be approved and be maintained in a safe and secure manner. It is the responsibilities of
the physical plant manager, under the supervision of the program administrator to maintain a
monitoring system to ensure overall compliance with the flammable, poisonous and toxic control
program to ensure compliance with written policy. The physical plant manager will maintain
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 61 (Revised August 2025)
inventories of all flammable, poisonous, and toxic fluids used at the facility. Fluids shall be
signed out when used and signed back in or noted as destroyed when returned or disposed of
and the corresponding inventory shall be updated as appropriate. Items identified as flammable,
poisonous, or toxic fluid may only be drawn by an authorized person. This includes the physical
plant manager, shift supervisors, dietary workers and the program administrator. The youth are
not allowed to handle these items, and they will not have access where these items are being
used and stored. As they are considered potentially hazardous or dangerous, youth will not be
permitted to clean, handle, or dispose of any other person’s bio-hazardous material, bodily
fluids, or human waste. All flammable, poisonous, and toxic fluids must remain secured when
not in use. All flammable materials are stored in a metal fireproof safety secured locker. All
hazardous chemicals no longer used or outdated will be disposed of by returning them back to
the venders or hazardous waste center and in accordance with the SDS (safety data sheet). All
bottles with chemicals are to be labeled to identify the solution. If a new chemical is introduced
to the facility, the physical plant manager will inspect it for safety purposes, obtain a safety data
sheet (SDS), and place it on the inventory. All chemicals are stored in locked
cabinets/closets/sheds. A monthly inventory is completed on all chemicals by the physical plant
manager. SDS are completed as required by the Occupational Safety and Health Administration
(OSHA). The physical plant manager will keep current copies of all SDS sheets and ensure and
they are posted throughout the facility as needed. The youth care worker is authorized to handle
the pre-mixed chemical solutions used for general cleaning of windows, toilets and sinks on the
dorms. Liquid waste not resulting from work details (dirty mops water, unused beverages) shall
be disposed of in the drain of the cleaning supply closet. Kitchen liquid waste, except for grease,
shall be disposed of in the kitchen drain. Grease shall be placed in a separate container for
disposal. In the case of a chemical spill, the following actions will be taken: once a chemical spill
is found, the shift supervisor is to immediately be notified; the supervisor must then direct the
shutdown of all air handlers and ventilation systems and close all windows and doors at the
direction of the program administrator or designee; and assistance from outside the facility shall
be contacted, should it be necessary and consistent with emergency procedures. Observation
of chemical storage areas appears the program maintains strict control of flammable,
poisonous, and toxic items and materials. There was no observation of youth handling or
disposing of any hazardous chemicals or bio-hazardous materials. Areas of where chemicals
are stored are restricted to any youth access. Five youth were interviewed, two stated they use
laundry soap, whereas the remaining three stated they do not use any chemicals at the
program.
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;
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 61 (Revised August 2025)
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Limited Compliance
The program allows visitation and communication for youth while in the program.
The program has written policy and procedures addressing visitation, youth correspondence
(mail), and use of telephone. Visitation postings were observed in each of the youth dormitories.
A review of visitation logs found the program appears to provide on-going visitation access to
youth. The program had some documentation to support youth telephone usage, though were
missing four months of telephone logs. The program had some documentation to support youth
mail usage, though missing two months of logs. In both cases (telephone/mail), the program
documentation did not support services being provided as there was missing months/times for
youth access. The program does allow for alternative visitation with parents/guardian if
necessary. There were no instances of a youth with a history of human trafficking. There was no
incoming/outgoing mail to be observed for search practices. Five youth were interviewed, and
each agreed they can call a parent/guardian or send a letter.
The facility administrator was interviewed and confirmed the program utilizes a language
transition service for all youth who presents a need and English is not their primary language.
This service is provided in all areas of treatment, including individual and family therapy and
formal and informal treatment team meetings.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program’s activity schedule prepares the youth for an array of supervised and structured
indoor and outdoor recreational and leisure type activities. Large muscle activities are provided
to youth at a minimum one hour each day. A review of the program logbook indicates recreation
was conducted as scheduled. Activities at the program promote social and cognitive skill
development, along with creativity, teamwork, healthy competition, mental stimulation, and
physical fitness. While on-site, recreational activities were observed, and measures were taken
to ensure youth and staff were safe to eliminate any physical stressors. The program’s contract
requires a recreation therapist with the required credentials, schedule, and services. A review of
five youth records documented the inclusion of the recreation therapist input. Five staff were
interviewed and were able to articulate types of indoor and or outdoor activities youth participate
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 61 (Revised August 2025)
in at the program. Five youth were interviewed and agree they are provided with physical
activities for at least one hour daily.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 61 (Revised August 2025)

report_type: QI Residential

program_name_raw: Redwood Youth Academy

rule: Indicator 1.01

excerpt: Initial Background Screening (Critical)

rating: Limited Compliance

rule: Indicator 1.06

rating: Failed Compliance

rule: Indicator 2.01

rule: Indicator 2.04

rule: Indicator 2.06

rule: Indicator 2.07

rule: Indicator 2.08

excerpt: Youth Needs Assessment Summary (YNAS)

rule: Indicator 2.09

rule: Indicator 2.13

rule: Indicator 2.15

excerpt: Exit Portfolio

rule: Indicator 2.16

excerpt: Exit Conference

rule: Indicator 2.19

rule: Indicator 3.03

rule: Indicator 3.05

excerpt: Mental Health and Substance Abuse

rule: Indicator 3.06

rule: Indicator 3.07

rule: Indicator 3.08

rule: Indicator 3.10

excerpt: Suicide Prevention Services (Critical)

rule: Indicator 3.18

excerpt: Safety Planning Process for Youth

rule: Indicator 5.02

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.07

excerpt: Key Control (CRITCAL)

rule: Indicator 5.08

excerpt: Contraband Procedures

rule: Indicator 5.09

excerpt: Searches and Full Body Visual Searches

rule: Indicator 5.13

excerpt: Tool Inventory and Management

rule: Indicator 5.15

excerpt: Outside Contractors

rule: Indicator 5.16

excerpt: Fire, Safety, and Evacuation Drills

rule: Indicator 5.18

rule: Indicator 5.21

excerpt: Visitation and Communication