summary: QI Residential - FY24-25 - 3 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Escambia Boys Base
AMIkids, Inc.
(Contract Provider)
640 Roberts Avenue Building 3780
Pensacola, Florida 32511
Review Date(s): April 22 - 25, 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:
Stephanie Solano, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Diwon Barron, Youth Opportunity Investments, Regional Director (Standard 5)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Ken Myers, Office of Education, Education Coordinator Circuit 1 (Standard 2)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 6)
Brad Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Escambia Boys Base MQI Program Code: 1271
Provider Name: AMIkids, Inc. Contract Number: 10761
Location: Escambia County / Circuit 1 Number of Beds: 28
Review Date(s): April 22 - 25, 2025 Lead Reviewer Code: 209
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Education
Services, which are included in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.07 Residential Assessment for Youth (RAY) 4.13 Episodic/First Aid Care/Emergency Care
2.11 Performance Summaries and Transmittals
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 66 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 66 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Limited
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Limited
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 66 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Satisfactory
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 66 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Failed
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 66 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Satisfactory
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 66 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Indicator Ratings
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 66 (Revised September 2022)
Program Overview
The Escambia Boys Base program is a twenty-eight bed program for fourteen to eighteen-year-
old males in Pensacola, Florida. The program is operated by AMIkids, Inc., through a contract
with the Department. The program provides the following services: Mental Health Overlay
Services (MHOS). In addition, the program fosters each youth by providing Aggression
Replacement Training (ART), Impact of Crime (IOC), and Cannabis Youth Treatment (CYT).
Program administration is comprised of an executive director, business manager, director of
operations, and director of treatment. Case management services are provided by a transition
coordinator and two case managers. Mental health staff at the program includes a director of
treatment, two therapists, and one psychiatrist. Medical services are offered seven days a week
and are provided by two full time registered nurses and one medical doctor. Sick call is offered
two times a day as required. Educational services are provided by Florida Virtual School. The
layout of the program includes one building, which houses all departments and youth rooms.
The program does not have a dining facility on-site. The program is co-located on the
Pensacola Naval Base and shares the cafeteria with the base. The program has forty-two
security cameras providing coverage. All cameras were observed as operable at the time of the
annual compliance review. The program has three vacant positions which are all direct care
staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 66 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a policy and procedures addressing initial background screenings of
employees, volunteers, mentors, and interns. The Annual Affidavit of Compliance with Level 2
Screening Standards was completed and submitted to the Department’s Background Screening
Unit (BSU)/Clearinghouse on January 29, 2025. The Annual Affidavit for the teachers was
submitted on January 28, 2025. Ten staff were applicable for initial background screenings.
Each of the ten staff had a background screening completed prior to contact with youth and
confidential records. Each staff reviewed had a criminal history report reviewed. Five staff had a
break in service as indicated in the Department’s Staff Verification System (SVS) and had a new
background screening completed as required. Each reviewed staff completed a pre-employment
assessment and had a passing score on the pre-employment assessment tool. Each staff
member was added to the Clearinghouse Employment Roster and had a signed contraband
attestation form on file. The program reported two volunteers since the last annual compliance
review. The two volunteers participated in fewer than ten hours a month and were not applicable
for the full background screening process.
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 maintains a policy and procedures addressing five-year background re-screenings
for all staff. Three staff were applicable for five-year background re-screenings. All five-year re-
screenings were completed every five years as required. The re-screenings were submitted to
the Department’s Background Screening Unit/Clearinghouse at least ten business days prior to
the five-year anniversary or retained prints expiration date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 66 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a policy and procedures addressing the reporting and investigating of
suspected or alleged child abuse. Since the last annual compliance review, the program
reported one incident related to physical, psychological, or emotional abuse. Following an
investigation, the incident was determined to be unsubstantiated. A review of five staff
personnel records confirmed all staff had reviewed and signed the Code of Conduct, which
outlines expectations for professional behavior. During the facility tour, it was observed contact
information for the Florida Abuse Hotline and the Department’s Central Communications Center
(CCC) was clearly posted throughout the program. The program’s protocol requires the director
of operations or designee to ensure all allegations or suspicions of child abuse are reported
immediately to the Florida Abuse Hotline. Additionally, the program completed a Trauma
Responsive and Caring Environment (TRACE) self-assessment on July 8, 2024, as part of its
commitment to trauma-informed care.
Five youth were interviewed and each of five youth reported they felt safe at the program, have
never been stopped from reporting abuse to the CCC or Florida Abuse Hotline, and have the
number or access to the number to the Florida Abuse Hotline. Three of the five youth reported
staff being respectful when talking to youth and have never heard a staff use curse words when
speaking to youth. The remaining two youth reported they had heard staff curse occasionally in
general conversation. All five youth reported they have never exchanged any personal contact
information such as emails, telephone numbers or social media information with staff. Five staff
were also interviewed, and each was able to articulate the process for allowing youth to call the
Florida Abuse Hotline and CCC. All five staff reported never observing another staff tell a youth
they could not call the Florida Abuse Hotline. Three of five staff reported never hearing and
other staff using profanity while speaking with youth. Of the remaining two, one reported hearing
it once, and the other said it occurred occasionally when speaking in general around youth. An
interview with the executive director confirmed the staff Code of Conduct enforces a zero-
tolerance policy for abuse and neglect. Leadership is responsible for ensuring both youth and
staff are aware of their rights and the process for reporting abuse. All allegations are reported
immediately to the Florida Abuse Hotline, followed by an internal investigation by management
to determine necessary actions. This process applies to all forms of abuse, including physical,
psychological, and emotional. The program emphasizes trauma-responsive practices,
conducting the TRACE self-assessment annually with input from both youth and staff. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 66 (Revised September 2022)
findings are reviewed and used to develop strategies promote a supportive and safe
environment. The program ensures reportable incidents are communicated to the CCC and
Florida Abuse Hotline within two hours of occurrence or awareness. Since the last annual
compliance review, one staff member faced disciplinary action due to allegations of abuse
toward a youth.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program maintains a policy and procedures addressing staff misconduct and consequences
of misconduct. The program had one incident where there were allegations of physical,
psychological, or emotional abuse in the program during the annual compliance review period.
There was evidence management took immediate action to address allegations of physical,
psychological, and emotional abuse. Documentation was reviewed to identify applicable
corrective actions by management.
An interview with the executive director revealed program administration must be immediately
made aware of the allegation. Depending on the nature of the allegation, a call will be made to
the Florida Abuse Hotline, followed by a call to the Department’s Central Communications
Center, if applicable. Program administration will conduct an internal investigation to determine
the implementation of any immediate action. Administration will review any incident reports,
interview staff and youth and implement corrective action to ensure the safety of youth.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a policy and procedures addressing incident reporting. The program had
a total of twenty-three reports to the Department’s Central Communications Center (CCC)
during the annual compliance review period. A sample size of five incidents were reviewed. All
five incidents were reported within two hours. Each of the incidents were documented in the
program logbook. No other additional incidents were discovered which should have been
reported to the CCC during the annual compliance review. The program experienced an
increased in the number of reportable incidents to the CCC from the eight last year. The
executive director reported the majority of CCC’s revolved around one youth due to behavioral
problems. The youth was also Baker Acted five of the seven times during the annual
compliance review period. The youth was transferred to an intensive program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 66 (Revised September 2022)
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program maintains a policy and procedures addressing Right Interactions (RI)/Protective
Action Response (PAR) reporting. The program had eight RI incidents during the annual
compliance review period. Monthly summaries were maintained by the program and submitted
to the Department. The RI plan was updated December 13, 2024. The RI Plan was approved by
the Department on December 17, 2024. Five RI incidents revealed the reports were completed
by the end of the staff’s workday and included statements from all staff involved. No mechanical
restraints were used during the RI incidents. One of five incidents resulted in an injury to the
youth. The Department’s Central Communications Center (CCC) was contacted following the
incident within the two hours of becoming aware of the incident as required. Each involved
youth received a medical review post-RI and a follow-up doctor’s appointment was made for the
youth. All RI Reports were reviewed by a supervisor and administrator within seventy-two hours
of the incident. A copy of the RI report was placed in the program’s centralized file. The
program’s PAR rate during the annual compliance review period was 0.49, which is below the
statewide Residential PAR rate of 1.71.
Five staff were interviewed regarding the Right Interactions (RI) process and each was able to
articulate the process. An interview the executive director (ED) revealed any time a physical
intervention is used, the director of operations is to be immediately notified. The director of
operations or designee will remain on twenty-four-hour call for this purpose. All RI reports will be
reviewed by the program’s compliance specialist or designee within seventy-two hours of the
incident.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program maintains a policy and procedures addressing pre-service training and certification
which states all direct care staff shall receive orientation training and the required pre-service
training. The career coordinator and maintenance staff occasionally supervise youth and are
counted in the staff-to-youth ratio. All instructors were qualified to deliver training. The program
submitted a pre-service training plan prior to its implementation. The training plan was approved
by the program director, the assistant secretary for the Department’s Office of Residential
Services, and the director of the Department’s Office of Talent, Leadership, and Culture (TLC).
Five staff training records were reviewed. Each staff completed the initial 120 required training
hours in the required timeframe. All staff completed the following required trainings prior to
youth contact: child abuse recognition, reporting, and prevention, cardiopulmonary resuscitation
(CPR), First-Aid, automated external defibrillator (AED), emergency procedures, program
operating procedures, Prison Rape Elimination Act (PREA), professionalism, interpersonal
communication, and ethics, right interactions, and suicide awareness and prevention. Each staff
completed the additional trainings such as active shooter preparedness, adolescent
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 66 (Revised September 2022)
development and behavior, balanced approach to restorative justice, the Department’s Central
Communications Center (CCC), civil rights, communication, Confidentiality and Health
Insurance Portability and Accountability Act (HIPPA), Department of Juvenile Justice Legacy,
equal employment opportunity, gang awareness, human trafficking intervention, infection
control/bloodborne pathogens, information security awareness, mental health and substance
abuse, Motivational Interviewing (MI), quality report writing, safety, security, and supervision of
youth, sexual harassment, effective and respectful treatment of youth, and trauma responsive
practices. Three of five staff completed Motivational Interviewing (MI) training. Of the two-
remaining staff, one previously completed MI training in 2015 but experienced a service break
exceeding one year and should have retaken the training upon rehire. The remaining staff
member is scheduled to complete MI training by the end of April 2025. Each staff also
completed the following contract-required trainings: adolescent healthcare, homicide risk,
triggers and prevention, immediate access to emergency healthcare, incident reporting
procedures, naloxone administration, responding to traumatized youth, Standardized Program
Evaluation Protocol (SPEP), and stress management. Four out of five staff members also
completed training on electronic vapor products, the grievance process, and specialized
treatment services. The remaining staff is within the 180-day training window and is on track to
complete all required trainings within the designated timeframe. Additionally, one newly hired
supervisory staff member successfully completed the mandated sixteen hours of training in
coaching, leadership, and personal accountability.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program maintains a policy and procedures addressing in-service training requirements. A
review of five staff training records confirmed each employee completed the mandated twenty-
four hours of in-service training. Topics covered included active shooter preparedness,
CPR/First Aid/AED, human trafficking, information security awareness, mental health and
substance abuse, the Prison Rape Elimination Act (PREA), Right Interactions (RI),
professionalism, interpersonal communication and ethics, sexual harassment, suicide
awareness and prevention, and trauma-responsive practices. All five staff currently hold active
certification in RI. Additionally, two supervisors were selected for review regarding their annual
supervisory training. Each supervisor completed at least eight hours of required training specific
to their role. All reviewed staff completed training mandated by Florida Administrative Rule in
the areas of emergency response and drills, infection control, bloodborne pathogens, exposure
control, and mental health overlay services. All training was delivered by qualified instructors.
Staff also completed supplemental trainings, including Naloxone administration, responding to
traumatized youth, safety awareness, stress management, substance use risk factors, and
overdose recognition and response. Of the five staff reviewed, three were applicable for
medication self-administration training and successfully completed it. The program submitted its
in-service training calendar in advance of implementation. The training plan received formal
approval from the executive director, the assistant secretary for the Department’s Office of
Residential Services, and the director of the Department’s Office of Talent, Leadership, and
Culture (TLC).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 66 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a policy and procedures addressing the grievance process which
includes the training requirements for staff. The grievance process consists of three distinct
phases: informal, formal, and appeal. During the informal phase, youth are encouraged to
resolve concerns directly with the staff member on duty at the time of the incident. If the issue is
not resolved to the youth’s satisfaction, they may proceed to the formal phase by submitting a
written and signed grievance to a supervisor. If further resolution is needed, the grievance
advances to the appeal phase, where it is reviewed by the executive director. The program
reported there were no grievances during the current annual compliance review period.
Interviews were conducted with five youth and all were able to clearly describe the grievance
process. Each youth confirmed assistance in completing a grievance form is available upon
request. Interviews were conducted with five staff and all demonstrated an understanding of the
grievance process. Three staff noted grievance forms are readily accessible throughout the
program and staff described the process as consisting of three phases, with supervisors initially
reviewing grievances and the executive director handling appeals. One staff member
specifically mentioned youth can request help in filling out the form. An interview with the
executive director confirmed the grievance process includes three phases: informal, formal
(supervisor review), and appeal (executive director review). All grievances are signed by both
the youth and a staff member, or documentation is provided if the youth refuse to sign.
1.10 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.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a policy and procedures for providing instruction focusing on developing
life and social skill competencies in youth. All youth receive an assessment of life skills at intake
during their comprehensive evaluation by a therapist. Based on the assessment, life skills and
social skills curriculum will be provided to youth based on their individualized need and
according to their treatment plan. The program’s only life skills group is considered primary;
therefore, the group is not applicable for review for this annual compliance review.
Five youth were interviewed and each reported participating in a life skills group. Examples
given were Aggression Replacement training (ART), Impact of Crime (IOC), Cannabis Youth
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Treatment (CYT), and Mental Health Overlay Services (MHOS). An interview with the executive
director (ED) revealed youth at the program participate in IOC, MHOS, CYT, and ART groups.
An interview with the designated mental health clinician authority (DMHCA) revealed MHOS
groups are provided four days a week and Substance Abuse Overlay Services (SAOS) groups
are provided to qualified youth one day a week during a CYT cohort. Services are provided by
the clinical case manager, master’s-level counselor, and the director of treatment. The case
manager completes a Residential Assessment for Youth (RAY) and the Youth Needs
Assessment (YNAS), which are assessment tools to determine what the youth's needs are. The
master’s-level counselor conducts a comprehensive assessment to determine needs of the
youth. A performance plan and treatment plan are developed with stated goals and needs for
services for the youth on these plans. The program utilizes ART and IOC, which are evidence-
based, to fulfill the needs of the youth according to their assessments.
1.12 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 the program. For details related specific to IOC service delivery, please refer
to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a policy and procedures addressing internal alerts which included
information on how alerts are identified, documented, updated, and communicated to staff. The
program’s policy states information concerning the youth, staff and public safety will be
communicated to the staff using a continually updated, internal alert system is easily accessible
to program staff and keeps them alerted about youth who are security or safety risks, including
escape risks. Direct care, supervisory, or clinical staff may place a youth on alert status if the
individual meets the established criteria for inclusion in the alert system. During a review of five
youth records, all internal alerts were found to be properly documented in both the internal alert
list and the Department’s Juvenile Justice Information System (JJIS) on the same date. All
alerts were consistent across both systems, as required.
Five staff were interviewed regarding alert notifications. All staff reported referencing the alert
log binder, while one staff also mentioned receiving updates through the electronic commitment
packet (ECP). An interview with nursing staff revealed nursing staff are responsible for updating
the medical alert system. An interview with the executive director revealed program
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management and healthcare staff hold weekly meetings to discuss significant medical issues
affecting youth. As part of the internal alert process, any direct care, supervisory, or clinical staff
may initiate an alert for a youth who meets the defined criteria. Specific alerts include a “Suicide
Risk Alert,” entered when a youth is identified during screening or evaluation as being at risk for
suicide, and a “Mental Health Alert,” entered when a youth is found to have a mental disorder or
is experiencing acute emotional distress may present a safety or security risk. Only a licensed
mental health professional, medical staff member, or the executive director may authorize the
downgrading or discontinuation of a youth’s alert status.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains a policy and procedures addressing youth records. Visual observation
confirmed the program maintains separate youth individual healthcare and management
records. Five Individual Healthcare Records and five case management records were reviewed
for compliance. Each individual management record contained the youth’s name, Department
identification number, date of birth, county of residence, and committing offense. The records
were organized into sections covering legal information, demographics, chronological
documentation, correspondence, case management activities, treatment team updates, and
miscellaneous materials. All records were clearly labeled “Confidential” and stored in a secured
room. Mental health records were also securely stored and marked “Confidential”; however,
while the case management records were located in a locked room, they were kept on an open
shelf rather than in a locked cabinet. Additionally, the room door and storage shelf were not
labeled “Confidential.”
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program maintains a policy and procedures addressing community advisory board
meetings. Meetings are held monthly. . Documentation indicates the executive director actively
recruits board members from a diverse range of community sectors, including law enforcement,
the judiciary, the business sector, the school board, faith-based organizations, and other
stakeholders. Recruitment efforts also extend to victims and parents of youth previously
involved in the juvenile justice system. The board is reported to meet monthly and is actively
engaged in the program’s operations. It contributes recommendations on community initiatives,
program improvements, programming, and volunteer efforts. An interview with a board
member—an executive with a local nonprofit organization—confirmed their monthly participation
and strong support for the mission of the provider. They stated they receive meeting
notifications by email and text messages and expressed a desire to continue their service on the
board.
An interview with the executive director further confirmed the advisory board meets at least
every ninety to 120 days. The executive director emphasized efforts to foster meaningful
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partnerships with community stakeholders and juvenile justice partners to support the program’s
goals.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has policy and procedures in place to address staff performance through annual
evaluations. A review of five staff job descriptions confirmed performance standards are clearly
defined. Additionally, five corresponding performance evaluations were examined, verifying
evaluations were conducted in alignment with policy guidelines. All five reviewed staff records
showed employees were evaluated annually, with performance expectations consistent with
their respective job descriptions. The program contract was also reviewed to ensure compliance
with staffing requirements. All contractually mandated positions are currently filled, despite the
program having three vacant positions overall. Notably, the program employs a recreational
therapist whose credentials, schedule, and service delivery meet all contract specifications.
Interviews with five staff regarding the frequency of formal evaluations revealed varying
responses: one reported annual evaluation, one cited evaluations every six months, another
quarterly, one every ninety days, and one mentioned having received only an informal
evaluation. In an interview, the executive director stated the program has not faced any staff
turnover issues during the annual compliance review period. The program promotes staff
recognition through monthly meetings, including a “Staff of the Month” award. Team members
are also given opportunities to engage in enriching activities with youth during their shifts. Each
manager is required to conduct a minimum of one performance review annually to provide
employees with performance-related feedback.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of the program’s contract and documentation supported the program provided and has
implemented all items or services either negotiated or outlined which are considered special
contract conditions. The program offered regular faith-based opportunities, challenge events,
decorated living areas, family participation in celebrations, birthday meals and cake, guest
speakers, and one-on-one mentoring opportunities, as required. An interview with the executive
director revealed all students receive three snacks a day, all youth receive a special meal of
their choice and cake on their birthday, and mentorship from military personnel.
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1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has established policies and procedures to incorporate the review and analysis of
data to inform decision-making practices. As part of its ongoing quality improvement efforts,
youth are required to complete Youth Satisfaction Survey Reports at least once each quarter.
The responses are analyzed to identify strengths and areas for improvement related to the
AMIKids Personal Growth Model. This data is submitted to the corporate office, which returns
graphical and comparative analyses benchmarking the program against other providers. These
findings help guide strategic planning and program development. According to the executive
director, the program also administers Youth Outcome Surveys quarterly to all youth and
distributes Parent Surveys to guardians at the time of each youth’s discharge. These survey
results are likewise submitted to the corporate office and reviewed during staff and management
meetings. Additionally, Trauma Responsive and Caring Environment (TRACE) surveys—annual
self-assessments completed by both staff and youth—are submitted to the Department. Results
are returned and reviewed during All Staff Meetings at the program. The program provided
examples of completed Youth Satisfaction Survey Reports, Youth Outcome Surveys, and
Parent Surveys. Documentation of Management Team Meeting minutes was also submitted,
demonstrating survey data is regularly reviewed. Email correspondence confirmed the provider
shares youth survey results quarterly. Furthermore, the executive director provided Advisory
Board meeting minutes indicating operational updates, including findings from survey data, are
shared with board members and stakeholders.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program maintains a policy and procedures addressing notification of youth parent/guardian
of admission to the program. Five youth case management records were reviewed for inclusion
of parental notification. Each of the five records contained evidence the program notified the
parent/guardian by telephone within twenty-four hours of admission, provided written notification
within forty-eight hours of admission and notified the committing court and juvenile probation
officer (JPO) within five working days and when applicable the post-residential services
counselor.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program maintains a policy and procedures addressing youth orientation. Documentation
review confirmed the program’s orientation process contained all elements outlined in its policy
such as services available, daily schedule, expectations and responsibilities of youth, written
behavior management system, availability of access to medical, mental health and substance
abuse services, access to the Florida Abuse and the Department’s Central Communications
Center Hotline, the program’s zero tolerance policy regarding sexual misconduct and availability
of special accommodations to ensure all written information about sexual misconduct policies
including reporting procedures is conveyed and available to youth with literacy, comprehension,
visual or hearing impaired disabilities. The program’s policy further includes the youth’s right to
be free from sexual misconduct, right to be free from retaliation for reporting misconduct, and
the agency’s sexual misconduct response policy’s and procedures, items considered
contraband including illegal prohibited items, performance planning process involving the
development of goals for achievement, dress code and hygiene practices, procedures for
visitation, mail and telephone use, expectation for release including successful completion of
individual performance plan goals, recommendations to the courts for release, and the court’s
decision to release, community access, grievance procedures, emergency procedures including
fire drills and building evacuations, facility tour and assignments to living units, treatment team,
and staff advisory or youth group. Five youth were interviewed, and each of the five youth
reported orientation to the program occurred within twenty-four of admission, and orientation to
the program included program rules, procedures, and schedules.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program maintains a policy and procedures addressing written consent for youth eighteen
years of age or older. Five youth case management records were reviewed for inclusion of
written consent. No youth was eligible for the notification process. A request for three additional
records of youth eighteen years of age or older was initiated. The program indicated there was
one youth eighteen years of age or older during the annual compliance review period.
Documentation review of the record confirmed written consent was obtained by the program
prior to providing or discussing physical, mental health screening, assessments or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program maintains a policy and procedures addressing classification factors, procedures
and re-assessments. The program’s policy and procedures clearly outline the classification
process and includes a classification system which promotes safety and security, as well as
effective delivery of treatment services based on determination of each youth’s individual needs
and risk factors, which addresses at a minimum, items outlined in Administrative Rule. The
program’s policy regarding reassessment indicates 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 is 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. Documentation review confirmed the program’s
classification forms included all the required elements such as physical characteristic of youth,
age and maturity level, identified special needs, history of violence, gang affiliation, criminal
behavior, sexual aggression or vulnerability to victimization, youth’s perception of potential or
verified human trafficking, suicide risk, medical risk, escape risk, and security risk. Five youth
case management records were reviewed for inclusion of initial classification documentation
and information. Documentation within each record confirmed youth were classified for the
purpose of room assignment and the Department’s Juvenile Justice Information System (JJIS)
was reviewed for alerts which may affect classification. Two of five records indicated the youth
was identified with a mental health, medical, substance abuse, or security risk factor which was
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immediately entered into the program’s internal alert system and JJIS. Documentation review
confirmed each record contained a reclassification prior to an increase in privileges or freedom
of movement, participation in work projects or activities involving tools, and participation in off-
campus activities.
The executive director was interviewed regarding the classification process and reported the
program provides a classification process which includes an initial classification of the youth for
purposes of room or living area assignment within the program based on the initial screening
which includes a review of the commitment packet, review of other information about the youth’s
history and status including JJIS alerts for the youth, initial collateral contacts, initial interactions
with and observations of the youth. The program goal is to protect youth through a classification
system which ensures the most appropriate unit assignment and sleeping room assignment
while providing the type of care best suited to the needs of the individual concerned and the
protection of the individual’s physical, mental, and moral integrity and well-being. The
management designee will review each new youth's legal record. New youth are assessed
based on the information obtained from their youth classification form, Massachusetts Youth
Screening Instrument- Second Version (MAYSI) results, collateral contacts, and information
contained in the commitment packet. For determining the most appropriate placement in
sleeping arrangements, a review of the commitment packet, youth classification form, and other
known information will be made, and the following will be considered: physical characteristics,
age and maturity level, history of violence or aggressive behavior, history of violence or
aggressive behavior, identified special needs, including mental, developmental, or intellectual,
and physical disabilities.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program maintains a policy and procedures addressing gang identification and law
enforcement notification. The program’s policy dictates all incoming youth will be questioned as
to gang affiliation; tattoos and body markings may be considered as part of the assessment
process. Information gained regarding gang involvement will be shared with any applicable
gang information database. The program shall share pertinent gang-related information, as
appropriate, with the Florida Department of Law Enforcement (FDLE), local law enforcement,
department of corrections (if eighteen years of age or older), school districts, and social service
agencies, as well as with a youth’s juvenile probation officer (JPO) and, if identified, their post
residential services counselor. For the annual compliance review period, the program had no
youth who were identified as being gang affiliated.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program maintains a policy and procedures for gang identification, prevention and activities.
For the annual compliance review period, the program had no youth who were identified as
being gang affiliated. The gang interventions and strategies implemented at the program include
Impact of Crime (IOC). If a youth is identified as a gang member or as having an affiliation with
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gangs, the program must provide some type of intervention such as gang court, intervention
classes, and guest speakers. The youth’s performance plan should also include goals and
objectives relating to gang activities for the youth to complete prior to release from the program.
The executive director was interviewed and reported if the program creates a sense of
community and acceptance of all its members, then this will start to erode the stronger pre-
existing gang ties and prevent recruitment. The best way to erode hard-core membership is to
help gang members to focus on his/her own personal goals and future. Somewhere deep down
they have a dream which is socially acceptable, and they just need help to see they can achieve
it. The staff can help by rigorously policing the program and eliminating gang symbolism and
activity. Those symbols have power, and their presence strengthens the gangs. Eliminate the
symbols and overt activity and interrupt their lines of communication by sensible scheduling and
grouping to pave the way for real and long-lasting change. It is the responsibility of the program
staff to make the program safe and remove the ability of youth to threaten other youth with
violence. A local gang liaison will provide a gang class to identified/suspected gang members
quarterly if available.
2.07 Residential Assessment for Youth (RAY) Assessments and
Limited Compliance
Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program maintains a policy and procedures addressing Residential Assessment for Youth
(RAY) assessments and re-assessments. Five youth case management records were reviewed
for inclusion of RAY assessment and re-assessments. Four of five reviewed records contained
an initial RAY assessment completed within the required thirty-day timeframe. The remaining
record contained an initial RAY assessment which was completed three days late. Each initial
RAY assessment was maintained within the Department’s Juvenile Justice Information System
(JJIS). Each of the five records contained a RAY re-assessment which was completed outside
of the required ninety-day timeframe. RAY re-assessments were completed 198, nineteen,
eleven, two, and one day late respectively. All reassessments were documented within the
youth’s official case management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program maintains a policy and procedures addressing Youth Needs Assessment
Summary (YNAS) to ensure a YNAS is conducted within thirty days of youth admission. Five
youth case management records were reviewed for inclusion of a YNAS. Four of five records
contained a YNAS which was completed within the required thirty-day timeframe. The remaining
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record contained a YNAS which was completed three days late. A review of the Department’s
Juvenile Justice Information Center confirmed each YNAS was documented.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program maintains a policy and procedures addressing performance plan development,
goals and transmittals. Five youth case management records were reviewed for inclusion of an
individualized performance plan (IPP). Four of five records included an IPP which was
completed within the required timeframe. The remaining IPP was completed six days beyond
the required thirty-day period. Each IPP was developed after the initial Residential Assessment
for Youth (RAY). Documentation review confirmed the intervention and treatment team leader,
youth, administrative representative, living unit representative, and education staff was present
and had an opportunity to sign each IPP. Each original IPP contained an attached signature
sheet, and the signature sheet was filed in each youth’s official case management record. No
youth was involved with the Department of Children and Families (DCF) or Agency for Persons
with Disabilities (APD). There was no record which contained a returned signature sheet from
parent/guardian. Documentation review confirmed a copy of each IPP was mailed to
parent/guardian for review and return signature. Each IPP contained required elements such as
individualized goals based on prioritized needs, and youth top three criminogenic needs. Each
IPP contained listed delinquency interventions, transition activities targeted for the last sixty
days of the youth’s stay, youth and program staff responsibilities and target completion dates.
Two of the five IPPs contained targeted court ordered sanctions which could be reasonably
initiated/completed while in the program. Documentation review confirmed a copy of the IPP
along with a transmittal letter was forwarded to the committing court, juvenile probation officer
(JPO), and parent/guardian within ten working days of completion of the plan. Five youth were
interviewed and each of the five youth reported having participated in the development of their
performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program maintains a policy and procedures addressing performance plan revisions. Five
youth case management records were reviewed for individual performance plan (IPP) revisions.
Each record contained a revised IPP due to demonstration of progress toward completing a
goal, one of five contained a revised IPP due to newly acquired information and lack of progress
toward completing a goal. One of five records contained a revised IPP due to the need to
facilitate transition activities during the last sixty days of the youth’s stay. The one youth was
subsequently removed from transition. Each record contained an IPP which incorporated an
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academic and treatment plan. No youth required a plan with the Department of Children and
Families (DCF) or Agency for Persons with Disabilities (APD).
2.11 Performance Summaries and Transmittals Limited Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program maintains a policy and procedures addressing Performance Summaries and
transmittals. Five youth case management records were reviewed for inclusion of Performance
Summaries. Three of five reviewed records contained a Performance Summary which was
completed outside of the required ninety-day timeframe. One reviewed record contained a
Performance Summary which was completed 198 days late, one was nineteen days late, and
one was twelve days late. One of five records indicated a Performance Summary which was
prepared prior to release and the youth was subsequently removed from transition.
Documentation review confirmed each Performance Summary included the required elements
such as the youth’s status on each goal, youth overall treatment progress, youth academic
status, youth behavior, level of motivation/readiness to change, interaction with peers and staff,
overall behavior adjustment to the program, and significant positive and negative events.
Documentation within each record confirmed the youth was allowed to read and add comments
prior to signing the summary, the youth was provided a copy of the summary, and the original
summary was filed in the case management record. Documentation review further confirmed
the treatment team leader, the staff preparing the summary, the executive director or designee,
and the youth signed and dated the Performance Summary. A copy of the Performance
Summary was provided to the committing court, juvenile probation officer (JPO), and
parent/guardian. Three closed case management records were reviewed for inclusion of release
summary information and documentation. Documentation within each record confirmed the
original summary included the reason for release and was sent with the Pre-Release
Notification (PRN) to the JPO, at least forty-five days prior to release, and a signed copy was
retained in each record. Each record contained evidence written notification was provided to
parent/guardian informing of planned release and each contained a completed exit Residential
Assessment for Youth (RAY). None of the youth were applicable for the completion of sex
offender requirements or victim notifications.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program maintains a policy and procedures addressing the encouragement and facilitation
of involvement of parents/guardians in the youth’s case management process. Documentation
review confirmed the program’s encouragement and facilitation process did include the
assessment process, participation in the development of performance plans, progress reviews,
advance notice of formal treatment team meetings dates and times, and transition planning.
Documentation review further confirmed the program provided the opportunity for
parents/guardians to participate during treatment team meetings via telephone conferencing or
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provide written input prior to meetings when unable to participate in person. The program
facilitates involvement by providing mailed notification of scheduled meeting dates. If the
parent/legal guardian is unable to attend in person, every attempt is made to allow participation
by telephone, video conferencing and the opportunity to provide written input. Visual
observation of a treatment team meeting was conducted during the annual compliance review.
Contact with the parent/guardian was attempted two times by way of telephone with no success.
The program director was interviewed and reported to facilitate this involvement, the program
invites the youth’s parent/legal guardian to participate in intervention and multidisciplinary
treatment team meetings for the purpose of developing the youth’s performance plan,
conducting formal performance reviews of the youth’s progress in the program, and planning for
the youth’s transition to the community upon release. If unable to attend, the parent/legal
guardian shall be given the opportunity to participate via telephone or video conferencing, or to
provide verbal or written input prior to the meeting. Five youth were interviewed and each of the
five youth were able to articulate how their parents/guardians are involved in their case
management process. Each youth reported parents are called during treatment team meetings.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program maintains a policy and procedures addressing treatment team members and
meetings. Five youth case management records were reviewed for inclusion of formal and
informal treatment team meetings. Reviewed documentation within each record confirmed
formal treatment team meetings were held at least every thirty days and informal reviews were
held bi-weekly each month alternating formal treatment team meetings. Documentation
regarding formal and informal treatment team meetings included youth’s name, date of review
and required attendees, comments from treatment team members, brief synopsis of youth
progress in the program, performance plan revisions, progress on performance plan goals,
positive and negative behaviors, youth opportunity to demonstrate skills acquired in the
program, treatment progress, and Residential Assessments for Youth (RAY) re-assessment
results. Formal and informal treatment team documentation was contained in each record. Each
record contained documentation to support parent/guardian and juvenile probation officer (JPO)
as well other pertinent parties were encouraged to participate. An observation of treatment team
meeting was able to be conducted during the annual compliance review. All required staff were
present including representative from education.
Five youth were interviewed and each of the five youth reported staff talks about their
performance including progress on performance plan goals, positive and negative behavior, and
treatment progress. Each of the five youth also was able to articulate how they show skills they
have learned in the program.
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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.
Three closed youth case management records were reviewed for inclusion of transition
conference and Community Re-entry Team (CRT) meeting documentation. Each record
contained documentation indicating a transition conference was held sixty days prior to the
youth’s targeted release. Documentation within each record further confirmed the youth,
treatment team leader, executive director, juvenile probation officer (JPO), parents/guardians,
education staff, and any other pertinent parties attended the transition conference. During the
conference, participants reviewed transition activities, identified additional transition activities
and target completion dates, and identified persons responsible for completion. The treatment
team leader obtained attendees’ dated signatures. Each record contained evidence a copy of
the transition plan was sent with a request for return with signature for those not in attendance.
Documentation within each record confirmed youth and case managers attended the CRT
meeting and the CRT meeting was conducted prior to the youth’s release. Each record included
documentation of an invitation for participation.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed youth case management records were reviewed for inclusion of exit portfolio
documentation and information. Each record contained documentation supporting the exit
portfolios were discussed during the transition conference. Each exit portfolio contained a state
issues identification card, copy of the youth’s transition plan, calendar with dates, times, and
locations of upcoming community appointments, social security card, birth certificate,
educational and/or vocational certificates, educational records, school transcripts, resume, and
sample employment application. Each exit portfolio was verified during the exit conference.
Each record contained documentation the youth received a copy of the completed exit portfolio
upon release and the exit portfolios were forwarded to the assigned juvenile probation officer.
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.
Three closed youth case management records were reviewed for inclusion of exit conference
documentation and information. Each record contained documentation to confirm the exit
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conference was held after the program notified the assigned juvenile probation officer (JPO) of
approved release. Each exit conference was conducted fourteen days prior to the youth’s
release. Reviewed documentation confirmed the date of the exit conference as well as
signatures of attendees of the exit conference was obtained along with a summary of pending
transition goals. Each record contained information to confirm youth date of admission and
release correlated with the Department’s Juvenile Justice Information System (JJIS). The status
of transition activities was established and finalized for youth’s release, as well as provisions for
education and employment. Visual observation confirmed the case manager and
parents/guardians were aware of the plan, documents, and post-release plan. Each exit
conference meeting contained evidence of the treatment team leader, parent/guardian,
education representative, JPO, youth, and other pertinent parties participated in the exit
conference. Each exit conference was held separately from the transition conference and
Community Re-entry Team meeting.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a policy and procedures addressing the formal process to promote
constructive input by youth. The program’s formal process dictates the program’s management
team will meet at least quarterly to assess the program’s position regarding staff retention,
morale, and overall operation of the program. The program will solicit input to improve program
operations and satisfaction from stakeholders. A youth advisory board will meet quarterly with
the director of operations or designee to solicit youth feedback and youth are surveyed
quarterly. Youth are encouraged to give input at treatment team meetings. The student council
is used by youth to express concerns they have regarding program related topics. Additionally,
youth are surveyed during exit. Visual observation of youth advisory board meeting minutes and
youth surveys confirmed the program’s compliance.
The executive director was interviewed and reported the program will provide a vehicle for youth
to provide input into program operations by way of youth advisory council, youth interviews, exit
surveys and idea suggestion box. Five youth were interviewed and each of the five youth were
able to articulate how they provide input about what happens in the program. Each of the five-
youth reported they provide input during monthly house meetings.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a designated mental health clinician authority (DMHCA) which is a licensed
clinical social worker. The DMHCA has a current and active license which expires on March 31,
2027. There were no other DMHCAs utilized during the annual compliance review period. The
DMHCA is on-site forty-hours a week and ensures appropriate coordination and implementation
of mental health and substance abuse services. The program maintains the DMHCA position
description within the program’s policy and procedures, which was reviewed. The program does
not currently have a back-up DMHCA. The program has an approved subcontract with the
provider for a backup DMHCA to be provided. During the annual compliance review period, the
provider did not need to send a backup DMHCA. The DMHCA was interviewed about the role at
the program. The DMHCA oversees the implementation of services. The DMHCA provides on-
site monitoring and ensures services are being deliver as outlined in the comprehensive plan
and in accordance with the Department standards. The DMHCA provides mental health and
substance abuse treatment services. The DMHCA is on-site with clinical staff for forty hours a
week, Monday through Friday, and meets with clinical staff for an hour weekly for 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.
The designated mental health clinician authority (DMHCA) is the only licensed clinical staff
currently at the program. The DMCHA ensures the clinical staff are working under their
supervision and are performing services they are qualified to provide. The program’s contract
does not require any additional licensed staff.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) is the clinical supervisor in the
program. The DMCHA ensures all non-licensed clinical staff are performing services in which
they are qualified to provided based upon education, training, and experience. Weekly
supervision documentation was provided for review and all non-licensed mental health clinical
staff received a minimum of one hour a week on-site, face-to-face direct supervision by the
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DMHCA. All supervision was documented on the Department’s Licensed Mental Health
Professionals and Licensed Substance Abuse Professionals Direct Supervision Log form. The
program does not have a Chapter 397 license at the time of the review. The mental health staff
are scheduled to be on-site five days a week Monday through Friday from 9:00 a.m.. to 5:00
p.m. and are on-call on the weekends. Three non-licensed clinical staff records were reviewed.
All three held a master’s-level degree from an accredited university or college in an appropriate
human services field. Each of the three clinical staff completed training for conducting
Assessments of Suicide Risks.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth mental health and substance abuse records were reviewed for the mental health and
substance abuse admission screening. All five youth received the Massachusetts Youth
Screening Instrument Second Version (MAYSI-2). All records included documentation the
screener reviewed available information to include the commitment packet and reports for the
youth. All initial screenings were completed on the dates of admission for each youth. Trained
staff completed four of the five screenings, in full within the Department’s Juvenile Justice
Information System (JJIS). All five screenings indicated a referral was needed for further
evaluation. All five records included documentation the appropriate referrals were made for
each youth as documented on the program’s referral form. The program’s policy indicates all
youth received an Assessment of Suicide Risk (ASR) and comprehensive evaluation upon
admission. All five youth received an ASR upon admission to the program during the intake
process which was documented in each record. None of the youth were found to be in crisis
during admission to the program. In all five youth records a referral form was completed and
indicated each youth received a referral for ASRs and comprehensive evaluations. The reason
for each referral was documented on the form. The program maintains a written policy and
procedures for the implementation of a standardized mental health and substance abuse
screening process. The reviewed policy included a review of the commitment packet
information, reports, records, administration of the MAYSI-2, and any necessary referrals for the
youth. The policy also includes staff training in mental health and substance abuse issues and
the MAYSI-2 and a standardized process for youth in need of immediate attention. The
executive director was interviewed and stated mental health and substance abuse screening in
residential commitment programs is accomplished through administration of the MAYS-2 or
clinical mental health and substance abuse screening.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The designated mental health clinician authority was interviewed. The DMHCA reported the
program is required to follow Department and provider policy for mental health and substance
abuse admission screening, and maintain compliance with Florida Administrative Code. Youth
are screened and a referral is made for mental health services through the mental health
referral form. The screening will allow the clinician to make a referral for a comprehensive
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assessment. Five youth mental health and substance abuse records were reviewed for a
mental health and substance abuse assessment and/or evaluation. One of the five records
included documentation a new combined mental health and substance abuse evaluation was
completed on the date of admission. Five youth received a new evaluation within thirty days of
their admission. All five records included signed consents for substance abuse services. All five
evaluations were completed by non-licensed mental health clinical staff and each were reviewed
and signed off on by the DMHCA. All five reviewed evaluations included the following required
elements: demographics, reason for evaluation, relevant background information, behavioral
observations, mental status examination, interviews of youth, discussion of findings, diagnostic
impressions including the Diagnostic and Statistical Manual of Mental Disorders Version Five
(DSM-V), patterns of alcohol and other drug abuse, impact of alcohol and other drug abuse on
major life areas, risk factors of continue 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.
Five youth mental health and substance abuse records were reviewed for the initial mental
health and substance abuse treatment plans. All five initial treatment plans were developed
within seven days of the initiation of treatment. All five initial treatment plans were developed on
the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. One of the five
youth entered the program on psychotropic medications. The applicable youth record indicated
the inclusion of psychiatric services, including psychotropic medication and frequency of
monitoring by the psychiatrist. Each of the five initial treatment plans indicated each youth would
see the psychiatrist as needed. All five initial treatment plans were signed by the non-licensed
mental health clinical staff, the designated mental health clinician authority (DMHCA), youth,
treatment team leader, program management, and medical staff. Parents/guardians were
indicated to be in attendance by telephone. Five youth records were reviewed for individualized
treatment plans. All reviewed treatment plans included psychiatric services. Forty treatment plan
reviews were reviewed and thirty-eight were completed within the required timeframes. The
remaining two plans were one and three days late. Each of the forty treatment plan reviews
were documented on the Department’s Individualized Mental Health and Substance Abuse
Treatment Plan Review form. All treatment plans and reviewss included signatures of the non-
licensed mental health clinical staff, DMHCA, youth, treatment team leader, program
management, living unit representative, education representative, and a medical team member.
All treatment plans included documentation the parents/guardians and assigned juvenile
probation officers were in attendance during treatment plan reviews by telephone. All treatment
plans included individualized prescribed services with goals and objectives for each youth.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
Five youth mental health and substance abuse records were reviewed for treatment and
discharge planning. All five records included documentation each youth was assigned to a
treatment team upon arrival to the program. Documentation reviewed reflected the following
treatment team members were in attendance for treatment team meetings: youth, program
administration, residential living unit, education staff, medical staff, and mental health and
substance abuse staff. It was documented the parents/guardians of the youth attended all
treatment team meetings by telephone. All five youth were determined to be in need of
individual counseling, group counseling, and family counseling and received all required
treatment from a licensed or non-licensed qualified professional in accordance with each
treatment plan. All five youth had a properly executed Authority for Evaluation of Treatment
(AET). All five youth records included documentation of a signed Youth Consent for Substance
Abuse Treatment. All five-youth received individual psychotherapy and/or counseling and
psychosocial skills training. A review of progress notes determined all the youth received
services as stipulated on their individualized treatment plans. All youth applicable for substance
abuse services received these services from only the licensed designated mental health
clinician authority (DMHCA). None of the selected youth were applicable for discharge
summaries. Three closed youth mental health and substance abuse records were reviewed for
discharge summaries. All three closed records included discharge summaries documented on
the Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. A
review of documentation revealed the discharge summaries included any future services
needed and the discharge plan was discussed with the youth, parents/guardians, and juvenile
probation officers (JPOs).
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’s required clinical groups according to the contract include Aggression
Replacement Training (ART) and Impact of Crime (IOC). Five youth were interviewed, of which
each said they are receiving family or individual counseling at least monthly. One youth stated
counseling is done every two weeks, while another stated counseling is conducted three times a
month. Five staff were interviewed about facilitating any mental health or substance groups.
One staff facilitates IOC and is a secondary ART facilitator. One staff indicated they conduct life
skill groups and three of the five staff stated they do not facilitate groups.The designated mental
health clinician authority (DMHCA) was interviewed. Youth determined in need of mental health
or substance abuse treatment must receive individual, group, or family counseling by a licensed
mental health professional or a non-licensed mental health clinical staff person working under
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the direct supervision of a licensed mental health professional in accordance with the youth’s
initial or individualized mental health treatment plan. All youth receiving treatment will have a
properly executed Authority for Evaluation and Treatment (AET) form. All youth will have a
signed Substance Abuse Consent and Release form or a court order for substance abuse
evaluation and treatment. Treatment notes will be documented in accordance with Florida
Administrative Code. The executive director was interviewed and reported the program is
designated as a Mental Health Overlay Services (MHOS) program, consisting of ART and
Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT-12), often referred
to as Cannabis Youth Treatment or CYT. The provided documentation revealed only the
DMHCA provided substance abuse services and groups. The DMHCA and clinical staff are on-
site for forty-hours each week. For Mental Health and Substance Abuse Overlay Services, the
counselor to youth ratios do not exceed sixteen youth. All non-licensed staff hold a master’s-
level degree. The program meets the requirements for Mental Health and Substance Abuse
Overlay Services to include individual therapy provided at least once every two weeks, or more
often as needed, family therapy provided at least monthly, and the psychiatrist provides services
at least once every two weeks. The licensed mental health counselor provided services on-site,
to include provision of therapeutic services, psychometric assessment and evaluation, complex
case consultation, behavior therapy and analysis, involvement in treatment planning, and staff
training and consultation. Group therapy included four mental health groups and one substance
abuse group each week. Therapists who work with these youth have caseloads of no more than
ten youth.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program provides psychiatric services through a psychiatrist who holds a clear and active
license which expires on January 31, 2026. The psychiatrist is available for emergency
consultation twenty-four hours a day, seven days a week. The psychiatrist provides a brief
update for each youth to the treatment team regarding their psychiatric status. The psychiatrist
provides evaluations and recommendations for the youth in the program. All recommendations
for the youth are documented within the treatment plans. The sign-in and sign-out logs for the
psychiatrist were reviewed and the psychiatrist was on-site as required for the annual
compliance review period with the exception of one visit which occurred two days late. The
program received permission from the Department’s Office of Health Services to conduct tele-
psychiatry for one of the visits during the annual compliance review period. The psychiatrist was
interviewed and stated they meet with medical staff every fourteen days and important medical
issues are reviewed at this time. Face to face or telephonic communication with representatives
from the treatment team are conducted as needed. The designated mental health clinician
authority (DMHCA) was interviewed and stated a meeting with the psychiatrist is conducted bi-
weekly. Five youth mental health and substance abuse records were reviewed for psychiatric
services, of which three were applicable. The program did not have two additional applicable
files to review. One of the three youth entered the program on psychotropic medications. It is
the program’s policy to refer all youth for a psychiatric interview upon admission. All youth
completed a psychiatric interview within fourteen days of admission to the program. All three
initial diagnostic psychiatric interviews included the following elements: youth history, mental
health status examination, the youth’s diagnosis based upon the Diagnostic and Statistical
Manual of Mental Disorders – Fifth Edition (DSM-V), treatment recommendations, and initial
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treatment goals. All initial treatment goals for the youth were for the youth to see the psychiatrist
as needed. All three initial psychiatric interviews were documented on the Department’s Clinical
Psychotropic Progress (CPPN) form. All three CPPN forms were clearly marked as an “Initial
Diagnostic Psychiatric Interview”. One of three youth were prescribed psychotropic medications
as a result of psychiatric interviews conducted at later dates. Twenty-two medication reviews
were conducted for the three youth and twenty-one were completed every thirty days as
required, the remaining review was conducted three days late. The following elements were
documented on page three of the CPPN: identifying data, diagnosis, target symptoms,
evaluation and description of effect of prescribed medication on target symptoms, the name,
dosage, and quantity of the medication, side effects, youth’s adherence to the medication,
height, weight, and blood pressure, telephone contact to the parents/guardians, along with the
dates and signatures of the psychiatrist. None of the youth were applicable for a requirement to
be monitored for Tardive Dyskinesia.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written Suicide Prevention Plan detailing suicide prevention procedures in
accordance with Administrative Rule. The written plan included identification and assessment of
youth at risk of suicide, staff training, which is six hours annually, suicide precautions, levels of
supervision (one-to-one, constant, close and standard) referrals, communication, notifications,
documentation, immediate staff response and a review process includes the process of suicide
attempts and mortality reviews. The executive director has an established review process for
every suicide attempt or mortality. The established review process includes circumstances
surrounding the event, facility procedures relevant to the incident, all relevant training received
by involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors and recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services and/or operational procedures. The written Suicide
Prevention Plan was reviewed annually by the executive director and the designated mental
health clinician authority on April 16, 2025.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Five youth records were reviewed for suicide prevention services. Each of the youth reviewed
were screened during the admission process and determined to be at risk and placed on
precautionary observation, with a level of constant supervision. An Assessment of Suicide Risk
(ASR) was completed on the department’s ASR at the time of admission for each of the five
youth. Each of the five reviewed youth records showed documentation the parent/guardian and
juvenile probation officer (JPO) were notified of the youth’s potential suicide risk. Four of the five
ASRs were completed by clinical staff under the supervision of the licensed mental health
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professional, with the fifth ASR being completed by the designated mental health clinician
authority (DMHCA). Each of the five youth were maintained on precautionary observation with
constant supervision until the ASR was completed and reviewed by the DMHCA.
Discontinuation of constant supervision was documented in the youth’s mental health/substance
abuse (MH/SA) record by a mental health clinical staff and there was documentation of a
conference held by the executive director and licensed mental health professional to reduce
level of supervision. An alert in the Department’s Juvenile Justice Information System (JJIS)
was ended following the recommendations of the ASR. The program had an internal alert
system where the suicide alerts were documented. There was documentation on the suicide risk
assessment indicating administration or supervisory staff provided instructions related to the
suicide risk assessment findings and suicide precaution decisions. While on precautionary
observation, the youth was allowed to participate in select activities with other youth in
designated safe housing/observation areas of the facility. Each of the five youth were removed
from precautionary observations at the time of admittance to the program, with no need for a
follow-up ASR. A video observation was conducted which showed the precautionary
observation was logged and maintained correctly.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “non-
applicable.”
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Five youth records were reviewed for suicide precaution observation (PO) logs. Each of the
reviewed youth logs showed the PO logs were maintained for the duration the youth was on
suicide precaution. Each log showed an appropriate level of supervision and observations of the
youth’s behavior documented in real time and not exceeding thirty-minute intervals. There were
no noted warning signs for each of the logs reviewed. For the PO logs reviewed, there was
documentation of the logs being reviewed and signed by each shift supervisor and mental
health staff. Each log reviewed noted safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
A review of five pre-service and five in-service training records show a completion of six hours
of annual suicide prevention training and confirmed each staff completed the suicide prevention
training, as required. Training included suicide drills, which were held no less than quarterly on
each shift. The program has three shifts and each of the three shifts completed suicide drills
quarterly for the duration of the annual compliance review period. The designated mental health
clinician authority (DMHCA) ensures all suicide drills are completed and each direct care staff
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simulate utilize cardiopulmonary resuscitation (CPR) and the automated external defibrillator
(AED) once a year. Three random suicide drills were selected to be reviewed for simulation by
closed circuit television (CCTV). The program was not able to locate two of the selected drills
during the CCTV playback. The video showed staff enter an area at the correct time; however,
inside the area where the drill is believed to have occurred there is no video. A mock suicide drill
was conducted on-site during the annual compaince review week, which was observed by this
reviewer. The location of the drill was not called on the radio. Medical staff did not respond. Staff
did not respond quickly to the drill. There was a breakdown of communication amongst staff and
lack of documentation during the drill. A mock tourniquet was applied; however, there was no
documentation as to the time of application. It was observed staff completed thirteen chest
compressions and then only twelve compressions, with no simulation of breaths being given in-
between chest compressions. The program had two suicide response kits, one in medical and
one in the soft chair area. Each suicide response kit was located with first-aid kits and include
the knife-for-life, wire cutters, and needle nose pliers. The executive director was interviewed
and reported all staff will review suicide prevention and precaution protocols annually, and this
will be documented in the staff’s training record. All staff will receive six hours of training in
suicide prevention and precaution protocols. Mock suicide drills are to be held, at a minimum,
quarterly. Five staff were interviewed. Three of five staff stated drills are done monthly. One of
five staff stated drills are conducted bi-monthly, while one staff was not sure how often drills are
conducted; however, has participated in some drills.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written crisis intervention plan which includes a notification and alert
system, means of referral, including youth self-referral, communication, supervision (one-to-one,
constant, close and standard supervision), documentation and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written crisis intervention plan which includes a process for implementation
of a Crisis Assessment form. The program had no crisis assessments for the annual compliance
review period.
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3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse plan which includes
immediate staff response, notifications, communication, supervision, authorization to transport
for emergency mental health or substance abuse services, transport for emergency mental
health evaluation and treatment under Baker Act, transport for emergency substance abuse
assessment and treatment under Marchman Act, documentation, training, and review.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
During the annual compliance review period, the program had three Baker Act incidents. Two of
the three reviewed youth records showed the youth was placed on supervision at the time of
discovery for the need of care. One of three records indicated the youth was already on
precautionary supervision at the time of discovery. Each of the three youth were maintained on
one-to-one supervision. Each of the three reviewed records showed mental health staff were
involved, each youth was taken off-site by the Escambia Sheriff’s Office upon authorization by
the designated mental health clinician authority (DMHCA) and the executive director of the
program. Once the youth was returned, the youth was placed on constant supervision and a
mental health referral was completed indicating a Mental Status Examination (MSE) needed to
be conducted.Two of the three reviewed records indicated the Assessment of Suicide Risk
(ASR) was completed by the licensed staff. The remaining ASR was completed by a non-
licensed staff and subsequently reviewed by the DMHCA. The youth’s supervision level was
maintained until an appropriate assessment was conducted.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Five youth records were reviewed, and documentation showed all youth had a safety plan which
included warning signs, the youth’s baseline behaviors, crisis recognition, coping strategies,
intervention strategies preferred by the youth, and a debriefing process. The safety plan was
completed within fourteen days in all five records reviewed. All five records indicated the plan
was jointly prepared with the youth parent/guardian, and clinical staff. All five safety plans
incorporated recommendations from previous or current clinical assessments or screening
instruments and incorporated trauma responsive practices. The plans reviewed and updated as
necessary following any significant behavioral or mental health event identified by the youth’s
intervention and treatment team. Forty-two of the forty-three reviewed plans were updated every
thirty days as required, the remaining safety plan review was completed six days late. Safety
plans are reviewed by staff who have contact with the youth. The plans are maintained in
mental health records, which are in the mental health therapists’ offices, behind two locks and
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labeled “Confidential”, only accessible to staff. Five youth were interviewed. Each of the five
youth stated they have participated in their safety plan. The executive director was interviewed
and stated the initial planning process must begin by the multidisciplinary treatment team during
their initial contact with the youth and shall be completed within fourteen days. The plan must be
updated every thirty days or following any significant behavioral or mental health event identified
by the youth’s intervention and treatment team.
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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 designated health authority (DHA) is clinically responsible for the medical care of all youth
at the program. The DHA is a licensed osteopathic physician, who holds an unrestricted license
and meets all requirements for independent and unsupervised practice in Florida. The licensure
expires March 31, 2026. The DHA’s specialty training is internal medicine with experience in
adolescent health. A review of for any disciplinary cases or public complaints was conducted
with no issues on record. The program does not have either a physician assistant or advanced
practice registered nurse employed. Sign-in and out logs were reviewed during the annual
compliance review period and found the DHA was on-site at least once a week for a minimum of
two hours a week. The program has not utilized telemedicine during the annual compliance
review period. An interview with the DHA establishes the availability, role, and service delivery
as the medical doctor for the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has three registered nurses (RN), providing on-site nursing coverage. Nursing
licensure credentials were reviewed, and all had clear and active licenses in accordance with
Florida Department of Health. Each of the nursing staff had a current certification in
cardiopulmonary resuscitation (CPR). The program has nursing coverage which meets contract
requirements at a minimum of forty hours a week. One of the RNs serves as the on-site health
service administrator (HSA) for the program. The HSA is on-site, pursuant to contract at a
minimum of forty hours a week.
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.
There were facility operating procedures (FOPs) which addressed all health-related procedures
and protocols utilized at the program. The designated health authority (DHA), along with the
facility administrator, and psychiatrist have reviewed and signed necessary FOPs for the
program. The last signed date from each clinical staff was August 28, 2024. Nursing staff have
also signed and dated a cover page on which all health-related FOPs, treatment protocols, and
other procedures were listed, which were last signed on March 25, 2025. No new policies or
changes occurred during the review period. The program had one nurse hired who was in
receipt of a comprehensive clinical orientation to the Department’s health care policies and
procedures, which was given by the program’s health service administrator. Documentation
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reviewed supports only the DHA shall approve treatment protocols or standing procedures for
the program.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A total of five youth Individual Healthcare Records (IHCRs) were reviewed for completion of the
authority for evaluation and treatment (AET) form. Four youth had an AET filed with a legible
stamped “COPY” on the form. The remaining youth was missing the stamped word “COPY” on
the filed AET. All five had an AET form filed which was signed by the youth’s parent/guardian.
Additionally, all forms were signed by a Department representative. All the reviewed AET’s were
found to be valid at time of the youths’ admission to the program. None of the youth reviewed
were eighteen years of age or older or were in the care of the Department of Children and
Families. The interview with nursing staff ascertained there are practices and policy in place for
obtaining a new or current AET.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
Five youth Individual Healthcare Records (IHCRs) were reviewed for parental notification of
significant changes in youth’s condition and to obtain consent for medication and treatment
prescribed. Four of the five youth IHCRs were applicable for parental notification for over-the-
counter (OTC) medications. In each of the cases, a consent was provided by the parent or
guardian. In addition, with new medications being ordered, there was documentation to support
attempts to contact parent or guardian found within progress notes. Each written notification
was sent using the proper Department form. One of the five youth was taking prescribed
psychotropic medication upon admission to the program. Two youth were later prescribed
psychotropic medication upon referral and review by the psychiatrist. One of the three youth
prescribed psychotropic medication had a missing notification on one of the Clinical
Psychotropic Progress Note for a significant change of the youth’s medication. Each of the
reviewed youth had a shot record contained in the IHCR. One of the five was not verified within
thirty days of the youth’s admission to the program. The one youth’s shot record had not been
verified for approximately five months after the youth’s admission. There were no youth who
were applicable for religious exemption from Immunization. The program uses MyFloridaShots
to verify youth immunizations. The interview with nursing staff addressed practices for parental
notifications at the program.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
Five youth Individual Healthcare Records (IHCRs) were reviewed for youth being screened at
admission for any healthcare concerns. Each youth reviewed contained a Facility Entry Physical
Health Screening form (FEPHS). Each of the FEPHS were completed on date of admission to
the program. All of the FEPHS were completed by a registered nurse (RN). None of the
reviewed FEPHS were completed by direct care staff. Four of the five youth reviewed were
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applicable for having been of physical custody of the program for greater than twenty-four
hours. Each of the four-youth had documentation of the program completing a new FEPHS re-
screening for each occurrence when there was a change in custody lasting greater than twenty-
four hours. The interview with nursing staff addressed the process and time for screening newly
admitted youth and documentation practices.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
All youth are oriented to the general process of health care delivery services upon admission to
the program. The five reviewed youth records indicated each received education addressing an
overview of basic medical topics. The program will provide at a minimum health education to
youth upon admission. The program utilizes an education binder to orient youth to medical
topics at the program. An observation was made of this practice while on-site.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Five youth Individual Healthcare Records (IHCRs) were reviewed for notification of the
designated health authority (DHA) or designee when youth admitted require either routine or
emergency care. The program’s practice is to notify the DHA for all youth admissions. A review
of chronological progress notes for each of the five reviewed admissions demonstrated the
program adheres to this practice for notifying the DHA. Notifications to the DHA all occurred
within twelve hours of the youth’s admission to the program. In one of the five youth admissions,
the youth was currently taking psychotropic medication. In this one case, the psychiatrist was
notified upon the youth’s admission. The interview with nursing staff addressed the notification
practices for youth entering the program with emergent or chronic conditions when necessary.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of the standard
Department Health-Related History (HRH) form for youth admitted to the program. Four of the
five youth had a completed and or updated HRH form, within seven days of admission. The
remaining one youth HRH form was late by five days being completed. Four of the five youth
had the HRH completed prior to the comprehensive physical assessment (CPA) being
completed. The remaining one youth had the CPA completed prior to the HRH. Three of the five
reviewed CPA were missing the check mark of the designated health authority (DHA) having
indicated the HRH form was reviewed. The remaining two youth had the appropriate annotation
marked indicating the HRH had been reviewed. The interview with nursing staff addressed who
is responsible for completing the HRH of youth admitted to the program.
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4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
Five youth Individual Healthcare Records (IHCRs) were reviewed for the standardized
comprehensive physical assessment (CPA) form completion for all youth admitted to the
program. Each new CPA was completed within seven calendar days of the youth admission and
on the Departments form. The reviewed CPAs were completed by the designated health
authority (DHA). One of the five CPAs had a medical grade documented as a one, whereas the
youth arrived at the program with a chronic condition and should have been annotated as a
medical grade two. Three of the five youth were missing either “O” and or “X” to annotate exam
results on the individual CPA. The remaining two youth had no discernable marks, with either
“O” and or “X” indicating any focused medical examination had occurred. Each youth did
complete and sign a refusal form for part of the examination notated on the CPA, which was
refused by the youth. The youth’s problem list was updated as required within each of the
records reviewed. Each of the reviewed youth had at least one verified tuberculosis skin test
(TST) documented. The interview with nursing staff addressed the timeframe of when a CPA is
completed by the DHA.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
Five youth Individual Healthcare Records (IHCRs) were reviewed to ensure youth were
evaluated and treated (if necessary) for sexually transmitted infections (STIs). Two of the five
youth records were applicable and one additional record was requested to make a minimal
sample size of three to be reviewed for this indicator. The three youth records had indications as
having been sexually active; therefore, clinically screened for STIs. Each of the three youth
records had documentation for further evaluation and referred to the designated health authority
(DHA). Testing was ordered for one of the three youth. The remaining two youth refused testing.
A signed refusal form was found in the two youth’s IHCR. The one youth who consented for
testing had testing performed, whereas all applicable test, screening, evaluations, and diagnosis
were documented within the youths IHCR. The same youth had two separate occurrences of
having been out of physical custody of the program and was subsequently re-screened each
time.
Six records including the five original records and one additional requested for STI testing, were
reviewed and offered counseling, testing, and if indicated, treatment/referral for human
immunodeficiency virus (HIV). Three of the six youth were in receipt of HIV testing. The
remaining three youth refused HIV testing, and a refusal form found filed in each youth IHCR.
The three youth having received testing had HIV results filed confidentially in a sealed envelope
marked “CONFIDENITAL” located in the IHCR. Each the envelopes had documentation of the
designated health authority (DHA) having reviewed and signed. The three applicable youth had
documentation of pre/post-test counseling documented within each of the individual health
education record. There were no alerts found posted of a youth HIV status. The program’s
written policy and procedure, addresses HIV test results and are only disclosed to youth and
those entities addressed in accordance with Chapter 381, Florida Statute. The provider uses
Oasis for HIV testing and education on a quarterly basis. The interview with five youth
determined each youth can request HIV testing if they want. The interview with nursing staff
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addressed the program’s practice for STI and HIV testing, evaluation, documentation, and
treatment if necessary.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of sick call
practices. A total of forty-one sick call complaints were reviewed. There were no indications any
of the youth having presented with a similar sick call compliant three or more times within a two-
week period. In each of the reviewed sick call complaints, all were filled out by the youth and
completed on a sick call request form. All the sick calls were completed by a registered nurse
(RN). The sick calls were found filed in the youths IHCR in reverse chronological order. None of
the youth were placed into restricted housing. Each of the sick calls were observed to be
documented in the required format in accordance with Florida Administrative Code. Each of the
sick calls were found documented on the sick call index, along with the program’s sick call
referral log. The dates listed on the sick call index corresponded to the completed sick call
forms, which were in the IHCR.
A review of ancillary documentation and observed practice, supports the program is conducting
sick call (when necessary) daily. Sick call hours were found posted outside the medical clinic in
the youth main hallway. Observed documentation supports only licensed medical staff conduct
sick call. There are written procedures which addresses supervisory staff accountability to
review sick call request when licensed medical staff are not present. Sick call request forms
were observed in a bin located outside the common area, in the main hallway. An exam table
and equipment are available to use in the performance of a sick call. The interview with youth
determined they can see a nurse within one day once a sick call request is made. The interview
with nursing staff addressed the process for when youth make a sick call request. Additionally,
the location and times of sick call practices.
A sick call observation was made during the annual compliance review. The youth was escorted
by direct care staff to the medical clinic. The medical provider identified themselves and affirmed
the purpose for the why the youth was there. The youth privacy was maintained throughout the
sick call process. The youth was examined by a licensed staff. The direct staff during the exam
was not in the room and afforded the youth and medical staff to maintain privacy.
4.13 Episodic/First-Aid and Emergency Care Failed Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
A review of documentation for drills revealed the program failed to conduct simulated
emergency medical drills during the annual compliance review period. Documentation reviewed
appeared to have information copied and pasted for most of all the medical drills. A drill
scenario was the same for each shift on the date of the discussion held with staff. The scenario ,
outcome, role of staff, and even nursing comments were photo-copied for twenty-seven of the
thirty-three training scenarios provided. The program was missing March 2025 drills for each of
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the program’s three shifts. the Department’s Office of Health Services (OHS) was consulted and
agreed medical drills documented appeared to not have been simulated;however, conducted as
a conversation with staff present. This was confirmed with the health services administrator
(HSA) who reported drills were conducted by previous medical staff. OHS was on-site January
28, 2025, and March 1, 2025, where the same issues with the medical drills were identified.
Sample drills were reviewed and discussed with the HSA. They were provided a list of sample
scenarios. OHS will be reviewing each drill moving forward and continue to provide feedback,
until they feel the program has a clear understanding of the proper process. A video review of
simulated drills could not be completed, as the program failed to complete any drills after OHS
assistance on March 1, 2025. The program does not have equipment, including a
cardiopulmonary resuscitation (CPR) mannequin on-site, to facilitate simulated CPR drills. No
episodic care events were able to be observed during the on-site compliance review week.
Five youth Individual Healthcare Records (IHCRs) were reviewed for the program’s
comprehensive process for the provision of episodic and first-aid care. Each of the youth
records had an indication the youth required first-aid care.One of the five youth was rendered
first-aid by a licensed healthcare staff which was documented using standard narrative charting
in the youth’s IHCR. The remaining four youth were provided first-aid care by non-healthcare
staff. Each of these youth had care documented on the Department’s Report of On-Site Health
Care by a Non-Cealth Care Licensed Staff form. In each case, the youth was in receipt of a
follow-up evaluation from a licensed healthcare staff the next time one was on-site.
The program has a total of eleven first-aid kits. There are two first-aid kits used for
transportation. The program’s medical staff review and check each of the eleven first-aid kits
monthly to ensure contents are maintained and stored in accordance with guidelines to prevent
expiration. A review of three first-aid kits revealed no issues. Each was fully stocked with
approved contents. A review spanning the scope of the annual compliance review revealed first-
aid kits are reviewed by medical staff monthly.
The program has two automated external defibrillators (AEDs) on-site. Each of the AEDs are
monitored by medical staff monthly. Each of the pads and batteries are up to date. A test was
conducted during the annual compliance review by medical staff with no issues. A list of
emergency numbers are posted for staff and inaccessible to youth. A review of training for non-
healthcare staff in the administration of the epinephrine auto-injector was reviewed and found
supervisory staff were trained. Five pre-service and five in-service training records were
reviewed for completion of episodic, first-aid, and emergency care with no issues observed.
The program has two locations in the medical office to store Narcan®. One container in the
medical cart and the other is in the programs “red box”, which is a container for non-healthcare
staff to utilize when medical staff are not present. A review of training materials for Narcan®
access and usage was reviewed. Supervisory staff are the ones who have been trained on
when and how to use Narcan® if needed. The Narcan® inventory is tracked with a daily
perpetual count, which completed by medical staff.
The interview with five youth determined they can see a doctor and dentist if needed. The
interview with five staff identified they are able to personally call 9-1-1 if youth have a medical
emergency. The interview with the nurse confirmed the location of first-aid kits in the program.
Additionally, the nurse identified the process for documenting on-site episodic care and tracking
methodologies. The interview confirmed the medical staff practices and documentation of AED
pads, batteries, and checks.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Five youth Individual Healthcare Records (IHCRs) were reviewed for timely referrals and
coordination of medical services to an off-site health care provider. All five youth had an
indication the youth required off-site care. In each of the cases, the summary of off-site care
consultation report form was utilized and subsequently filed in each youth IHCR. There was no
indication any of the youth required off-site emergency care. Four of the five youth had
applicable parental notification efforts documented. The one remaining youth was missing
parental notification for a scheduled appointment off-site. All youth off-site discharge instructions
and other applicable documents were found filed in the IHCR. Additionally, the designated
health authority (DHA) had reviewed and signed all off-site care findings, instructions, and
information. Only one of the five youth required any follow-up appointment. The youth’s IHCR
contained the required treatment follow-up. An interview with nursing staff addressed how
medical staff track youth for off-site care needs. Additionally, the practice for documenting,
notification, and follow-up treatment when necessary.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Five youth Individual Healthcare Records (IHCRs) were reviewed to ensure youth who have
chronic conditions receive regularly scheduled evaluations and follow-ups. Three of the five
youth reviewed were applicable. Each of the three applicable youth were identified on the facility
entry physical health screening form with a current chronic condition. One of the three youth had
a medical grade documented as a one, whereas the youth arrived at the program with a chronic
condition and should have been annotated as a medical grade two. Each of the three identified
youth was placed on the program’s chronic illness list. Each youth was in receipt of periodic
evaluations at a minimum of every ninety-days. There was no indication of lapses in care or
missed periodic evaluations. The Department’s problem list was update in accordance with
Florida Administrative Code.
An interview with the executive director confirmed the formalized procedures in place for
healthcare staff to review youth medical issues. The interview with the designated health
authority (DHA) confirmed the frequency for completing and tracking periodic evaluations for
youth with chronic conditions. The interview with nursing addressed practices for up-to-date
monitoring of youth with chronic conditions.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
Five youth Individual Healthcare Records (IHCRs) were reviewed to ensure medication is
received, stored, inventoried, and provided in a safe and effective manner. Two of the five youth
records indicated they were admitted with medication. The youth admitted with medication had
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documentation to support medications were verified prior to admission into the program. The
appropriate contact to the designated health authority (DHA) or psychiatrist was made for each
of the youth admitted to the program on medication. The remaining three youth were later
prescribed medication after admission to the program. All reviewed medications had a current,
valid order, and administered pursuant to prescription. Each of the medications reviewed,
whether continued, discontinued, changed, or newly ordered, contained an order on the
Practitioner Order form. Each youth had Medication Administration Record (MAR) clearly
indicating start and stop times/dates for medication. The MARs contained all the required
elements with no exceptions.
Three of the five youth reviewed had occurrences were non-healthcare staff assisted in the
delivery of medications. The staff providing assistance were each trained in the proper process
for administering medication. Four of the five reviewed IHCRs had a documented lapse in
weekly side-effect monitoring missing from the MAR. One youth was missing one week for the
month of October and December. Another youth was missing two weeks in the month of March.
Another youth was missing one week in November and December. Lastly, one youth was
missing one week of side effect monitoring in October and November. Three of the five youth
were found to have refused medication at some point during the annual compliance review.
Documentation of refusals were found signed by each youth and were documented on the
Departments Refusal of Treatment form. Additionally, refusals were properly annotated on each
youth’s MAR. One youth was applicable for inclusion of psychotropic medication at admission.
Two other youth were later referred and subsequently prescribed psychotropic medication. The
three applicable youth were in receipt of medication monitoring every thirty days as required.
There was no indication the program had any standing orders, or emergency treatment
protocols, or pro re nata (PRN) orders for psychotropic medication.
A medication pass was observed at approximately 7:00 a.m., which corresponded with the
program’s set time for administering medications, which were7:00 a.m. and 5:00 p.m.. Youth
were observed being escorted to the medical clinic for medication administration by direct care
staff. The medical staff identified themselves and stated why the youth was present. The
medical staff was the person who prepared and administered the medication to all youth. The
nurse went through the Six Rights of Medication Administration.
Five interviewed youth were able to confirm nurses provide youth with medication. The interview
with the nurse addressed the practices for admitted youth with medication, protocols for non-
healthcare administration of medication, training, inventory, and contact with either the DHA or
psychiatrist when necessary.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
There are processes in place at the program to account for medical equipment classified as
sharps, and stock medications being secured and inventoried through a perpetual inventory.
Observations of the medical clinic found the program maintains an on-going perpetual count of
sharps and medications. The medical clinic has a means to secure all sharps and medications.
All medications were stored in a separate, secured area, inaccessible to youth. Any medications
requiring refrigeration would be stored in a secured refrigerator used for medication only. The
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program’s process for destruction and disposal or expired or discontinued medications includes
medication destruction to be performed by two licensed personnel, to include two registered
nurses (RN) or the RN and pharmacy consultant. Controlled medication destructions must be
performed by two licensed personnel, to include two RNs or the RN and pharmacy consultant
and a staff supervisor or the executive director, who must sign as a witness to the destruction.
Observation of inventories of sharps and over-the-counter (OTC) medications documented
counts were conducted as required. Each observed countdocumented counts matched ending
inventory numbers. A review of past controlled substance logs demonstrated shift-to-shift counts
were completed. Five non-healthcare staff records were observed for completion of training for
the delivery and oversight of administering medication. Training observed was delivered by the
on-site RN. The program has a practice in place for reporting any inventory discrepancies. The
interview with nursing staff addressed processes for disposal of medication and for securing
controlled substances.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has implemented an infection control plan, which includes prevention,
containment, treatment, and reporting requirements related to infectious diseases, in
accordance with Occupational Safety and Health Administration (OSHA) federal regulations and
the Centers for Disease Control (CDC) and prevention guidelines. The designated health
authority (DHA) last reviewed on August 6, 2024. The executive director last reviewed the plan
on August 6, 2024 and the health service administrator (HSA) last reviewed on August 6, 2024.
Hepatitis B immunizations are available for all staff through a referral to the Department of
Health. There is safety and protective equipment available for all staff. There have been no
occurrences of the program requiring reporting to the local county health department, CDC,
and/or the Department’s Central Communications Center (CCC), for infectious diseases.
Additionally, the program has an established file maintained for any youth or staff who have
experienced any occupational exposure.
The interview with the executive director addressed the location for the program’s exposure and
infection control plans. An interview with nursing confirmed the location of the program’s
exposure and infection control plans and addressed how often and by whom infection control
training is provided to youth.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures which define active supervision, to include active
involvement, supportive supervision, and static supervision. Each level of supervision focuses
on engaging with youth. The program’s contract requires a one staff to eight youth ratio during
awake hours and one staff to twelve youth during nighttime. Supervision was observed each
day of the annual compliance reviews during various activities and found staff were always
within the required ratio and interacting positively with youth. There were no obstructions to staff
being able to properly supervise youth. Three staff were informally interviewed on the number of
youth in their supervision and each was able to recite the number of youth without counting. A
program tour found the daily activity schedule was posted in each youth area and promotes a
full schedule of constructive activities. Video observation of ten-minute checks confirmed staff
conduct checks as required when youth are in their sleeping rooms.
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’s behavior management system (BMS) was developed by all appropriate parties,
including education, and has not been updated since the last annual compliance review period.
The program’s policy and procedures regarding their BMS includes protocol where staff are
provided feedback regarding their implementation of the BMS. All education staff received
training from the program; however, they are not responsible for its implementation. Five youth
records revealed each of them received BMS training as part of their orientation to the program.
Three position descriptions for direct care personnel and case management staff revealed BMS
implementation as part of their expectations for their position responsibilities. Five pre-service
staff training records documented each staff completed training in the BMS as required. The
program’s BMS is contractually required to be the provider’s Personal Growth Model and is
comprised of a rank system. The BMS rank system was observed posted visible in large
dayroom areas. An interview with executive director revealed AMIkids has established a proven
comprehensive and consistent Behavior and Skills Training system, as part of the AMIkids
Personal Growth Model. The purpose of the Behavior and Skills Training (BST) program is to
empower youth to develop skills for self-regulation as well as positive relationships with peers
and adults. Program leadership is responsible for monitoring Behavior and Skills Training to
ensure consistent and fair implementation of the system and Supervisors are trained to monitor
the use of rewards and consequences by their staff. The BMS is documented in both the
program’s policy and the youth handbook. The BMS governs conduct, outlines positive
incentives and negative consequences, and includes all required elements. The BMS does not
include increased length of stay, denial of basic rights, group discipline, punishment of youth by
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other youth, or disciplinary confinement. Observations of staff supervision throughout the annual
compliance review found all youth and staff interactions to be positive and promote the BMS.
Documentation supported incentives include off-campus activities. Five staff were interviewed
and each was able to explain the BMS and rank process. Five youth were interviewed and
provided examples of negative consequences to include behavior reports and redirection.
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 total of forty-four cameras used to monitor video of various program areas.
All cameras were reportedly functioning as required during the time of the annual compliance
review week. The video surveillance system retains recorded footage for up to thirty-two days. A
sample of twenty-two ten-minute room checks was reviewed. Each log showed checks were
documented in real time and included staff initials, confirming accountability. Observations of
the ten-minute checks indicated they were conducted at the required intervals and with fidelity,
consistent with program policy. A review of check sheets covering the annual compliance review
period confirmed room checks were consistently performed as required. During staff interviews,
all five staff confirmed ten-minute room checks are conducted whenever youth are placed in
their rooms for sleeping or non-disciplinary reasons. The executive director also verified the
program maintains forty-four functioning surveillance cameras, each with the capacity to store
footage for thirty-two 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.
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The program has established policy, procedures, and a Continuity of Operations Plan (COOP)
addressing the census, tracking, and accountability of youth. According to program policy, youth
counts are required at a minimum at the beginning of each shift, following any outdoor activity,
and during emergency situations such as escapes or riots. During the annual compliance review
observations confirmed youth counts were being conducted appropriately, with no issues noted.
Additionally, a review of logbooks for twelve randomly selected days within the annual
compliance review period showed consistent documentation of counts at the start of each shift,
after outdoor activities, during emergency situations, and during youth movements. The
logbooks also recorded total daily census counts and individual head counts. Interviews with
five staff confirmed youth counts are conducted during every movement and at intervals of
every thirty minutes to one hour. All interviewed staff were able to describe the procedure
followed when a count cannot be reconciled, which includes gathering all youth, placing the
facility on lockdown, and conducting a recount. Staff also provided examples of scenarios
requiring emergency counts, including natural disasters, escapes, active shooter situations, fire
drills, and COOP drills.
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 primary logbook to record daily movements and activities. The shift
supervisor, or their designee, is responsible for keeping the logbook in their possession and
ensuring its accuracy throughout the shift. A review of logbook entries from twelve randomly
selected days during the annual compliance review period revealed each entry included the
date and time of events, the names of involved staff and youth, a brief description of incidents,
and the name and signature of the recording staff member. All logbooks were properly bound
with numbered pages, as required. Incoming staff reviewed entries from the previous two shifts
to remain informed of prior events. On seven of the twelve reviewed days, minimal disruptions
to educational instruction were documented; however, on five days, classes ended several
minutes early, and on one day, youth arrived to class thirty minutes late. Recreation activities
were conducted as scheduled across all twelve days. A review of twelve shift reports revealed
each contained summaries of events, incidents, and activities reflected in the central logbook.
Incoming staff signed and dated the shift reports from the prior shift to confirm they had
reviewed or been verbally briefed on their contents. The logbook also included special
instructions regarding youth supervision and monitoring, perimeter and other security checks
conducted by staff, population counts at the beginning and end of each shift, and any additional
population counts taken during the shift. Copies of the shift reports were stored in the common
area accessible to program staff.
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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 which address key control, key assignment and
usage. These procedures address restrictions on key use, inventory and tracking, secure
storage of keys not in use, processes for reporting and replacing lost or damaged keys, and the
handling of missing keys. During the annual compliance review period, the distribution of keys
by master control or by supervisors/designees was not directly observed; however, a review of
the key inventory confirmed alignment with the actual key rings in use, with no discrepancies
noted. An observation of the key storage area revealed all keys are securely kept in a separate
locked box located in the program’s foyer. The storage box is not easily accessible while locked,
ensuring secure storage of keys when not in use. In an informal interview, the operations
director provided information on permanent key assignments, which are limited to designated
positions. Restricted keys are only accessible to approved personnel such as the therapists,
case managers, supervisors, administrative, and medical staff. The process for managing
restricted keys was reviewed, and no issues were identified. The procedure for handling
damaged keys requires they be exchanged directly between staff members and never passed
through youth. Abel Locksmith is the designated vendor for key replacement. A review of
reports to the Department’s Central Communications Center (CCC) found no documentation of
missing or lost keys for the annual compliance review period. The program employs a daily
process for key tracking and reconciliation. There are two direct care facility keys in use, which
must be turned in to the shift supervisor (SS) or director of operations (DO) at the end of each
shift. These keys are then transferred to the incoming SS or DO and the transaction is
documented in the daily log. If staff leave the campus with program-issued keys after their shift,
they are immediately called to return them. Disciplinary action may be taken as appropriate. A
sample of five staff key rings was reviewed and compared to the key inventory log. Each key
ring was clearly labeled, matched the inventory log, and the number of keys was consistent.
Informal interviews with three staff confirmed each was knowledgeable about the keys on their
ring and their functions. Five staff interviewed were able to clearly summarize the program’s key
control procedures, including the securing of personal keys, the daily tracking process, and the
assignment of program keys.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures which address contraband and searches for
contraband throughout the program. These measures include clearly defining items and
materials considered contraband, identifying any exemptions, and providing youth with a list of
prohibited items. Youth are also informed of the consequences of possessing contraband. To
prevent the introduction of contraband, the program conducts regular searches of the facility,
including the physical plant, facility grounds, youth, and both incoming and outgoing mail. A
contraband attestation statement is included in the facility visitor log, as required. During the
annual compliance review period, ten new staff members were hired, each of whom completed
the required contraband attestation form. The policy further outlines disciplinary actions for staff
found in possession of contraband, which may include dismissal, and requires notification of law
enforcement in such instances. The program maintains detailed records of confiscated items,
including documentation of the confiscation and disposition, which is stored in the youth’s case
record. The program clearly identifies items considered contraband and documents the disposal
of both illegal and non-illegal contraband. One incident involving illegal contraband was reported
to the Department’s Central Communications Center (CCC) during the review period and a
review of the report indicated contraband was turned over to law enforcement as required.
Facility logbooks, incident reports, and search reports were reviewed to assess the frequency,
quality, and outcomes of searches conducted. Interviews with five staff members confirmed
youth room searches are conducted randomly on every shift by both staff and supervisors. An
interview with the executive director confirmed the program maintains documentation verifying
searches are conducted as needed to control contraband and ensure safety. Additionally, the
program documents any items confiscated from youth, the reasons for confiscation, and the
method of disposition. This documentation is maintained in writing and filed in the facility’s
contraband log.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
During the annual compliance review week, searches of youth, staff, and visitors were
observed. All youth were consistently searched upon entering and exiting classrooms each day.
On one occasion, youth were also observed being searched prior to transportation. Searches of
youth conducted during admission, before and after visitation, upon returning from off-campus
activities, and before or after the use of tools were not observed during the annual compliance
review week, as these events did not occur. The searches were conducted in alignment with the
Right Interactions (RI) curriculum. Youth were treated with dignity and respect throughout the
search process to minimize stress and embarrassment. Searches were conducted by the
appropriate number of staff and always by staff of the same gender as the youth. Observations
focused on the thoroughness of the searches, the clarity of staff instructions, and the
professional demeanor displayed by staff when explaining the purpose and scope of the
searches. A video review of five searches involving staff and visitors was conducted, with no
concerns or issues noted. Interviews were conducted with five youth and all confirmed they are
searched during every movement. Similarly, five staff members were interviewed and all
reported youth are searched at every movement within the facility.
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 utilizes two nine-passenger vehicles to transport youth off program grounds. Each
vehicle is equipped with a window punch, seat belt cutter, and fire extinguisher. First aid kits are
signed out prior to departure and returned upon return. Twenty-seven staff and facility vehicles
were inspected one day during the annual compliance review week, one program and two staff
vehicles were found to be unsecured. Both facility transport vehicles underwent inspection and
were confirmed to have current annual safety inspections and up-to-date maintenance records.
During the annual compliance review week, it was verified both vehicles were appropriately
equipped with a fire extinguisher, seat belt cutter, window punch, and the required number of
seat belts. Additionally, the doors to the youth passenger areas are designed so they cannot be
opened from the inside. Based on the program’s assessed risk level, safety screens are not
required. No deficiencies were identified which required corrective action.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures which addresses the transportation of youth, which
align with all Departmental requirements, including those related to driver eligibility. A review of
these policies and procedures, as well as staff interviews and direct observations, confirmed full
compliance. Transporters are issued a cellular phone or radio to ensure communication during
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transport. The program maintains a staff-to-youth ratio of one-to-five for all transports. During
the annual compliance review week, an observed transport demonstrated adherence to this
ratio, with one staff member of the same gender as the youth present. Both youth and staff were
properly secured with seatbelts, and youth were not restrained in any way beyond standard
seatbelt use. The program utilizes the Samba Safety online system to monitor staff driving
records and receives alerts for any infractions would impact driving eligibility. A current list of
approved drivers was reviewed. Youth are strictly prohibited from driving any program or staff
vehicles. Five youth were interviewed; all reported they had never been handcuffed or
improperly restrained in a vehicle, nor had they witnessed any contraband being placed in
transport vehicles. Similarly, all five interviewed staff confirmed youth are secured with seatbelts
during transport. Four staff reported a duty phone is provided; the fifth staff had not participated
in any transports and was unaware of the communication protocol. All five staff identified the
presence of safety equipment in transport vehicles, including first aid kits, fire extinguishers, and
window punches. None of the staff are permitted to use personal vehicles for youth transport.
They also reported vehicles are searched for contraband both before and after each use. Staff
demonstrated knowledge of emergency response procedures, which include notifying the
program, calling 9-1-1, and contacting the Department’s Central Communications Center
(CCC). The one-to-five staff-to-youth ratio was consistently confirmed across all interviews. The
question regarding safety screens in transport vehicles was deemed not applicable due to the
program’s assessed risk level.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures outlining the Weekly Safety and Security Audit
inspection process. This policy designates the director of operations as responsible for
conducting weekly safety and security audits. It also includes provisions for the development
and implementation of corrective actions in response to any deficiencies identified during
internal or external reviews, audits, or inspections. The program has established an internal
system to verify all identified deficiencies are addressed, existing systems are improved, and
new systems are implemented as necessary to maintain compliance with all applicable
requirements of the Florida Administrative Code. During the annual compliance review period,
the Residential safety and security specialist confirmed safety and security audits were
conducted on a weekly basis. One minor deficiency was identified in February 2025 and
resolved by April 2025. In response, the program established and implemented a
comprehensive set of measures, including cleaning schedules, a pest control system, a garbage
removal process, and a facility maintenance system. This system includes maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment. These inspections are conducted at specified intervals of bi-weekly,
monthly, quarterly, semiannually, annually, and every three years, as outlined in the Preventive
Maintenance Checklist. The program’s Preventive Maintenance Checklist was reviewed to
ensure all maintenance activities and repairs were performed in accordance with the Florida
Administrative Code. An interview with the executive director confirmed weekly safety and
security audits are conducted by the director of operations, who submits the completed audits
electronically to the designated representative at the Department Regional Office and initiates
corrective actions when warranted.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures which addresses tool inventory and management of
tools used at the program. The policy outlines protocols for the issuance, control, and inventory
of all tools and equipment. It specifies tools must be inventoried prior to issuance for work-
related activities and re-inventoried immediately following their use. Tools classified as sharp-
edged or pointed are subject to daily inventory, except on days when they are not utilized. Tools
without sharp edges or points are inventoried on a monthly basis. The policy strictly prohibits the
possession or use of machetes, bowie knives, or any other long-bladed knives. The procedures
for handling missing or lost tools are clearly defined. Staff are required to immediately report any
missing tool to the director of operations (DO) or shift supervisor (SS). Upon notification, staff
must secure the youth in the group by seating them together under continuous visual
supervision and securing the surrounding area. The DO initiates an investigation and conducts
a thorough search to locate the missing tool. If the tool cannot be located, a security alert is
issued to all staff and documented in the shift log. All vocational activities must be suspended
until the tool is found or the investigation is concluded. The staff member who signed out the
missing tool is required to complete a written incident report. Additionally, an item tag must be
placed in the tool’s designated storage location to indicate its absence. The Department’s
Central Communications Center (CCC) must be notified within two hours of discovering a
missing tool. An informal interview with the maintenance staff confirmed there were no
instances of missing or damaged tools during the annual compliance review period. A review of
the program’s tool inventory validated proper documentation of tool issuance and return.
Observations confirmed maintenance tools were securely stored in a locked garage located
outside. A sample review of ten tools verified all tools were accounted for, appropriately marked
for identification, and accurately listed on the maintenance tool inventory form.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures which addresses tool inventory and management of
tools used at the program. This policy outlines supervision requirements for youth during tool
use, the process for issuing tools to both youth and staff and includes an assessment protocol
to evaluate a youth’s risk to self and others prior to tool assignment. It also specifies staff-to-
youth supervision ratios and procedures for tool distribution, collection, and searches during
work projects. According to the policy, the required supervision ratio is one staff member to five
youth during general tool-related activities, one staff member to three youth during disciplinary
work projects, and one staff member to five youth during vocational training activities. During the
annual compliance review week, no youth were observed engaging in tool related activities.
However, five youth records were reviewed, all of which confirmed the youth had received
training on the safe use of tools. Each record also included documentation of a completed risk
assessment prior to the youth using any tools. Interviews were conducted with five youth
regarding their permitted tool use. All reported they were allowed to use mops, brooms, and
scrub brushes. Similarly, all five interviewed staff confirmed youth are authorized to use these
basic cleaning tools. Additionally, three staff indicated youth may operate a lawn mower,
provided a risk assessment is completed and proper supervision is maintained.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures addressing guidelines for outside vendors and
contractors which includes information regarding tool control and tools restrictions within the
program grounds. These guidelines include specific protocols for tool control and restrictions
while on program grounds. A review of sign-in sheets and instruction documents provided to
external contractors revealed no issues or concerns. The program’s procedures for tools used
by repair personnel and external workers require all tools are checked upon arrival and
departure. Certain tools may be restricted within the program, and youth are not permitted in
designated work areas during vendor activity. Any missing tools are subject to immediate follow-
up to ensure accountability and safety. A review of three project invoices submitted by a vendor
showed each invoice accurately matched the corresponding logs, tool inventory records, and
visitor sign-in sheets. In one instance, the program confirmed five tools were brought on-site
and the same number were accounted for upon the vendor’s departure. The program’s policies
also clearly define the personnel responsible for providing approval or permission when tools or
equipment are required on-site.
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 operates on two primary shifts. As part of the annual compliance review,
documentation for all fire drills and Continuity of Operations (COOP) drills was received and
thoroughly reviewed. The program provided documentation of required drills and were
conducted monthly on each shift, as required. Drill records included key details such as the type
of drill, date and time, list of participants, a brief scenario description, and any findings or
recommendations. Fire egress routes and illuminated exit signs were visibly posted throughout
various areas of the program. The program maintains ten fire extinguishers across the
premises, all of which were found to have been inspected monthly by the maintenance staff,
with documentation to support compliance. Interviews were conducted with five youth. All
reported knowing what actions to take in the event of a fire. Three youth indicated fire drills are
conducted monthly, one reported they occur twice a month, and one was unsure of the
frequency. Interviews with five staff members confirmed each had participated in emergency
drills within the past twelve months. Staff cited various types of drills, including suicide
prevention, fire, severe weather, active shooter, power outage, COOP, and bomb threats. An
interview with the executive director confirmed the facility conducts a wide range of drills. These
include, but are not limited to, fire, hurricanes, tornadoes, riots, hostage situations, bomb
threats, chemical spills, and brush fires.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a Continuity of Operations Plan (COOP), which is stored in the copier
room located within the large dayroom area and is accessible to all staff. The COOP was last
reviewed and approved by the Department’s Residential Operations regional director on April
14, 2024. The plan outlines procedures for emergency relocation, including alternative sites
have been approved by the appropriate Department regional director or designee. The COOP is
integrated with the program’s Emergency Disaster Preparedness Plan into a single,
comprehensive document. Per an email notification from the Executive Director, the COOP is
reviewed annually by the program. Emergency supplies, such as flashlights, are stored in the
copier room, and food supplies are provided by the Pensacola Naval Air Station (NAS). The
program also maintains a mobile, administrative hard-copy binder containing essential
identifying information for each youth. This binder is readily accessible in the event of an
emergency requires immediate relocation or in situations where electronic systems are
unavailable. An interview with the executive director confirmed the location of the COOP in the
copier room. A review of five youth records in the COOP binder confirmed each file included the
youth’s name, Department identification number, admission date, date of birth, gender, and
race. It also contains the name, address, and telephone number of the parent or guardian, as
well as the name, address, phone number, and relationship of the individual with whom the
youth resides. Emergency contact information is included, along with the name, circuit/unit, and
contact details for the juvenile probation officer (JPO). The records also list the names and
contact information for the committing judge, state attorney, and public defender or attorney of
record, as well as the committing offense and the judicial circuit in which the offense occurred. A
notation is included regarding whether the judge retains jurisdiction, along with victim notification
contact information, if required. Additionally, the binder includes a physical description of each
youth, including height, weight, eye and hair color, and any identifying marks, as well as their
overall health status, chronic illnesses, current medications, allergies, personal physician
information, and a photograph. This documentation ensures critical information is available to
staff in the event of an emergency requiring rapid response or program relocation.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures addressing the storage and inventory of all
flammables, poisonous, and toxic items, and materials. This policy emphasizes strict control and
require a comprehensive inventory of all such substances. All hazardous items are securely
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stored in a locked shed, ensuring they remain inaccessible to youth at all times. A current list of
authorized personnel permitted to handle these materials is maintained. Authorized individuals
include maintenance staff, the executive director, and the director of operations. The facility’s
procedures designate maintenance personnel, or other trained staff equipped with appropriate
safety gear, are responsible for the dilution, handling, and disposal of hazardous or solid waste.
At present, only maintenance personnel are authorized to dispose of hazardous items. All
disposal practices are conducted in accordance with Occupational Safety and Health
Administration (OSHA) standards and follow the manufacturer’s Safety Data Sheets (SDS) for
each material. A review of the program’s disposal log confirmed documentation of the type,
frequency, and method of hazardous material disposal. Hazardous liquid waste is stored in a
designated hazardous materials area and is disposed of in accordance with its SDS. Liquid
waste generated from work details is discarded through appropriate plumbing drains. In the
event of a chemical spill, staff are instructed to immediately notify director of operations (DO) or
shift supervisor (SS) with the spill location. The (DO) or (SS) will then initiate shutdown of all air
handlers and ventilation systems and close all windows and doors as directed by the on-scene
supervisor or executive director. If needed, emergency assistance from external agencies is
contacted in accordance with the facility’s emergency response protocols. The program
currently uses only three specific chemicals. An inspection verified all three chemicals were
securely stored and inaccessible to youth, with each having a corresponding and accurate
Safety Data Sheet. Inventory records matched the actual chemical quantities on hand. An
interview with the executive director confirmed the Navy Base is the primary entity responsible
for chemical disposal. In cases where the base is unable to assist, the program utilizes two local
disposal facilities as alternatives.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures addressing the storage and inventory of all
flammables, poisonous, and toxic items, and materials. The program has established policies
and procedures governing the storage and inventory of all flammable, poisonous, and toxic
materials. These policies strictly regulate access to such items and explicitly prohibit youth from
handling any chemicals. Youth are not permitted to clean, handle, or dispose of biohazardous
materials, bodily fluids, or human waste under any circumstances. Access to the shed where
flammable, poisonous, and toxic substances are stored is restricted to authorized staff only,
ensuring these materials remain secured and inaccessible to youth. During the annual
compliance review, one youth was observed sweeping and mopping. The used mop water was
properly disposed of down a drain. Five interviewed youth confirmed they do not handle or use
any cleaning chemicals or products as part of their daily routines.
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5.20 Elements of the Water Safety Plan, Staff Training, and
Satisfactory Compliance
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 has a written policy and procedures which addresses elements of the water safety
plan, staff training, and swim testing for youth. The policy outlines safety standards and
protocols for a variety of water-based activities such as SCUBA diving, swimming,
snorkeling/skin diving, canoeing/kayaking, sailing/windsurfing, fishing, water park visits, and
seamanship. Reviewed documentation confirmed swim tests are conducted by certified
instructors and are aligned with the specific type of water activity planned. The Water Safety
Plan includes detailed guidance on safety measures, emergency procedures, and behavioral
expectations during all water-related activities. Risk assessments for participating youth
consider multiple factors, including swimming ability, age and maturity level, special needs to
include physical or mental health conditions, physical stature, and conditioning. All water
activities take place in a swimming pool staffed with certified lifeguards. Environmental factors
such as water clarity, turbulence, and bottom conditions are also taken into account. A lifeguard-
to-youth ratio is maintained, and lifeguard positioning is strategically planned for optimal
supervision. In addition to the lifeguards, there is one staff for every five youth participants.
Required safety equipment is provided, including personal flotation devices (PFDs) for youth in
watercraft and lifelines for shoreline or offshore activities. The program employs two certified
lifeguards, both with current certifications, and a certified diving instructor oversees SCUBA,
snorkeling, and skin/free diving activities. A review of five staff records confirmed all have
received training in emergency procedures. During youth interviews, one of the five youth
reported having completed a swim test and participated in water activities, noting the presence
of a lifeguard during those activities. The remaining four youth stated they have not yet
participated in water activities but are scheduled to do so in the near future.
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Office of Accountability and Program Support Page 60 of 66 (Revised September 2022)
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program’s visitation schedule was observed posted along with the weekly activity schedule
on walls throughout program areas. Visitation is held every other Sunday from 1:00 PM to 4:00
PM. Youth become eligible for visitation after completing fourteen days of enrollment.
Authorized visits from attorneys, juvenile probation officers (JPOs), and clergy are permitted
upon scheduling with the director of operations or the assigned case manager. Requests for
special visitations are submitted through the executive director, director of operations (or
designee), or the case manager and are reviewed on a case-by-case basis. All visitors are
required to sign in and out using the visitor log located in the lobby. Review of the log confirmed
adherence to the visitation schedule, with proper documentation of visitor entry and exit times,
including those of family members. An approved correspondence list was observed for each
youth. All youth phone calls occur at scheduled times on designated days, as documented in
the program’s phone log binder, which also includes the mail log. Youth are permitted to send
mail to individuals on their approved list. Outgoing mail is searched by staff to ensure it is free of
contraband prior to being sent. During an interview, the case manager explained for every youth
admitted into the program, a review of the Department’s Juvenile Justice Information System
(JJIS) Face Sheet is conducted to verify approved contacts. The assigned JPO is also
contacted to confirm contact information. At the time of the review, no youth in the program had
an alert for human trafficking or designation as an endangered person. Staff confirmed outgoing
mail is searched in accordance with policy. Interviews with five youth confirmed they are able to
make phone calls and send letters to their parent or guardian. The executive director stated the
providers can provide interpreter services when needed. Additionally, the program uses
documentation available in languages other than English to accommodate non-English-
speaking youth and families. The executive director also confirmed the program has access to
the provider for additional resources, interpreter services, and overall support.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a posted daily activity schedule which documents a range of supervised and
structured indoor and outdoor recreation and leisure activities for the youth at least one hour
daily. The schedule allows for indoor and outdoor large muscle activity. A review of the
program’s logbook also indicated recreation is conducted as scheduled. Activities offered
promote social and cognitive skill development, creativity, teamwork, healthy competition mental
stimulation, and physical fitness. Recreational activities were observed ensuring the program
takes precautionary measures to prevent overexertion, illness, or physical injury due to weather
related issues. The program employs a recreational therapist who met all contract requirements
for the position. Interviews with five youth confirmed they participate in physical activities for at
least one hour each day. Youth reported engaging in activities such as basketball, football,
strength workouts, use of pull-up bars, and group discussions. Similarly, interviews with five
staff affirmed youth are provided opportunities for outdoor recreation daily. Staff cited examples
including basketball, football, swimming, volleyball, soccer, and other various sports.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 66 (Revised September 2022)
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 62 of 66 (Revised September 2022)
Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
According to the provider’s contract, as well as an interview with the executive director, the
program provides the following Career and Technical Education (CTE) services, to include
Florida Ready to Work, cardiopulmonary resuscitation (CPR) and first-aid (FA), Occupational
Safety and Health Administration (OSHA)-10, and ServSafe. Based on a review of youth
certifications earned, youth received certification for these trainings during the annual
compliance review period. Twenty-five youth recieved Florida Ready to Work certifications,
sixteen recieved OSHA-10 certifications, twenty recieved ServSafe certfications, and thirty-nine
recieved CPR/FA certifications. The program’s schedule indicated classes are held Monday
through Friday from 4:00 p.m. until 5:00 p.m. The program’s career coordinator and transition
coordinator work to facilitate and coordinate these classes. A review of these two staff training
records revealed both had certifications to train in the areas reviewed. No on-site observations
of CTE classes were able to be reviewed during the annual compliance review week. Five open
youth records were reviewed for completion of these classes. Four of five youth records had
evidence youth completed and received certifications for Florida Ready to Work. Two of five
youth records had an OSHA-10 certification, and all five youth records had CPR/FA
certifications. Each of the five interviewed youth confirmed the program provides educational
services. All five youth gave examples of education classes they are currently attending. The
executive director was interviewed and stated education services are provided according to the
contractual agreement.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The program
provides education services through Florida Virtual School (FLVS). A review of the program’s
activity schedule and the daily academic schedule indicated the program’s activity schedule
incorporates the daily school schedule. No discrepancies were found. The interview with the
lead teacher indicated all the youth receive credit for completing a course. They also reported
the school schedule is adhered to. Five youth were interviewed and each indicated there are no
interruptions during school. A review of twelve randomly selected days, one day each month of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 66 (Revised September 2022)
the annual compliance review period, in the logbook indicated education classes started and
ended on time or within a few minutes of the schedule. There was one day where the youth
were sixty minutes late for first period. Observations of the program video were viewed for three
days. The video observation showed teachers and students were moved at the appropriate
times.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 a.m. through 2:45 p.m. with a sixty-minute lunch break from 12:05 p.m.
through 1:05 p.m., fulfilling the weekly requirement of twenty-five hours of instructional time. The
interview with the lead teacher indicated all the youth receive credit for completing a course.
They also reported the school schedule is followed. Observations of the program video were
viewed for three days. The video observation showed teachers and students were moved at the
appropriate times.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The program’s career education program is appropriate for the educational abilities and goals of
the youth, and length of stay of the youth in the program. Career education programming
includes communication, interpersonal, and decision-making skills. The program’s moderate risk
component is a Type 2 program, which allows youth to explore and gain knowledge of
occupation options and work to achieve essential prerequisites to skill training. The executive
director was interviewed and stated education services are provided according to the
contractual agreement. The lead educator was interviewed and stated students are provided
with individualized instruction in an online platform. Career and Technical Education courses
and certifications are available to students such as Digital Information Technology (DIT) and
Foundations of Programming. Youth take these courses through Florida Virtual School (FLVS).
General Education Diploma (GED) Essentials program is provided for youth who are on the
GED Track. Ready to test GED youth are allowed to test on site with mobile GED computer.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The educational provider’s contract requires the provider to develop an Education Transition
Plan for each youth. Upon entering a residential commitment program, an Education Transition
Plan must be developed for each youth. Three closed youth records were reviewed; two
contained an education transition plan and all three had an Electronic Educational Exit Plan
(EEEP). The provider trained staff in initiating Education Transition Plans upon admission on
December 1, 2024 and created a plan template for staff to use. The interview with the
instructional leader indicated Exceptional Student Education (ESE) services are provided for
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Office of Accountability and Program Support Page 64 of 66 (Revised September 2022)
students with disabilities, English Language Learner (ELL) services are provided for language
learners, and intervention groups are provided for those below grade level in reading and/or
math. The Instructional leader reported an Educational Transition Upon Entry form is completed
with each student which discusses their educational needs and goals after leaving the program.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has policy and procedures in place to provide qualified
instructional personnel. In reviewing the educational instructional staff for the program, including
flex teachers who provide virtual education at the program, it indicated all the teachers have an
active certification, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects and one teacher is
teaching both courses out of the field. The Florida Virtual School (FLVS) provided parent
notification for those teachers who were also teaching out of the field; however, the letter did not
indicate which subjects were taught out the field. One teacher was providing Exception Student
Education (ESE) services at the program, and FLVS provided their certification as an ESE
instructor.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The program administration and Florida Virtual School (FLVS) staff were interviewed, and all
confirmed the program had no closed youth records which were applicable for referrals to the
Florida Youth College for the annual compliance review period. One youth was applicable and
recently referred to FYC and is still in the program. The lead educator was interviewed and
stated FLVS works in conjunction with Florida Youth College (FYC). Youth names are entered
on a survey for FYC. An FLVS instructor was interviewed and stated the program had only one
youth who was referred for Florida Youth College. The youth is still currently enrolled the
residential program and has only been in the program for approximately two months. The
program did not have any released youth who required referrals for FYC for the annual
compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 66 (Revised September 2022)
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
The program had not released any youth who required referrals for Florida Youth College (FYC)
for the annual compliance review period; however, one youth who is still in the program was
applicable and referred. The program reported the youth has not yet had an orientation to the
program due to scheduling conflicts.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 66 (Revised September 2022)

report_type: QI Residential

file_name: EBB-FINAL-FY2425 .pdf

rule: Indicator 2.07

rating: Limited Compliance

rule: Indicator 2.11

excerpt: Performance Summaries and Transmittals

rule: Indicator 4.13

excerpt: Episodic/First-Aid and Emergency Care

rating: Failed Compliance