facility_name: Silver Springs Youth Academy

summary: QI Residential - FY25-26

raw_content:
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STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Silver Springs Youth Academy
Youth Opportunity Investments
(Contract Provider)
10420 NW Gainesville Road
Ocala, Florida 34482
Review Date(s): August 12 - 15, 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:
Forrest Hallam, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Interviews)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Jamie Franz, Post Secondary and Workforce Education, Deputy Director (Standard 2)
Jennifer Harris, Rite of Passage, Regional Compliance Director (Standard 4)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Minetricia Monbrun, Office of Research, Data, and Innovation, Operations Analyst (Standard 2)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Silver Springs Youth Academy MQI Program Code: N/A
Provider Name: Youth Opportunity Investments Contract Number: 10856
Location: Marion County / Circuit 5 Number of Beds: 40
Review Date(s): August 12-15, 2025 Lead Reviewer Code: N/A
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 64 (Revised August 2025)
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Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (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 ).
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 64 (Revised August 2025)
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) A s s e s s m e n ts a n d R e a s s e s s m e n ts 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls , a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s a n d In c o rp o ra tio n o f O th e r P la n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 3
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 4
E x it P o rtfo lio 2 .1 5
E x it C o n fe re n c e 2 .1 6
Y o u th In p u t 2 .1 7
E d u c a tio n A c c e s s (R e s id e n tia l P ro v id e r) * 2 .1 8
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s (R e s id e n tia l C o n tra c t P ro v id e 2 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 64 (Revised August 2025)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t * 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
S u ic id e P re v e n tio n P la n * 3 .0 9
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 0
S e c u re O b s e rv a tio n * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
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S a tis fa c to ry
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N o n -A p p lic a b
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e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
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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 64 (Revised August 2025)
Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised August 2025)
5555555555555555555555555 .0 1
C .0 2
.0 3
.0 4
.0 5
.0 6
.0 7
.0 8
.0 9
.1 0
.1 1
.1 2
.1 3
.1 4
.1 5
.1 6
.1 7
.1 8
.1 9
.2 0
.2 1
.2 2
.2 3
.2 4
.2 5
* T h e D e
p ro g ra m o
in d ic a to
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
Y o u th S u p e rv is io n *
o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g
U s e o f R o o m R e s tric tio n
T e n M in u te C h e c k s *
C e n s u s , C o u n ts , a n d T ra c k in g
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w
K e y C o n tro l *
C o n tra b a n d P ro c e d u re
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s
V e h ic le s a n d M a in te n a n c e
T ra n s p o rta tio n o f Y o u th
W e e k ly S a fe ty a n d S e c u rity A u d it
T o o l In v e n to ry a n d M a n a g e m e n t
Y o u th T o o l H a n d lin g a n d S u p e rv is io n
O u ts id e C o n tra c to rs
F ire , S a fe ty , a n d E v a c u a tio n D rills
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P )
S to ra g e , In v e n to ry , a n d D is p o s a l o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t *
V is ita tio n a n d C o m m u n ic a tio n
R e c re a tio n a n d L e is u re
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m
C o n tro lle d O b s e rv a tio n
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s
p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
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S a tis fa c to ry
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N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
N o n -A p p lic a b le
N o n -A p p lic a b le
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
m a re a (d e te n tio n ,
Program Overview
The Silver Springs Youth Academy is a forty bed program, for fourteen- to eighteen-year-old
males, located in Ocala, Florida. The program is operated by Youth Opportunity Investments,
through a contract with the Department. The program provides mental health overlay services
(MHOS) and substance abuse overlay services (SAOS). In addition, the program fosters each
youth by providing Moral Reconation Therapy, The Seven Challenges, Trauma-Focused
Cognitive Behavioral Therapy, Skillstreaming the Adolescent, and Impact of Crime. Additional
treatment services provided includes family, individual, and group therapy. Program
administration is comprised of a facility administrator, assistant facility administrator, human
resources business manager, and physical plant manager. Case management services are
provided by a director of case management, two case managers, a career and technical
education manager, and a transition services manager. Mental health staff at the program
include a clinical director, a licensed therapist, two mental health and substance abuse
therapists, and a recreational therapist. Medical services are offered seven days a week and are
provided by a registered nurse manager, four registered nurses, three licensed practical nurses,
a licensed physician, a licensed psychiatrist, and a licensed psychiatric advanced practical
nurse. The contract provider operates another program in close vicinity and has arranged for
their nurses to serve as-needed at this facility. Educational services are provided by the Florida
Virtual School. The layout of the program includes: two administration buildings, shared school
classroom portables, dining area, laundry facility, and two living modules with two sides each.
The program has 124 operating security cameras providing coverage. At the time of the annual
compliance review, the program had two vacant positions: a physical plant worker and a safety
and security specialist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 64 (Revised August 2025)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedure which indicates initial background screenings will be
completed for staff, volunteers, mentors, and interns. The program completed and sent a signed
Annual Affidavit of Compliance with Level 2 Screening Standard to the Department’s
Background Screening Unit (BSU) on January 20, 2025. Nineteen staff were reviewed as new
hires and each had an initial background screening conducted prior to contact with youth and
confidential youth records. Seven staff had breaks in service, and a new background screening
was completed for each of those seven staff. A criminal history report was reviewed, pre-
employment assessment with a passing score, and clearinghouse information was entered for
all nineteen staff. The program did not have any applicable contracted/provider, volunteers,
mentors, or interns who required a background screening during the annual compliance review
period.
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 which indicate all staff receive a background re-
screening every five years from initial date of employment. The five-year resubmission will be
completed on or before the five-year anniversary date. Since this contract has been in effect for
less than a year, there are no staff members which qualify for a five-year 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.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (Revised August 2025)
▪ 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 maintains a policy and procedures to ensure it provides an environment in which
youth, staff, and others feel safe, secure, and not threatened by any form of abuse or
harassment. Seven staff were interviewed. All seven staff indicated, if needed, they were able to
make an abuse call, and if any youth wanted to make an abuse call, they were permitted to.
Staff also indicated they would make sure their supervisor was informed, and their supervisor
would contact the assistant facility administrator (AFA). All seven staff indicated they have never
witnessed any staff telling a youth they could not call the Florida Abuse Hotline or the
Department’s Central Communication Center (CCC). Two of the interviewed staff stated they
had witnessed other staff using curse words around the youth; however, it was not directed at
the youth themselves but rather at a situation. Seven youth were interviewed. The youth
interviewed never witnessed or experienced any type of physical or sexual abuse. All youth
interviewed stated they could call the Florida Abuse Hotline or the CCC if they need to and
stated the numbers to call hotline are posted in the dormitories and cafeteria. Six youth
interviewed have never heard any curse words from staff. One youth stated he heard a staff use
a curse word once, but it was not directed at a youth but rather from surprise of an event
occurring. All seven youth feel safe in the program and felt the staff were there to help them and
are respectful to all youth in the program. None of the youth interviewed have exchanged
contact information with staff. Seven staff records were reviewed and contained a staff code of
conduct. During the program tour the CCC and Florida Abuse Hotline numbers were present in
large group areas and on the housing modules. The facility administrator stated the program’s
practice for incident reporting is all reportable incidents are called into the CCC within two hours
of the program learning of the incident, and the regional director is notified of any serious
incidents. A review of CCC incidents showed there were three closed incidents relating to
physical abuse resulting in two staff having corrective actions and one still under investigation.
The program provides new hire and annual in-service training regarding incident reporting. The
program completed a Trauma Responsive and Caring Environment (TRACE) self-assessment
on May 7, 2025.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures for reporting incidents to the Department’s Central
Communication Center (CCC). During the annual compliance review period, the program had
eleven incidents reported to the CCC, of which five were reviewed. All five of the incidents
reviewed were reported within two hours of the occurrence or within two hours of the program
becoming aware of the incident. The program currently has two open incidents pending findings.
No additional reportable incidents were discovered during the annual compliance review. The
program has not seen an increase in reportable incidents.
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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.
Right Interactions (RI) is the Department approved Protective Action Response (PAR)
curriculum which the program is trained in and uses for contact with youth. The program had a
total of six RI incidents during the annual compliance review period. The RI plan was updated
on December 10, 2024, and was approved by the Department on December 13, 2024. All six
reviewed reports were completed on the same workday, had statements from all involved staff,
were reviewed by a supervisor or RI instructor, had a medical review completed within thirty
minutes, and were reviewed by the facility administrator (FA) within seventy-two hours. None of
the RI incidents required the use of mechanical restraints, resulted in injuries to staff or youth, or
the youth alleged abuse. The program’s RI rate was 1.22 which is below the statewide
Residential RI rate of 2.41. Seven staff were interviewed, and each were able to explain the RI
process. All seven staff confirmed they use verbal communication with the youth all day. The
staff relayed they hardly ever use a takedown on youth, but when it happens, they write up a
PAR (PAR) report to explain what happened during the situation. Any staff who see the
interaction of a takedown must indicate on the PAR report what they witnessed. The interviewed
FA stated PAR incidents are tracked using an incident report tracker and monthly RI reports.
Closed circuit television is reviewed to ensure the interventions are appropriate with deviations
resulting in corrective action as necessary. The PAR incident tracker is reviewed by the program
and corporate staff monthly to determine if there is an increase in incidents and to develop a
correction action plan to deter escalation if required.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures for pre-service and certification requirements for new
staff during the first 180 days of employment. Staff in the positions of safety and security
specialists, supervisors, maintenance, and administrators are considered direct-care staff and
are counted in the youth-to-staff ratio. Documentation confirmed all instructors were qualified to
deliver training as provided in Right Interactions (RI), first-aid, cardiopulmonary resuscitation
(CPR), and automated external defibrillator (AED) use. The program’s training plan was signed
and approved by the facility administrator, the assistant secretary for residential services, and
the director of Talent, Leadership, and Development. Seven staff records were reviewed, and
each had the 120 hours of training completed within the180 days of hire. All seven records had
essential skills of CPR, first-aid, AED, emergency procedures, program operating procedures,
Prison Rape Elimination Act, child abuse recognition, reporting and prevention, professionalism,
interpersonal communication, ethics, standards of conduct, RI, and suicide awareness and
prevention completed prior to youth contact. All remaining essential courses were completed as
required, except for one staff not completing the equal employment opportunity course, who
resigned prior to completion. The program had no direct care staff with less than two years from
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separation which have returned. Three newly hired staff records were reviewed and found staff
completed all required training prior to being in the presence of 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 a policy and procedures for in-service training requirements. The program
provided credentials to verify instructors were qualified to deliver trainings. The program has an
annual in-service training plan which was approved by the facility administrator, assistant
secretary for Residential Services, and the direct of Talent, Leadership, and Culture. Due to the
program being in service less than one fiscal year, there are no applicable records to review for
staff 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 procedures which include the training requirements of the
grievance process. The grievance process includes an informal, formal, and appeal phase. The
program’s informal process involves youth access to communication request forms and the
option to resolve issues informally and immediately either verbally or using the forms. Grievance
forms are available on all housing units if the youth is dissatisfied with the informal resolution
process. The program’s policies and procedures correlate to their process. Five formal
grievances were reviewed from the annual compliance period. All five grievances were resolved
and completed within the specified time frames. Seven staff were interviewed, and each were
able to explain how a youth can file a grievance if they choose to. All seven staff stated the
grievance forms are in the shared living space of the dormitories and youth can ask for help if
the need help writing the grievance. All seven staff confirmed the assistant facility administrator
(AFA) and the facility administrator (FA) review the grievances each day. Four of the seven staff
also believed the supervisor reviews the grievances as well. Two of seven staff were able to
explain the grievance process as three phases (informal, formal, appeal) and each phase has a
timeframe. Seven youth were interviewed, and each were able to explain the grievance process
or at least know how to start the process. All seven interviewed youth explained there are
grievance forms on the wall in each dormitory and they can fill one out and place in a locked
box. One youth confirmed the AFA checks the box for grievances every morning. All seven
youth stated they could ask for assistance if they needed help with spelling. The youth who
have filed a grievance were able to talk to the AFA and explain what happened with more
description. The FA interview affirmed the administrator was aware of the three phases of the
grievance process, the practice which occurs at the program, and the timeframes for response
to grievances.
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1.9 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.10 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures in which the program shall provide a delinquency
intervention model or strategy which is an evidence-based practice, promising practice, or a
practice with demonstrated effectiveness, as well as life and social skills training for each youth.
The program provides life and social skills activities addressing communication, interpersonal
relationships and communication, non-violent conflict resolution, anger management, critical
thinking, including problem solving and decision making, and also addresses needs of the
program’s targeted population. In addition, the program provides groups on educational life
skills, inter-personal, health/hygiene, finances, and independent living. Each youth’s
criminogenic needs, risk and responsive to treatment are assessed by the case manager at
intake, using the Residential Assessment for Youth (RAY). The results of the assessment(s) are
used to develop and revise a youth’s RAY, performance, treatment and transition plans, and
generating goals to be achieved by the youth to progress through and ultimately completing the
program. The clinical director or trained designee conducts fidelity checks at least one time a
month. A review of the activity schedule showed groups occur daily. Seven youth records were
reviewed, and each youth received a Denial Memorial Life Skills Assessment upon admission
and notates the top three needs on youth’s performance plans. Seven interviewed youth stated
they were learning life skills in group counseling. Some of the things mentioned was skill
streaming, a workbook called “How to escape your own prison,” and how to respond in certain
situations when in the community. All seven interviewed youth relayed they practice things they
learn in group in treatment teams and every day within the program. The interviewed facility
administrator advised the youth participate in groups to include Impact of Crime (IOC), Moral
Reconation Therapy (MRT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and
Seven Challenges. The designated mental health clinician authority (DMHCA) interview advised
the youth complete MRT two to three times a week and Skillstreaming the Adolescent groups
one to two times a week. The DMHCA advised the youth are provided an opportunity to practice
the skills they learn daily.
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 Silver Springs Youth Academy. For details related specific to IOC service
delivery, please refer to the annual SPEP report.
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1.12 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedure to determine how new alerts are identified,
documented, updated, and communicated to staff. The policy states the Department’s Juvenile
Justice Information System (JJIS) critical alert list can be used by the mental health clinical staff
or other staff to indicate risk type and special instructions. Mental health clinical staff shall input
or have appropriate staff (medical, case management, or operations) input alerts based upon
the type and updated information. Food service staff will receive special dietary and food allergy
alert information from the medical department as alerts are updated and upon admission of new
youth. An alert communication board is utilized by the program and is maintained in the
conference room. The alert communication board contains all youth’s names, identification
number, and photograph. A color dot system is placed for all program related alerts such as
victimization, medication, suicide risk, allergies, special diet, gang alert, escape risk, out of
placement, and activity restriction. Only clinical mental health staff may classify a youth as high
risk or downgrade a high risk youth regarding a mental health situation, and only a medical
professional may classify a youth as a high risk or downgrade a high risk youth for medical.
However, administration and direct care staff may place a youth on constant or one-to-one
supervision until evaluated by the mental health clinician to assess the youth. Shift supervisors
are responsible for communication of alerts in the shift briefing and logbook communication.
Seven youth were reviewed and found to have a total of sixteen alerts which were on the alert
board and in JJIS according to the program’s process. All seven youth had records updated by
the medical or mental health professional, and all alerts were placed in JJIS in a timely manner.
The facility administrator interview stated internal alerts are updated daily as needed and are
reviewed during the daily management meeting. The alerts are communicated to staff through
the shift briefings and recorded in the logbook. Depending on the nature of the alert, updates
are also completed in JJIS by appropriate department heads. The nursing interview confirmed
medical alerts are entered and updated by the program nurses. Seven staff were interviewed.
All interviewed staff were able to articulate how they are notified of alerts and indicated it can be
done through shift briefings, alert logbook in master control, two-way radios, board in
conference room, allergy alerts in the kitchen, and verbally from the supervisors.
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
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The program separates youth records into two separate records: an individual healthcare record
(IHCR) and an individual management record. The IHCR is further separated into a medical and
mental health record. The individual management records for the seven youth reviewed had the
youth’s name, Department identification number (DJJID), date of birth, county of residence, and
committing offense listed on each record. Each record contained legal, demographics and
chronological information, correspondence, case management and treatment activities, and
miscellaneous sections. All youth records were labeled as confidential. Youth records were
maintained in a secure room within a locked filing cabinet. The filing cabinet was also labeled
confidential.
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 an advisory board and meets once at least every ninety to 120 days. The
program has active involvement from local law enforcement, judiciary, businesses, Florida
Scholar’s Academy, the faith community, and other community partners. The program also has
a victim advocate and a parent/guardian of a youth previously involved in juvenile justice system
on their advisory board. The program has had two meetings since opening and both meetings
were in person. Board meeting sign-in sheets and photographs were reviewed. The facility
administrator was interviewed and advised the Community Advisory Board (CAB) meets
quarterly to serve as a support to the program and a link to community resources. The CAB
includes members from law enforcement, the judiciary, the school board, local businesses, faith-
based organizations, victims, and former parents. An interview was conducted with the
community liaison officer with the Ocala Police Department and an advisory board member.
They advised the meetings occur quarterly and they are given a tour, provided an agenda, and
usually have a presentation by the youth. The advisory board member comments regarding the
program demonstrated a positive working relationship between their agency and the program.
1.15 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures to evaluate staff and set performance standards.
Formal evaluations are conducted annually. Five staff position descriptions were reviewed, and
the performance standards were clearly identified and matched the job descriptions for those
staff. Position descriptions were reviewed of staff which contained functions of implementation
of the program’s behavior management system (BMS) to include the clinical director, therapist,
safety and security specialist, and supervisor. The program’s contract was reviewed, and all
required positions were appropriately staffed. The program’s staff roster was reviewed, and an
appropriately credentialed recreational therapist was present as required by contract during the
entire compliance review period. The facility administrator advised monthly coaching occurs with
staff, as well as ninety day and annual performance evaluations. Seven staff were interviewed.
Three staff confirmed they were evaluated monthly. One staff stated they were evaluated every
six months and three staff said they were coached every ninety days. The program has not
been in service for a year, and some staff did not know if they would receive an annual
evaluation.
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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.
In the program’s contract with the Department there are services and items outlined in the
contract as special contract conditions. Each youth when released is provided a leather-bound,
zippered iHope experience portfolio to keep all their exit information, certificates, numbers, and
information, which was evident in three reviewed closed records. The transition services
manager attempts to keep in contact with all youth post-release for the first thirty days.
Examples of this were logged and reviewed in youth closed records. The program provides
youth with brand name clothing the youth keep when released as required. The program
conducts weekly awards for youth during town halls, provide student of the week, ‘Gotcha’
Positive Recognition, and awards from mental health staff as required. The program has a
friends in blue mentoring program and is partnered with the Ocala Police Department. Photos
were observed of a recent off-site opportunity with the agency. The program is required to and
provided non-denominational faith-based groups who come to the program and provide
religious services for the youth bi-weekly, as confirmed by a review of the program’s visitor log.
The program has the required two entertainment zones including the Creative Hope Music
Studio and a community barbershop. The youth are provided guidance in pro-social music by a
producer and given a copy of their created content on a media file once they leave the program.
The facility administrator interview confirmed the program’s current vocational opportunities.
1.17 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program practice regarding data trend analysis is to provide satisfaction surveys involving
the monitoring and verification of activities as a part of the program’s quality assurance.
Satisfaction surveys shall be provided routinely and will be completed on at least a quarterly
basis. Surveys include youth surveys, family surveys, and staff surveys. Surveys will target
admission activities, topic-specific assessments, and discharge satisfaction. Survey data is
reviewed and evaluated monthly in program-level and corporate leadership meetings. The
information is shared monthly through incident trackers which are distributed to the provider’s
programs and describe trends. Program and corporate leadership meetings include monthly
quality assurance review processes which incorporate reviews of program data, surveys, and
findings of formal monitoring and verification activities. Within each meeting, progress to date,
program strengths, improvement needs, and corrective action will be discussed.
Recommendations are made by the team with ongoing review, follow-up, and technical
assistance being provided as required. Meeting invites for program quarterly meetings between
corporate staff and Department of Juvenile Justice stakeholders as well as meeting minutes
were reviewed. The program shares information with providers and stakeholders and uses it for
long-term planning and staffing provisions. Stakeholders are informed and provided
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opportunities for feedback, performance improvement, and budgeting. This was reviewed
through the program’s advisory board meeting minutes, and additional documents. Survey
outcomes are collected and communicated by the program to improve their processes.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures in place to address notifying the youth’s
parents/guardians, juvenile probation officer (JPO), the committing court, and the post-
residential services case manager (if applicable), of the youth’s admission to the program. A
review of seven youth records indicated telephone notifications were made to each youth’s
parents/guardian within twenty-four hours of the youth’s admission. All seven records indicated
each youth’s parents/guardian were notified in writing within forty-eight hours of the youth’s
admission. Each youth record also indicated the JPO and committing court were notified of the
youth’s admission to the program within five working days.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to facilitate the orientation of youth upon admission.
The review of seven youth case management records revealed each youth received orientation
on the day of their entry into the program. Observations and subsequent review of the
orientation process established all essential components are reviewed, such as available
services, daily schedule, youth expectations and responsibilities, behavior management system,
access to medical, mental health, and substance abuse services, access to the Florida Abuse
Hotline and the Department’s Central Communications Center (CCC), zero-tolerance policy,
special accommodations, right to be free from sexual misconduct, contraband regulations,
performance planning process, dress code and hygiene standards, procedures for visitation,
mail, and telephone use, expectations for program release, community access, grievance
procedures, emergency protocols, facility tour, living room assignment, and treatment team.
Seven youth were interviewed, and all confirmed the orientation covered program guidelines,
procedures, and timeframes. All interviewed youth confirmed they received a handbook to
review and were encouraged to raise any questions they might have. The Behavior
Management System was clearly explained, outlining the behaviors leading to incentives and
those resulting in disciplinary actions. Additionally, all seven youth acknowledged they received
the orientation within twenty-four hours.
2.03 Written Consent of Youth Eighteen Years or Older Non-Applicable
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.
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The program has not had any youth eighteen years of age or older during the annual
compliance review period; therefore, this indicator is rated non-applicable.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures to effectively address classification factors,
processes, and the reassessment of activities. The program’s policy and procedures clearly
outline the classification process and include a classification system which promotes safety and
security as well as effective delivery of treatment services, based on each youth’s individual
needs and risk factors. A review of seven youth case management records confirmed an initial
classification form was completed on each youth’s admission date to the program. This
classification form encompassed vital information including the youth’s physical characteristics,
age, maturity, any special needs, history of violence, gang affiliation, criminal behavior, a newly
conducted screening for Vulnerability to Victimization and Sexually Aggressive Behavior
(VSAB), perceived vulnerability, and a documented history of potential or verified human
trafficking, alongside each youth’s identified risks related to suicide, medical conditions, escape,
and security. All seven records demonstrated the youth were appropriately classified for the
purposes of assignment to living areas, sleeping accommodations, group placements, and staff
advisors. Four of the seven records reviewed had medical risk and three records had security
risks. Additionally, a review of the Department’s Juvenile Justice Information System (JJIS)
confirmed alerts were entered for all youth identified with risk factors. The program maintains
written policy and procedures mandating the completion of risk assessments prior to
considering any increase in privileges or freedom of movement, as well as participation in work
projects or activities involving tools or instruments which could be used as weapons or means of
escape, including off-campus activities. A review of the seven youth case management records
indicated risk assessments were conducted for all youth as required. According to program
policy, youth are to be reassessed and reclassified as necessary. Such reassessments are
reviewed during formal treatment team meetings. The review of the seven youth records
revealed six youth were applicable and documentation showed each were reassessed for
increases in privileges, freedom of movement, and participation in specific work projects or off-
campus activities. One youth was deemed ineligible for reassessment during the annual
compliance review period. A formal interview with the facility administrator verified treatment
team meetings are held and all required factors are discussed prior to assigning youth to their
respective rooms.
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2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures for gang identification and notifying law enforcement.
Seven youth records were reviewed, and those cases were not applicable for gang identification
or necessary law enforcement notifications. The program has had only one applicable youth
since the program has been in operation who qualifies for gang identification. The program
notified their administration including education, the youth’s juvenile probation officer, local law
enforcement, and law enforcement from the youth’s home county of the youth’s suspected gang
activity. A suspected gang activity alert was entered into the Juvenile Justice Information
System.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures designed to address strategies for gang prevention
and intervention. In accordance with these policies, youth are provided with the opportunity to
develop a plan to dissociate from criminal street gangs if they choose to pursue this course of
action. A review of seven youth case management records indicated none of the youth required
access to gang intervention and prevention strategies. The program has had only one youth
who required gang intervention since the program has been in service. The youth in the
program required gang intervention which was notated on the youth’s performance plan. The
program utilizes, “Gangs: Fifty + Stories of Fractured Lives” group lessons for gang intervention.
The facility administrator interview confirmed the curriculum is utilized and advised the services
are provided monthly.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure an initial Residential Assessment for Youth
(RAY) is completed within the first thirty days of a youth’s admission. Additionally, RAY
reassessments are to be conducted every ninety days thereafter. A review of seven youth case
management records revealed an initial RAY was completed for six youth within thirty days of
their admission to the program. This initial RAY was properly documented in the Department’s
Juvenile Justice Information System (JJIS). One youth was not applicable because they were
still within their first thirty days at the program. Out of the six applicable youths, three were
deemed eligible for a RAY reassessment by the ninety-day timeframe or based on
recommendations from the intervention and treatment team. One reassessment was completed
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in the required timeframe and two were completed two and fifty-six days late. The remaining
three youth had been in the program for less than ninety days and not applicable for a
reassessment.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures requiring a Youth Needs Assessment Summary
(YNAS) to be completed within thirty days of a youth's admission. A review of seven case
management records confirmed a YNAS was completed for six youth within this timeframe, and
each was documented in the Department's Juvenile Justice Information System (JJIS). One
youth had not been in the program over thirty days at the time of the annual compliance review.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a policy and procedures to manage the development of performance plans
based on findings from the youth’s initial assessments within thirty days of admission, set goals
and target dates, and facilitate transmittal of the plan to the appropriate parties. Seven youth
case management records were reviewed. Six of the seven youth records showed the
performance plan was created within thirty days of each youth’s admission into the program.
One youth has been in the program for less than thirty days, and a performance plan has not
been developed yet. The performance plan for the six applicable youth was created following
the initial Residential Assessment for Youth (RAY) and the Youth Needs Assessment Summary
(YNAS) for each youth.
All individuals with substantial responsibility in the achievement of the youth's goals were
present during the creation of each youth's Individualized Performance Plan (IPP). Present
members included the leader of intervention and treatment, the youth, an administrative
representative, a living unit representative, treatment staff, educational staff, and any additional
parties who have a significant responsibility in goal completion. One youth reviewed was
involved with the Department of Children and Families (DCF) but has been at the program less
than 30 days. The DCF case manager has been notified in advance of the creation of the plan.
None of the youth were involved with the Agency for Persons with Disabilities (APD). A
signature sheet from the IPP was filed for the six applicable youth in the official case records.
A review of the six applicable youth case management records indicated each youth had an IPP
to include individualized goals based upon prioritized needs reflecting the risk and protective
factors identified during the initial assessment process, the youth’s three top criminogenic
needs, specific delinquency interventions with measurable outcomes, targeted court ordered
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sanctions, transition activities targeted for the last sixty days of youth’s anticipated stay, youth
and program staff responsibilities to enable youth to complete goals, and targeted dates for goal
completion. Further review of the six youth case management records indicated the program
sent each youth’s IPP to the committing court, the juvenile probation officer (JPO), and
parent/guardian within ten working days of the plan being completed. Seven youth were
interviewed, and all of them participated in the development of their IPPs, with one of those
youth’s performance plan in progress due to being in the program for less than thirty days.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures for managing revisions to performance plans. A
review was conducted of seven youth case management records. Four of the seven youth
performance plans were eligible for revisions, since three of the remaining youth had been in
the program for less than ninety days. Revisions were finalized for each of the four relevant
youth, based on the results of the Residential Assessment for Youth (RAY) reassessment,
newly obtained or disclosed information, and/or the youth's demonstrated progress or lack
thereof in achieving a goal. None of the reviewed youth were appliance for transition activities.
Additional plans incorporated into the performance plan included academic and treatment plans.
None of youth reviewed for performance plan revisions were involved with the Department of
Children and Families or Agency for Persons with Disabilities.
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 to address Performance Summaries and transmittals
at ninety-day intervals. Seven youth case management records were reviewed and three were
applicable for completion of a ninety-day Performance Summary following the signing of the
performance plan. One of the three summaries was completed in the required time frame. One
performance plan was six days late and the another was sixty days late. The program advised
the initial case manager took a different role within the program, and the new case manager
was not aware of the youth needing an updated performance summary. The director of case
management became aware of the need for summary to be completed during a records review
and took action to have it completed. None of the performance summaries reviewed were
eligible for having justification for release, discharge, or transfer information included in their
Performance Summaries.
Three closed youth records were reviewed for transition and release summaries. All three
applicable records included documentation indicating the original summary was sent with a Pre-
Release Notification (PRN) to the juvenile probation officer (JPO), and the release summary and
PRN were sent at least forty-five days prior to planned release. All three youth records included
a signed copy of the PRN for release, approval and written notification to the parent/guardian
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regarding the youth’s anticipated release. Once approved, the program completed a Residential
Assessment for Youth (RAY) exit assessment for all three reviewed records. The regional
compliance manager indicated there were no youth released from the program during the
annual compliance review period who required victim notification or were applicable for the
sexually violent predator program.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to ensure parents or guardians are actively involved
in the case management services provided to youth. A review of seven youth case management
records revealed the program took appropriate steps to engage the parent/guardian in the case
management process. This included their involvement in the assessment process, participation
in the development of performance plans, progress reviews, provided advance notice of formal
treatment team meeting dates and times, and involved with transition planning. An observation
of a treatment team meeting during the annual compliance review week could not be conducted,
as these meetings were not scheduled during the review week. A review of the case
management records for the seven youth indicated the program provides the youth’s
parent/guardian with the opportunity to participate by telephone or video conferencing, or to
submit verbal or written input prior to the meeting if they are unable to attend. Furthermore, the
parent/guardian is encouraged to provide feedback and pose any questions they may have
during the treatment team meetings. Seven youth were interviewed, and all confirmed their
parent/guardian participated in the treatment team and family counseling. Each youth reported
they are allowed to call their parent/guardian once a week, with the opportunity for an additional
call during the week as an incentive. Those who live closer to the program also visit on family
days and attend treatment team meetings at the office. The facility administrator advised during
an interview, the program encourages parent involvement through a variety of opportunities,
including quarterly family days, family forums, monthly treatment team meetings, and family
sessions. In addition, youth are provided weekly visitation and regular phone call opportunities.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures which mandates the intervention and treatment team
to convene bi-weekly, both formally and informally, to assess each youth's performance. A
review of the case management records for six out of seven youth indicated these formal and
informal reviews were conducted as required. The remaining youth has been in the program for
less than thirty days and has not yet participated in a treatment team meeting. The
documentation from the treatment team meetings for each applicable youth included essential
details such as the youth's name, the date of the review, required attendees, feedback from
treatment team members and others, a concise overview of the youth's progress within the
program, any revisions to the performance plan, updates on performance plan goals,
observations of positive and negative behaviors, instances of behaviors leading to physical
interventions, confirmation the youth was provided the opportunity to demonstrate the skills
acquired in the program, treatment progress, and the results from the Residential Assessment
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for Youth (RAY) reassessment. A review of the six youth case management records revealed
both formal and informal treatment team documentation was consistently included in each
youth's records. Additionally, all seven case management records contained evidence indicating
the juvenile probation officer (JPO), parent/guardian, and all relevant parties were invited and
encouraged to participate in the process, either in person or through verbal or written
communication with adequate prior notice.
An observation of a treatment team meeting during the annual compliance review week was not
feasible, as these meetings were not scheduled during the review week. Nevertheless, a review
of the six case management records confirmed all required staff members were present,
including those from the education department. Furthermore, the youth's treatment plans were
reviewed to establish the anticipated release dates for each youth. Documentation contained
comments from treatment team members, the youth’s progress in program, progress with
performance plan goals, update on youth’s behaviors including those involving physical
intervention if applicable, opportunity to demonstrate skills, treatment progress, and RAY
reassessment results if applicable. Seven youth were interviewed, and each reported the staff
actively listened to them and provided constructive feedback. The staff praised them when they
performed well and explained how they could handle situations better if similar issues arose in
the future. The seven youth worked on various items within the treatment team. Two of the
youth shared their improvements, while three reported being respectful to everyone during the
sessions. Two youth discussed their struggles and explored strategies to avoid those
challenges.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures to address transition planning, conferences, and
Community Re-Entry Team (CRT) meetings. A review of three closed records revealed each
youth's transition conference was held at least sixty days prior to their targeted release date.
Documentation in each record indicated the youth, the treatment team leader, the program
director or their designee, and other team members attended the transition conference or
provided information to the team leader beforehand. The treatment team leader actively invited
and encouraged participation from all required parties, including the youth's juvenile probation
officer (JPO), parent/guardian, education staff, and any other relevant individuals.
Further examination of the three closed youth records showed participants reviewed transition
activities outlined in the youth's performance plan, made revisions, when necessary, identified
additional transition activities, set target completion dates, and designated individuals
responsible for each task. Each youth's record included documentation the treatment team
leader obtained dated signatures from attendees, indicating their acknowledgment of the
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transition goals and their accountability for their completion. A copy of the transition plan was
sent to anyone not in attendance who had responsibilities for achieving the transition goals,
along with a request for their signed acknowledgment. If the plan was sent electronically to
required parties, the return email acknowledgment receipt was printed and filed with the plan.
Additionally, information in the three closed youth case management records indicated a CRT
meeting was held before the youth's release, which included the case manager. An email or
Outlook invitation for the meeting was also present in each youth's record.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to create an exit portfolio for each youth. A review of
three closed records showed the exit portfolio was discussed and initiated during the transition
conference. Each of the three closed records included a copy of the youth’s transition plan, a
calendar detailing all dates, times, and locations of upcoming community appointments,
educational and vocational certificates earned during the program, academic records, school
transcripts, and résumés. One youth record had sample employment applications while two
youth records did not have a sample employment application. One youth already possessed a
state identification card, while the other two did not have identification cards due to incomplete
documentation from their parent/guardian; however, the records documented numerous
attempts to obtain the necessary information for these youths. Furthermore, notifications were
made to the juvenile probation officer (JPO) and relevant organizations to assist the youth in
obtaining their state identification cards, Social Security cards, and birth certificates following
their release. A review of each youth’s record confirmed the exit portfolio was verified during the
exit conference, completed, and given to the youth upon their release. Additionally, each youth’s
exit portfolio information was forwarded to their JPO. The program’s contract also indicated a
requirement for a thirty-day post-release follow-up, which was completed in each reviewed
record.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures to conduct an exit conference for each youth.
A review of three closed records showed an exit conference was held for each youth at least
fourteen days prior to their release and after the juvenile probation officer was notified. Each
record included the date of the conference, signatures or names of those who participated by
telephone, and a summary of pending transition goals. Additionally, an examination of the
Department’s Juvenile Justice Information System (JJIS) confirmed the admission and
termination dates for the youth matched the information documented in each youth’s record.
The status of transition activities and exit portfolio was determined during the transition
conference, and the education and vocational plans for the youth’s release were reviewed, as
noted in each youth’s record. Further review of the three closed records indicated the
intervention and treatment team leader, parent/guardian, education representative, juvenile
probation officer (JPO), youth, and other relevant parties participated in each youth’s exit
conference. These conferences were held separately from the transition and Community Re-
Entry Team meetings.
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2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures in place to address youth input. A review of the
program’s procedures and advisory board meeting sign-in sheets indicated youth advisory
board meetings are conducted bi-weekly to promote constructive input by the youth. The
program also conducts weekly town hall meetings. Seven youth were interviewed, and five
youth indicated they provide input through student council. One youth indicated input is through
grievances, talking to the counselor, and discussions in house meetings. The one remaining
youth replied by saying “yes”. An interview with the facility administrator (FA) confirmed advisory
board meetings are conducted bi-weekly to solicit input from youth and administrative staff. The
FA further indicated the program conducts weekly town hall meetings to ensure all youth and
staff can add input for any program changes.
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 program
provides education services through Florida Scholars Academy. A review of the program’s
activity schedule and the daily academic schedule indicated the program activity schedule
incorporates the daily school schedule. The interview with the lead teacher indicated all youth
receive credit for completing a course and the school schedule is adhered to. Seven interviewed
youth reported education services are being provided to them. Four interviewed youth reported
no interruptions. Three youth attributed the issue to students talking in class and felt the
administration was trying to improve learning conditions in school. A review of randomly
selected days in the logbook since the program opened indicated education classes started and
ended on time according to the schedule, except on two days where one day classes began ten
minutes late however was held over to make up the time, and the other day class started five
minutes late. Observations of the program video for three days showed youth were in school
during scheduled times. Video observation revealed lunch period was taken a few minutes
earlier than scheduled; however, since school started early and ended later in the previous
schedule, all required instructional time was met.. Seven interviewed youth reported education
services are being provided to them. Four youth reported no interruptions. Three youth reported
the interruptions were due to other youth being disruptive and they felt the administration
addressing the disruptions to improve learning conditions.
2.19 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
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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 has contract specific conditions for career and technical education (CTE) services.
Thirty-four youth have completed cardiopulmonary resuscitation (CPR) and First Aid. Forty
youth have acquired Occupational Safety and Health Administration (OSHA-10) certification,
and thirty-two youth have completed the O*NET career profile assessment. One youth has
attained forklift certifications, and forty-three youth have attained the Serv-Safe Food safety
worker certification. A review of the program’s activity schedule confirmed the program provided
services as required. The program’s food service manager provides food service certification
and is qualified. CPR and First Aid certification is completed by certified program staff.
Observations of CTE services were not completed due to the time services are completed. The
facility administrator was interviewed and stated the Florida Ready to Work, OSHA-10, food
handling, and CPR and First Aid are the provided CTE services. Seven youth were interviewed.
All seven youth mentioned they have received career and technical education while at the
program. Some career education received by the youth are OSHA certifications, Save Serve for
working in restaurants, and CPR/First Aid. Some of the other education mentioned was working
on a forklift/truck driver simulator, cutting hair in the barbershop, and learning how to work in a
music studio.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a designated mental health clinician authority (DMHCA) who is responsible for
the administrative oversight and management of mental health and substance abuse services in
the program. The DMHCA is a licensed mental health counselor with an active license expiring
March 31, 2027. The DMHCA was on-site weekly, or as required by contract, to ensure
appropriate coordination and implementation of mental health and substance abuse services
were taking place. Copies of the DMHCA agreement and position description were reviewed
and found to meet all requirements. The program offers Mental Health Overlay Services
(MHOS) and Substance Abuse Overlay Services (SAOS). The DMHCA, who is a licensed
mental health professional, is responsible for the coordination and implementation of mental
health/substance abuse services. The back-up DMHCA holds an active license expiring March
31, 2027. An interview with the DMHCA confirmed during the youth’s intake process, the
licensed mental health professional (LMHP) identifies youth needs and assigns each youth to
an individual therapist based on the therapist’s expertise as well as the youth’s clinical needs.
The DMHCA has daily communication with the non-licensed therapists and provides one hour of
face-to-face weekly clinical supervision.
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.
A review of the job descriptions and the informal interview with the designated mental health
clinician authority (DMHCA), confirmed the DMHCA ensures the licensed clinical staff working
under their supervision are performing services they are qualified to provide based on
education, training, and experience. The licensed mental health and substance abuse clinical
staffing is in accordance with the current contract and Florida Administrative Code. Copies of all
licenses of each licensed mental health professional and licensed qualified professionals were
available on-site and reviewed.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
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The clinical supervisor assures the non-licensed clinical staff working under their supervision
are performing services they are qualified to provide based on education, training, and
experience. Reviewed documentation reflected each non-licensed mental health clinical staff
working under the direct supervision of a licensed mental health professional received a
minimum of one hour a week of on-site, face-to-face direct supervision by a licensed mental
health professional for the purpose of overseeing and directing the mental health services
provided in the program during the annual compliance review period, as required. Direct
supervision is recorded on a form which included all required elements of the Department’s
Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals
Direct Supervision Log form. The program has a Chapter 397 license expiring April 1, 2026.
Non-licensed mental health and substance abuse clinical staffing were in accordance with
current contract to include number of on-site hours. The program had five non-licensed mental
health clinical staff who hold a master’s-level degree from an accredited university or college in
the field of counseling, social work, psychology, or related human services field during the
annual review period. The non-licensed substance abuse clinical staff are employees of a
provider licensed under Chapter 397. All non-licensed mental health clinical staff who conducted
Assessments of Suicide Risk completed twenty hours of training and supervised experience in
assessing suicide risk, mental health crisis intervention, and emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Seven youth records were reviewed for mental health and substance abuse admission
screenings. All seven youth had a Massachusetts Youth Screening Instrument 2 (MAYSI-2)
completed during intake. The screener reviewed available information to include the
commitment packet and reports and/or records for existing documentation of mental health or
substance abuse problems or history of human trafficking in each record, as required. Each
reviewed youth had the screening completed in the Department’s Juvenile Justice Information
System (JJIS) on the date of admission, by a trained staff. All seven MAYSI-2 forms were
completed in full. Five of the MAYSI-2 forms indicated further assessment was required, and a
referral was made for further evaluation in all five applicable records. In the five records, the
MAYSI-2 indicated the need for an assessment, crisis intervention, or emergency services, the
facility administrator or designee was notified, and a referral was made to alert the designated
mental health clinician authority (DMHCA). An Assessment of Suicide Risk (ASR) was
completed on all youth within twenty-four hours of admission in all seven records. None of the
youth were applicable for emergency services or were in crisis. None of the youth were placed
on Precautionary Observation as a result of the ASR during intake processing. All seven youth
received an ASR and comprehensive evaluation as part of the intake process and the referral
reason was documented, as required. The facility administrator is responsible for developing a
written policy and procedures for the implementation of a standardized admission/intake mental
health and substance abuse screening process. The policy addresses a standardized screening
process which includes review of commitment packet information, reports and records,
administration of the MAYSI-2 in JJIS or Clinical Mental Health Screening is completed by a
licensed mental health professional and Clinical Substance Abuse Screening by a qualified
professional, and referral of juvenile offenders identified by screenings as in-need of further
evaluation or immediate attention. The policy also includes staff training in mental health and
substance abuse issues, administration of the MAYSI-2, and a standardized process for referral
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of youth identified as in-need of further mental health and/or substance abuse evaluation to an
appropriate service provider/professional or, when immediate attention is needed, to a hospital
or Baker Act or Marchman Act receiving facility. An interview with the facility administrator
confirmed the program’s policy regarding the screening process to identify youth at risk for
mental health and substance abuse problems and suicide.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
An interview with the designated mental health clinician authority (DMHCA) indicated during the
intake process, the licensed mental health professional (LMHP) gathers current information from
youth and, within five days, the LMHP confirm each youth's reports by referring to collateral
information obtained in youth's records to complete the Brief Behavioral Health Status Exam.
Each youth receives a comprehensive assessment within thirty days of the intake based on their
current and past behavior by licensed or non-licensed mental health professional and reviewed
by clinical director or designee. Seven youth records were reviewed for mental health and
substance abuse assessment/evaluation. The program completed a new, combined mental
health and substance abuse evaluation for six of seven youth within thirty days of admission.
One youth was a recent intake and was within thirty days of admission. All seven of the youth
records were applicable to substance abuse treatment and all seven youth records had a
consent for substance abuse services. Four of the six evaluations were completed by a non-
licensed clinical staff and were reviewed and signed by a licensed mental health professional.
All six applicable youth combined mental health and substance abuse evaluations contained all
the required elements, including identifying information, reason for evaluation, relevant
background information, behavioral observations, mental status examination, procedures
administered, discussion of findings, diagnostic impression, patterns, impact, and risk factors of
alcohol and other drug abuse, and recommendations.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Seven youth records were reviewed for initial mental health and substance abuse treatment
plans. All seven youth records showed the initial plans were developed on the day of admission,
regardless of the youth’s psychotropic medication status. All seven initial mental health and
substance abuse treatment plans included all the elements of the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Four youth records were applicable for
psychiatric needs, and the information was included in the plan, as required. Two plans were
completed by a license clinical staff and five initial treatment plans were completed by a non-
licensed mental health clinical staff which were signed by the licensed clinical supervisor within
ten days of completion. All seven plans included signatures of the youth, treatment team leader,
program management, living unit representative, and medical staff. All seven plans had parent
involvement and juvenile probation officer (JPO) by phone documented.
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Seven youth were reviewed and six were applicable for having individualized treatment plans,
one youth was still within their first thirty days of admission. Four applicable plans included
psychiatric services, including psychotropic medication (when applicable) and frequency of
monitoring by the psychiatrist for all youth who received psychotropic medication. All six
treatment plans were completed on a form which contained all the elements of the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan Review form. Treatment plan
reviews were completed every thirty days, as required, in five applicable records reviewed. Two
youth were within thirty days of the development of their treatment plan. Individualized treatment
plans and reviews included signatures of all the required parties in all six applicable records
reviewed. Prescribed services were outlined in the youth’s individualized treatment plan and
included family, individual, and group therapy, and psychiatric services, when necessary, in
each plan reviewed. Goals and objectives were individualized for each of the six youth, as
required.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
Seven youth records were reviewed for treatment and discharge planning. All seven youth were
assigned to a treatment team upon arrival to the program. Documentation reflected treatment
teams included the youth, program administration, residential living unit representative,
education, medical, mental health, and substance abuse staff, and the parent/guardian for all
seven youth. All seven youth who received mental health treatment have a properly executed
Department’s Authority for Evaluation and Treatment (AET) form. All seven youth were
applicable to receiving substance abuse treatment and provided consent through a signed
Department’s Youth Consent for Substance Abuse Treatment form. Mental health treatment
and/or substance abuse treatment notes were documented on the Department’s
Counseling/Therapy Progress Notes form in all seven records. All seven youth received mental
health and substance abuse therapy which included individual psychotherapy or counseling and
psychosocial skills training. Progress notes determined all seven youth received services as
stipulated on the treatment plan.
A sample of three closed youth records were reviewed for treatment and discharge planning. All
three discharge plans were documented on the Department’s Mental Health/Substance Abuse
(MH/SA) Treatment Discharge Summary form. None of the youth were released while on
suicide alert/precautions. The MH/SA Treatment Discharge Summary documented any future
services needed for all three youth. A review of documentation reflected the discharge plans
were discussed with the youth, parent/guardian (when allowed), and juvenile probation officer
(JPO) during the exit conference in all three records. A copy of the MH/SA Treatment Discharge
Summary was provided to the youth, Juvenile Probation Officer, and to the parent/guardian in
each record.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program offers mental health overlay services (MHOS) and substance abuse overlay
services (SAOS) as part of their specialized treatment services. The program’s required clinical
groups include Seven Challenges, Moral Reconation Therapy, and Impact of Crime. Seven
youth were interviewed. All seven youth confirmed they receive individual and family counseling.
Seven staff were interviewed, and six of seven staff denied facilitating any mental health or
substance abuse groups. One staff interviewed conducts the Impact of Crime group, in which
the staff is certified. An interview with the designated mental health clinician authority (DMHCA)
confirmed individual, family and group therapy are provided at the program. The facility
administrator stated the program provides specialized treatment services of MHOS and SAOS.
The focus of treatment services shall include targeting and reducing/alleviating the youth’s
symptoms of mental health and substance related disorders, as applicable, and enabling the
youth to improve functioning and return to the community. Ancillary services are provided
directly or through referral in instances where the provider cannot or does not provide certain
services needed by individual youth.
For both MHOS and SAOS, the counselor to youth ratio is one-to-sixteen. All non-licensed staff
hold a master’s level degree. Individual therapy is provided at least once every two weeks, and
family therapy is provided at a minimum of once every month, as applicable. A review of
documentation shows the psychiatrist provides services at least once every two weeks, as
required. A licensed mental health counselor provides on-site services, as needed, and is
involved in treatment planning. None of the youth during the annual compliance review period
were MHOS youth. Group therapy included four total substance abuse groups each week for all
youth, as required. No youth missed services due to being in medical quarantine.
3.09 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written plan detailing suicide prevention procedures which includes
identification and assessment of youth at risk of suicide, staff training, suicide precautions,
levels of supervision, referral, communication, notification, documentation, immediate staff
response, and a review process. The review process for suicide attempts and mortality review
includes circumstances surrounding the event, facility procedures relevant to the incident, all
relevant training received by the staff involved, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations, if any, for changes in
policy, training, physical plant, medical or mental health services, and/or operational
procedures. The Suicide Prevention Plan was reviewed July 31, 2025, and signed by the facility
administrator and designated mental health clinician authority (DMHCA).
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3.10 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Seven youth records were reviewed for suicide prevention services. None of the seven records
were applicable for needing suicide prevention services, as such, the program provided three
additional records for review. The youth were determined to be at-risk through staff observation
or youth self-representation. The Assessment of Suicide Risk (ASR) was completed on the
Department’s Assessment of Suicide Risk form for all three records reviewed. All three youth
were placed on constant supervision. The ASR included precautionary observation date and
ASR referral date. The youth’s parent/guardian was notified of the youth’s potential suicide risk,
as indicated by the ASR, in all three records. The parent/guardian and juvenile probation officer
(JPO) notification was documented on the ASR in all three records. Mental health staff provided
support services in each record. The ASRs were completed by licensed mental health
professional or clinical staff under the supervision of licensed mental health professional in all
three records. For all three records reviewed, the ASR was completed within twenty-four hours
of screening/concerns by a licensed staff or an appropriately trained non-licensed staff. Each
record required one or more Follow-Up Assessments of Suicide Risk (FASR) to be completed
prior to removing the youth from precautionary observation. The FASRs were documented on
the Department’s Follow-Up Assessment of Suicide Risk form, in all three records. Each youth
was maintained on suicide precautions and either one-to-one or constant supervision until the
FASR indicated suicide precautions could be discontinued. When the youth’s FASR indicated
suicide precautions could be discontinued, the youth was stepped down to close supervision
prior to transition to normal routine and standard supervision in all three records. Close
supervision was maintained until it was determined no longer necessary by the designated
mental health clinician authority (DMHCA), or licensed mental health professional in each
record. There was documentation of a conference held by the facility administrator and licensed
mental health professional to reduce the level of supervision in all three records. The
discontinuation of close supervision was documented in accordance with the program’s suicide
prevention plan, a suicide alert was initiated in the Department’s Juvenile Justice Information
System (JJIS) for the youth placed on suicide precautions, and the JJIS Suicide Risk alert was
accurately closed following the recommendations of the FASR in all three records. There was
evidence in the facility logbook indicating administration or supervisory staff provided
instructions related to the suicide risk assessment findings and suicide precaution decisions in
all three records. While on Precautionary Observation (PO), all three “at-risk” youth were
allowed to participate in select activities with other youth in designated safe housing/observation
areas of the facility. No youth were on PO during the previous thirty days, as such, video review
was not able to be completed.
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3.11 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “Non-
Applicable.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Seven youth records were reviewed for suicide precaution observation logs. None of the seven
records were applicable for needing suicide prevention services, as such, the program provided
three additional records for review. The Department’s Suicide Precaution Observation (PO)
Logs were maintained for the duration the youth was on suicide precaution, and the appropriate
level of supervision and observations of the youth’s behavior was documented in real time and
not exceeding thirty-minute intervals in all three applicable records. When warning signs were
observed, notification was made to the facility administrator or designee and mental health
clinical staff documented on the PO Log in all three records. PO Logs were reviewed and signed
by each shift supervisor and mental health staff in all three records. The PO Logs documented
safe housing requirements for all three records reviewed.
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.
Seven in-service and seven pre-service direct care staff were reviewed for suicide prevention
training. The program has one suicide response kit, co-located with the first-aid kit, located in
master control. A review of mental health drills showed training included mock suicide drills held
no less than quarterly on each shift for all staff who come in contact with youth, including kitchen
and maintenance staff. A review of video confirmed mock mental health drills were in response
to a suicide attempt and/or incident of serious self-injury and were simulated. No program youth
were used in drill simulations related to mental health or substance abuse care. The program
provided semi-annual training on emergency response procedures which includes “mock”
training in emergency response to a suicide attempt or incident of serious self-inflicted injury
and included the use of cardiopulmonary resuscitation (CPR). Staff who were not present during
a quarterly drill were given the opportunity to review each drill scenario and procedures to
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or incident of serious self-inflicted injury in the facility, as required. An interview with the
facility administrator (FA) determined the program conducts monthly mock drills facilitated by
designated program staff. These drills include scenarios such as fire, Continuity of Operations
Plan (COOP), escape, medical emergencies, and mental health crises. Additionally, staff
participate in mock drills on each shift which focus on emergency responses to suicide attempts
or incidents of self-inflicted injury. Seven staff were interviewed and six staff stated they must
contact mental health immediately. The facility administrator was notified of the results and
advised training would be completed with all staff. None of the staff stated they would put the
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youth in a locked room. All seven staff confirmed there is a knife for life, wire cutters and needle
nose pliers in 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 a notification and alert system,
means of referrals, including youth self-referral, communication, supervision, documentation,
and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Seven youth records were reviewed for crisis assessments. None of the youth were applicable,
as such, the program provided the one youth record which was applicable for having a crisis
assessment during the annual compliance review period. A review of documentation showed
the crisis assessment was conducted immediately based on the needs of the youth as required.
The crisis assessment included the reason for the assessment, mental status examination,
determination of danger to self and others, initial clinical impressions, supervision, treatment,
and follow-up recommendations, and notification to the parent/guardian. The crisis assessment
was conducted by a non-licensed mental health clinical staff working under the direct
supervision of a licensed mental health professional. A mental health alert was entered into the
Department’s Juvenile Justice Information System (JJIS) when the youth was placed on
precautions after completion of a crisis assessment. Constant supervision of the youth while on
the mental health alert was documented on the Department’s Mental Health Alert – Observation
Log. The youth did not require off-site care and was not a Prison Rape Elimination Act (PREA)
related event.
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3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse services and crisis
intervention plan which includes immediate staff response, notifications, communication,
supervision, authorization to transport for emergency mental health or substance abuse
services, transport for emergency mental health evaluation and treatment under Chapter 394
Florida Statute Baker Act, transport for emergency substance abuse assessment and treatment
under Chapter 397 Florida Statute Marchman Act, documentation, training and review.
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 Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The safety planning process for youth was reviewed in seven youth records. All seven youth
had a safety plan completed on their date of admission. The plans were prepared jointly with the
youth, parent/guardians, and clinical staff. All seven youth safety plans incorporated
recommendations from previous or current clinical assessments or screening instruments and
incorporated trauma responsive practices. The plans were reviewed and updated as necessary
following any significant behavioral or mental health event identified by the youth’s intervention
and treatment team, or at least every thirty days, in five of seven records, as required. One
youth was within thirty days of admission, and one youth was within thirty-days after the initial
safety plan was completed, therefore neither were applicable. All seven safety plans included
warning signs, the youth’s baseline behavior, crisis recognition, jointly developed coping
strategies, intervention strategies preferred by the youth, and debriefing process. Safety plans
are reviewed by staff who have contact with the youth and are maintained in the safety plan
binder in master control. Seven youth were interviewed, and each confirmed they contributed to
the creation of their safety plan. An interview with the facility administrator confirmed safety
plans are updated every thirty days or following significant behavioral or mental health events.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a board-certified physician who is a
licensed medical doctor (MD) who specializes in Internal Medicine. The DHA license is
unrestricted and meets all requirements to practice in the state of Florida, which expires on
March 31, 2026. The program does not utilize an advanced practice registered nurse (APRN) or
physician’s assistant (PA); therefore, a collaborative practice protocol is not warranted. A review
of the sign-in logs for the annual compliance review period indicated the DHA was on-site once
a week, as required. If the DHA has scheduled absences, the program has a backup DHA,
however the backup DHA had not been utilized during the annual compliance review period. No
tele-medicine was used during the annual compliance review period. The DHA was interviewed
and stated their role was performing Comprehensive Physical Assessment’s, conducting
periodic evaluations, sick call, and policy and procedure development. The DHA stated they
communicate with the program staff regarding youth medical needs by phone or when they are
on site. If off-site, they are on call twenty-four hours a day, seven days a week, and staff call
them with any needs or concerns. Any off-site care findings, instructions, or information is
reviewed by the DHA on a weekly basis and signed off on. The DHA stated if they were to be
absent, the back-up DHA would be contacted and cover the rotation.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has three licensed practical nurses (LPN) and five registered nurses (RNs), which
one of the RNs serves as the health services administrator (HSA). A review of each RN’s
license credentials reflected each of the nurses have a clear and active license, in the State of
Florida, according to the Florida Department of Health Medical Quality Assurance website, with
expiration dates of April 30, 2027, April 30, 2026, July 31, 2026, and July 31, 2027. In addition,
each of the LPNs and RNs had current cardiopulmonary resuscitation (CPR) certifications with
expiration dates of March 26,2027, September 23, 2026, August 1, 2027, May 27, 2027, and
March 21, 2027. The required on-site hours according to the contract are seven days a week for
a total of 120 hours. The nursing staff was in compliance with the contractual requirements and
nursing coverage is provided at a minimum of 120 hours a week.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program utilizes facility operating procedures (FOP) for all health-related procedures and
protocols. During the annual compliance review period, it was found the designated health
authority (DHA) and the facility administrator signed the FOP’s December 3, 2024. The
psychiatrist signed the FOP’s on January 14, 2025, for all respective treatment FOP’s. No new
policies or changes were made during the annual compliance review period. FOPs and nursing
protocols were reviewed annually as required and signed January 14, 2025. Newly employed
healthcare personnel received a comprehensive clinical orientation to the Department’s health
care policies and procedures, which was conducted by a registered nurse (RN) as evidenced in
a review of their training packets. Nursing staff reviewed, signed, and dated a cover page
between the dates of January 14, 2025, and July 7, 2025, of all medical FOP’s, treatment
protocols, and other procedures. Approved treatment protocols or standing procedures were
written and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Department’s
Authority for Evaluation and Treatment (AET) authorizing treatment of youth in the program’s
custody. Seven youth Individual Healthcare Records (IHCR) were reviewed for AET
requirements. Six of the seven IHCRs included a valid AET obtained prior to providing medical
services and one contained a court order authorizing physical, mental health, and all treatment
care for a committed youth in the custody of the Department of Children and Families (DCF).
Each of the six applicable youth’s AETs were either originals or stamped as a “COPY” and filed
in the youth’s IHCR. All six AETs were signed by the youth’s parent/guardian. Each applicable
AET was signed by a Department representative, was valid, and was obtained prior to the
provision of medical services. The nursing staff was interviewed and stated the AET is obtained
upon intake and nursing contacts the juvenile probation officer (JPO) to obtain signatures from
the parent/guardian. For youth who are eighteen years or older, a separate specific consent is
signed by the youth.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. Seven
youth Individual Healthcare Records (IHCR) were reviewed for parental notification/consent
requirements. Three out of nine youth were found to require parental notification for over-the-
counter (OTC) medications beyond those covered by the Department’s Authority for Evaluation
and Treatment (AET). All three youth IHCRs included documentation of consent provided by the
parent/guardian. Six youth were applicable for new medications being ordered. Each youth
IHCRs included written notification sent utilizing the Department’s Parental Notification of
Health-Related Care form. Three of the seven youth were taking psychotropic medications upon
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admission and a staff witnessed telephone attempts in two of the applicable youth for the third
youth was in the care of The Department of Children and Families with a court order. Two of the
three applicable youth had parental consent for prescribed, discontinued, or dosage changed
psychotropic medication as documented on the Clinical Psychotropic Progress (CPPN) form.
One of the reviewed youth was involved/committed to the Department of Children and Families.
All seven youth’s vaccinations were verified within thirty days of the youth’s admission with one
youth receiving a vaccine. Review of the one applicable youth’s IHCR contained a consent form
signed prior to the vaccine being administered. None of the youth IHCRs contained religious
exemptions or refusals of parental consent for immunizations. Nursing staff was interviewed and
stated parents/guardians shall be notified of any significant changes in a youth's condition when
new medications are prescribed, if the youth complains of the same complaint three or more
times in a two week period, if the youth is taken off-site for healthcare, or if there are any
changes in existing medications. Parents/guardians are notified either verbally or in writing the
same date of occurrence. If a youth requires emergency care, 911 is called then notification to
the DHA, facility administrator, and parent is made. For procedures regarding parental consent
for psychotropic medication, telephone consent must be attempted by the psychiatrist and must
include discussion of the information contained on page three of the CPPN, with all telephone
consents for psychotropic medication being witnessed and documented with a witness
signature. The Acknowledgment of Receipt of CPPN and a copy of the 3rd page of the CPPN is
mailed to the parent/guardian. Nursing staff advised immunization records are obtained from the
youth's record the day they are admitted into the program. If a complete immunization record is
not available, the health services administrator or designee shall obtain a school printout or
Florida Shots Record of the youth as a means to verify immunizations. If a parent/guardian does
not consent to vaccination for medical or religious reasons, then an approved exemption form
must be provided to the program by the youth's parent, and a copy of the form will be filed in the
IHCR.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Seven youth Individual
Healthcare Records (IHCR) were reviewed for healthcare admission screening requirements. All
seven youth received a medical and mental health admission screening completed on the
Department’s Facility Entry Physical Health Screening (FEPHS) form on the date of admission
by a registered nurse (RN) or licensed practical nurse (LPN). None of the reviewed youth
changed physical custody since admission to the program. The nurse was interviewed
regarding healthcare admission screenings and re-screenings and stated nursing staff is notified
by email, prior to the youth arriving, providing information with date and time youth will arrive.
Admission screening is completed by a nurse. No direct care staff complete admission
screenings. If a youth is out of custody for greater than twenty-four hours, upon the youth
returning to the program a full body search is conducted on the youth along with completing a
new FEHPS, body chart, and urine drug screening.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring healthcare service orientation is provided to
all youth when admitted to the program. Seven youth Individual Healthcare Records (IHCRs)
were reviewed, confirming all youth received a general care orientation upon admission. A
review of the Health Education forms, signed by all seven youth and filed in each IHCR,
confirmed orientation discussion included access to medical care, sick call procedures, what
constitutes an emergency and when to notify staff, medication process, right to refuse care and
how it is documented, what to do in the case of a sexual assault or attempted sexual assault,
the role of non-disciplinary healthcare providers, and Standard Universal Precautions. All seven
youth IHCRs confirmed the program provides monthly health education in accordance with the
programs contract. The monthly education rotates between topics and include the following:
usage of seatbelts, alcohol and drug related problems, sexually transmitted disease/infection,
tobacco products, smoking cessation, dental hygiene, personal hygiene, immunizations,
infection control, prevention of sexual violence, nutrition, physical fitness, parenting skills, and
testicular self-examinations.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Seven youth
Individual Healthcare Records (IHCRs) were reviewed, five of the youth were admitted with a
known or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency care upon admission. All records documented the DHA
notification in the youth’s Chronological Progress Notes and the Chronic Conditions Log was
updated after the notification for the applicable youth. Three reviewed youth were taking
psychotropic medication upon admission, and notification to the psychiatrist was documented.
The nursing staff was interviewed and stated both the DHA and psychiatrist is notified within
twelve hours of every youth's admission to the program regardless of the youth's medical or
mental health status
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed for all youth admitted into a department program. A review of seven
youth Individual Healthcare Records (IHCRs) found each HRH was completed on the day of the
admission. All seven IHCRs indicated the HRH form was completed prior to the Comprehensive
Physical Assessment (CPA) which included date and signatures. In all IHCRs, the designated
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health authority (DHA) reviewed the HRH form as evidenced by a checkbox on the CPA and a
focused note in the admission documentation. Nursing staff was interviewed and stated they are
responsible for completing the HRH upon youth admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring a Comprehensive Physical Assessment
(CPA) is completed for all youth admitted into the physical custody of a Department program
within seven days of youth’s admission. A review of seven Individual Healthcare Records
(IHCRs) confirmed the program utilized the Department’s CPA form. All CPAs were completed
by the designated health authority (DHA) within seven days of the youth’s admission to the
program. All seven had the youth’s Medical Grades documented on the CPA. The program
completes a new CPA for all youth, no prior CPAs were utilized. All sections of the CPA were
completed in full utilizing “O” or “X” markings. All seven youth refused the genital exam which
was documented as “youth refused” on each CPA in the IHCRs, and all seven youth signed a
refusal form which reflected the refused portion on the CPA. The CPA in all seven records
included documentation of the most recent verified Tuberculosis Skin Test (TST), which was
administered within the last year to determine exposure to tuberculosis (TB). The results of the
TST were documented on each youth’s CPA and matched the documentation on the
Department’s Infectious and Communicable Diseases (ICD) forms. The Department’s Problem
List was updated for each youth, when applicable. Nursing staff was interviewed and stated the
designated health authority (DHA) completes the CPA within seven days of a youth's admission
to the program and annually if needed. A TB screening is completed within seventy-two hours of
a youth's admission to the program.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). A review of seven Individual Healthcare Records (IHCRs)
found all youth were clinically screened and evaluated for STIs on the date of admission. The
program has a standing order for STI testing for all youth who advise they are sexually active.
All youth were tested for STI however none of the youth required further evaluation. All testing,
screening, clinical evaluations, and diagnoses were documented on the Department’s Infectious
and Communicable Diseases (ICD) forms and were filed in the lab section of the IHCR. None of
the youth were out of the Department’s physical custody; therefore, a rescreening was not
applicable. Five youth consented to receive a HIV test and documented consents were
executed. All five youth were offered pre/post-test counseling and testing. The pre/post-test
counseling was documented on the youth’s Individual Health Education Records. One of the
five received their HIV results, which were filed confidentially in a sealed enveloped marked
“Confidential.” The envelope was signed by the DHA indicating their review. The youth’s
confidentiality was protected by not including the youth’s HIV status on the program’s internal
alert system. The other four youth are still awaiting their test results. The program’s policy
ensures the youth’s HIV test results are only disclosed to the youth’s legally authorized
representative, healthcare providers during treatment, the Department of Health for purposes of
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reporting, health facility staff committees conducting facility monitoring, medical personnel who
have been subject to significant exposure, and healthcare facility personnel or agents for
healthcare provider who have a need to know during patient care. A licensed registered nurse
(RN) provides pre and post-test counseling services under the direction of the medical doctor.
Seven youth were interviewed and all seven advised they can request HIV testing. Nursing staff
was interviewed and stated youth are screened at intake for STIs and offered HIV testing to
include pre/post counseling, which is documented in their IHCR and appropriate log. If a youth
consents or requests testing, the youth is placed on the Comprehensive Health of Orlando log,
who come monthly to test the youth.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. A review
of seven Individual Healthcare Records (IHCRs) found none had requested a sick call since
their admission. Three additional youth records were selected and reviewed. None of the youth
presented with a similar sick call complaint three or more times within a two-week period. All
three reviewed sick call requests were addressed by the registered nurse (RN). Each of the Sick
Call Request forms were filed in each youth’s Individual Healthcare Record (IHCR) in reverse
chronological order. None of the youth were in restricted housing of any kind. The Sick Call
Request forms and progress notes were documented in accordance with Health Services Rule,
including vital signs, treatment, education, and follow-up plans. Each of the sick call events were
documented on the Sick Call Index and on the program’s Sick Call Referral Log. All the dates
listed on the Sick Call Index corresponded to the completed Sick Call Request forms located in
each of the youth IHCRs. Sick call occurs seven days a week, twice a day. Sick call hours are
posted on the medical office door and in the dorms. Sick call forms are located on each dorm
and in the cafeteria. An exam table and equipment are used to perform sick call. Sick call was
not observed during the annual compliance review week as none occurred. Seven youth were
interviewed and six youth stated upon submission of a sick call request, they were seen by
medical staff within a day and the remaining was seen immediately after placing the sick call.
Nursing staff was interviewed and stated sick call requests are collected twice daily, and youth
are seen within twenty-four hours of submission. All sick call forms are submitted by the youth
and completed by the nurse in the medical clinic prior to filing in the IHCR. The nurse confirmed
there are designated health authority treatment protocols, and the process for assessing youth
in restrictive housing.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure the youth have access to episodic and first-
aid care. A review of seven youth Individual Healthcare Records (IHCRs) found three youth
required on-site episodic care. In all three applicable IHCRs, the on-site care provided by a
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licensed healthcare staff was documented in the problem-oriented, subjective, objective,
assessment, and plan (SOAP) elements. An observation of an episodic care event was unable
to be performed due to the program not having an event during the annual compliance review
week. First aid kits are located in the medical office, master control, kitchen, and in supervisor
office. There are two additional kits in master control for transports. The program has a process
for ensuring contents of the first-aid kits are maintained and stored in accordance with
guidelines to prevent expiration and maintain the viability of each kit’s contents. An observation
of three first-aid kits confirmed the kits were fully stocked with designated health authority (DHA)
approved contents, a list of contents with expiration dates on the outside of the box, and a seal
was placed over the top. The nurse monitors the first-aid kits monthly and checks for expired
contents, which is documented on the first-aid kits logs. The program has one automated
external defibrillator (AEDs) located in master control. The AED procedures are located with the
AED. The AED battery and pads are checked by the registered nurse (RN) once a month.
Documentation confirmed the RN monitored the AED as required. The RN checked the
expiration dates of the AED in the presence of the Monitoring and Quality Improvement regional
monitor. The nurse conducted a self-test of the AED in front of the regional monitor with no
issues. The batteries and pads have not been changed since the device was new, with the
battery expiration date of July 16, 2029, and the pads expire February 28, 2027. The program
had a list of emergency numbers which were inaccessible to youth. The emergency numbers
are posted in master control, medical, and administration. A review of seven training records
confirmed all staff were trained in episodic, first-aid, and emergency care, and the administration
of the epinephrine auto-injector. A review of the emergency drills confirmed the program
conducted and maintained an emergency drill to include cardiopulmonary resuscitation
(CPR)/AED annually. The conducted emergency medical drills included scenarios simulating an
episodic care event which called for immediate first-aid and/or administration of CPR
techniques, and the initiation of emergency procedures to follow when a life-threatening
emergency does occur. The program has a policy and procedures regarding the use, access,
and inventory of Narcan. The policy states all newly employed staff and admitted youth shall
receive education on recognizing and treating symptoms of opioid overdose. Training will
include risk factors for overdose, strategies to prevent overdose deaths, overdose recognition
and response, and administration of Narcan. The training and prevention plan also includes
emergency response procedures. Narcan is stored in medical and inventoried along with other
medication. Supervisors are trained on the use of Narcan. Seven staff were interviewed and all
seven stated they would contact master control to call 9-1-1 in case of an emergency. Seven
youth were interviewed, and all confirmed they can see a doctor when needed. The nursing staff
was interviewed and confirmed the program has one AED and six first aid kits in the facility.
Nursing staff perform monthly checks of the AED and the kits which are documented in a
logbook.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure the processing of timely referrals and the
coordination of medical services to an off-site healthcare provider. A review of seven Individual
Healthcare Records (IHCRs) found two youth were applicable for off-site care, one additional
youth record was provided for review. In all applicable IHCRs, there was an indication the youth
required off-site care. The Department’s Summary of Off-Site Care Consultation Report form
was utilized and filed in all three youth’s IHCRs. All three youth IHCRs had documentation of the
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parent/guardian notification efforts. None of the youth were applicable for discharge
documentation. The designated health authority (DHA) reviewed and signed all off-site care
findings, instructions, and information in each of the three applicable IHCRs. One of the youth
required follow-up testing, referrals, or appointments. The IHCRs had documentation the
referrals were tracked, and the youth received appropriate and timely follow-up care. Nursing
staff were interviewed and stated off-site appointments are tracked through an off-site transport
binder, kept in the medical office. All documentation is reviewed by the nursing staff and the
DHA as evidenced by signature and date, any orders from the off-site provider is then
transcribed into the Medical Administration Record (MAR).
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who has
chronic conditions receive regularly scheduled evaluations and any necessary follow-up care. A
review of seven youth Individual Healthcare Records (IHCRs) found three were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form with a current chronic
condition at admission. None of the youth were identified as having a communicable disease.
One of the applicable youth was taking prescribed medication on an on-going basis, two youth
were not. One of the applicable youth was undergoing treatment for a physical health condition.
All three youth were classified with a Medical Grade of at least two to four and were placed on
the program’s Chronic Illness List. One youth was applicable to receive periodic evaluations at
least every ninety days. The other two youth had not been in the program for ninety days at the
time of the annual compliance review; therefore were not applicable to receive periodic
evaluations. None of the youth were applicable for taking anti-tuberculosis medications and
were not identified as being pregnant. None of the youth were applicable to receive a timely
periodic evaluation prior to the renewal of prescription medication expiration. None of the three
youth required an off-site evaluation or off-site care. There was no evidence of any lapses in
care or missed periodic evaluations. The Department’s Problem List was updated for each
youth. The facility administrator was interviewed and stated formalized procedures are in place
for healthcare staff to review important youth medical issues during the daily management
meetings with the leadership team. Nursing staff was interviewed and stated youth with chronic
medical conditions are entered into our internal alert with their common symptoms to monitor.
These youth are scheduled to see the designated health authority a minimum of every three
months.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure the accurate and safe administration of
youth medications. A review of seven youth Facility Entry Physical Health Screening (FEPHS)
forms found four youth were taking medication at the time of admission. All four youth
medications were verified prior to the youth being admitted into the program, and the
prescription notification was documented in the youth’s Chronological Progress Notes. The
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designated health authority (DHA) and, when applicable, the psychiatrist was contacted to
obtain an order to resume the specified medications prescribed prior to admission for each
youth. Each of the four reviewed youth’s Individual Healthcare Record (IHCRs) documented the
youth received medication while in the program and all medications were continued,
discontinued, changed, or new medications ordered utilizing the Practitioner Order form. Each
medication had a current and valid prescription or order. None of the youth were in restricted
housing of any kind. Three of the seven youth were applicable for over-the-counter (OTC)
medications which were administered according to approve practitioner’s orders. Five youth
were applicable for being prescribed medications after admission. The Department’s Medication
Administration Record (MAR) was used to document all medications and treatments for the five
applicable reviewed IHCRs. The MAR clearly indicated medication start and stop dates of all the
medications each youth was prescribed. In all five applicable IHCRs, the staff initialed each
administered medication entry. There were no undocumented explanations for lapses or errors
in medication administration for any of the reviewed IHCRs. The registered nurse (RN)
documented side-effects monitoring weekly on the MAR for the five applicable youth IHCRs.
One of the applicable youth received medications administered by non-healthcare staff. Youth
initial each medication entry, regardless of who administered the medication. Non-healthcare
staff who assisted with medication also initial each entry. None of the youth had a refusal. The
MAR contained all the required elements: youth name, DJJ ID number, date of birth, allergies,
precautions, Medical Grade, medical alerts, and a current photograph of each youth. None of
the reviewed youth required parenteral medication. There were no standing orders for
psychotropic medications, emergency treatment orders for psychotropic medication, or any pro-
re-nata (PRN) orders for psychotropic medications. A medication pass was observed. The youth
were escorted by the direct care staff and approached the nurse individually at the medical
office window. The nurse identified themselves and confirmed the reason the youth was
present. The nurse prepared the medication and verified the youth’s allergies and alert status.
The nurse and youth initialed the MAR, and the nurse observed to ensure the medication was
swallowed by conducting a mouth check. The Six Rights of Medication Delivery/Administration
were maintained for each youth. Seven youth were interviewed and each youth confirmed
medication is given to the youth by the nurse. All seven youth stated they must line up
alphabetically in the morning and/or in the afternoon to receive their medication. Two of the
youth stated they do not take medication but still know the process. Nursing staff was
interviewed and stated non-healthcare staff provide medications to the youth and are trained by
the health services administrator (HSA). A copy of the list and training is kept in the medical
clinic.
4.17 Psychiatric Services Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program utilizes a psychiatrist who is board certified and has a clear and active license in
the State of Florida, which expires January 31, 2026. The psychiatrist advised in their interview
they are available twenty-four hours a day, seven days a week. The psychiatric evaluation and
recommendations are utilized in developing the individualized mental health and substance
abuse treatment plan. The psychiatrist is on site bi-weekly to provide medication management,
psychiatric services, input for treatment team, and is on-call for any psychiatric needs of the
program. The program also utilizes a Psychiatric Advance Practical Registered Nurse (APRN).
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Office of Accountability and Program Support Page 46 of 64 (Revised August 2025)
The APRN has an active and clear license in the State of Florida and licensure in psychiatry is
included in their licensing. The APRN’s license expires on July 31, 2026. A collaborative
practice protocol is in place and was verified on-site. The APRN is only utilized when the
psychiatrist is not available to come on-site. Reviewed documentation confirmed the psychiatrist
was on-site as required by contract during the annual compliance review period. The
psychiatrist was available to the APRN by telephone when they were not on-site. The
designated mental health clinician authority (DMHCA) advised in an interview they meet with the
psychiatrist every other week on Wednesdays. Seven youth medical records were reviewed for
psychiatric services. Three youth records indicated the youth came into the program on
psychotropic medications. All seven youth reviewed were referred for a psychiatric interview,
which was conducted within fourteen days of admission. One youth was placed on psychiatric
medication as a result of the interview. The initial diagnostic psychiatric interview included
history, mental status examination, Diagnostic and Statistical Manual of Mental Disorders –
version five (DSM-5) diagnosis, treatment recommendations, prescribed medications if
applicable, explanation of the need for psychotropic medication related to the youths diagnosis,
target symptoms, initial treatment goals, potential side effects, risks and benefits of taking the
medication, frequency of medication, and monitoring/management of medication. The initial
diagnostic psychiatric interview was documented on the Departments Clinical Psychotropic
Progress form (CPPN), which contains all information for all seven youth reviewed. Seven
reviewed youth records indicated the CPPN form was clearly identified as an “initial diagnostic
evaluation”. Three applicable youth records indicated a change in their current medication and
one applicable youth record indicated a new prescription for a psychotropic medication was
ordered. All four youth records indicated the changes on page three on the CPPN form. Four
youth records indicated youth were evaluated for a medication review by the Psychiatrist, and
any changes were documented on page three of the CPPN form. None of the youth reviewed
were applicable for an updated psychiatric evaluation. The four applicable reviewed youth
records indicated identifying data, diagnosis, target symptoms for each medication, evaluation
and description of effect for prescribed medication, name of medication, dosage of medication,
frequency and route of administration and reasons for any changes in dose, youth adherence to
the medication regime, and youths vital signs were all documented on page three of the CPPN
form and kept in the youths medical record binder. All applicable youth records indicated
telephone contact with the youth’s parent/guardian was completed. The CPPN form was signed
and dated by the psychiatrist for all applicable youth, and the records kept in the youth’s
individual medical binder. The program does not utilize tele-psychiatry services.
4.18 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as sharps
and medications are secure and inventoried utilizing a routine perpetual inventory. Reviewed
medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory descending count. Reviewed medications
were identified and secured in a locked, clean, and organized medication cart designated for
storage of medication, located in a secured area inaccessible to youth, with narcotics and other
controlled medications being stored behind two locks. Over-the-counter (OTC) medication was
stored in a locked cabinet inside the medical clinic and inventoried daily. Refrigerated
medication is stored in a secured refrigerator only used for medication; however, the facility did
not have any refrigerated medication during the annual compliance review. The program’s
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process for the destruction and disposal of non-controlled medications is for two nurses to
destroy all medication using the chemical drug buster. Controlled medication is destroyed when
the pharmacist consultant is on-site with one registered nurse (RN). Discontinued medications
which are not expired are sent back to the pharmacy. A review of the program’s perpetual and
weekly inventory of all sharps and stock OTC medications verified completion as required with
no discrepancies. Reviewed documentation verified the nursing staff maintain a shift-to-shift
inventory of all controlled substances which is documented by each youth’s Individualized
Controlled Medication Inventory Record. Nursing staff are on-site twelve hours a day, seven
days a week, to provide oversight and the delivery of medication. A review of seven staff
records found supervisory level, non-healthcare staff are trained in medication self-
administration by an RN. Observations were conducted of inventory counts of one controlled
medication (the program had only one controlled medication), three OTC medications, and three
sharps with no discrepancies found. The nursing staff confirmed in the interview controlled
medications are located behind double locks in the medical office and are destroyed as
witnessed by the pharmacist consultant and one nursing staff. The health services administrator
(HSA) reported if there is a discrepancy in the count, the nursing staff will inform the HSA and
facility administrator (FA) immediately and conduct a recount and inventory to determine where
the discrepancy originated. Once confirmed, a call to the Department’s Central Communications
Center (CCC) will be placed. Nursing staff stated in the event a sharp is missing, all youth and
their rooms are searched, a call to the CCC is conducted, then a program incident report is
completed.
4.19 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures related to an Infection Control and Exposure Control
Plan. The Infection Control and Exposure Control Plan, written in accordance with Occupational
Safety and Health Administration (OSHA) standards, is signed annually and was reviewed and
signed by the designated health authority (DHA), facility administrator (FA), and provider’s
corporate designee on December 3, 2024. The program’s infection control procedures included
common infectious diseases of childhood, 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. The program offers Hepatitis B
immunizations to staff as well as access to personal protective equipment. The program has a
comprehensive process for needle stick post-exposure evaluation. If necessary, the program
would have a separate file containing all documents of youth and staff who have experienced a
program or occupational exposure; however, there has not been any incidents of reportable
infectious disease by either staff or youth. The interviewed FA confirmed the plan is located in
medical and master control, with the staff completing a bi-annual review of the plan. Nursing
staff was interviewed and stated they provide infection /exposure control training and education
to both staff and youth.
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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 in an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a policy and procedures stating they will maintain active supervision of
youth at all times. According to policy and procedures, staff-to-youth ratios are as follows: one-
to-eight during day-time activities, two-to-two during transportation, and one-to-twelve during
sleep hours. Observations of staff during the annual compliance review week included
observing staff with the youth during school hours, breakfast, and medication pass, as well as
video observation of daily cleaning activities and during sleep hours. During each observation,
staff-to-youth ratio was appropriate and in accordance with policy. Positive interactions between
staff and youth were observed. An informal interview with three staff indicated they immediately
knew the number of youth they were supervising. The program’s policy and procedures
consider interacting positively with youth, engaging in a full schedule of constructive activities,
closely observing behavior of youth and changes in behavior, and consistently applying the
behavior management system while actively supervising youth. The daily schedule is posted
and available to youth in each living unit and in the dining hall. Observations of youth rooms
confirmed windows were not covered by any means which would affect the direct line of sight of
youth. There were no escapes during the annual compliance review period.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the development, implementation,
and on-going maintenance of the behavior management system (BMS) by all appropriate
parties, to include education. The policy addresses staff feedback of the BMS by their
supervisor and administration. Feedback to staff is provided on an on-going basis or as needed.
There is an agreement between the program and school to ensure staff and teachers monitor
the BMS during school. The facility administrator (FA) provided training to the education staff. A
review of seven youth case management records indicated each youth participated in
orientation upon arrival to the program to include a review of the BMS. A review of three position
descriptions found the BMS to have been addressed for those staff whose job functions
includes implementation of the program’s BMS. A review of seven staff pre-service training
records found all staff received BMS training. Observations during the annual compliance week
found the BMS was posted in each dormitory, dining hall, and all common areas where the
youth gather. The BMS included the rules governing conduct as well as positive and negative
consequences. Each youth is provided a program handbook which describes the BMS. A review
of the youth handbook indicated the BMS is included and clearly written. The BMS was not
updated during the annual compliance review period. The program’s BMS included information
on promoting safety, respect, fairness, and protecting youth rights, positive and negative
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consequences, non-punitive constructive disciplinary actions, opportunities for positive
reinforcement, recognition of accomplishment and positive behaviors at a four-to-one ratio,
promoting socially acceptable means for youth to meet their needs, a process for explaining to
the youth the reasons for sanctions being imposed, youth having the opportunity to explain their
behavior, opportunities for staff and youth to discuss the impact their behavior may have on
others, reasonable reparations for harm caused to others, discussions of alternate behaviors,
and promoting positive dialogue and peaceful conflict resolution. A review of the BMS confirmed
it is not used to increase a youth’s length of stay, deny basic rights or services, promote the use
of group punishment, allow youth to punish other youth, or include disciplinary confinement.
Observations of staff and youth interactions during the annual compliance review week verified
staff were adhering to the BMS by utilizing a ratio of four-to-one positive to negative
consequences when redirecting the youth as indicated in the program’s policy. Staff use point
cards to monitor how well the youth are progressing in the program. Staff review the point cards
with the youth prior to the end of their shift or when the youth received a loss of points. The
youth and staff sign the point card once reviewed. Youth earn points daily for complying with the
program rules. At the end of the week, the points are totaled, and the youth are rewarded based
on the number of points earned. Rewards include point store, game night, pizza, ice cream,
popcorn, popsicles, and access to a gaming station. If youth gain enough points throughout the
month, there are monthly incentives like bowling, playing arcade games at a local
establishment, and roller skating. Special conditions in the contract require the program to
provide two small entertainment zones which will include a music studio, Creative Hope Music
Studio, and game room(s) (which will have several big screen televisions, gaming consoles,
blacklights, and other games, such as a foosball table, as well as require the program to provide
an incentive point store and a community barbershop where youth will have an informal place to
engage in Barbershop Talks! Meetings. A tour of the program and documentaion verified the
program does have and is providing all required special conditions. Seven staff were
interviewed. All staff confirmed the BMS works on a point system. Youth cannot lose points
unless they have been prompted three times. The youth start with ten points each hour and can
drop to a five or to a zero. The youth can also gain points back if they start acting appropriately.
Youth can make up to 180 points a day. They get daily, weekly, and monthly incentives when
making positive choices. Some incentives staff mentioned were canteen, playing board games,
studio time, movie nights, staying up until ten p.m. and playing the gaming station. The staff
confirmed consequences can be documented in a progress behavioral report in which youth
must have a special treatment team and early bedtime. All seven staff stated youth’s basic
rights cannot be taken away at any time. Seven youth were interviewed and asked what some
of the consequences for bad behavior are at the program. All youth gave examples such as
level freeze, early bedtime, progress behavior report, privilege restrictions, and extra days
added to their time. All youth were asked what kind of rewards they could earn in the program to
which they gave examples such as having a pizza party, board game night, outings, items from
the canteen, student of the week, and playing with the gaming station. All youth confirmed the
staff are consistent in what behaviors they give rewards and consequences to. All youth stated
they could not punish another youth. All youth were able to explain the difference between each
level and what they needed to do to move up a level. All were able to list the levels, which are
Orientation, Rookie, Pro, All-Star, and Hall-of-Fame. With each level up, the youth receive more
incentives. The FA was interviewed and stated the program utilizes the iChoose System, a BMS
which promotes, monitors, recognizes, and rewards a youth’s progress. The FA stated the
system is a program of incentives and consequences which promotes individualized skill
building, appropriate behavior, and accountability. The FA interview also confirmed how rewards
and consequences are implemented, staff implementation of the BMS, and how consistency
with the BMS is monitored.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures to 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. The program has 124 cameras, all of which were operational at the
time of the annual compliance review. The video recordings are stored for thirty days. The
program’s practice is to conduct checks of youth in their rooms every eight to ten minutes. Ten-
minute check sheets were reviewed for the nine month annual compliance review period.
Findings confirmed no more than ten minutes passed without the staff actively observing each
youth except for one check, which was one minute late. Video review of nine samples of ten-
minute checks in thirty-minute increments on both dormitories was conducted. Forty-one total
ten-minute checks were reviewed. All ten-minute checks were conducted within the required
frequency except for one check, which was one minute late. Seven staff were interviewed, and
all confirmed room checks are conducted every eight minutes when a youth is placed in their
room for sleeping or non-punishment reasons. The facility administrator was interviewed and
confirmed the program has 124 operational security cameras and footage is maintained for
thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures which addresses population census, counts,
and tracking of youth. The program’s policy indicates program staff shall be able to account for
the whereabouts of youth under their supervision at all times. The program’s system for
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accounting of youth requires the physical counting of youth at various times throughout the day.
Staff shall conduct and document counts minimally at the beginning of each shift, after each
outdoor activity, and during emergency situations such as escapes or riots. The program shall
maintain a chronological record of events as they occur, or, if an event disrupts the safety and
security of the program, as soon as is practicle after order has been restored. All staff shall
monitor the movement of youth in and out of the facility. The facility administrator or designee
shall be provided with up to the minute information regarding all movement of the youth. Daily
census information at a minimum, shall include the total daily census count, new admissions,
releases or direct discharges, transfers, and youth temporarily away from the program. The
program shall ensure staff observe youth at least every ten minutes while they are in their
sleeping rooms, either during sleep, rest periods, or other times youth are in their rooms. Staff
observations shall be completed and documented in real time ensuring the safety and security
of each youth. An observation of counts occurred during the annual compliance review week
where the noon count was observed in master control. The census was forty youth and the
count was cleared with forty youth. The program utilizes the master conrol logbook to document
youth counts and movements. Logbooks were reviewed for the nine month annual compliance
review period. Counts were conducted at beginning of shift, after each outdoor activity, and
during emergency situations. The logbook also tracks daily census counts, head counts, youth
movements, transfers, and youth temporarily away from the program. Seven staff were
interviewed. Each staff confirmed youth counts are conducted every hour and during every
movement. The staff relayed emergency counts are conducted when physical altercations
occur, during fire drills, when the power goes out, or natural disasters occur.
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 policy and procedures addressing logbook entries. The program
maintains a chronological record of events, incidents, and activities in a logbook as required by
policy. Logbooks for the nine month annual compliance review period were reviewed. Each
reviewed logbook was bound with numbered pages, and entries were made in ink with no white-
outs or logbook entries being destroyed or removed. In two applicable logbooks, all errors were
struck through with a single line and initialed by the staff correcting the error. In each logbook,
entries included the dates and times of the events, with the names of staff and youth involved,
brief descriptions of the events, and the names and signatures of the staff making the entries.
All logbooks included any internal incidents reported to the Florida Abuse Hotline or the
Department’s Central Communications Center. The activity schedule and logbooks documented
minimal interference of educational instruction with entries indicating education classes were
conducted as scheduled, and the youth arrived and departed school on time. Logbook entries
also confirmed recreation time for the youth was conducted as scheduled. Logbook entries
included emergency situations, incidents, special instructions for supervision and monitoring of
youth, population counts at the beginning and end of each shift, and any other population
counts conducted during a shift, as well as perimeter security checks and other security checks
conducted by direct care staff, transports away from the facility (including the names of the staff,
youth involved, and the destination), requests by law enforcement to access any youth, removal
of any youth from the mainstream population, and admission and releases which included the
name, date, and time of anticipated arrival or departure and mode of transportation. The
program did not have any escapes or escape attempts during the annual compliance review
period requiring documentation in the logbook. On-coming staff members participate in a shift
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briefing and sign the logbook acknowledging they are aware of all information from the last shift
and any alert changes. Each reviewed logbook entry was legible and included the time and date
of the entry, printed name, and the signature of the staff member making the entry.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to address key control. Policy and procedures
addressed key assignment and usage including restrictions on usage, inventory and tracking of
keys, secure storage of keys not in use, missing or lost keys, and reporting and replacement of
damaged keys. A review of the inventory matched the key rings in use. Observations during the
annual compliance review week found the staff personal keys are kept in a secure lock box
within master control which is not accessible to youth. Each set of program keys has an
assigned key hook. Keys are assigned to staff according to their department. The facility
administrator states there are five staff who have permanent key assignments; facility
administrator (FA), assistant facility administrator (AFA), operations manager, physical plant
manager, and shift supervisors. A tamper proof box was observed in master control where
restricted keys are stored. The program’s process for reporting and replacement of damaged
keys states damaged keys are reported to the shift supervisor and then returned to the AFA,
who will be responsible for updating inventories and the issuance of replacement keys. There
were no incidents reported to the Department’s Central Communications Center (CCC) or
Program Monitoring and Management (PMM) deficiencies related to key control concerns
during the annual compliance review period. An informal interview with the master control
operator about the process for restricting usage of keys such as medical and youth and staff
records keys confirmed keys are kept in a locked key box in master control. Medical keys are
kept in a separate locked box and are only given to medical staff. Case management staff are
given access to youth records and human resource staff, and administration are given access to
staff records. A sampling of five key rings was observed and compared to the inventory and key
log which found the number of keys were correct. An informal interview was conducted with
three staff. Each staff knew the number of keys on their key ring and the function of each key.
Seven staff were interviewed. All staff confirmed they give their personal keys to master control
upon entry and their personal keys are securely stored. Six staff confirmed visitor keys are given
to master control upon entry and three staff stated the visitors are given a chit to receive their
personal keys upon leaving. Six staff confirmed program keys are assigned to the staff at the
beginning of their shift and an inventory of the keys is kept. Seven staff relayed there is a daily
key log kept in master control. Two staff mentioned youth are never given access to keys, and
four staff mentioned if they lose their keys, master control must be notified and then an
emergency count is conducted.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system in place to prevent contraband entering the facility which includes
the program defining items/materials considered contraband, as well as exemptions, providing
youth with a list of contraband and informing them of consequences if found with contraband,
and searching the physical plant, facility grounds, youth, incoming mail, and outgoing mail. The
program’s visitor log contains a contraband attestation statement. There were twenty-one new
staff hired since the last annual compliance review and all twenty-one staff completed
contraband attestation forms. The policy also states any staff who is found in possession of
contraband in the program will be subject to disciplinary action up to, and including, dismissal,
as well as procedures regarding notification of law enforcement for items considered illegal as
defined in Florida Statutes. The program clearly delineates those items considered contraband
to include, but not limited to, sharps, escape paraphernalia, tobacco products, lighters or
matches, electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage, any controlled substance, any prescription or non-prescription drug, any
firearm or weapon of any kind, any explosive substance, non-facility issued electronic
equipment or devices to include smartwatches, metals, personal cell phones, unauthorized
currency or coin(s), and non-facility issued keys. The program maintains room search forms
which document any contraband findings and documents these findings in the program logbook.
A review of contraband forms for the nine month annual compliance review period was
completed. The only contraband found on the forms were unauthorized articles of food and
clothing. The program documented confiscation and disposition of these items. There were no
incidents of illegal contraband being turned over to law enforcement during the annual
compliance review period. The facility administrator was interviewed and stated in the event
contraband is confiscated, an incident report is completed and documented in the logbook.
Administration is required to notify the Department’s Central Communication Center (CCC)
within two hours of the incident. If the contraband is illegal, law enforcement is contacted for
reporting and proper disposal. Seven staff were interviewed. All staff confirmed the youth’s
rooms are checked daily in the morning. The administrative facility assistant and the operations
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manager complete the checks while the youth are in the shower. During the annual compliance
review week, random checks were observed to be completed by supervisors. Observations
confirmed staff methodically completed the room check and checked all items, including
mattresses and ensuring the beds are not unbolted from the floor.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures addressing searches and full body visual
searches. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the facility. During the annual compliance review week,
youth searches were observed during movement to and from class, to and from meals, and
before a transport. Youth searches were observed following access to tools. Youth were
observed using a broom, dustpan, mop, and mop bucket. Youth were being observed at a ratio
of one-to-one. Youth were supervised closely during the entire time they were using tools. Youth
were searched after completion of using tools by a staff member of the same gender. Youth
were treated with dignity and respect during the searches, to reduce stress and embarrassment.
Searches were thorough with youth listening to instructions given by staff and also conducted as
required by the right interactions (RI) training manual. Youth searches during admission, before
and after visitation, and upon return from off-campus activities were unable to be completed as
there were no admissions during the annual review week, visitation only occurs while monitoring
team was off-site, as well as youth returning from off-campus activities happened while
monitoring team was off-site. Video review of five staff and visitor searches was completed. Two
days of visitor searches were observed showing the visitors walked through the metal detector,
were scanned with the handheld metal detector, patted down, and their shoes were removed
and searched. Three days of staff searches were observed showing staff walking through the
metal detector, being scanned with the handheld metal detector, being patted down, removing
their shoes and having them searched, and having their bags searched. Seven staff were
interviewed. All seven staff confirmed the youth are checked every movement and they are
always completed by the male staff. The staff check shoes and around the elastic in the shorts.
If the youth are carrying a folder, those are checked. If a youth comes on or leaves campus,
they have a full search completed. Seven youth were interviewed, and all stated they receive
visual and full body searches. They stated the searches occur when returning from off-campus
activities, after outdoor activities, after visitation, and after meals.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures addressing vehicles and maintenance. The
program has two vans to transport youth. Of special note, during the annual compliance review
period, one of the vans was at the cooperate office since February 2025 and didn’t return it to
the program until August 8, 2025. One day during the annual compliance review week, seven
vehicles, (five staff vehicles and two program vehicles) were checked to ensure the vehicles
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were locked while not in use; all vehicles checked were locked. Neither of the two program vans
have had an annual safety inspection completed as they have not had the vehicles over a
period of one year. Maintenance records for both vehicles documented both were secured at all
times, and both contained a fire extinguisher, approved first-aid kit, seatbelt cutter, window
punch, appropriate number of seat belts, and child safety locks.
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 maintains a policy and procedures addressing transportation of youth and outlining
staff-to-youth ratio during transports as one-to-five; however, if there are five or less youth, a
minimum of two staff are needed to perform all transports and one must be the same gender as
the youth. The program’s policy and procedures meet all requirements outlined by the
Department’s policy. Policy and procedures, observations, and interviews verified staff will
utilize a facility cellular telephone during transports During the annual compliance review week,
an observation of a transport was observed. The staff transporting the youth was observed
searching the vehicle and conducting a routine check of the vehicle prior to the youth being
transported. Two youth were transported to medical appointments. Youth were searched prior to
entering the vehicle. Staff-to-youth ratio was two-to-two. Youth and staff wore seat belts during
transportation. Both staff were of the same gender as the youth on the transport. The program is
not a secure or high-risk program, making the requirement for a safety screen not applicable.
The human resource manager at the program ensures all staff operating a program vehicle has
a current driver’s license by completing a driver’s license check during the hiring process. Youth
are not permitted to drive program or staff vehicles. Seven staff were interviewed. All seven
confirmed if youth are coming or going from a court hearing they are handcuffed and shackled
with their seatbelt on. One staff drives and the other staff will ride in the back with the youth.
Two females cannot take youth by themselves. There always needs to be a male staff on board.
If the youth are going on an outing for incentives, they are not handcuffed or shackled but all
have a seatbelt on. All staff taking youth on transports have a two-way radio and a cell phone
they check out from master control. The program has a full-time staff who transports regularly.
The staff confirmed they check out a black box from master control when transporting. The
black box contains a first aid kit, a binder with the face sheets and information of the youth, gas
card, seatbelt cutter, and light flashers. All seven staff stated youth are never transported in
personal vehicles and the transport vehicles are checked for contraband prior and after each
use. The staff indicated when an emergency occurs while on transport, the staff would either
call 9-1-1 or master control depending on what the emergency is. Six staff mentioned pulling
over to a safe area if at possible. Six staff stated the ratio of staff to youth during transport is
two-to-five. One staff stated two-to-one all the way up to two-to-four. All seven staff relayed a
staff must always ride in the back with the youth. Seven youth were interviewed. Two youth
confirmed they hadn’t been on an outing or on a transportation, so they were not sure. One
youth stated no shackles or handcuffs were used when going on outings. Five youth confirmed
they were never handcuffed to any part of the vehicle. All seven youth confirmed they had never
seen anyone place contraband in a transport vehicle.
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures which designates the assistant facility administrator
(AFA) as the person responsible for conducting the weekly security audits and safety
inspections. The development and implementations of corrective actions, when warranted, shall
be developed and implemented based upon the identified safety and security deficiencies found
during any internal or external review, audit, or inspection. Program leadership shall ensure
review of the findings, submission to the Department, verification of all deficiency corrections,
and shall implement improvements when needed to maintain compliance. Follow-up and
verification of identified deficiencies and corrective action steps completion shall be completed
by the AFA and reported on during the daily management meeting. A review of the weekly
safety and security audit binder ensured all weekly safety and security checks were completed
as required during the annual compliance review period. There were no deficiencies
documented in the Department’s Juvenile Justice Information System during the annual
compliance review period. The program’s Preventative Maintenance Checklist was reviewed
and meets the requirements outlined in Florida Administrative Code. The interview with the
facility administrator confirmed the weekly safety audits are conducted in accordance with
program policy and procedures.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to address tool inventory and management of
tools. The policy addresses the issuance, inventory, and control of equipment and tools. All
tools are inventoried prior to being issued for work and following work activities. The physical
plant manager completes a sign-in and out sheet when a tool is used. Machetes, bowie knives,
and other long blade knives are not allowed. There were no missing or lost tools during the
annual compliance review period. The physical plant manager has a practice in place in the
event this happens, which is to file an incident report and notify administration immediately.
There were also no broken tools which had to be disposed of and replaced during the annual
compliance review period; however, there is a practice in place should this event occur. The
program will document the damaged tool disposal and replacement on the inventory sheet. A
review of the inventory and verification of ten tools found the tools to be secure, to have marking
for easy identification, and the inventory to be accurate.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures addressing youth tool handling and supervision
and includes supervision requirements when youth use tools, issuing tools to youth and staff,
including an assessment to determine a youth’s risk to self and others, established ratios, tool
distribution and collection, and search criteria during work projects. During activities involving
tool use, the program maintains a ratio of one staff to five youth as well as during vocational
training. Youth do not participate in disciplinary work projects. Based on observations during the
annual compliance review week, the staff-to-youth ratio while youth were using tools was one-
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to-one. During search procedures, the staff-to-youth ratio was two-to-eight. Youth were
searched after each work period. Seven youth case management records were reviewed, and
each record indicated youth have been trained on the proper usage of class B tools during their
orientation process. Youth signed an acknowledgement of tool training form during the
orientation process. All reviewed case management records contained a risk assessment which
was completed prior to the use of tools. Seven staff were interviewed and confirmed youth are
allowed to use mops and brooms under supervision. One staff stated the youth can use
dustpans and mop buckets as well. One staff stated the youth must qualify first before being
able to clean. Seven youth were interviewed. All seven youth confirmed they could use a mop or
a broom in front of staff when cleaning. Two of the youth stated they were able to use a vacuum
and a dustpan in addition to the mop and broom.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures which addresses outside contractors. The
physical plant manager is responsible for escorting any outside contractors around the facility
and ensuring tools are signed in and out. The program has a procedure in place where private
contractors shall receive written instruction detailing responsibilities regarding tool management
and contraband and shall confine their work to the authorized area using safety and security
precautions. The guidelines for repairman/external worker tools include tools checked upon
arrival and departure, tool restrictions while in the facility, youth being restricted from the work
area, and missing tool follow-up. Sign-in sheets for the contractors were reviewed. Each sheet
includes the contractor's name, purpose of visit, arrival time, whether or not tools are required,
statement where staff checked the contractors tools upon arrival, a list of tools to be utilized
during the visit, whether or not tools were missing after completion of project and if so, was
there immediate reporting of the missing tool(s) and follow-up which occurred; arrival and
departure times; and signatures of the contractor staff and program staff. There was a
contractor on-site during the annual compliace review week and the review team was able to
confirm this form was completed in its entirety. The program inventoried the tools or other
equipment when the vendor arrived and left. Three program invoices were reviewed to ensure
outside contractor agreements were signed on the date of service. All invoices and contractor
agreements matched and there were no discrepancies found.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a policy and procedures to provide for the safety and security of both
staff and youth in the event of an emergency or disaster. All drills for the annual compliance
review period were reviewed. The documentation showed drills were consistent with the
Continuity of Operations Plan (COOP). All drills contained the type of drill, date, time,
participants, and a brief scenario, including findings and recommendations. Drills were
conducted monthly on each staffing shift on a rotating basis. The types of drills completed were
fire, mental health, escape, medical, COOP (bomb threat), COOP (tornado drill), COOP
(hurricane drill), and Right Interactions (RI). Evacuation and egress routes were posted
throughout the facility, and all twenty-one fire extinguishers were inspected annually. Seven
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staff were interviewed and asked which drills they had participated in within the last twelve
months. The drills confirmed were fire, suicide, medical, mental health, flood, escape, hurricane,
and safety and security. Seven youth were interviewed and confirmed they participate in fire
drills regularly. Three youth stated they had fire drills at least once a week, one youth stated
they participated in ten or more fire drills since being in the program over five months, one youth
stated has been in three fire drills within a month, and one youth stated fire drills are more than
once a month.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a policy and procedures addressing the Continuity of Operations Plan
(COOP). The program maintains a combined COOP and Emergency Disaster Preparedness
Plan. The policy states the COOP is located in the facility administrator’s (FA) office and master
control and observations during the annual compliance review week confirmed this practice as
well as confirming it is readily available to staff. The COOP was submitted to the Department for
approval on March 5, 2025, and last reviewed and updated on March 13, 2025. The plan
addresses alternative housing plans approved by the Department regional director/designee.
The program has food and necessary supplies readily available in case of emergency
evacuation, which are maintained on-site in the kitchen storeroom and in master control.
Emergency equipment maintained at the program includes first-aid kits, compass, gloves, soap,
window break, medications, and hygiene items. The program maintains an administrative hard
copy file on all youth in case of an emergency. This information is contained in the COOP
Binder/Transport Binder which contains all required information on all youth. Seven youth
emergency files were reviewed which confirmed this practice. The FA interview confirmed the
COOP is in the FA’s office and master control.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The program’s policy and procedures also address
chemical spills and clean-up of chemical spills. The program’s flammable, toxic, caustic and
poisonous materials shall be stored in secure areas inaccessible to youth. Substances labeled
“Keep out of Reach of Children” or “May be Harmful if Swallowed” shall also be kept under strict
control. Program youth shall not be permitted to use, handle, or clean dangerous or hazardous
chemicals, respond to chemical spills, or clean, handle, or dispose of any other person’s
biohazardous material, bodily fluids, or human waste. The program’s flammable, poinsonous,
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and toxic items are located in a flame-resistant cabinet located in the physical plant manager’s
office and in locked dormitory closets inaccessble to youth. The program maintains proper
inventory of these items. The physical plant manager, facility administrator (FA), assistant
facililty administrator, direct-care staff, and kitchen staff are the individuals authorized to handle
flammable, poisonous, and toxic items. The program’s policy and procedures on the disposal of
flammable, toxic, caustic and poisonous items states the program shall dispose of hazardous
items and toxic substance or chemicals in accordance with Occupational Safety and Health
Administration (OSHA) Standard 29. All flammable, toxic, caustic, and poisonous items are
disposed of by the physical plant manager at the county waste management site, if the chemical
cannot be returned to the vendor. The program’s physical plant manager was interviewed on the
proper procedures of disposing chemicals and stated all items for disposal are collected by the
county waste disposal or returned to the vendor. The physical plant manager further stated the
program has not needed to dispose of any chemicals during the annual compliance review
period. Liquid water (dirty mop water, unused beverages) from work details was disposed of in
the plumbing drains. Kitchen staff dispose of kitchen waste by use of the plumbing drains.
Kitchen grease is disposed of monthly by a contracted grease disposal company. If a there was
a chemical spill, the policy included notifying master control, shutting down all ventilation
systems and closing all windows and doors, and if necessay, contacting outside assistance
consistant with empergency procedures. A review of the five flammable, toxic, caustic, and
poisonous items being maintained on-site were confirmed by the inventory with no items
missing and a safety data sheet (SDS) included for each. An interview with the FA confirmed
the program disposes of flammable, toxic, caustic, and poisonous items off-site at the city’s
disposal sites as applicable.
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 maintains a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The program’s policy states program youth shall not
be permitted to use, handle, or clean with dangerous or hazardous chemicals, respond to
chemical spills or clean, or handle or dispose of any other person’s biohazardous material,
bodily fluids or human waste. The program maintains strict control of flammable, poisonous, and
toxic items and materials. There is restricted youth access to areas where these items are used
or stored. Video observation during the annual compliace review week reflected youth using a
broom and dust pan, as well as a mop and mop bucket. Staff were seen supervising youth
during the entire time youth were in possession of cleaning tools. Seven youth were
interviewed. Four youth confirmed they had never used any chemicals or cleaning products.
Two youth stated bleach was used when they were washing clothes, but they did not handle the
bleach. One youth stated they were able to place a tide pod in the washer with staff standing
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next to them, and two youth used window cleaner, but stated the staff sprayed the window, and
they used a rag to wipe away any dirt or grime.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures to allow visitation and communication for youth
while in the program. The program’s policy states all program youth shall be provided
opportunities to promote communication and engagement which fosters family reunification and
community connections. The program shall assist youth and families in maintaining connections
in a visitation environment which provides monitoring, control of movement, and security
practices to ensure visitor, youth, staff, and program safety. The program shall maintain a list of
approved visitors. Attorneys, representatives of the court, juvenile probation officers, other
agency representatives, and clergy are authorized to visit at any time. Searches of visitors will
be conducted upon entry and all youth shall be searched following visitation sessions. The
visitation schedule is posted in case management offices. An informal interview with case
management confirmed visitation is scheduled on Saturdays from 1 p.m. to 3 p.m. A review of
the visitation log confirmed visitation is being offered on Saturdays during the scheduled times.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 64 (Revised August 2025)
A review of the telephone log and schedule determined telephone calls are offered Monday
through Friday. Case management has a schedule of when each youth makes their telephone
call and on which day. Friday is usually held for make-up days for telephone calls which were
not successful during the week. Case management advised mail can be sent out any day. A
review of the mail log confirmed mail is being sent out and is being searched prior to being sent.
Alternative visitation arrangements with parent/guardian(s) were available, if needed. Case
management verified for youth with a history of human trafficking, they request clarification from
the juvenile probation officer (JPO) to verify the youth’s parent/guardian and other family
members are not under current or past investigation for human trafficking-related charges. The
program also has an agreement with a third-party language service. They have an agreement
with American Sign Language Services Cooporation (ASL Services, Inc.) where ASL Services
provides professional interpreting services for Video Remote Interpreting (VRI) requests. The
agreement is effective for two years and will automatically renew for one-year periods unless
terminated in writing by either party. Seven youth were interviewed. All seven youth stated they
can call their parent/guardian once a week and/or can send a letter. An interview with the facility
administrator confirms the program offers interpreter services for youth whom English is not
their primary language.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures stating recreation and leisure activities shall be
provided. The policy states staff will work with the youth to plan activities to expose youth to a
variety of recreation and leisure choices, exploration of interests, constructive use of leisure
time, and social and cognitive skill development, as well as to promote creativity, teamwork,
healthy competition, mental stimulation, and physical fitness. Staff will provide the youth with
varying degrees of mental and physical exertion throughout the day such as, board games,
creative arts, sports, and physical fitness activities. Additionally, the youth will be provided with
at least one hour of large muscle activity daily. The program will also provide an array of
vocational opportunities which include career enrichment components. A review of the
program’s activity schedules confirms a range of supervised and structured indoor and outdoor
recreation and leisure activities are provided for the youth for at least one hour daily with large
muscle activity also being provided. Activities which promote social and cognitive skill
development, creativity, teamwork, healthy competition, mental stimulation, and physical fitness
are also being provided. A review of the logbook indicated recreation was conducted as
scheduled. During the review, recreational activities were observed and monitored to ensure the
program takes precautionary measures to prevent overexertion, heat stress, dehydration,
frostbite, hypothermia, and exacerbation of existing illness or physical injury. The program is
contractually required to have a recreational therapist on staff. A review of the staffing roster
revealed the program has one recreational therapist with the appropriate credentials. A review
of seven youth records revealed recreational therapy was included in each youth’s
individualized performance or treatment plan. Seven youth were interviewed. All seven youth
stated physical activities last at least one hour. Some of the activities included basketball, both
indoor and outdoor, football, kickball, soccer, dodgeball (inside), and able to walk around within
the fencing or, if indoor, around the gym. Seven staff were interviewed regarding indoor and
outdoor activities. All staff confirmed activities are at least one hour. Outdoor activities included
football, basketball, soccer, kickball, and field days. Indoor activities included board games, arts
and crafts, dodgeball, basketball, relays, and whiffleball.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 64 (Revised August 2025)
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 64 of 64 (Revised August 2025)

report_type: QI Residential

program_name_raw: Silver Springs Youth Academy