Oak Grove Academy

Limited compliance, DJJ review : Indicator 1.04 Education Staff Training (Education Contract Provider)

The Educational Provider staff shall complete staff training as outlined within the contract. The contracted educational provider is required to provide assigned staff with professional development/training as specified in their contract. Thirteen teachers, five on-site and eight flex, were reviewed. All five on-site teachers completed the four mandatory required trainings of Behavioral Management and De-escalating, Professionalism, Interpersonal Communication, and Ethics including Standards of Conduct, and child abuse trainings. The on-site teachers completed five of the seven additional required trainings, with none completing Mental Health and Substance Abuse and adolescent development trainings. All eight flex teachers completed three of the four mandatory required trainings, with none completing the required Behavioral Management and De-escalating training.

Limited compliance, DJJ review : Indicator 1.05 Exit Portfolio (Education Contract Provider)

The Educational Provider shall develop and upload an Exit portfolio at least three school days prior to the youth’s exit from a residential commitment program. Three closed youth records were reviewed for components of the exit portfolio. Each exit plan contained an individual education transition plan, culminative transcript, and list of coursed in progress with grade, which were all uploaded into the Department’s Juvenile Justice Information System within the required timeframes. None of the three records and exit plans contained progress monitoring plans. None of the exit plans were applicable for district or statewide assessments, a Section 504 plan, a English Language Learner (ELL) plan, a behavior intervention plan, an Individual Education Plan (IEP), earned industry certifications, or high school equivalency diploma (GED) results.

Failed compliance, DJJ review : Indicator 1.06 Career Education (Education Contract Provider)

Education staff shall develop and implement a career education competency development program. Florida Scholars Academy, the contracted education prover, is currently in the process of developing the Career Education curriculum. At the time of review, no documentation of Career Education was available. Currently, youth at all programs are working with Career Power Workplace Skills workbooks. A review of the program activities confirmed no career exploration services are being provided beyond soft skills instructions, which does meet the requirements of the Florida Administrative Code for the program, which is not incorporating any Type 1 career education nor any additional Type 2 career preparedness. The instructional leader indicated career education activities are limited to the use of workbooks, with no additional curriculum or industry recognized credential instruction currently available. According to the program schedule, eligible youth participate in Career Power Workplace Skills activities during designated instructional periods Monday through Friday.

Limited compliance, DJJ review : Indicator 1.04 Education Staff Training (Education Contract Provider)

The Educational Provider staff shall complete staff training as outlined within the contract. The contracted educational provider is required to provide assigned staff with professional development/training as specified in their contract. Thirteen teachers, five on-site and eight flex, were reviewed. All five on-site teachers completed the four mandatory required trainings of Behavioral Management and De-escalating, Professionalism, Interpersonal Communication, and Ethics including Standards of Conduct, and child abuse trainings. The on-site teachers completed five of the seven additional required trainings, with none completing Mental Health and Substance Abuse and adolescent development trainings. All eight flex teachers completed three of the four mandatory required trainings, with none completing the required Behavioral Management and De-escalating training.

Limited compliance, DJJ review : Indicator 1.05 Exit Portfolio (Education Contract Provider)

The Educational Provider shall develop and upload an Exit portfolio at least three school days prior to the youth’s exit from a residential commitment program. Three closed youth records were reviewed for components of the exit portfolio. Each exit plan contained an individual education transition plan, culminative transcript, and list of coursed in progress with grade, which were all uploaded into the Department’s Juvenile Justice Information System within the required timeframes. None of the three records and exit plans contained progress monitoring plans. None of the exit plans were applicable for district or statewide assessments, a Section 504 plan, a English Language Learner (ELL) plan, a behavior intervention plan, an Individual Education Plan (IEP), earned industry certifications, or high school equivalency diploma (GED) results.

Failed compliance, DJJ review : Indicator 1.06 Career Education (Education Contract Provider)

Education staff shall develop and implement a career education competency development program. Florida Scholars Academy, the contracted education prover, is currently in the process of developing the Career Education curriculum. At the time of review, no documentation of Career Education was available. Currently, youth at all programs are working with Career Power Workplace Skills workbooks. A review of the program activities confirmed no career exploration services are being provided beyond soft skills instructions, which does meet the requirements of the Florida Administrative Code for the program, which is not incorporating any Type 1 career education nor any additional Type 2 career preparedness. The instructional leader indicated career education activities are limited to the use of workbooks, with no additional curriculum or industry recognized credential instruction currently available. According to the program schedule, eligible youth participate in Career Power Workplace Skills activities during designated instructional periods Monday through Friday.

Limited compliance, DJJ review : Indicator 1.07 In-Service Training

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 Department’s Learning Management System (SkillPro), staff training records, training plans, and the program’s training tracker were reviewed for in-service training. Seven staff records were reviewed and all seven contained more than the twenty-fours of required annual training. Three staff were missing required training; two were missing three courses and one was missing seven courses. All three of these staff completed the missing courses in 2025 and are now in compliance with required training. Five staff had all trainings required by other rules and manuals; one staff was missing two courses, and the other staff was missing one course which has been completed during the current year’s training. Three supervisory staff had over nine hours of supervisory training for the annual compliance review period. All training required according to the contract were Skillpro courses and were completed. All instructors were qualified to deliver the training provided. The program had an updated annual in-service training plan which was approved by the ...

Limited compliance, DJJ review : Indicator 5.13 Tool Inventory and Management

The program shall have a tool management system ensuring youth do not use tools or equipment as weapons or security breaches. The program has a policy and procedures addressing issuance, inventory, and control of equipment and tools. A review of documentation showed tools are inventoried prior to being issued for work and following work activities. All tools are inventoried daily such as sharp-edged, pointed tools, except on days not used. The program prohibits machetes, bowie knives, and other long blades. The program was maintaining a monthly inventory of tools which do not have sharp edges or points; however, the inventory was not accurate. There was no documentation provided for sharps inventory prior to August. A review of ten tools, including sharps in the kitchen, revealed the shadow board does not match the master inventory. All tools had identifying marks, although none of the tools matched the master inventory sheet. There was also no documentation of quantity of tools notated. Residential leadership did provide documentation from an internal audit which was conducted in September which revealed the issues with tools and sharps. The program was given a corrective action date of October 19, 2025, to correct the deficiencies. The program maintains procedures for missing/lost tools. Any missing/lost tools will be documented. The program director (PD) and director of group living will be immediately notified. Sign in/out logs will be reviewed to see when the tool was ...

Limited compliance, DJJ review : Indicator 1.04 Education Staff Training (Education Contract Provider)

The Educational Provider staff shall complete staff training as outlined within the contract. The contracted educational provider is required to provide assigned staff with professional development/training as specified in their contract. Thirteen teachers, five on-site and eight flex, were reviewed. All five on-site teachers completed the four mandatory required trainings of Behavioral Management and De-escalating, Professionalism, Interpersonal Communication, and Ethics including Standards of Conduct, and child abuse trainings. The on-site teachers completed five of the seven additional required trainings, with none completing Mental Health and Substance Abuse and adolescent development trainings. All eight flex teachers completed three of the four mandatory required trainings, with none completing the required Behavioral Management and De-escalating training.

Limited compliance, DJJ review : Indicator 1.05 Exit Portfolio (Education Contract Provider)

The Educational Provider shall develop and upload an Exit portfolio at least three school days prior to the youth’s exit from a residential commitment program. Three closed youth records were reviewed for components of the exit portfolio. Each exit plan contained an individual education transition plan, culminative transcript, and list of coursed in progress with grade, which were all uploaded into the Department’s Juvenile Justice Information System within the required timeframes. None of the three records and exit plans contained progress monitoring plans. None of the exit plans were applicable for district or statewide assessments, a Section 504 plan, a English Language Learner (ELL) plan, a behavior intervention plan, an Individual Education Plan (IEP), earned industry certifications, or high school equivalency diploma (GED) results.

Failed compliance, DJJ review : Indicator 1.06 Career Education (Education Contract Provider)

Education staff shall develop and implement a career education competency development program. Florida Scholars Academy, the contracted education prover, is currently in the process of developing the Career Education curriculum. At the time of review, no documentation of Career Education was available. Currently, youth at all programs are working with Career Power Workplace Skills workbooks. A review of the program activities confirmed no career exploration services are being provided beyond soft skills instructions, which does meet the requirements of the Florida Administrative Code for the program, which is not incorporating any Type 1 career education nor any additional Type 2 career preparedness. The instructional leader indicated career education activities are limited to the use of workbooks, with no additional curriculum or industry recognized credential instruction currently available. According to the program schedule, eligible youth participate in Career Power Workplace Skills activities during designated instructional periods Monday through Friday.

Limited compliance, DJJ review : Indicator 1.07 In-Service Training

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 Department’s Learning Management System (SkillPro), staff training records, training plans, and the program’s training tracker were reviewed for in-service training. Seven staff records were reviewed and all seven contained more than the twenty-fours of required annual training. Three staff were missing required training; two were missing three courses and one was missing seven courses. All three of these staff completed the missing courses in 2025 and are now in compliance with required training. Five staff had all trainings required by other rules and manuals; one staff was missing two courses, and the other staff was missing one course which has been completed during the current year’s training. Three supervisory staff had over nine hours of supervisory training for the annual compliance review period. All training required according to the contract were Skillpro courses and were completed. All instructors were qualified to deliver the training provided. The program had an updated annual in-service training plan which was approved by the ...

Limited compliance, DJJ review : Indicator 5.13 Tool Inventory and Management

The program shall have a tool management system ensuring youth do not use tools or equipment as weapons or security breaches. The program has a policy and procedures addressing issuance, inventory, and control of equipment and tools. A review of documentation showed tools are inventoried prior to being issued for work and following work activities. All tools are inventoried daily such as sharp-edged, pointed tools, except on days not used. The program prohibits machetes, bowie knives, and other long blades. The program was maintaining a monthly inventory of tools which do not have sharp edges or points; however, the inventory was not accurate. There was no documentation provided for sharps inventory prior to August. A review of ten tools, including sharps in the kitchen, revealed the shadow board does not match the master inventory. All tools had identifying marks, although none of the tools matched the master inventory sheet. There was also no documentation of quantity of tools notated. Residential leadership did provide documentation from an internal audit which was conducted in September which revealed the issues with tools and sharps. The program was given a corrective action date of October 19, 2025, to correct the deficiencies. The program maintains procedures for missing/lost tools. Any missing/lost tools will be documented. The program director (PD) and director of group living will be immediately notified. Sign in/out logs will be reviewed to see when the tool was ...

Limited compliance, DJJ review : Indicator 1.08 In-Service Training

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 Department’s Learning Management System (SkillPro), staff training records and plans, and the program’s training tracker were reviewed for in-service training. Only two of the seven reviewed staff completed all of the mandatory training. One staff was missing one training, two were missing two trainings, two were missing three, and one staff was missing ten trainings. Reviewed documentation confirmed the staff who did not have all essential trainings to have contact with youth and records was scheduled and supervising youth. A review of the current year’s trainings revealed the staff is not in compliance with the required essential training. The program relayed the staff has been taken off the schedule and is to complete all trainings before having youth or record contact. Three of seven reviewed staff completed all other mental health and substance abuse with one staff missing one training and three staff missing three trainings. None of the staff had the required Substance Abuse Treatment Overly Services specialty training. One of the ...

Limited compliance, DJJ review : Indicator 1.17 Special Contract Conditions

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 documents found five of the ten special conditions from the Memorandum of Negotiations were being completed as required. Video-chat is being utilized for conferences, a licensed practical nurse (LPN) is being utilized, vocations services are being provided as required, parent/teacher conferences are being held during family day, and, though currently vacant, the previous kitchen manager had the required experience. The program does have 4.5 therapeutic managers on staff however the part time therapist has been out on workers compensation for over two years. The program is holding family days as required with a therapeutic manager however the recreational therapist position has been vacant for over seven months during the annual compliance review period. All staff are not being training in motivational interviewing during the pre-service timeframe. No documentation of the three reviewed closed youth records contained monthly checks being completed post release as ...

Failed compliance, DJJ review : Indicator 2.05 Gang Identification: Notification of Law Enforcement

The program shall gather information on gangs, (e.g., gang members, tattoos, other body markings) and share this information with law enforcement. Seven youth records were reviewed for gang identification and notification of law enforcement. One record was applicable, as such, the program provided two more records for review. Each applicable youth was identified as having gang involvement after their admission into the program. The local law enforcement was notified for one of the three youth’s gang association. The program did not send notification in the required timeframe to each of the applicable youth’s home county law enforcement nor education or their juvenile probation officer once the youth was identified of possible gang association. The program sent one notification while the annual compliance review team was on-site. Each youth’s applicable gang alert was entered into the Department’s Juvenile Justice Information System (JJIS) and the internal alert system at the program.

Failed compliance, DJJ review : Indicator 2.08 Youth Needs Assessment Summary (YNAS)

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. Seven youth records were reviewed for Youth Needs Assessment Summary (YNAS). Four YNAS were due when the Department’s Juvenile Justice Information System (JJIS) was offline. During this time frame, paper YNAS were utilized. Once JJIS was activated, directive was given to input the YNAS into JJIS and to keep the paper copies as documentation for completion in the required timeframe. The program did input the five YNAS in JJIS however the paper YNAS were not retained therefore was not able to determine if they were completed in the required thirty-day timeframe. One YNAS was due prior to JJIS becoming inactive and was not completed within the required thirty-day timeframe however is unable to determine if ever completed for JJIS became inaccessible thirteen days later. Two YNAS were due after JJIS was operational again. Both YNAS were completed late, seven and eighty-one days late.

Limited compliance, DJJ review : Indicator 2.11 Performance Summaries and Transmittals

The intervention and treatment team shall prepare a Performance Summary at ninety day intervals, beginning ninety-days from the signing of the youth’s performance plan, or at shorter intervals when requested by the youth’s committing court. Additionally, the intervention and treatment team shall prepare a performance summary prior to the youth’s release, discharge, or transfer from the program. The program shall distribute the Performance Summary, as required, within ten working days of signing. The program has a policy and procedures which indicate the program's case manager is to complete a performance summary for each youth every ninety days after the development of the Individualized Performance Plan (IPP) unless the committing court requests a summary at a shorter interval of thirty days. Seven youth records were reviewed for performance summaries and transmittals. Five records were applicable, as two youth have not been at the program long enough for a performance summary to be due. Five applicable reviewed records showed all performance summaries were completed late; seven, seventeen, twenty-nine, twenty-nine, and thirty-four days late. Each performance summary included the youth’s status for each performance plan goal, the youth’s overall treatment progress, academic status, and credits earned in the program. Each performance summary included a review of the youth’s behavior at school, their overall behavior in the program, their level of motivation/readiness to ...

Limited compliance, DJJ review : Indicator 1.08 In-Service Training

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 Department’s Learning Management System (SkillPro), staff training records and plans, and the program’s training tracker were reviewed for in-service training. Only two of the seven reviewed staff completed all of the mandatory training. One staff was missing one training, two were missing two trainings, two were missing three, and one staff was missing ten trainings. Reviewed documentation confirmed the staff who did not have all essential trainings to have contact with youth and records was scheduled and supervising youth. A review of the current year’s trainings revealed the staff is not in compliance with the required essential training. The program relayed the staff has been taken off the schedule and is to complete all trainings before having youth or record contact. Three of seven reviewed staff completed all other mental health and substance abuse with one staff missing one training and three staff missing three trainings. None of the staff had the required Substance Abuse Treatment Overly Services specialty training. One of the ...

Limited compliance, DJJ review : Indicator 1.17 Special Contract Conditions

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 documents found five of the ten special conditions from the Memorandum of Negotiations were being completed as required. Video-chat is being utilized for conferences, a licensed practical nurse (LPN) is being utilized, vocations services are being provided as required, parent/teacher conferences are being held during family day, and, though currently vacant, the previous kitchen manager had the required experience. The program does have 4.5 therapeutic managers on staff however the part time therapist has been out on workers compensation for over two years. The program is holding family days as required with a therapeutic manager however the recreational therapist position has been vacant for over seven months during the annual compliance review period. All staff are not being training in motivational interviewing during the pre-service timeframe. No documentation of the three reviewed closed youth records contained monthly checks being completed post release as ...

Failed compliance, DJJ review : Indicator 2.05 Gang Identification: Notification of Law Enforcement

The program shall gather information on gangs, (e.g., gang members, tattoos, other body markings) and share this information with law enforcement. Seven youth records were reviewed for gang identification and notification of law enforcement. One record was applicable, as such, the program provided two more records for review. Each applicable youth was identified as having gang involvement after their admission into the program. The local law enforcement was notified for one of the three youth’s gang association. The program did not send notification in the required timeframe to each of the applicable youth’s home county law enforcement nor education or their juvenile probation officer once the youth was identified of possible gang association. The program sent one notification while the annual compliance review team was on-site. Each youth’s applicable gang alert was entered into the Department’s Juvenile Justice Information System (JJIS) and the internal alert system at the program.

Failed compliance, DJJ review : Indicator 2.08 Youth Needs Assessment Summary (YNAS)

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. Seven youth records were reviewed for Youth Needs Assessment Summary (YNAS). Four YNAS were due when the Department’s Juvenile Justice Information System (JJIS) was offline. During this time frame, paper YNAS were utilized. Once JJIS was activated, directive was given to input the YNAS into JJIS and to keep the paper copies as documentation for completion in the required timeframe. The program did input the five YNAS in JJIS however the paper YNAS were not retained therefore was not able to determine if they were completed in the required thirty-day timeframe. One YNAS was due prior to JJIS becoming inactive and was not completed within the required thirty-day timeframe however is unable to determine if ever completed for JJIS became inaccessible thirteen days later. Two YNAS were due after JJIS was operational again. Both YNAS were completed late, seven and eighty-one days late.

Limited compliance, DJJ review : Indicator 2.11 Performance Summaries and Transmittals

The intervention and treatment team shall prepare a Performance Summary at ninety day intervals, beginning ninety-days from the signing of the youth’s performance plan, or at shorter intervals when requested by the youth’s committing court. Additionally, the intervention and treatment team shall prepare a performance summary prior to the youth’s release, discharge, or transfer from the program. The program shall distribute the Performance Summary, as required, within ten working days of signing. The program has a policy and procedures which indicate the program's case manager is to complete a performance summary for each youth every ninety days after the development of the Individualized Performance Plan (IPP) unless the committing court requests a summary at a shorter interval of thirty days. Seven youth records were reviewed for performance summaries and transmittals. Five records were applicable, as two youth have not been at the program long enough for a performance summary to be due. Five applicable reviewed records showed all performance summaries were completed late; seven, seventeen, twenty-nine, twenty-nine, and thirty-four days late. Each performance summary included the youth’s status for each performance plan goal, the youth’s overall treatment progress, academic status, and credits earned in the program. Each performance summary included a review of the youth’s behavior at school, their overall behavior in the program, their level of motivation/readiness to ...

Limited compliance, DJJ review : Indicator 2.07 Residential Assessment for Youth (RAY) Assessments and

Re-Assessments The program shall ensure an initial assessment of each youth is conducted within thirty days of admission. Documentation of the initial assessment process is to be maintained in JJIS. The program shall ensure reassessments are completed for each youth at least every ninety days from the initial assessment. The program shall ensure any other updates or reassessments are completed, when deemed necessary, by the intervention and treatment team to effectively manage the youth’s case. The program shall maintain all reassessment documentation in the youth’s official youth case record. Five case management records were reviewed and all five contained a completed Residential Assessment for Youth (RAY) within thirty days of admission into the program. The RAYs were maintained in the Department’s Juvenile Justice Information System (JJIS) and the youth’s official case record. One youth record contained RAY Reassessments at least once every ninety days after the completion of the initial RAY; however, the remaining four records documented the RAY Reassessments were not completed at least once every ninety days after the initial RAY with one reassessment reflecting it was two days late, one reassessment was three days late, one reassessment was four days late, and the remaining record documented the reassessment was six days late.

Limited compliance, DJJ review : Indicator 3.03 Non-Licensed Mental Health and Substance Abuse Clinical

Staff The program director is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure clinical staff working under their supervision are performing services the staff are qualified to provide based on education, training, and experience. The program has three non-licensed, master’s-level mental health staff working under a full-time designated mental health clinician authority (DMHCA), a licensed mental health counselor (LMHC). One non-licensed clinical staff has been on extended leave since before the previous annual compliance review, including the entire current annual compliance review period. In the interim, the regional clinical director and a non-licensed mental health clinical staff from a partner program are filling in for coverage requirements. Each of the non-licensed therapists hold a master’s-level degree from an accredited university. All applicable therapists were providing substance services in a program under a Chapter 397 licensure and working under the direct supervision of a qualified professional. The non-licensed master’s-level therapists carried a caseload under the required sixteen youth limit. The program’s DMHCA is responsible for providing face-to-face clinical supervision to the non-licensed clinical staff. Reviewed Clinical Supervision Logs, since the last annual compliance review, found the DMHCA conducted the required weekly face-to-face ...

Limited compliance, DJJ review : Indicator 3.06 Mental Health and Substance Abuse Treatment (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. A review of five youth mental health and substance abuse records indicated an Initial Treatment Plan was developed within seven days of initiation of treatment and documented on a form containing all elements of the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each of the initial treatment plans were developed within seven days of the onset of treatment, signed by the non-licensed clinical staff who completed the form, and signed by a licensed clinical supervisor within ten days of completion. Signatures from all treatment team members who participated in the development of the plan and the youth were documented on the plan. The plan was mailed out for signature to each youth’s parent/guardian, who signed as allowed. None of the Initial Treatment Plans were applicable for psychiatric needs to be included. The Individualized Treatment Plan was developed for each youth within thirty days of admission in all five records on a form which contained all the elements of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. The ...

Limited compliance, DJJ review : Indicator 3.12 Suicide Precaution Observation Logs (Critical)

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. A review of five youth mental health and substance abuse records found one youth was applicable for suicide prevention log documentation. Two additional youth records were reviewed. All three records utilized the Department’s Suicide Precaution Observation Log forms documenting the appropriate level of supervision, observations of the youth’s behavior in real time, not exceed thirty-minute intervals, and safe housing requirements. Two youth logs were applicable for documented warning signs while on precautionary observation. Neither log documented notification was sent to the program director or mental health clinical staff when the warning signs were observed. All three logs were reviewed and signed by each shift supervisor and mental health clinical staff.

Limited compliance, DJJ review : Indicator 3.15 Crisis Assessments (Critical)

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 had two youth requiring a Crisis Assessment since the last annual compliance review. The date each youth was in crisis was not documented on either assessment, however, an examination of the Department’s Central Communication Center incident report associated with each crisis allowed for the establishment of the date for each. One Crisis Assessment was determined to have been completed within the required twenty-four-hour time frame. The other assessment was determined to have been completed eighteen days late ...

Failed compliance, DJJ review : Indicator 5.08 Contraband Procedures

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 ...