1. (1) Protocols shall adhere to community standards of practice and identify and support the need for maintaining youth privacy during examination and handling of health information. Clinical encounters shall be conducted in private. Escorting, non-health care staff/officers, shall maintain distance from the examination for privacy, however, shall also maintain presence within medical to ensure the safety of medical personnel.
2. (2) All newly employed health care personnel, whether state-employed or contracted health care staff, shall receive a clinical orientation to department health care policies and procedures, given by a Registered Nurse or designated licensed health care professional.
3. (3) The facility Designated Health Authority shall review and approve treatment protocols for the onsite licensed nursing staff and non-licensed staff to utilize when administering care in response to commonly encountered complaints. These protocols must be within the scope of practice and level of expertise and training of the staff conducting the evaluation for care.

4. (4) Treatment protocols shall be specifically developed for:

   1. (a) Registered Nurses;
   2. (b) Licensed Practical Nurses; and,
   3. (c) Non-licensed staff.
5. (5) When utilizing treatment protocols, the Designated Health Authority or Physician Designee, PA or APRN shall be contacted when deemed necessary based upon clinical judgment and when the protocol indicates.

6. (6) Documentation of the implemented treatment protocol shall be recorded by one of the following:

   1. (a) Within the Electronic Health Record;
   2. (b) Directly on the Sick Call Request Form (HS 032, February 2010);
   3. (c) For non-licensed staff, the Report of Onsite Health Care by Non-Health Care Staff Form (HS 049, December 2023), which is incorporated into this rule and is available electronically at HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-17495"http://www.flrules.org/Gateway/reference.asp?No=Ref-17495.
   4. (d) Chronological Progress Notes.
7. (7) The Designated Health Authority, the Psychiatrist, and the Dentist (if services are provided on site), must review, sign and date all of their respective written treatment protocols annually, each time a new protocol is developed and when an existing one is changed.
8. (8) Nursing staff must review, sign and date a cover page on which all applicable Facility Operating Procedures, treatment protocols, and other procedures are listed, annually. Any changes in these documents that are made during the year must be reviewed, signed, and dated by each nurse on the individual documents or a designated page.
9. (9) An annual review of all applicable Facility Operating Procedures and treatment protocols is required. This is demonstrated by the signature and date of the DHA and facility Superintendent/Program Director.
10. (10) Facility-operating procedures shall be facility-specific. Corporate policies and procedures shall include language that articulates how the individual facility shall implement the corporate policy or procedure.

Rulemaking Authority 985.64(2) FS. Law Implemented 985.64(2), 985.145, 985.18 FS. History–New 3-16-14, Amended 2-5-25.