summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Orange Youth Academy
Orlando Intensive Youth Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
3150 39th Street
Orlando, Florida 32839
Review Date(s): February 21 - 23, 2024
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:
Bonita Williams, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Office of Education, Deputy Director (Standard 1)
Belinda Alexander, Office of Education, Southwest Region Education Coordinator (Standard 2)
Teresa Andersen, Office of Accountability and Program Support, Central Region Deputy
Supervisor (Standard 3)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 5)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 1
and 4)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Orlando Intensive Youth Academy/Orange Youth Academy MQI Program
Code: 1166/1127
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10758
Location: Orange County / Circuit 9 Number of Beds: 16/40
Review Date(s): February 21 – 23, 2024 Lead Reviewer Code: 148
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, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 86 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
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 Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
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 86 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification 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) Satisfactory
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 Satisfactory
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
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan 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 86 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 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 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 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 86 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 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 86 (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 Satisfactory
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 and Inventory 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 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
5.26 Controlled Observation Safety Checks and Release Procedures 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 8 of 86 (Revised September 2022)
Program Overview
Orlando Intensive Youth Academy is a sixteen-bed program, for twelve to eighteen year old
males, located in Orlando, Florida. The program is operated by TrueCore Behavioral Solutions,
LLC, through a contract with the Department. The program is co-located with the sister program
Orange Youth Academy, sharing staff, buildings, mental health and medical services, groups,
and education. The program provides intensive mental health services. In addition, the program
fosters each youth by providing Impact of Crime (IOC), Thinking for Change (T4C),
SkillStreaming the Adolescent, Passport Program, Dialectical Behavioral Therapy (DBT) Skills,
Aggression Replacement Training (ART), and Cannabis Youth Treatment (CYT). Additional
treatment services provided include family and individual counseling.
Orange Youth Academy is a forty-bed program, for fourteen to twenty-one year old males,
located in Orlando, Florida. The program is operated by TrueCore Behavioral Solutions, LLC,
through a contract with the Department. The program provides Mental Health Overlay Services
(MHOS), and Substance Abuse Treatment Overlay Services (SAOS). In addition, the program
fosters each youth by providing DBT Skills, T4C, IOC, CYT, and Passport Program. Additional
treatment services provided includes family and individual counseling.
Facility administration is comprised of one facility administrator (FA) and one assistant facility
administrator (AFA). Case management services are provided by one director of case
management (DCM), two transitional service managers, and four case managers. Mental health
staff at the program include one designated mental health clinician authority (DMHCA), two
licensed mental health counselors (LMHC), five non-licensed mental health counselors, a
psychologist, and a psychiatrist. Medical services are offered 7:00 a.m. to 7:30 p.m. daily and
are provided by the designated health authority (DHA), three full-time registered nurses (RNs),
and one licensed practical nurse (LPN). Educational services are provided by the local school
district.
The layout of the program includes multiple buildings, one larger, three smaller, and two
portables. The main building is the largest and houses administration, staff offices, master
control, and all youth modules. One of the smaller buildings is used as the dining hall and
kitchen. The remaining two portables and two smaller buildings are for the teachers, divided into
offices and classrooms. The program has eighty-nine operating security cameras providing
coverage; four were not working during the annual compliance review week. At the time of the
annual compliance review, the program had twelve vacant positions including one therapist, one
case manager, two youth specialist IIs, five youth specialist Is, and three master control staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 86 (Revised September 2022)
Strengths and Innovative Approaches
• Obtained a Florida Chapter 397 Substance Abuse License.
• Implemented a culinary arts program through Orange Technical College, utilizing a grant
from School Board of Orange County (SBOC).
• Created a “Club Level Suite” with gaming and musical choices for youth who display
positive behaviors. The suite is located in the school building.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 86 (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 has a policy and procedures outlining the process of conducting initial background
screening for new hires, volunteers, and contracted staff. Since the last annual compliance
review, the program hired fifty-two new staff, six volunteers, and four contracted staff. A total of
sixty-two staff and volunteers were reviewed.
A review of the program’s volunteer roster and sign-in logs verified the program did have
volunteers who required a background screening during the annual compliance review period.
Each of the sixty-two staff, contracted staff, and volunteers were found to have an eligible
background screening in the Agency for Healthcare Administration (AHCA) Clearinghouse
system and the Department’s Background Screening Unit (BSU), which was completed prior to
each staff/volunteer’s hire date. A review of each staff’s personnel record found the program
reviewed each staff’s criminal history report and Staff Verification System (SVS) report. The
volunteers and contracted hires are not required to take the pre-employment assessment tool.
Seventeen of the fifty-two staff were not applicable for the pre-employment assessment leaving
thirty-five applicable staff. Twenty-eight of the applicable staff completed and passed the pre-
employment assessment tool. The remaining seven staff scored below passing. The program
provided documentation showing each of the seven staff had a second interview to determine if
the staff were appropriate for hire despite their low scores. None of the newly hired staff
required an exemption prior to working with youth. The program had one staff with a break in
service indicated in SVS and a new background screening was completed.
An Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the BSU
on December 15, 2023, meeting the annual requirement. The program utilizes local school
board teachers and the annual screening was submitted to the BSU on December 12, 2023,
meeting the annual requirement.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 86 (Revised September 2022)
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures outlining the process of conducting five-year
rescreenings on staff meeting the criteria. A review of the staff, volunteer, mentor, and intern
roster found the program had three staff applicable for a background rescreening during the
annual compliance review period. Each staff was found to have a completed and eligible
background rescreening in the Agency for Healthcare Administration (AHCA) Clearinghouse
system and the Department’s Background Screening Unit prior to their five-year anniversary
date.
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 has a policy and procedures outlining the provision of an abuse-free environment
for both staff and youth. During the program tour, during the week of the annual compliance
review, observations confirmed information for the Florida Abuse Hotline and the Department’s
Central Communications Center (CCC) were posted throughout the facility. Each of the fifty-two
staff reviewed and signed a code of conduct during orientation. The program completed the
Trauma Responsive and Caring Environment (TRACE) self-assessment on May 10, 2023. The
FA reported the TRACE is due March 15, 2024. The facility administrator (FA) reported youth
have safety plans which are created during admission/assessments.
Orange Youth Academy
The program had a total of five incidents related to either physical, psychological, or emotional
abuse since the start of the provider’s new contract and none of the incidents were found
substantiated.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 86 (Revised September 2022)
Orlando Intensive Youth Academy:
Since the start of the provider’s new contract the program did not have any applicable incidents.
The FA reported in their interview, the code of conduct includes offenses and possible
disciplinary actions if warranted. In the event a violation occurs, disciplinary actions can range
from verbal warning to termination of employment. If the incident is reportable the FA gathers all
information necessary prior to calling the CCC within two hours of the incident.
Six staff were interviewed. Each interviewed staff reported knowing the telephone number or
knew the where telephone number for the Florida Abuse Hotline and CCC were posted
throughout the facility. None of the staff reported observing staff deny a youth from calling the
Florida Abuse Hotline. None of the staff reported observing staff using profanity when speaking
with youth. Each staff was able to explain the process for allowing youth and/or staff to call the
Florida Abuse Hotline or CCC.
Each of the six youth reported feeling safe while in the program. Each of the youth reported staff
are respectful when speaking with youth and never observed staff using profanity toward youth.
Each of the youth reported not exchanging emails, telephone numbers, or social media
information with staff. None of the youth reported ever having to call the Florida Abuse Hotline
or CCC since being in the program; however, knew the location of where the telephone
numbers are located throughout the facility.
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 has a policy and procedures outlining the process of how management responds
to allegations of physical, psychological, and emotional abuse. The facility administrator ( FA)
reports no abuse allegations toward youth were substantiated. Upon management being made
aware of an allegation of abuse an internal investigation is initiated.
Orange Youth Academy (OYA)
The program had five allegations of abuse against staff since the provider’s new contract. The
incidents were found to be unsubstantiated. Documentation confirmed investigations were
conducted for each incident; investigations included interviews, a review of written
documentation, and a review of video.
Orlando Intensive Youth Academy (OIYA)
Since the start of the provider’s new contract the program did not have any applicable incidents.
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 has a policy and procedures outlining the process of reporting incidents to the
Department’s Central Communications Center (CCC). Since the start of the provider’s new
contract with the Department, Orange Youth Academy had eight and Orlando Intensive Youth
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 86 (Revised September 2022)
Academy had eleven incidents reported to the CCC. The contract for the program began on
June 23, 2023; therefore, the CCC data cannot be compared to data from the previous annual
compliance review. The facility administrator (FA) reported if the incident is reportable the FA
gathers all information necessary prior to calling CCC, within two hours of the incident.
Orange Youth Academy
Five CCC reports were reviewed and were documented in the logbook as required. The CCC
reports were reported within the two-hour time frame from the incident. A review of internal
incident reports and grievances found no additional incidents which should have been reported
to the CCC.
Orlando Intensive Youth Academy
Five CCC reports were reviewed and were documented in the logbook as required. The CCC
reports were reported within the two-hour time frame from the incident. A review of internal
incident reports and grievances found no additional incidents which should have been reported
to the CCC.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
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 PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program has a policy and procedures outlining the use of Protective Actions Response
(PAR)/Right Interactions (RI). The facility administrator (FA) reported during an interview,
PAR/RIs are reviewed during morning management meetings, a video review is conducted, and
monthly PAR/RI summary reports are reviewed and submitted to the Department for tracking.
The program’s monthly summaries of PAR/RI incidents were submitted to the Department,
since the start of the provider’s new contract with the Department. The PAR/RI Plan was last
updated on January 6, 2023, and approved by the Department on January 12, 2023. The
contract for the program began on June 23, 2023; therefore, the PAR/RI incidents cannot be
compared to data from the previous annual compliance review. During the interviews with six
staff, two of the staff report using PAR/RI and the remaining staff had not used PAR/RI.
Orange Youth Academy
The program’s PAR/RI rate during the previous quarter was 3.75, which is above the statewide
Residential PAR/RI rate of 1.76. Five PAR/RI Reports were reviewed, and each report was
completed by the end of each staff’s workday and reviewed by a PAR/RI certified
instructor/supervisory staff. All reviewed incident reports were reviewed by the FA or designee
within seventy-two hours, and a copy was placed in the program’s centralized file within forty-
eight hours of approval by the FA. Each of the five reports included statements from all staff
involved. Mechanical restraints were used during one of the incidents; however, the appropriate
supervision log was not filled out completely. No injuries were reported for the youth or staff,
and the Department’s Central Communications Center (CCC) and Florida Abuse Hotline did not
need to be contacted in any of the five incidents. A medical review was not required for any of
the reviewed incidents.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 86 (Revised September 2022)
Orlando Intensive Youth Academy
The program’s PAR/RI rate during the previous quarter was 4.50, which is above the statewide
Residential PAR/RI rate of 1.76. Five PAR/RI Reports were reviewed, and each report was
completed by the end of each staff’s workday. Four of the five were reviewed by a PAR/RI
certified instructor/supervisory staff and one was not filled out. All reviewed incident reports
were reviewed by the FA or designee within seventy-two hours, and a copy was placed in the
program’s centralized file within forty-eight hours of approval by the FA. Each of the five reports
included statements from all staff involved. No injuries were reported for the youth or staff, and
the CCC and Florida Abuse Hotline did not need to be contacted in any of the five incidents. A
medical review was not required for any of the reviewed incidents.
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.
The program has a policy and procedures for ensuring staff satisfy the pre-service training
requirements within 180 days of hire. According to the program’s policy and procedures, staff
must complete a minimum of 160 hours of required training in the pre-service period. Staff are
shared between the two programs. Training documentation was available for review within the
Department’s Learning Management System (SkillPro).
Each of the ten reviewed staff completed the required training prior to having any contact with
youth to include cardiopulmonary resuscitation (CPR), first-aid, automated external defibrillator
(AED), Protective Action Response (PAR)/Right Interactions (RI), ethics, facility operating
procedures, child abuse recognition, reporting, and prevention, suicide prevention, emergency
procedures, child abuse reporting, and Prison Rape Elimination Act (PREA). Additional trainings
were completed by each staff for active shooter preparedness, adolescent development and
behavior, restorative justice, incident reporting, civil rights, diversity, Department of Juvenile
Justice History, equal employment opportunity, gang awareness, infection control, information
security awareness, the Department’s Juvenile Justice Information System (JJIS), mental health
and substance abuse, motivational interviewing, report writing, safety, human trafficking,
standards of conduct, and trauma responsive practices. Five of the ten reviewed staff have met
the 180 days of hire and completed more than 160 training hours. The remaining five staff have
yet to meet the 180 days of hire; however, completed at least 140 training hours.
Documentation review confirmed all instructors were qualified to facilitate CPR, AED, and
PAR/RI trainings.
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 has a policy and procedures outlining annual in-service staff trainings. The 2023
in-service training plan was submitted by the Department’s regional director on December 30,
2022. There is an annual training calendar which is maintained and updated by the program as
changes occur. Ten staff training records were reviewed for in-service training, of which three
records were supervisory staff. Each record included all updated annual certifications in
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 86 (Revised September 2022)
cardiopulmonary resuscitation (CPR), first-aid, automated external defibrillator (AED), and
Protective Action Response (PAR)/Right Interactions (RI). Reviewed documentation confirmed
all instructors were qualified to facilitate CPR, AED, and PAR/RI trainings. All ten staff training
records reflected training completion in Prison Rape Elimination Act (PREA). The prenatal and
neonatal education, monitoring, observation, and emergency care of pregnant females and their
infants is not applicable because the program has only male youth. All trainings were entered in
the Department’s Learning Management System (SkillPro).
The program provides enhanced specialized treatment through Mental Health Overlay Services,
Developmental Disabilities Treatment Services, and Intensive Mental Health Treatment
Services, and each staff completed the training. Each of the ten staff completed the annual two-
hour SkillPro web-based suicide awareness and prevention training and the bi-annual human
trafficking intervention training. Each of the three supervisory records included documentation of
the required eight hours of management and supervisory training, including coaching,
leadership, and personal accountability. One record did not include completed training in sexual
harassment, active shooter preparedness, bloodborne pathogens, professionalism and ethics,
and standards of conduct.
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 has a policy and procedures outlining the grievance process. This process
includes staff training with regards to time frames, the phases of grievances, appeals, and
orienting youth upon admission on the grievance process. The program uses "Let's Talk" as
their form for informal grievances. The youth complete the portion of the form indicating what
they wish to discuss and a desired solution or positive suggestion. This is then reviewed by the
staff who the form was addressed to, and the staff will meet with the youth to discuss the
request. Once the youth and staff meet and agree on a resolution, the outcome is noted on the
form, and the youth and staff both sign the form. The facility administrator (FA) was interviewed
and advised the grievance process is to ensure youth are treated fairly, respectfully, and without
discrimination. Youth who file a grievance will not be subject to retaliation or barriers to services.
The FA also outlined the grievance process, to include the informal, formal, and appeal phases.
Orange Youth Academy (OYA)
Since the start of the provider’s contract, the program did not have any grievances for review.
Orlando Intensive Youth Academy (OIYA)
Since the start of the provider’s contract, the program did not have any grievances for review.
Six youth were interviewed and reported the process of submitting a grievance. Five youth
reported being able to ask for assistance when writing a grievance, the remaining one youth
stated not being able to ask for assistance. Each of the six interviewed staff were able to explain
the grievance process.
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1.10 Interventions and Facilitator Training Satisfactory Compliance
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 has a policy and procedures describing what type of delinquency interventions
shall be provided to the youth. A review of the provider’s contract confirmed the only non-clinical
group provided is Impact of Crime (IOC) which is reviewed by the Department’s Office of
Fidelity, Accountability, and Support. The program’s daily activity schedule confirmed the
program is providing structured, planned programming, for at least sixty percent of the youth’s
awake hours. The facility administrator (FA) reported the therapists use Cognitive Behavioral
Therapy (CBT) and trauma informed care to provide therapeutic group and individual services.
The designated mental health clinician authority reported the therapist and one transition
service manager provide interventions. The services include Aggression Replacement Training
(ART), Skillstreaming the Adolescent, Dialectical Behavioral Therapy (DBT), and Cannabis
Youth Treatment (CYT), all of which are clinical and primary groups.
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 provides daily therapeutic activities, which are facilitated by the mental health
clinical staff. The program’s life skills groups are considered primary services. Since the start of
the provider’s contract, the program provided delinquency interventions, specialized services,
and restorative justice. Four of the six youth reported during interviews they participated in
Aggression Replacement Training (ART) since being in the program. One youth reported not
attending any groups and one reported being in substance abuse groups. The facility
administrator (FA) reported youth received mental health, intensive mental health, ART, and
Impact of Crime (IOC) groups. In addition, the FA reported there is no gender specific
programming. The designated mental health clinician authority reported youth are encouraged
to practice skill development during education, recreation, and leisure time activities.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
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.
The program has a policy and procedures regarding restorative justice awareness services. The
program provided Impact of Crime (IOC) as a group to address restorative justice services. In
addition, the program daily schedule states restorative justice is held on Monday’s and
Wednesday’s. This was confirmed through review of sign-in sheets as well. The activities, or
instruction planned, are designed to address all required elements. The program provided
documentation of youth feeding the homeless three times since the start of the provider’s new
contract. Observations of youth participating in restorative justice activities were unable to be
completed the week of the annual compliance review. The facility administrator (FA) reported
youth participate in community service outings such as working at the homeless shelter. In
addition, if youth have previously completed IOC, they will participate in Aggression
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Replacement Training (ART) or Cannabis Youth Treatment (CYT). The designated mental
health clinician authority (DMHCA) reported staff who are providing services have been trained
in specific trainings. Four of the six interviewed youth reported participating in IOC and the
remaining two youth reported not being in IOC. Three of the six youth reported using skills
learned while in the program, the remaining three stated they have not.
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 has a policy and procedures to determine how alerts are identified, documented,
updated, and communicated to staff through the program's internal alert system and alerts
entered into the Department's Juvenile Justice Information System (JJIS). The program had an
Outcome Based Corrective Action Plan (OBCAP) between August of 2023 and February 2024
when it was successfully closed. During the annual compliance review week, a tour of the
facility was completed. Reviewers observed the program conference room, which included an
internal alert board displaying an overview listing of alerts for each applicable youth. The alert
board is accessible to staff; however, not to the youth. All youth with medical and/or dietary
allergy alerts are posted in respective departments, such as the medical and kitchen areas, for
staff access. The facility administrator reported during their interview the program’s internal
alerts are located in the conference room, logbook, and shift briefing reports. In addition, the
alert system includes an alert roster and alert board which details all applicable youth alerts and
is updated as necessary. Alerts are discussed during morning management meetings. Six staff
reported during interviews, they are informed of alerts by reviewing shift debriefings, logbooks,
as well as the alert board in the conference room. The nursing staff reported the licensed
healthcare staff are responsible for updating the medical alert system.
Orange Youth Academy (OYA)
Five youth individual mental health, case management, and healthcare records were reviewed
during the annual compliance review week. Each applicable youth record is comprised of
current and updated appropriate alerts entered with the staff’s name and credentials in JJIS. All
alerts related to medical conditions, medications, diet, and allergies and were entered in JJIS
upon the youth’s admission or when verification of a health condition was confirmed. None of
the alerts were located in the logbook because all were medical related alerts; however, they
were included on the internal alert list.
Orlando Intensive Youth Academy (OIYA)
Five youth individual mental health, case management, and healthcare records were reviewed
during the annual compliance review week. Each applicable youth record is comprised of
current and updated appropriate alerts entered with the staff’s name and credentials in JJIS. All
alerts were related to medical conditions, Prison Rape Elimination Act (PREA) medications, diet,
and allergies and were entered in JJIS upon youth admission or when verification of the health
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condition was confirmed. None of the alerts were located in the logbook because each were
medical related alerts; however, they were included on the internal alerts.
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 Management Record
The program has a policy and procedures requiring youth records to be separated into an
individual case management and Individual Healthcare Records. The healthcare records are
further divided into health and mental health/substance abuse records. Ten youth records were
reviewed, and all had individual case management, healthcare, and mental health records.
Each record contained the youth’s name, Department identification number, date of birth, county
of residence, and committing offense. Each record also included legal information, demographic
and chronological information, correspondence, and case management and treatment team
activities. All youth records were marked ‘Confidential.’ The case management records are
stored in locked cabinets within the case managers offices and are marked ‘Confidential.’ The
healthcare and mental health/substance abuse records are kept in a locked office within the
medical department. No records were observed to be accessible to youth.
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 has a policy and procedures addressing implementation and maintaining a
community advisory board. A review of the community advisory board binder with sign-in sheets
and meeting agendas since the provider’s new contract start date, confirmed meetings were
held on June 28, 2023, September 21, 2023, and November 29, 2023, as required. The
advisory board is shared between the two programs. There were no rescheduled or canceled
meetings, and none of the meetings were held virtually. Supporting documentation revealed
several emails soliciting communications for recruiting and inviting involvement from a judiciary
community representative, other community partners, parent/guardian, a business community
representative, a district representative or school board member, and a faith community
representative. There was no documentation of solicitation of a representative from law
enforcement or the LGBTQIA+ community. During the annual compliance review period,
reviewers contacted a board member by telephone on separate dates to discuss their level of
involvement in program activities, however, no call was returned. The facility administrator (FA)
reported the advisory board meets quarterly and includes church, local mentors, education, a
victim advocate, and others.
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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 a policy and procedures addressing the evaluation of all staff’s performance
within the completion of the first ninety days of hire and then annually subsequently. Reviewed
job and/or position descriptions ensured each staff’s performance standards were clearly
identified for each of the five job descriptions reviewed. A review of three performance
evaluations confirmed they were completed as outlined in policy and procedures at least
annually. The performance standards match the job descriptions for each staff. The facility
administrator (FA) reported the consequences of COVID and better opportunities made it more
difficult to hire staff. The program has monthly job fairs and a corporate recruiting team. The
program has a morale committee and they have incentives for staff in order to build staff morale.
The FA reported evaluations are conducted within ninety days of date of hire and staff are
evaluated on performance of job duties. Six staff were interviewed and four reported the
communication between staff is good, while two stated it was fair. The six staff reported
receiving evaluations yearly, every six months, or every three months.
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.
The program’s contract with the Department includes a Memorandum of Negotiation (MON),
Summary of Negotiated Points, or Secretary letter. The items listed as special contract
conditions included the program obtaining a Florida Chapter 397 License, the program must
provide three medical drills every month with one on each shift, the program must provide
periodic medical evaluations to youth, the program must provide Alcoholics Anonymous
(AA)/Narcotics Anonymous (NA) to youth, the program must allow for family visitation a
minimum of three times weekly and hold Family Days on a quarterly basis, the program must
provide Career Days at least twice a year, the program must provide follow-up contact by
telephone for a sixty-day period for youth who are directly released and for thirty days for youth
who are assigned to an aftercare provider, the program must employ two recreational therapists
and a vocational program manager, and the program must provide high school equivalency
diploma (GED) testing for youth. A review of ten youth Individual Healthcare Records (IHCRs),
sign-in sheets, licenses, staff records, follow-up documentation, and drill logs confirmed all
special contract conditions are being met. The remaining items were reviewed in December
2023 and confirmed the program has meet the contract requirements.
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1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
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), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The Provider’s contract requires the provider to offer Career and Technical Education (CTE)
Services including Career Planning through ONET, ServSafe and/or Food Safety Manager
certification(s), Occupational Safety and Health Administration (OSHA) Outreach Training
Program for General Industry, Florida Ready to Work career readiness program, Digital
Information Technology computer skills, cardiopulmonary resuscitation (CPR), first-aid, and
automated external defibrillator (AED) certification(s), and high school equivalency diploma
(GED) preparation. The facility administrator reported the youth participate in Florida Ready to
Work, first-aid/CPR, Digital Programming, OSHA 10, and culinary programs.
Two of the six interviewed youth reported they are or have participated in CTE services, such as
Food Handler, Florida Ready to Work, and CPR training. One of the two youth stated they
participated weekly and the remaining stated they completed the programs. The remaining four
stated they are not participating in a CTE program. The four youth who are not participating in a
CTE service stated they will start participating soon, they are not sure why they are not
participating, they do not have CTE services, and the remaining did not answer as to why.
Since the providers new contract, fifty youth participated in CPR, first-aid, and AED, eighteen
youth participated in OSHA 10 training, forty-eight youth participated in Florida Ready to Work
Soft Skills, and twenty-seven youth participated in the Food Handler Certificate Program. As a
result of the CTE services offered, thirty-five youth completed the CPR/first-aid course. Eighteen
were listed as non-applicable and left the program before completion. Eighteen youth are either
enrolled or are in progress for OSHA 10 training; none have earned a certification. Twenty-eight
received a Food Handler's certificate. Twenty of the twenty-eight were dated prior to the contract
review period. Twenty youth completed the Florida Ready to Work Soft Skills component and
four were in progress at the time of the annual compliance review.
1.19 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 a policy and procedures to review data trends for utilization in decision-making
practices. The program has implemented an internal database and dashboard system allowing
for daily data entry by every program. This information is compiled into weekly and monthly
totals and provided back to the program's corporate office as well as program management for
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the purposes of tracking trends and informing risk management. The dashboards are updated
weekly with the previous week's data. The program's regional compliance staff are responsible
for ensuring data integrity by conducting on-site checks to ensure the uploaded data matches
facility records and documentation. Data which is compiled on the internal database is shared
with staff during daily management meetings and during monthly staff meetings with all staff.
Trends are also reviewed for possible policy changes, if necessary. Revised policies are
discussed with the facility administrator (FA) during their monthly meetings with senior
leadership and then with all staff during monthly staff meetings. Survey results are also shared
with staff during monthly meetings. The program shares compiled data with providers and
stakeholders during the quarterly community advisory board meetings.
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Office of Accountability and Program Support Page 22 of 86 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures for initial contacts to parents/guardian and court
notification.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and all contained documentation which
confirmed the parent/guardian was contacted by telephone and informed of each youth’s arrival
and program information. All five case management records contained a copy of a written
notification which was mailed to the parent/guardian on the day of intake informing the
parent/guardian of the youth’s admission. In addition, all five youth case management records
contained written notification of intake to the juvenile probation officer (JPO) and committing
court.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed. All five case management records
included documentation the program notified the parents/guardians by telephone within twenty-
four hours of each youth’s admission. All five records included documentation the program
notified the parents/guardians in writing within forty-eight hours of admission. The court and
JPO were notified within five working days of each youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures which state the program shall provide each youth an
orientation to the program’s rules, expectations, goals, and services, which is to begin on the
day of each youth’s admission.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and all contained documentation verifying
the youth received an orientation on the day of admission. All five youth case management
records contained all the elements required to be reviewed during orientation. The program had
one youth admission during the annual compliance review week and the observation confirmed
the program followed their policy for conducting a youth orientation.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed, and each contained documentation
verifying the youth received an orientation on the day of admission, and each orientation
included all the required elements.
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Office of Accountability and Program Support Page 23 of 86 (Revised September 2022)
Six youth were interviewed and indicated they received orientation within twenty-four hours.
Each of six youth stated they received information about program rules, procedures, and
schedules during their orientation.
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 has a policy and procedures requiring written consent of any youth eighteen years
of age or older.
Orange Youth Academy (OYA)
None of the five youth reviewed were over the age of eighteen. A review of three additional
applicable case management records confirmed each contained documentation with a signature
from the youth allowing the release of information regarding physical or mental health
screenings, assessments, and/or treatment with their parent/guardian.
Orlando Intensive Youth Academy (OIYA)
Five youth were reviewed for written consents. One of the five youth was applicable. The youth
case management record included documentation a written consent was completed timely. An
additional closed record was reviewed and included documentation the youth signed a written
consent timely. The program had no other youth who were applicable since the start of the
provider’s new contract with the Department.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures for a classification system which promotes safety,
security, and effective delivery of treatment, based on the determination of each youth’s
individual needs and risk factors. The facility administrator (FA) was interviewed and reported
youth are assigned to their room and dorm by service need and based upon the screening for
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB). The FA also reported
the youth classification process assesses for living unit and room placements based upon
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alerts, such as a youth on a security alert would be placed in a room furthest from the main
entrance and a vulnerable youth will not be placed in a room with aggressive youth. The FA
went on to report during the admission classification, input is solicited from the youth and the
youth’s parent/guardian to make this determination as well.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and each contained a copy of the
admission classification form, which was completed on the day of admission, and addressed all
suspected risk factors. A review of the Department’s Juvenile Justice Information System (JJIS)
confirmed alerts were entered for any issues affecting classification. All youth were classified for
purposes of assignment to a living area, sleeping room, and youth group or a staff advisor.
Three of five youth had a medical issue, one youth had a suicide issue, two youth had a security
issue, and four youth had alerts affecting classification. Each youth identified with a medical,
mental health, substance abuse, security risk factors, and/or special needs immediately had the
appropriate alert entered into the program’s internal alert system and JJIS. None of the five
youth records reviewed were applicable for a reassessment. No youth at the program
participate in off-campus activities. The FA was interviewed and indicated youth are assigned by
service need to the dormitory and the VSAB will dictate dormitory room assignment. The youth’s
living assignment is based on alerts identified during the VSAB and admission classification.
During the admission classification input is solicited from the youth and the youth's
parent/guardian to make this determination as well.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed for classification factors and procedures.
All five youth had an admission classification completed on the date of admission. All five youth
had medical risk factors and additional suspected risk factors. Two youth had risk factors for
suicide risk and security risk. One youth had an escape risk factor. All five youth were classified
for purposes of being assigned to a living area and sleeping room; all alerts were entered into
the program’s internal alert system and JJIS. Three of the five youth reviewed were applicable
for reassessments. The other two youth were still within the initial thirty-days of admission. Two
of the youth were reassessed and allowed an increase in privileges or freedom of movement
and participation in work projects to include tools or instruments. One of the youth was
reassessed for participation in off-campus activities. One youth was reassessed; however, was
not allowed an increase in privileges or freedom of movement, participation in work projects, or
participation in off-campus activities.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures in place to gather information on youth with any
involvement in gangs and share this information with law enforcement.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and three of the youth were applicable for
gang involvement. The three applicable youth case management records contained
documentation which confirmed notifications were made to the local sheriff’s office. The
applicable three youth’s residential commitment placement was not in their home county. Law
enforcement in the three applicable youth’s home counties were notified of the youth’s gang
affiliation. An alert was updated in the Department’s Juvenile Justice Information System (JJIS)
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and the program’s internal alert system for the three applicable youth. Information of the three
applicable youth’s gang status was shared with the education department and the youth’s
juvenile probation officer.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed for gang identification and notification of
law enforcement. None of the youth were applicable. The program provided an additional youth
record for review. The program did not have any other youth with a gang affiliation since the
start of the provider’s new contract with the Department. The youth was identified as a gang
associate before being placed in the program. The youth case management record included
documentation law enforcement in the youth’s home county was notified of suspected gang
activity and the notification was completed prior to the program’s annual compliance review
seven-day notice. The youth record also included documentation county law enforcement where
the program is located was notified of the youth’s gang affiliation. A review of JJIS revealed the
gang alert was entered into the internal alert system when the youth was initially identified as a
gang associate. The youth’s gang status was shared with the educational provider and the
youth’s juvenile probation officer.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures for gang identification with prevention and
intervention activities. The program’s gang intervention strategies include Impact of Crime (IOC)
groups. The facility administrator was interviewed and reported, upon admission a review of the
youth’s history and/or alerts is conducted to identify if a youth is gang affiliated. If a youth is
identified as having gang involvement/membership/affiliation, the youth will be assigned a gang
intervention goal on their Individualized Performance Plan. The youth will be provided with
various materials to educate them on the risks of being involved in a gang through the duration
of the commitment. A gang binder is maintained which includes the youth’s goals, the Security
Threat Group Questionnaire, and notifications made to law enforcement.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and two of the youth were applicable for
gang involvement. An additional youth record was provided for review. Each of the three
appliable youth are enrolled in gang intervention activities. Two of the three youth performance
plans did not include gang related goals due to being recently admitted to the program. The
remaining youth performance plan included goals and objectives related to gang intervention.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed for gang identification and notification of
law enforcement. None of the youth were applicable. The program provided one additional
youth record for review. The program did not have any other applicable youth since the start of
the provider’s new contract with the Department. The youth was identified as a gang associate
before being placed in the program. The youth’s case management record included
documentation the youth participates in gang prevention and intervention strategies. A review of
the youth’s case management record confirmed it included documentation the youth’s
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Office of Accountability and Program Support Page 26 of 86 (Revised September 2022)
performance plan included relevant goals and objectives related to gang intervention strategies
for the youth to complete prior to release from the program.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures for completion of Residential Assessment for Youth
(RAY) and RAY Reassessments.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and all had the RAY completed within
thirty days of admission. The initial assessments were all maintained in each of the five youth
case management records as well as in the Department’s Juvenile Justice Information System
(JJIS). Two of the five youth case management records were reviewed for ninety-day
reassessments. The two applicable youth for reassessments had their reassessments
completed within ninety days from the time of the initial assessment. The reassessments were
maintained in each youth’s case management record.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed and all five included documentation of the
initial RAY being completed within the first thirty days of admission. All five initial assessments
were maintained in JJIS. Two of the five youth reviewed were applicable for RAY
Reassessments. The other three youth have not been at the program long enough to have a
RAY Reassessment completed. The three youth did not require RAY Reassessments according
to the intervention and treatment team. The program maintained all reassessment
documentation in each youth 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 JJIS on the YNAS.
The program has a policy and procedures requiring the Youth Needs Assessment Summary
(YNAS) be completed within thirty days of admission.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and all had the YNAS completed within
the first thirty days of each youth’s admission. All YNASs were documented in the Department’s
Juvenile Justice Information System (JJIS).
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Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed. All five youth case management records
included documentation the YNAS reports were completed within thirty days of admission. The
YNAS reports were documented in JJIS.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures for performance plan development, goals, and
transmittals.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and three records contained
documentation of the Individualized Performance Plan (IPP) being developed within thirty days
of each youth’s admission. The program had an Outcome Based Corrective Action Plan
(OBCAP) between August of 2023 and February 2024, when it was successfully closed. Two of
the five youth chosen for the annual compliance review were a part of the OBCAP. The
documentation for the youth who were a part of the OBCAP were marked non-applicable for the
purposes of this review. The three applicable performance plans were developed following the
youth’s initial Residential Assessment for Youth (RAY) and the Youth Needs Assessment
Summary. All members of the treatment team were present during the development of each
IPP, as indicated by their signature on each plan. None of the three youth were under the care
of the Department of Children and Families (DCF). The three applicable youth had their
parent/guardian attend by telephone, and a copy of the signature sheet was mailed to each
parent/guardian; however, none had been returned. The signature sheets for all youth were filed
in each youth case management record. In the three applicable youth case management
records reviewed, the performance plans included the individualized goals and were based
upon the prioritized needs reflecting the risk and protective factors identified during the initial
assessment process. Each of the three reviewed case management records contained all
required elements. The three applicable reviewed youth case management records contained a
transmittal letter and copy of the performance plan confirming each was sent to the committing
court and the juvenile probation officer (JPO) within ten days of completing the plan. One of the
letters was dated prior to the completion of the performance plan. It was explained as human
error. All three applicable youth had a copy of their performance plan mailed to their
parent/guardian within ten days of completing the plan.
Orlando Intensive Youth Academy (OIYA)
The program had an Outcome Based Corrective Action Plan (OBCAP) between August of 2023
and February 2024, when it was successfully closed. Three of the five youth chosen for the
annual compliance review were a part of the OBCAP and no other youth were applicable to
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review. The documentation for the youth who were a part of the OBCAP were marked non-
applicable for the purposes of this review.
Five youth case management records were reviewed. Two of the five youth were applicable for
IPP development, goals, and transmittals. Both youth case management records included
documentation the initial IPP was developed within thirty days of each youth admission. Both
IPPs were developed after the initial RAY and Youth Needs Assessment Summaries (YNAS).
The required intervention and treatment team members attended the IPP development and
signed each initial IPP. Each applicable IPP included all required elements.
Six youth were interviewed. Each interviewed youth reported receiving a copy of their
performance plan and knew their goals.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a policy and procedures in place to ensure the performance plans are
reviewed monthly and revised as necessary.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and three were applicable and contained
documentation showing each performance plan was reviewed every thirty days during each
youth’s formal treatment team review. Three of the five applicable youth case management
records contained revisions which were a result of the youth demonstrating progress towards
completing a goal. Two youth were not applicable for revisions to the Individualized
Performance Plan (IPP) due to not being in the program for ninety days or more.
Orlando Intensive Youth Academy (OIYA)
Three of the five reviewed youth were applicable for IPP revisions. Two of the youth reviewed
were within thirty days of admission to the program. Two of the three youth case management
records included documentation the performance plans were updated based upon the
Residential Assessment for Youth (RAY) results warranted. One plan was updated in regard to
newly acquired information. All three youth IPPs were updated due to youth demonstrating
progress or lack of progress toward completing a goal.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures which require the treatment team to 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. Four of the six interviewed youth reported their parent/guardian has been involved in their
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case management. The facility administrator (FA) reported every attempt is made to ensure the
parent/guardian are included in the admission process, admission classification, youth needs
assessment and monthly youth treatment team meetings.
Orange Youth Academy (OYA)
Five youth case management records were reviewed and none of the five youth were applicable
for having a ninety-day Performance Summary. Three additional youth records were reviewed
and all three contained documentation confirming Performance Summaries are being completed
within the required time frame. All Performance Summaries included the youth’s status on
performance plan goals, the youth’s overall treatment progress, the youth’s academic status,
behavior, level of motivation/readiness for change, interaction with peers, interaction with staff,
overall behavior adjustment to the program, and any significant positive or negative events. All
three records indicated each youth was allowed to read and add comments to the Performance
Summary prior to signing, and verified the youth received a copy. The original Performance
Summaries are maintained in each youth’s case management record. All the Performance
Summaries were signed by the treatment team leader, staff who prepared the summary, the
facility administrator or designee, and the youth. A copy of the summaries was sent to the court,
the juvenile probation officer (JPO) within ten working days for all three of the youth. A sample
of three closed youth case management records were reviewed to ensure release summaries
were being completed as required. A review of three records confirmed the release summaries
included the original summary, justification for release, and the Pre-Release Notification (PRN)
were sent to the JPO. The release summary and PRN were sent prior to the youth’s planned
release, with a signed copy retained in the youth’s case management record. The court
objected to one youth’s release. The program resubmitted a new PRN and Performance
Summary twice before the judge approved the youth’s release. Once the release was approved
in all three applicable youth case management records, the program provided written
notification to the youth’s parent/guardian and completed a Residential Assessment for Youth
(RAY). There were no youth case management records eligible for the sexually violent predator
program (SVPP). None of the three closed youth case management records were applicable for
victim notifications.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed. Two of the five youth records were
applicable for Performance Summaries and transmittals. Three of the youth selected had not
been in the program long enough to warrant a Performance Summary. The program provided a
third closed record for review. All three youth case management records included
documentation the Performance Summaries were completed every ninety calendar days
following the signing of the performance plan. One of the three youth had a Performance
Summary prepared prior to their release. The other two youth were not being released close to
the week of the annual compliance review. All three Performance Summaries included the
youth’s status on each performance plan goal, youth’s overall treatment progress if the youth
have a specific treatment plan, youth’s academic status, youth’s behavior, interaction with
peers, interaction with staff, overall behavior adjustment to the program, and significant positive
and negative events. None of the reviewed Performance Summaries included the level of
motivation or readiness to change. One Performance Summary included a justification for
release from the program. All three Performance Summaries included documentation the youth
was allowed to read and add comments prior to signing, the youth was provided a copy of the
Performance Summary, and the original summary was filed in the youth’s case management
record. All three Performance Summaries included the signatures from the treatment team
leader, staff preparing the summary, FA or designee, and the youth. All three youth case
management records included documentation a copy of the Performance Summaries was sent
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within ten working days to the committing court, youth’s assigned JPO, and the
parents/guardians. None of the youth were applicable for SVPP and each of the three
applicable youth waived the victim notification.
Three closed case management records were provided for review of release summaries. All
three case management records included documentation the original Performance Summary,
justification for release, and the PRN were sent. All release summaries and PRNs were sent, at
least, forty-five days prior to the youth’s planned release. All youth case management records
included documentation a signed copy of each Performance Summary was retained in the
record. All three youth case management records included documentation the program provided
written notification to the youth’s parents/guardians regarding planned release and an exit RAY
was completed. One youth did not have the initial PRN approved. Once the youth made
progress, the program resubmitted the PRN and updated Performance Summary to the
committing court and assigned JPOs. Victim notifications were waived for all three youth
reviewed.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate the involvement of the
youth’s parent/guardian in the case management process. The program includes
parents/guardians in the admission process, classification, needs assessment, treatment team
meetings, and weekly calls to their parent/guardian. Six youth were interviewed and four said
their parents/guardians are involved in their case management. Two of the youth reported they
have not had their parents/guardians participate yet. The program encourages parent/guardian
involvement in the assessment process, in the participation of the performance plan, during
progress reviews, during treatment team meetings, and during transition planning. If the
parent/guardian is unable to attend any of these meetings in person, they are given the
opportunity to participate by telephone and can provide verbal or written input as well. There
was one treatment team meeting observed during the annual compliance review week. All
members of the treatment team were involved, the juvenile probation officer (JPO) and
parent/guardian were on the telephone. The program provides family visitation, and the case
managers and therapists encourage parents/guardians to visit whenever they speak to them
during treatment team meetings. The FA was interviewed and advised parent/guardian
engagement is encouraged throughout the duration of the youth's commitment. Every attempt is
made to ensure the parents/guardians are included in the admission process, admission
classification, youth needs assessment, and monthly youth treatment team meetings. They are
invited with ample notice to all youth meetings. Parents/guardians are encouraged to provide
input/feedback to their youth’s treatment.
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2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a policy and procedures in place to ensure the youth’s performance plan
references or incorporates the youth’s treatment or care plan.
Orange Youth Academy (OYA)
Five youth case management records were reviewed, and all contained plans in addition to the
performance plans, which included academic and treatment plans. The performance plans
referenced and incorporated the additional plans for each youth. Each youth has a separate
treatment plan, such as medical, mental health, and substance abuse. None of the five youth
were under the supervision of the Department of Children and Families (DCF).
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed. All five youth case management records
included documentation the youth had additional plans, including academic and treatment
plans. Three of the five Individualized Performance Plans (IPPs) included references to the
education plan and treatment plan. Two IPPs did not include other plans. The program was
notified of the missing plans. The case management staff updated the IPPs prior to the end of
the annual compliance review week.
2.14 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.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a policy and procedures governing treatment team meetings and their
composition. Each of the six interviewed youth reported staff review their overall performance.
Four of the six youth reported being able to demonstrate skills learned and the remaining two
youth have yet to attend treatment team.
Orange Youth Academy (OYA)
Five youth case management records were reviewed for formal and informal treatment team
meetings. Three interviewed youth reported staff review their overall performance and treatment
progress. Two of the three interviewed youth reported being able to demonstrate what they
learned during treatment team, the remaining youth reported not attending a treatment team
meeting. Two of the five youth records were applicable for treatment team reviews; therefore,
one additional applicable youth case management record was added. All three youth had formal
treatment team reviews conducted at least every thirty days The documentation for formal
treatment team meetings included the youth’s name, date of review, required attendees,
comments from members, a brief synopsis of the youth’s progress in the program, performance
plan revisions and progress of the goals, treatment progress, and Residential Assessment for
Youth (RAY) Reassessment results. None of the three youth had behaviors which resulted in
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physical interventions. All formal treatment team documentation was contained in each
reviewed youth record. Reviewed documentation confirmed informal treatment team meetings
were conducted for all three youth bi-weekly each month, alternating with the formal treatment
team meetings, which result in each youth having an informal or formal treatment team meeting
every two weeks. The informal treatment team meetings documented the youth’s name, date of
review, required attendees, comments from members, a brief synopsis of the youth’s progress
in the program, performance plan revisions and progress of the goals, any behaviors which
resulted in physical interventions, treatment progress, and RAY Reassessment results. In all
formal and informal treatment team meetings, each youth was provided an opportunity to
demonstrate skills acquired in the program. The youth’s juvenile probation officer,
parent/guardian for those youth under the age of eighteen. and any other pertinent parties were
invited and given the opportunity to provide input. During the annual compliance review week, a
treatment team meeting was observed for one youth. All required staff were present, and there
was a review of the treatment plan to determine each youth’s anticipated release date.
Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed for formal and informal treatment team
meetings. Three of the five youth records reviewed were applicable. Two of the youth selected
were within thirty days of admission and did not have a treatment team meeting at the time of
the annual compliance review. All three youth case management records included
documentation formal treatment team meetings were held. All three youth case management
records included documentation the treatment team meeting forms included the youth’s name,
date of review, required attendees, any comments from treatment team members, brief
synopsis of the youth’s progress in the program, performance plan revisions, progress on
performance plan goals, positive and negative behaviors, behaviors resulting in physical
interventions, youth provided an opportunity to demonstrate skills acquired in the program,
treatment progress, and RAY results. All treatment team documentation was contained in the
youth case management records. All three youth records included documentation informal
treatment team reviews were held bi-weekly or alternating with formal treatment team meetings.
The informal treatment team documentation included all required elements and was contained
in all three youth records. All required treatment team members were invited and encouraged
through advance notification to participate in treatment team meetings.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures in place to ensure the intervention and treatment
team is planning for the youth’s successful transition to the community upon release from the
program.
Orange Youth Academy (OYA)
Three closed youth records were reviewed, and all had documentation confirming each youth
attended a transition conference. One was held ninety days prior to the youth’s targeted
release, one was held one day late, and one was held two days late. The transition conferences
were attended by the youth, treatment team leader, assistant facility administrator (AFA) or
designee, the youth’s juvenile probation officer (JPO), the parent/guardian, and education staff.
During the transition conference, the participants reviewed the youth’s performance plan for
transition activities, revised the activities, if necessary, identified additional activities/services, if
needed, and identified target completion dates with persons responsible for completion. The
treatment team leader obtained the dated signatures from all attendees for all treatment team
forms reviewed. A copy of the plan was sent with a request for return with signature from
anyone who did not attend the meeting, and each plan was transmitted electronically to the
JPO, with the return email acknowledgement printed and filed with the plan for each of the three
applicable youth. One youth was applicable for having a revision to their transition plan and the
plan was updated as required. Community Re-Entry Team (CRT) meetings were also
conducted prior to each youth’s release. Each closed youth record contained copies of the
invitation for participation in the CRT meeting, and each CRT meeting was attended by the
youth and case manager at a minimum.
Orlando Intensive Youth Academy (OIYA)
Three closed youth case management records were reviewed. All three records included
documentation the transition conferences were held at least sixty days prior to the youth’s
targeted release date. All three records included documentation the intervention and treatment
team members in attendance included the youth, treatment team leader, and other team
members. One youth case record included documentation the signature of the facility
administrator or designee was missing from the Transition Plan form. The assigned JPO,
parents/guardians, education staff, and any other pertinent parties were all invited and
encouraged to attend the transition conference. All three closed records included documentation
the participants reviewed transition activities on the performance plan, revised performance
plans, identified additional transition activities, identified target completion dates, identified
persons responsible for completion, and the treatment team leader obtained attendees’ dated
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signatures. All three closed youth records included documentation a copy of the transition plan
was sent with a request for return with signature to anyone not in attendance and who had a
responsibility for completion of transition goals. The plan was transmitted electronically or by
mail to the assigned JPOs. All three youth case management records included documentation a
CRT meeting was conducted and the youth and case manager attended the meeting. Each
youth case management record included documentation invitations were sent for the youth and
case manager to participate in the CRT meeting.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures requiring the assembly of an exit portfolio for each
youth to assist them once released back into the community.
Orange Youth Academy (OYA)
Three closed youth case management records were reviewed, and all contained an exit portfolio
which had been discussed and initiated for each youth during the transition conference. The exit
portfolios contained a copy of each youth’s state-issued identification card, a copy of each
youth’s transition plan, and a copy of each youth’s calendar with dates, times, and locations of
upcoming community appointments. A copy of each youth’s Social Security card was not found
in any of the three youth closed records; however, letters asking the parent/guardian for a copy
was found in all three. The parents/guardians refused to provide a copy of the three youth’s birth
certificates. The exit portfolio contained educational and vocational certificates, educational
records, a résumé, and completed sample employment applications. All exit portfolios were
verified during each youth’s exit conference, and the documentation indicated the exit portfolio
was completed and given to the youth upon release, with the exit portfolio information forwarded
to the juvenile probation officer (JPO).
Orlando Intensive Youth Academy (OIYA)
Three closed youth case management records were reviewed for exit portfolio information. All
three records included documentation the exit portfolio was discussed and initiated at the
transition conference. The records included a copy of the youth’s transition plan, calendar with
all dates, times, and locations of upcoming community appointments, educational and/or
vocational certificates earned in the program, all educational records and documents, school
transcripts, résumé, and a completed sample employment application. Two of the three youth
records included a state-issued identification card. One youth record included a Social Security
card. None of the closed youth records included a birth certificate. There was documentation in
one closed record the youth was born out of state and the transition case manager was unable
to obtain a copy of the youth’s birth certificate. In another closed record the case management
staff attempted to obtain a copy of a birth certificate on multiple occasions. In the third closed
youth record, the youth had obtained a valid driver’s permit prior to entering the program;
therefore, a birth certificate was not required. All three closed youth case management records
included documentation the youth’s exit portfolio was verified during the exit conference. All
three closed records included documentation the exit portfolio was completed and provided to
the youth upon release from the program. All three exit portfolios were forwarded to the
assigned juvenile probation officers.
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2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures which require an exit conference be conducted, in
addition to a formal or informal meeting to review the status of any goals developed during the
transition conference, and to finalize release plans.
Orange Youth Academy (OYA)
Three closed youth case management records were reviewed, and all had an exit conference
which was conducted at least fourteen days prior to the youth’s release, and after the program
notified the juvenile probation officer (JPO) of each youth’s release. A review of the
documentation confirmed the date of each conference, signatures of the attendees, and a
summary of transition goals. Each youth’s date of admission and date of termination
documented in the case record matched with the dates in the Department’s Juvenile Justice
Information System. Each youth’s exit conference was attended by the treatment team leader,
parent/guardian, education representative, JPO, and the youth. Each exit conference was held
separately from the transition conference and the Community Re-Entry Team (CRT) meetings.
Orlando Intensive Youth Academy (OIYA)
Three closed case management records were reviewed. All three records included
documentation the exit conference was conducted after the program notified the JPO of each
youth’s release and were conducted at least fourteen days prior to release. All three closed
records had evidence of participants in the exit conference by signatures, dates, and a summary
of pending transition goals. Each youth’s date of admission and date of release documented in
the case management records correlated in JJIS. There was also documentation in all three
closed records for the status of transition activities which were established at the transition
conference and release plans were reviewed and finalized. The exit conference documentation
included signatures from the intervention and treatment team leader, parents/guardians, JPO,
youth, and other pertinent parties. The education representative participated in two of the three
exit conferences reviewed. The education representative provided information for the exit
conference not attended. All three exit conferences were held separately from the transition
conference and CRT meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures for obtaining youth input. The program provides the
youth surveys. The youth are also able to submit Let’s Talk forms which allow the youth to
request to talk with administrative staff, case management, or a staff member concerning non-
grievance issues. The youth are also able to submit a grievance when applicable. The program
has youth advisory board meetings. The program maintains documentation of monthly youth
advisory meetings, which were reviewed and no issues were noted. The program holds daily
youth meetings, monthly town hall meetings, and youth advisory board meetings. The program
maintains a youth advisory board binder with all sign-in sheets and agendas for the meetings.
The recreation therapist documents the youth advisory board information. A review of the sign-
in sheets revealed the meetings are being held on a regular basis. Six youth were interviewed.
One youth reported the program has town hall meetings which are held with administration, one
youth reported the program recently started daily meetings, and two youth reported having “mod
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meetings” and the youth can talk with the facility administrator. One youth reported being able to
talk with staff when needed and the remaining youth was not aware of ways to give input. The
facility administrator was interviewed and reported there are daily living module meetings,
monthly town hall meetings, and youth advisory board meetings.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide career education. Educational services are
provided through the Orange County School District. The program provides vocational
competency development programs to all youth. The facility administrator interview indicated
the career opportunities provided to the youth include Occupational Safety and Health
Administration (OSHA) certifications, first-aid, digital programing (in school), and a culinary
program. According to the interview with the lead teacher, all youth are enrolled in career and
technical education classes which lead to certifications upon completion and provide
employability skills. The courses are all age appropriate and aligned with the youth’s
educational abilities and goals.
Orange Youth Academy (OYA)
Three closed youth case management records were reviewed, and two of the three completed
sample employment applications included a résumé and a State of Florida Identification (ID)
card. Although the remaining youth had a résumé, they were born out of state and the transition
service manager (TSM) was unable to obtain the birth certificate to obtain their ID. The local
Career Source information was present in two of the three youth records reviewed.
Orlando Intensive Youth Academy (OIYA)
Three closed youth case management records were reviewed, and all three completed sample
employment applications included a résumé and an ID card. The local Career Source
information was present in all three youth records reviewed.
2.20 Educational Access (Critical) 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 policy and procedures to provide for educational access. The program
integrates education into the daily schedule in such a way to ensure the integrity of the required
minimum instruction time distributed over a twelve-month period. The district approved calendar
and daily school schedule were reviewed, which incorporated the required 250 days of
instruction, with ten days used for teacher planning, and a minimum of twenty-five hours of
instruction weekly. Youth are enrolled in academic courses through Orange County Public
Schools and receive credit, as appropriate, when courses are completed. In a review of the
youth interviews, all six youth indicated there are no interruptions during the school day. A
random sample of eight logbooks and three video reviews showed all school movement was
done according to their schedule.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a policy and procedures to provide for an educational transition plan.
Orange Youth Academy (OYA)
Three closed youth records were reviewed, and all three had an education transition plan
developed upon entry based on each youth’s post-release goals. All key personnel related to
transition activities were included and the plans were developed with the youth,
parents/guardians, program, education, and aftercare staff involved. The transition plans placed
specific monitoring responsibilities on individuals responsible for the reintegration and
coordination of the provision of support services upon the youth’s release, and the youth’s case
manager and parent/guardian were aware of the plan. All three youth reported not experiencing
interruptions during school.
Orlando Intensive Youth Academy (OIYA)
Three closed youth records were reviewed, and all three had an education transition plan
developed upon entry based on each youth’s post-release goals. All key personnel related to
transition activities were included and the plans were developed with the youth,
parents/guardians, program, education, and aftercare staff involved. The transition plans placed
specific monitoring responsibilities on individuals responsible for the reintegration and
coordination of the provision of support services upon the youth’s release, and the youth’s case
manager and parent/guardian were aware of the plan. Three interviewed youth reported not
experiencing interruptions during school.
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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 policy and procedures stating the facility administrator is responsible for the
administrative oversight and management of the mental health and substance abuse services in
the program. The program provides specialized treatment services and must have a single
licensed mental health professional serving 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 full-time State of Florida licensed
clinical social worker (LCSW) who serves as the DMHCA. The DMHCA’s license is clear and
active, with an expiration date of March 31, 2025. The DMHCA is on-site weekly Monday
through Friday, for enough time to ensure appropriate coordination and implementation of
mental health and substance abuse services. Documentation of the DMHCA’s position
description was reviewed for accuracy to the program’s requirements, and no issues were
noted. The program provides specialized treatment services where the licensed mental health
professional is responsible for the coordination and implementation of mental health/substance
abuse services with specialization of Juvenile Sexual Offender Treatment Services. These
services are provided by the DMHCA. The program has a licensed mental health counselor
(LMHC) who serves as the back-up when the DMHCA is not available. The LMHC has an active
license in the State of Florida with an expiration date of March 31, 2025.
An interview with the DMHCA revealed their responsibility of the daily mental health/substance
abuse group scheduling. Every youth admitted undergoes a series of screening processes
which include a record review of the youth's previous records, evaluations, assessments, and a
review of the Department’s Juvenile Justice Information System (JJIS) alerts the youth received
prior to admission. Upon completion of a thorough records review, a therapist conducts an
admission interview with the youth and completes the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2), Assessment of Suicide Risk (ASR), and Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB), along with any other assessments
needed based on the results of the MAYSI-2. The final stage of the admission process includes
an admission classification meeting including the therapist, case manager, nurse, administrator,
living unit representative, and the youth. Within the meeting, the findings of the records review,
MAYSI-2, ASR, VSAB, and the initial interview are reviewed. Based upon this information, the
classification team identified needs for referrals.
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3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures requiring all substance abuse and mental health
services to be provided by licensed and/or non-licensed clinical staff. The clinical supervisor
makes sure the licensed clinical staff working under their supervision are performing services
they are qualified to provide based on education, training, and experience. A review of their job
descriptions, and an informal discussion with the designated mental health clinician authority
(DMHCA) confirmed this requirement. The licensed mental health and substance abuse clinical
staffing is in accordance with the current contract and Florida Administrative Code. During the
annual compliance review week, copies of the licenses of all mental health professionals were
examined, with no issues noted. Observations of the Chapter 397 license confirmed it was
posted at the entrance of the program. A review of mental health licenses verified one therapist
was a licensed mental health counselor, and the program has had one licensed mental health
counselor vacancy since the start of the provider’s contract. Each licensed therapist had active
intern registrations in the State of Florida. The psychiatrist is on-site once a week to provided
services such as initial comprehensive psychiatric evaluation, medication management,
medication adjustments, education to youth and staff on medications and potential side effects,
and coordination with guardians regarding consent for medications. The psychologist is on-site
for two hours every Wednesday. The psychologist has a license which is free and clear in the
State of Florida with an expiration date of September 10, 2024.
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 program has a policy and procedures outlining the requirements for qualified professionals
in the delivery of mental health and substance abuse services. The program’s clinical director
serves as the designated mental health clinician authority (DMHCA) and is responsible for
supervising all on-site clinical staff. The clinical supervisor ensures the non-licensed clinical staff
working under their supervision are performing services they are qualified to provide based on
their education, training, and experience. This information was verified through a review of their
position descriptions and an informal interview with the DMHCA. The reviewed documentation
reflected each non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the program during the annual compliance
review period. Reviewed direct supervision was recorded on the program’s form and included all
elements on the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professionals Direct Supervision Log form. The program has a Chapter 397
license, displayed in the front of the building outside of master control, and which an expiration
date of September 6, 2024. The program’s contract requires two recreation therapists. The
program’s staffing roster was reviewed, as well as each recreational therapist’s credentials,
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schedule, and services provided to youth, which confirmed there were no issues. All non-
licensed mental health clinical staff held a master’s-level degree from an accredited university or
college in the field of psychology or a related human services field. Each non-licensed staff
providing clinical services who was employed by the program was licensed under Chapter 397.
Each of the five non-licensed clinical staff received training in the administration of the
Assessment of Suicide Risk (ASR) or Crisis Assessments conducted on-site in the physical
presence of the licensed mental health professional. All training was documented on the
Department’s Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of
Suicide Risk form.
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.
The program has a policy and procedures requiring identification of each youth’s mental health
and substance abuse treatment needs through a comprehensive screening process to ensure
referrals are made for youth identified with substance and/or mental health needs or as a
possible suicide risk. An interview with the facility administrator (FA) indicated upon intake, the
Assessment of Suicide Risk (ASR) is used to assess youth for suicide, if the youth is found to
be a harm to themself, they are placed on precautionary observation. The Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) is used to assess for suicidal ideation,
substance abuse, mental health, and history of trauma. MAYSI-2 hits determine if a youth shall
receive a Trauma Symptom Checklist for Children (TSCC), Reynolds Adolescent Depression
Scale, 2nd Edition (RADS-2), or Structured Assessment of Violence Risk in Youth (SAVRY). All
youth will receive the Adolescent Psychopathology Scale (APS) and substance abuse youth
receive the Substance Abuse Subtle Screening Inventory (SASSI) assessment. All youth
receive a comprehensive assessment to identify issues which will be addressed in their
treatment plan. The program’s Comprehensive Plan for Mental Health and Substance Abuse
Services includes the procedures for implementing a standardized admission/intake mental
health and substance abuse screening process. This includes the review of commitment packet
information, reports, and records, and administration of the MAYSI-2 in JJIS. All staff completing
the five MAYSI-2’s were trained in mental health and substance abuse issues and the
administration of the MAYSI-2. When further mental health and/or substance abuse evaluations
are required or when immediate attention is needed to transport a youth to a hospital, Baker
Act, or Marchman Act receiving facility, a referral is made.
Orange Youth Academy (OYA)
Five mental health youth records were reviewed and each contained a completed MAYSI-2. The
screener reviewed all available information to include the commitment packet and reports for
existing documentation of any history of mental health, substance abuse, or human trafficking.
Each of the five MAYSI-2’s were completed in the Department’s Juvenile Justice Information
System (JJIS), on the day of admission, by trained staff. Four of the five MAYSI-2’s were
complete; however, one did not have the Service Response section completed, as required.
Three of the five youth records contained a referral for further assessment as a result of the
MAYSI-2; two were not completed. The program’s compliance director stated all youth are
referred for further assessment; therefore, a referral is not required. The FA signed off on the
three completed referrals. All five youth had further assessments based off their MAYSI-2
results. Two of the five youth required an ASR referral and all five required a comprehensive
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evaluation referral. The three completed referrals documented the reason for the referral. The
remaining two youth did not have a referral completed.
Orlando Intensive Youth Academy (OIYA)
Five applicable youth mental health records were reviewed for mental health and substance
abuse admission screening. Each record contained a completed MAYSI-2. Reviewed
documentation confirmed the screener utilized available information for each youth, which
included the commitment packet, reports, and documentation concerning each youth’s mental
health and/or substance abuse problems or history. Each of the reviewed MAYSI-2s were
completed on the date of admission to the program. The screenings were conducted by trained
staff, and each screening was completed in full. Each of the five reviewed youth were applicable
for a referral. The program’s practice is to refer all youth for further evaluation. It is the
program’s practice to generate a referral for further evaluation or immediate attention, with a
referral reason, and the utilization of a tracking log when the MAYSI-2 indicates further
assessment is required. One youth’s MAYSI-2 indicated further assessment was required and a
referral was made for further evaluation or immediate attention. The youth’s MAYSI-2 or other
admission information indicated the need for an assessment, crisis intervention, or emergency
services, where the FA or designee was notified, and a referral was made to alert the
designated mental health clinician authority. One of the five reviewed youth case records
indicated the need for an ASR. This was confirmed by the FA and was completed within twenty-
four hours of when the MAYSI-2 category “suicide ideation” indicated further assessment was
needed, or other information obtained at intake/admission suggested potential suicide risk. One
youth received a comprehensive evaluation, with the reason for the referral documented. The
program’s practice is to complete a new comprehensive mental health and substance abuse
evaluation within thirty days of each youth’s admission.
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 program has a policy and procedures outlining the delivery of mental health and substance
abuse assessment/evaluations. The designated mental health clinician authority (DMHCA)
reported results from evaluations, assessments, and the Department’s Juvenile Justice
Information System (JJIS) for the comprehensive mental health/substance abuse assessment
are reviewed. Group counseling is provided four days a week, individual counseling bi-weekly,
and family therapy is monthly.
Orange Youth Academy (OYA)
Five youth mental health records were reviewed and each contained a combined mental health
and substance abuse evaluation which was completed within thirty calendar days of the youth’s
admission. Four of the five evaluations were completed by non-licensed mental health staff and
each was reviewed and signed by a licensed mental health counselor within ten days. One
evaluation was completed by a licensed clinical social worker. Each evaluation contained all
required elements. Each of the five reviewed records contained a consent for substance abuse
services.
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Orlando Intensive Youth Academy (OIYA)
A review of five youth mental health records revealed the program completed a combined
mental health and substance abuse evaluation referral at admission. A new mental health
evaluation was completed for four youth. Four of the five evaluations were completed within
thirty calendar days of admission. One evaluation was not due, and the program still had time to
complete it. Each of the mental health evaluations were completed by licensed mental health
clinical staff. Each evaluation included identifying information/demographics, the reason for the
evaluation, relevant background information including home environment and family functioning,
history of physical abuse, sexual abuse, neglect, witnessing violence and other forms of trauma,
behavioral functioning, physical health, mental health and substance abuse history, and
education functioning. Additionally, the evaluations included behavioral observations, a Mental
Status Examination, interview, procedures administered, the discussion of findings, diagnostic
impression/formulation including, Diagnostics and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis, and recommendations. All five youth records had a consent for
substance abuse services, and a new substance abuse evaluation was completed within thirty
calendar days of admission including the reason for the assessment. The substance abuse
assessments included relevant background information, home environment and family
functioning, history of physical abuse, sexual abuse, neglect, witnessing violence and other
forms of trauma, behavioral functioning, physical health, mental health and substance abuse
history, education functioning, behavioral observations, methods of assessment, and patterns of
alcohol and other drug abuse. The assessments also included the impact of alcohol and other
drug abuse on major life areas, risk factors of continued alcohol and other drug abuse, clinical
impression, DSM-5 diagnoses, and recommendations. None of the five youth records reviewed
were applicable for an updated comprehensive mental health evaluation.
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.
The program has a policy and procedures requiring the designated mental health clinician
authority (DMHCA), mental health and substance abuse clinical staff, and other multidisciplinary
treatment team members to ensure each youth’s treatment plans are individualized and relevant
to each youth’s specific needs. The DMHCA reported the treatment team assists the primary
therapist in developing, reviewing, and updating plans, as well as the individual mental
health/substance abuse treatment plans. Ongoing reviews of the treatment plan occur on at
least a bi-weekly basis with formal revisions and modifications to the treatment plan occurring
on a monthly basis.
Orange Youth Academy (OYA)
Five youth mental health records were reviewed and an initial treatment plan was developed for
each youth within seven days of initiation of treatment. The program utilizes a program form for
the initial treatment plan; however, it contains all required elements from the Department’s Initial
Mental Health/Substance Abuse Treatment Plan form. Each of the five initial treatment plans
were completed and signed by the program’s licensed mental health counselor. Each of the five
initial treatment plans were signed by all treatment team members who participated in the
development of the plan. All five youth’s individualized treatment plans were developed within
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thirty days of admission. The program utilizes a program form for the individualized treatment
plan; however, it contains all required elements from the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan form. Four of the five individual treatment plans were
completed by non-licensed mental health staff and signed by the program’s licensed mental
health counselor within ten days. One individual treatment plan was completed and signed by
the program’s licensed mental health counselor. Each of the five individual treatment plans were
signed by all treatment team members who participated in the development of the plan. A
combined total of nineteen individual treatment plan reviews were completed for the five youth
reviewed. The program utilizes a program form for the individualized treatment plan reviews;
however, it contains all required elements from the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form. Fifteen reviews were completed on time,
while four were reviewed two days, eight days, ten days, and twenty five days late respectively.
The goals and objectives documented on each youth’s individual treatment plan were
customized for each youth. A review of two dates for each month, since the admission of each
of the five youth, group sign-in sheets, and logbooks confirmed groups were conducted for the
required length of time for the designated group.
Orlando Intensive Youth Academy (OIYA)
A review of five youth mental health records indicated the initial treatment plans were developed
within seven days of initiation of treatment. The initial plans were documented on the program’s
form which included the elements from the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form. Each reviewed initial treatment plan was signed by the DMHCA as well as
all treatment team members who participated in the development of the plan. Each reviewed
youth record was applicable for psychiatric needs, including medication and frequency of
monitoring by the psychiatrist, which were included on the initial plans. Three of the five
reviewed youth records also included an individualized treatment plan, signed by the DMHCA,
which was developed within thirty days of the youth’s admission and signed by all treatment
team members who participated in the development of the plan. Each reviewed youth record
was applicable for inclusion of psychiatric needs including psychotropic medication and reviews
were completed at least every thirty days, as required. The youth’s individualized treatment
plans documented each youth’s prescribed services, including twice monthly individual
counseling, daily group counseling, and monthly family therapy sessions. The plans for the
three youth applicable for inclusion of psychiatric needs included monthly medication
management and monitoring by the psychiatrist. The other two youth were not applicable. The
review of treatment plans indicated the services prescribed were individualized for each youth.
Observations of surveillance video footage from three randomly selected groups in comparison
to logbooks, sign-in sheets, and facilitator documentation validated the groups occurred as
documented and for the required duration.
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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.
The program has a policy and procedures delineating the criteria for mental health and
substance abuse treatment, as well as discharge planning requirements. The program is
licensed under Chapter 397.
Orange Youth Academy (OYA)
Five youth mental health records were reviewed and confirmed each youth was assigned a
treatment team on the day of admission. A review of treatment team documentation for all five
youth confirmed each youth, representation from program administration, residential living unit,
and mental health/substance abuse staff participated. Education and medical staff did not
participate in two of the youth’s treatment team meetings. The parent/guardian did not
participate in two of the youth’s treatment team meetings. All five youth received mental health
and substance abuse treatment services which included individual, group, and family counseling
provided by licensed mental health staff or a non-licensed substance abuse clinical staff, who
work under the direct supervision of licensed mental health staff. Each of the five youth’s mental
health records contained a properly executed Authority for Evaluation and Treatment (AET)
form. All five youth provided consent through a signed Youth Consent for Substance Abuse
Treatment form. Each of the five youth records contained a signed Youth Consent for Release
of Substance Abuse Treatment Records form. The program utilizes a program form for mental
health and substance abuse treatment notes; however, it contains all required elements from
the Department’s Counseling/Therapy Progress Notes form. Each of the five reviewed youth
were prescribed mental health and substance abuse group therapy. The program’s group
therapy included individual psychotherapy, counseling, and psychosocial skills training. A review
of each youth’s progress notes, confirmed three of the five youth received services as stipulated
on their treatment plan. Two youth were missing prescribed services. One youth was missing
one of four weekly prescribed groups for four weeks. One youth was missing three of five
prescribed individual sessions, and one of five weekly prescribed groups for six weeks.
Three closed youth mental health records were reviewed and each contained a discharge plan
which were all documented on the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form. Each of the three youth’s Mental Health/Substance Abuse Treatment
Discharge Summaries documented the services needed for daily maintenance of the positive
improvement in behavioral, emotional, and social skills made by each youth during treatment.
A review of chronological notes confirmed the discharge plan was discussed with each youth,
parent/guardian, and each youth’s juvenile probation officer (JPO) during the exit conference.
Each youth’s Release Chronological form confirmed a copy of the Mental Health/Substance
Abuse Treatment Discharge Summary was provided to each youth, parent/guardian, and each
youth’s JPO.
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Orlando Intensive Youth Academy (OIYA)
Five youth case management records were reviewed for treatment and discharge planning.
Upon arrival to the program, each youth was assigned to a treatment team. Reviewed
documentation reflected the members in attendance during treatment team meetings included
the youth, program administration, representatives of the youth’s residential living unit, the
program’s education, medical, mental health, and substance abuse staff, as well as the youth’s
parent/guardian, when available. Reviewed documentation confirmed each youth needed, and
received, substance abuse services including individual, group, and/or family counseling
services provided by a non-licensed clinician working under the direct supervision of a qualified
licensed professional. Four out of five reviewed youth receiving mental health treatment had a
properly executed AET form. One of the five youth was over eighteen years of age; however, it
is the program’s practice to get a signed AET from a parent/guardian, if available, in addition to
a youth over eighteen consent form. Each youth receiving substance abuse treatment provided
consent through a signed Youth Consent for Substance Abuse Treatment form. Additionally,
Youth Consent for Release of Substance Abuse Treatment Records forms are to be signed if
records are being released. Mental health and substance abuse treatment notes were
documented on the program’s form which contained all elements of the Department’s
Counseling/Therapy Progress Notes form. Each youth’s mental health and substance abuse
group therapy included individual psychotherapy or one-to-one counseling between a youth with
a diagnosed mental health disorder and a mental health clinical staff professional. The reviewed
psychosocial skills training activities were designed to address specific skill deficits or
maladaptive behaviors and promote skill development and improve functioning of youth with
mental disorders. Each of the five youth had progress notes to indicate the youth received
services as stipulated on their treatment plan. A review of five youth records indicated none
were applicable for a discharge plan; therefore, an additional three youth records were
requested.
Each of the three closed youth records indicated a discharge plan was completed and
documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. None of the youth were applicable for being released while on suicide
alert/precautions; therefore, a notification regarding the youth’s suicide risk was not needed.
Each Mental Health/Substance Abuse Treatment Discharge Summary form documented the
services needed for daily maintenance of the positive improvement in behavioral, emotional,
and social skills made by the youth during treatment. Upon reviewing the documentation, it
reflected the discharge plans were discussed with the youth, parent/guardian, and JPO during
the exit conference. A review of each youth’s discharge release letter confirmed a copy of each
Mental Health/Substance Abuse Treatment Discharge Summary was provided to each youth,
their JPO, and to the parent/guardian.
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 provides clinical groups for mental health treatment services, substance abuse
treatment services, and major disorders such as dual diagnostic/intensive. The program’s
contract-required clinical groups are Aggression Replacement Training, Cannabis Youth
Treatment, Skillstreaming the Adolescent, Passport Program, A New Direction, and Dialectical
Behavioral Therapy Skills. The program provides each youth with individual, group, and family
therapy at least five days a week as part of each youth’s individualized treatment plan.
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Therapeutic activities, including psychosocial skills training, psycho-education, supportive
counseling, are provided by mental health clinical staff five days a week. All youth identified with
co-occurring substance abuse disorders receive substance abuse services. The program
contracts with a psychologist to provide services as needed. Each clinical counselor’s caseload
is limited to no more than twelve youth, with each maintaining an average of ten to twelve. A
review of therapy group sign-in sheets confirmed each group was limited to ten or fewer
participants for mental health treatment groups. All substance abuse groups are provided by
clinical staff who are qualified to provide substance abuse education. Substance abuse
treatment groups are provided to youth with substance abuse risk factors. Urinalysis drug
testing is provided to youth upon intake into the program, with positive tests followed by
appropriate clinical intervention and sanctions. A review of substance abuse group therapy sign-
in sheets confirmed there was no more than fifteen participants in each group. The program is
licensed under Chapter 397 and only licensed qualified professionals provide substance abuse
services prior to receiving the license. There is a therapist on-site seven days a week. The
program contracts with a licensed psychiatrist who provides psychiatric evaluations and
medication management, and who also participates in treatment planning. Each clinical
counselor’s substance abuse caseload is limited to no more than ten youth. The program offers
mental health and substance abuse evaluations and treatment planning. The program provides
bi-weekly individual therapy, monthly family therapy, and daily support services, daily on-site
psychiatric services, substance abuse therapeutic activities, and mental health crisis
intervention twenty-four hours/seven days a week for each youth. The program maintains a
part-time licensed psychiatrist who is on-site four hours a week, mental health clinical staff who
are on-site seven days a week, a psychologist who is on-site two hours a week to provide
psychological evaluations and services within the program, and is available for emergency
consultation services, and a registered nurse who is on-site daily to ensure appropriate
administration of medication, provide nursing observations, and assessments, as needed.
Five of the six interviewed youth participate in family and/or individual counseling at least weekly
and the remaining youth reported not receiving services yet. Each of the six interviewed staff
reported direct care staff do not facilitate mental health or substance abuse groups. The
designated mental health clinician authority (DMHCA) at the program provides group, family,
and individual counseling, in addition to supportive counseling and crisis intervention, as
needed. The facility administrator indicated the program provides Mental Health Overlay
Services (MHOS), Substance Abuse Treatment Overlay Services (SAOS), and Intensive Mental
Health (IMH) services, which are provided through group therapy, family therapy, and individual
therapy.
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 diagnosed DSM-
IV-TR or 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 has a policy and procedures specific to the psychiatric services provided to the
youth in the program. The psychiatrist is scheduled to be on-site weekly for two hours and
provides medication evaluation and on-going monitoring of psychiatric medications. The
psychiatrist’s license was free and clear and expires on January 31, 2026. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. A review of
documentation revealed the psychiatrist is a brief representative of the treatment team for each
youth receiving psychiatric services who is scheduled for treatment team review. A review of
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sign-in/out logs confirmed visits during the annual compliance review period were conducted as
required. The psychiatrist actively participated in, managed, and supervised psychotropic
medication services in the program. An interview with the psychiatrist confirmed they meet with
the designated mental health clinician authority (DMHCA) and the facility administrator to
discuss youth receiving psychiatric services weekly, prior to seeing youth at each scheduled
psychiatric clinic. An interview with the DMHCA indicated they meet with the psychiatrist to
discuss youth receiving psychiatric services bi-weekly. In additions, the psychiatrist completes
psychiatric evaluations for new admissions and medication management for youth on
psychiatric medications and coordinate with treatment team to manage mental health needs of
youth.
Orange Youth Academy (OYA)
Five reviewed youth mental health records confirmed none of the five youth entered the
program on psychotropic medication; however, all youth are referred for a psychiatric interview
as part of the intake process. Each of the five had a completed psychiatric interview within
fourteen days of admission. A review of each youth’s initial diagnostic psychiatric interview
confirmed all required elements were included. One youth was prescribed psychotropic
medication post admission to the program. The applicable youth’s psychiatric interview included
the youth’s prescribed medication, explanation of the need for the medication, target symptoms,
initial treatment goals, potential side effects, the risks, and benefits of taking the medication, and
the frequency of medication monitoring and management. All five initial diagnostic psychiatric
interviews were documented on the Department’s Clinical Psychotropic Progress Note (CPPN).
Each initial diagnostic psychiatric interview was clearly identified as an “Initial Diagnostic
Psychiatric Interview”. The applicable youth receiving psychotropic medication was seen for a
medication review by the psychiatrist at a minimum of every thirty days. The applicable youth
received a follow-up psychiatric evaluation which included all required elements, to include the
date and signature of the evaluating psychiatrist. The psychiatrist and nursing staff documented
monitoring for Tardive Dyskinesia on a monthly basis as indicated on the youth’s CPPN. The
program did not utilize tele-psychiatry since the start of the program’s new contract with the
Department. The designated mental health clinician authority (DMHCA) stated as the clinical
director, they meet with the psychiatrist on a weekly basis to discuss youth and the services
they are receiving while at the program. The psychiatrist stated he is on-site once a week and
meets with the DMHCA while on-site. The psychiatrist stated there is a weekly meeting with the
psychiatrist and the healthcare staff to discuss important medical issues prior to seeing youth
during each scheduled clinic. He further stated services provided include an initial
comprehensive psychiatric evaluation, medication management, medication adjustments,
education to youth and staff on medications and potential side effects, and coordination with
parent/guardians regarding consent for medications.
Orlando Intensive Youth Academy (OIYA)
A review of five youth records revealed each youth was applicable for entering the program on
psychotropic medication. All five youth received a diagnostic interview within fourteen days of
admission as it is the program’s practice to refer youth entering the program for a psychiatric
interview. At the time of the annual compliance review the program only had a total of three
youth admitted on psychotropic medication and each youth was referred for an evaluation. All
five records were applicable for an initial diagnostic psychiatric interview as the program
completes one for each admitted youth included the youth’s history, medical mental health and
substance abuse history, Mental Status Examination, and a Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis. Each documented diagnosis was consistent
with the youth’s treatment plan. All five reviewed youth were prescribed medications and an
explanation of the need for psychotropic medication related to the youth’s diagnosis and the
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targeted symptoms were listed. The interviews also listed potential side effects, risks, and
benefits of taking medication, and frequency of the medication monitoring/management. Each
youth had an initial diagnostic psychiatric interview documented on the CPPN form. Each CPPN
form was clearly identified as an Initial Diagnostic Psychiatric Interview. Three youth had an
initial psychiatric diagnostic interview resulting in the prescription of psychotropic medications or
changes to the youth’s existing psychotropic medication regimen, where page three of the
CPPN was completed. Two of the three applicable youth receiving psychotropic medications
also received medication reviews by the psychiatrist, at a minimum, every thirty days, while the
third youth received one medication review. Each psychiatric evaluation was documented on
page three of the CPPN. All applicable records documented each youth’s identifying data,
diagnosis, the targeted symptoms of each medication, an evaluation/description of effects of
prescribed medication on target symptoms, the name of the prescribed psychotropic
medication, including the dosage and quantity of the medication, normal dosage range, ordered
dosage, the frequency and route of administration, and the reason for any change in medication
or dosage. A list of side effects for each of the three applicable youth included a description of
both positive and adverse responses to the medication, each youth’s adherence to their
medication regime, height, weight, blood pressure, most recent serum drug levels or laboratory
findings, whether telephone contact was made with the youth’s parent/guardian to discuss
medication, as well as the signature/date of the psychiatrist. All three applicable youth records
documented the nursing staff monitored for Tardive Dyskinesia on a monthly basis, as indicated
on the CPPN.
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 plan detailing suicide prevention procedures. The plan includes
identification and assessment of youth at risk of suicide, staff training, which includes six hours
annually, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and the review process. The review process for
suicide attempts and mortality review includes circumstances surrounding the event, facility
procedures relevant to the incident, all relevant training received by 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 Suicide Prevention Plan is reviewed annually, and
was last reviewed on February 7, 2024, by the program’s designated mental health clinician
authority.
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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.
The program has a Suicide Prevention Plan which outlines essential guidelines for the
identification, management, and assessment of potential suicide or at-risk youth. The program’s
practice is to complete an Assessment of Suicide Risk (ASR) for every youth admitted into the
program. Only five of the six interviewed staff responded and were able to identify the location
of the program’s suicide response kits. Six interviewed staff stated if a youth expresses suicidal
thoughts, direct care staff are responsible for notifying mental health, maintaining constant sight
and sound monitoring, and to document supervision.
Orange Youth Academy (OYA)
The program had no applicable youth who were placed on precautionary observation (PO) or
secure observation (SO) since the start of the provider’s new contract with the Department. The
program maintains a Suicide Prevention Plan, which states all youth admitted to the program
are screened for mental health and substance risk factors as part of the intake and admission
classification process. An ASR is completed for each youth during this process, at which time no
youth are permitted out of the constant sight and sound supervision of staff. The program has
not had any youth placed on PO or SO since a deficiency was closed February 6, 2024.
Orlando Intensive Youth Academy (OIYA)
Five youth mental health and substance records were reviewed for suicide prevention services.
None of the five youth reviewed were applicable for suicide prevention services. The program
has not had any youth placed on PO or SO since a deficiency was closed February 6, 2024.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program has a Suicide Prevention Plan which defines essential guidelines for the
identification, management, and assessment of potential suicidal or at-risk youth.
Orange Youth Academy (OYA)
The program had no applicable youth who were placed on precautionary observation (PO) since
the closure of the deficiency in February 2024. The program maintains a Suicide Prevention
Plan, which states in the event a youth demonstrates the possibility of suicide risk factors, the
youth must be immediately placed on suicide precautions. From there on, the program
implements the use of the Suicide Precaution Observation Log.
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Office of Accountability and Program Support Page 50 of 86 (Revised September 2022)
Orlando Intensive Youth Academy (OIYA)
A review of five youth records indicated none were applicable for being placed on suicide
precautions. The program reported they did not have any youth placed on PO to review for
suicide prevention services since the deficiency which was cleared in February 2024.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a Suicide Prevention Plan which details suicide prevention training
requirements. Each staff who works with youth shall be trained to identify verbal and behavioral
cues indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Additionally, all staff with direct contact, on a day-to-day basis, with youth, must participate in at
least one drill which includes the use of cardiopulmonary resuscitation (CPR) annually. A review
of five pre-service and five in-service staff training records was completed for completion of
suicide prevention training, with no issues. Completed trainings included simulated suicide drills,
which were conducted at least quarterly on each shift. There was no indication of youth having
been utilized for simulated suicide drills. Reviewed mental health and medical drills since the
last annual compliance review confirmed the mock suicide drills were conducted for all staff who
come in contact with youth. Reviewed documentation validated drills demonstrated the use of
life-saving measures including the use of CPR and/or an automated external defibrillator (AED).
Staff not present during quarterly suicide drills had the opportunity to review each drill scenario
in an effort to understand the process and receive the necessary training to respond to an
incident of a suicide attempt or incident of serious self-inflicted injury in the program. The
program has a total of two suicide response kits, which included a knife-for-life, wire cutters, and
needle nose pliers. The kits were maintained in master control, and in the breakroom. Each of
the suicide response kits were co-located with the first-aid kits. An interview conducted with the
facility administrator indicated clinical mental health drills are done on a monthly basis for each
shift and each staff receives two drills on a yearly basis. An interview with six staff confirmed
medical emergency and suicide drills are conducted on each shift monthly. Each interviewed
staff was also able to identify the location of the program’s suicide response kits.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written crisis intervention plan. The plan includes a notification and alert
system, means of referral, including youth self-referral, communication, supervision,
documentation, and review.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a Crisis Intervention Plan, which addresses mental health crisis intervention
services and Crisis Assessments.
Orange Youth Academy (OYA)
The program had no applicable youth for Crisis Assessments since the start of the provider’s
new contract with the Department. The program maintains a policy and procedures for crisis
assessments. The procedures indicate a qualified mental health professional shall interview a
youth in crisis and complete a Crisis Assessment immediately or within two hours for
emergencies. The primary goal of crisis intervention at the program is to respond to the youth in
crisis in the least restrictive method possible and protect the personal safety of the youth and
others while maintaining control and safety of the program.
Orlando Intensive Youth Academy (OIYA)
A review of five youth records indicated none of the youth were applicable for a Crisis
Assessment; therefore, three additional youth records were requested. All three assessments
identified the date the youth was determined to be in crisis, and the date of the Crisis
Assessment. Each Crisis Assessment was conducted immediately, within two hours for
emergencies, or within twenty-four hours based on the needs of the youth. The Crisis
Assessments included the reason for the assessment, Mental Status Examination and
interview, the determination of danger to self and/or others including imminence and intent of
behavior, clarity and lethality of behavior, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
evaluation, and a notification to parent/guardian. Each Crisis Assessment was conducted by a
licensed mental health professional. One out of the three youth qualified for a mental health
alert. The information was entered into the Department’s Juvenile Justice Information System
(JJIS), and the youth was placed on precautions after completion of a Crisis Assessment. The
Crisis Assessment determined the youth posed a safety and security risk, and the youth
remained on alert until a follow-up Crisis Assessment and/or follow-up Mental Status
Examination was completed. Reviewed documentation of a form developed by the program,
which contained all required information, confirmed the youth was placed on constant
supervision.
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3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse plan. The plan
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transportation for
emergency mental health evaluation and treatment according to the Baker Act and Marchman
Act statutes, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Orange Youth Academy (OYA)
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
Orlando Intensive Youth Academy (OIYA)
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to address the safety planning process for each
youth. An interview with the facility administrator (FA) reported youth safety plans are updated
every twenty-eight days or during treatment team meetings. Three of the six interviewed staff
were aware where the safety plans are kept and three did not. Four of the six staff indicated
they can review them any time and two staff did not know how often. An interview with six youth
was conducted and each youth provided input to their safety plan.
Orange Youth Academy (OYA)
Five youth mental health records were reviewed and each contained a safety plan. Each safety
plan included warning signs, youth baseline behavior(s), crisis recognition, jointly developed
coping strategies, intervention strategies preferred by each youth, and a debriefing process.
Each of the five youth’s safety plans were completed on the day of admission. Each youth’s
safety plan was jointly prepared by the youth and the program’s clinical staff. According to the
program’s regional compliance director the parent/guardian is not part of the planning of the
safety plan; however, each parent/guardian is sent a letter with a copy of the safety plan and
can reach out to make any comments or suggestions. Each of the five youth’s mental health
records contained the letter to the parent/guardian and a copy of the safety plan. Each of the
youth’s safety plans incorporated recommendations from previous and current clinical
assessments and screening instruments and incorporated trauma responsive practices. There
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was a total of nineteen safety plan reviews for all five reviewed youth. Sixteen of the safety
plans were reviewed and updated as necessary at least every thirty days. Three safety plans
were reviewed twenty-four days late, twenty-six days late, and two days late respectively. None
of the reviewed youth’s safety plans required a review due to a significant behavioral or mental
health event. Each youth’s safety plan was reviewed by their therapist. Safety plans are
maintained in the program’s briefing room and reviewed by staff as needed.
Orlando Intensive Youth Academy (OIYA)
A review of five youth records indicated the safety plans were developed and updated as
required. All safety plans were completed within fourteen days of the youth’s admission. Each
reviewed plan was jointly prepared by the youth, parent(s)/guardian(s) or family member, the
program’s clinical staff, and behavioral specialist, if applicable. Each safety plan incorporated
any recommendations from previous or current clinical assessments or screening instruments
and incorporated trauma responsive practices. Three out of the five plans were reviewed and
updated as necessary at least every thirty days, and the plans were reviewed and updated as
necessary following any significant behavioral or mental health events identified by the youth’s
intervention and treatment team, with the documented dates. Two of the plans were not due for
review at the time of the annual compliance review. Documentation confirmed the safety plans
were reviewed by the staff who had contact with the youth, and were maintained and located in
the youth’s record under the clinical assessment tab, as well as in program’s briefing room.
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Office of Accountability and Program Support Page 54 of 86 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program maintains a policy and procedures ensuring a designated health authority (DHA)
shall be clinically responsible for all healthcare services provided and for the medical care of all
youth at the program. The DHA holds an active, unrestricted license under Chapter 458, Florida
Statute, and is a medical doctor with a license expiration date of January 31, 2026. The
physician’s specialty training is in family practice. A review of the Florida Department of Health
records confirmed the DHA had no current disciplinary cases and/or public complaints on
record. The program does not utilize a physician’s assistant or advanced practice registered
nurse. The DHA is scheduled to be on-site weekly for at least four hours for acute medical
concerns, emergency care, and coordination of off-site care. Reviewed DHA Logs during the
annual compliance review period validated the DHA was on-site weekly according to contract.
The program has a back-up physician in the event of the DHA’s absence, who holds a clear and
active medical license, with an expiration date of January 31, 2025; however, the back-up DHA
had not been utilized since the last annual compliance review. The DHA is responsible for
communication with program staff regarding youth medical needs and is available for
consultation twenty-four hours a day, seven days a week. All applicable medical facility
operating procedures were reviewed by the DHA. The program did not have any contractual
provisional language included for either telemedicine or telehealth services. The program’s
policy and procedures outline specific duties of the DHA to include conducting Comprehensive
Physical Assessments (CPAs), conducting sick call and/or conducting medical evaluations, and
providing treatment based on referrals either through the program’s sick call process or episodic
care. The DHA reports being available by mobile telephone or through an answering service
when not on-site.
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 maintains facility operating procedures for all health-related procedures and
protocols utilized. The program provides on-site nursing coverage seven days a week from 7:00
a.m. to 7:00 p.m. The program’s contract indicates the program shall have a health services
administrator (HSA), three full-time registered nurses (RNs), and one full-time licensed practical
nurse (LPN). The provider provides five nursing positions to include one full-time RN supervisor,
three full-time RNs, and one full-time LPN to ensure on-site nursing coverage for twelve hours
each day, seven days each week, for a total of two hundred hours each week. All RNs are to be
licensed in the State of Florida. The program had a total of nine RNs providing services since
the last annual compliance review. A review of the nine licensees reflected one expires April 30,
2024, five expire April 30, 2025, one expires July 31, 2024, and two expire on July 31, 2025.
The program hired four new nurses since the last annual compliance review. A review of the
four nursing staff training records validated training on the treatment protocols and healthcare
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policies and procedures on various dates throughout the annual compliance review period.
Each of the thirteen nursing staff who provided services at the program throughout the annual
compliance review period had a current certification in cardiopulmonary resuscitation (CPR).
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The program’s designated health authority (DHA) conducts an
annual review of all health-related policies, procedures, and protocols. Reviewed documentation
supported the DHA signed all healthcare policies and procedures on June 13, 2023, the prior
facility administrator (FA) on June 13, 2023, and the current FA signed the applicable policies
and procedures on February 15, 2024. The DHA reviewed and signed nursing protocols on
June 13, 2023. There were no noted applicable policy changes during the annual compliance
review period. An annual review of the policy and procedures for all health-related procedures
and protocols was documented as required. The program maintains a training requirement
whereby newly employed healthcare staff shall receive a comprehensive clinical orientation to
the Department’s healthcare policies and procedures. Reviewed documentation confirmed
nursing staff reviewed, signed, and dated a cover page indicating their review of the FOPs,
treatment protocols, and other procedures on June 14, 2023, June 15, 2023, January 22, 2024,
February 12, 2024, February 13, 2024, and February 14, 2024. Approval of treatment protocols
or standing procedures were written and authorized by the DHA and were not delegated to any
other person.
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.
An interview with nursing staff was conducted, confirming the nurse reviews all projected
intakes in the Departments Juvenile Justice Information System (JJIS) and validates the
Authority for Evaluation and Treatment (AET). All new admissions are discussed with case
management prior to the youth’s arrival. If needed, the juvenile probation officer (JPO) is
contacted through case management to obtain a new AET. Those youth eighteen years old or
older upon admission or who turn eighteen years old while in the program, complete the
Release of Information Authorization form wherein the youth can designate whether or not they
want medical information released to parent/guardian.
Orange Youth Academy (OYA)
The program has a policy and procedures ensuring the completion of the AET for all youth
admitted into the program. The AET form is signed by the parent/guardian who has legal
custody of the youth. The AET serves as informed consent for non-invasive medical procedures
which can be completed by healthcare staff or for minor ailments requiring over-the-counter
(OTC) medications. A review of five youth Individual Healthcare Records (IHCRs) found four of
five contained a valid and legible copy of an AET and the word “Copy” was clearly stamped on
each AET. All four AETs were signed by a Department representative and the parent/guardian.
None of the reviewed youth were over eighteen years of age or older. One of the reviewed
IHCRs was applicable for a court order being filed in the record due to the father of the youth
being deceased and the grandmother possessing no legal documents for custody.
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Orlando Intensive Youth Academy (OIYA)
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of the
Authorization for Evaluation and Treatment (AET) form. Four of the five youth had a completed
AET filed in the IHCR. The one remaining youth was nineteen, whereas no AET or court order is
required since the youth is responsible for authorizing their own physical and mental health
care. In addition, for this one youth, there was documentation found in the IHCR for release of
information. In each of the four applicable AET’s the forms were signed by the youth’s
parent/guardian. There were no AET’s found where a parent/guardian refused to sign. Each of
the four applicable AET forms were signed by a Department representative. Each of the AET
forms were found to be valid. There were no cases of youth in the care of the Department of
Children and Families.
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.
An interview with nursing staff was conducted. The nurse stated written parental/guardian
notifications are sent anytime a youth is seen by the designated health authority (DHA),
psychiatrist, or an off-site provider. Verbal notification is provided when obtaining consent for
over-the-counter (OTC) medications. Parents/guardians are notified by written notification within
twenty-four hours of an on-site or off-site appointment occurring. Consent is obtained as soon
as possible after an order is written by the physician. All attempts are made to verbally contact a
parent/guardian prior to a youth leaving for the emergency room. The parent/guardian is also
contacted upon the youth’s return with results of the emergency room visit. Written notification is
completed after return from the emergency room visit. Witnessed verbal consent is obtained to
initiate a new psychotropic medication. The Clinical Psychotropic Progress Note (CPPN) page
three is then mailed to the parent/guardian each time the youth is seen by the psychiatrist. This
can also be signed by the parent/guardian and returned to consent to the start of psychotropic
medications when unable to obtain verbal consent. Vaccinations are provided off-site at the
local health department. Immunization records are obtained from the prior medical record or
retrieved by Florida Shots portal. The youth's medical information contained in the commitment
packet is reviewed prior to the youth’s arrival at the program. Medical records are reviewed
again upon admission in at least twenty-four hours. The parent/guardian will need to
provide/obtain the appropriate form from the Department of Health (DOH) for exemption from
immunizations. Following completion, the parent/guardian will need to submit a copy of the
completed form to the DOH as well as provide a copy to the program. The form is then filed in
the youth's Individual Healthcare Record (IHCR).
Orange Youth Academy (OYA)
At the time of the annual compliance review, four youth were applicable for having a new
medication prescribed to them, discontinued, or had the dosage significantly changed.
Documentation in the four youth IHCRs found the parent’s/guardian’s verbal consent was
documented on page three of the CPPN. Only one of the five reviewed youth was taking
psychotropic medications and was applicable for parental/guardian notifications for psychotropic
medications. The IHCR contained documentation of staff who witnessed telephone call attempts
and conversations for psychotropic medications. In each of the five IHCRs reviewed, the youth
vaccinations were verified within thirty days of the youth’s admission to the program. None of
the five reviewed youth were applicable for requiring consent to be obtained prior to
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administering vaccinations within thirty days of the youth’s admission. None of the youth were
applicable for a religious exemption from immunization.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of the parental/guardian notification/consent.
Four of the five youth were applicable for parental/guardian notification pertaining to OTC
medications beyond those covered by the AET. Each of the four youth had documented consent
provided for by the parent/guardian. Three of the five youth records were applicable for having
new medication ordered. In each of these three records, documentation was found where an
attempt was made to contact the parent/guardian in the progress notes. All five youth were
applicable and had necessary written notifications sent utilizing the appropriate Department
forms. Four youth came in on either OTC and/or psychotropic medication. The one remaining
youth was later prescribed psychotropic medication during the annual compliance review period.
Each of the youth had documented staff witnesses for all telephone call attempts and
conversations for administering psychotropic medication. Two of the five youth had either a
significant change or new psychotropic medication prescribed. In each of the records
parental/guardian verbal consent for psychotropic medication was found documented on page
three of the CPPN. There were no youth who were under the care of the Department of Children
and Families (DCF). All five youth had completed documentation of the program having
received and verified each youth’s vaccination records on the date of admission. None of the
youth were applicable for requiring any new vaccinations or requesting religious exemption.
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.
An interview with nursing staff was conducted. A nursing assessment is completed immediately
following the initial search, normally within ten to fifteen minutes of the youth’s arrival to the
program. The program is often times notified by the commitment manager by email of
scheduled admissions. Once the youth arrive at the program, medical is immediately notified of
the youth’s arrival. The admission screening is conducted by licensed healthcare staff. If the
admission screening is completed by non-healthcare staff the form is reviewed and signed by
the licensed healthcare staff acknowledging it has been reviewed. Upon return to the facility, the
nurse completes a new Facility Entry Physical Health Screening (FEPHS), and
operations/medical staff complete a new body chart.
Orange Youth Academy (OYA)
The program maintains a policy and procedures ensuring each youth receives a screening for
health concerns upon admission, or at a minimum, each time the physical custody of the youth
changes and they are returned or readmitted to the program. A review of five youth Individual
Healthcare Records (IHCRs) validated each youth received an initial admission screening
utilizing the FEPHS form. The FEPHS form was completed for each youth by a registered nurse
(RN) on the date of the youth’s admission to the program. None of the FEPHS were completed
by a direct care staff. The RN notifies the designated health authority (DHA) with the youth’s
history and applicable identified chronic conditions and documents the notification on the DHA
Notification form and in the nursing admission chronological notes. Youth are not placed in
general population until any identified healthcare needs are deemed to not require immediate
medical attention and/or a referral for further assessment.
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Orlando Intensive Youth Academy
Five youth IHCRs were reviewed for completion of healthcare admission screening and
rescreening form. Four of the five IHCRs contained a FEPHS form completed by a RN. The
remaining one youth had a FEPHS form completed by a licensed practical nurse (LPN). All
FEPHS were completed on day of the youth’s admission to the program. None of the FEPHS
were completed by direct care staff. None of the youth were applicable for a change in custody
lasting greater than twenty-four hours.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a policy and procedures to ensure all youth are oriented on the general
process of healthcare delivery services at the program. The program’s policy outlines
orientation/admission health education shall be provided by the healthcare staff, in writing, and
during an individual session with the youth to ensure youth with identified disabilities can
understand the information provided.
Orange Youth Academy (OYA)
Five youth Individual Healthcare Records (IHCRs) were reviewed for healthcare orientation.
Each youth received a general care orientation on the day of admission. The program’s
healthcare orientation included all required topics including access to medical care, sick call,
what constitutes an “emergency” and when to notify staff, medication process to include side-
effect monitoring, the right to refuse care and how it is documented, what to do in the event of
sexual assault or attempted sexual assault, the non-disciplinary role of healthcare providers,
and standard universal precautions. Informal interviews with youth validated this practice. A
review of the program’s medical operating procedures covered the necessary health-related
topics for youth orientation to the program. Each youth received a health education packet
specifically designed for male adolescents.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of orientation to healthcare services. Each of
the reviewed youth records contained documentation orientation to healthcare services was
conducted upon admission to the program. Each of the youth’s orientations included all required
topics and was documented on an orientation sheet, which was signed by the youth.
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.
An interview with nursing staff was conducted and confirmed the process and time frame for
notifying the designated health authority (DHA). The DHA is notified by telephone or in-person if
on-site at the time of a new admission once the initial nursing assessment has been completed.
The licensed healthcare staff are responsible for DHA notification. The documents are
maintained in the Individual Healthcare Records (IHCRs) as part of the chronological nursing
notes.
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Office of Accountability and Program Support Page 59 of 86 (Revised September 2022)
Orange Youth Academy (OYA)
The program has a policy and procedures to ensure the DHA is notified when youth are
admitted to the program. Five youth IHCRs were reviewed. Two of the five reviewed youth had
a known or suspected chronic condition upon admission. None of the reviewed youth were
identified as in-need of an emergency response upon admission. All five youth had a referral to
the DHA and/or psychiatrist upon admission to the program. The DHA and/or psychiatrist were
notified, and documentation was found for each of the applicable youth within the chronological
progress note section of the IHCR.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of notification to the DHA and/or designee.
Three of five youth were applicable for known or suspected chronic conditions. In each of the
three records, there was evidence of the referral being sent to the DHA. None of the reviewed
youth needed emergency care upon admission. All five youth had documentation within the
IHCR where the DHA and/or psychiatrist were notified within twelve hours of the youth’s
admission; only three due to a chronic condition.
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.
An interview with nursing staff was conducted. The nursing staff confirmed the Health-Related
History (HRH) form is completed by the licensed healthcare staff during the initial nursing
assessment. Furthermore, it is updated annually and if a new significant medical event or
change occurs.
Orange Youth Academy (OYA)
The program maintains a policy and procedures ensuring nursing staff shall complete the
Department’s HRH form prior to the Comprehensive Physical Assessment (CPA). A review of
five youth Individual Healthcare Records (IHCRs) indicated each had a completed and/or
updated HRH form, within seven days of admission. Reviewed practice supported the HRH form
was completed on the day of admission for each youth. Each of the reviewed IHCRs indicated
the HRH form was completed prior to the CPA. The HRH was reviewed by the designated
health authority (DHA) for each of the reviewed youth. This was evidenced by a checkbox on
the CPA, indicating the HRH was reviewed for each youth. The program’s practice is to
complete a new HRH and CPA annually.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of the HRH form. Four of five reviewed youth
records contained a HRH completed within seven calendar days of admission. The one
remaining youth had a HRH marked as being completed seven days prior to the youth’s arrival
to the program. Upon further review, the program indicated this was a typographical error,
whereas the drop-down calendar date chosen, was exactly seven days off from the youth’s
actual arrival date. All of the reviewed HRHs were completed prior to completion of the CPA; as
evidenced by the date and signatures on the HRH and CPA. Each of the HRHs were reviewed
by the DHA, as documented by the checkbox on the CPA, indicating the HRH was reviewed.
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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.
The program maintains a policy and procedures ensuring each youth receives a routine
healthcare screening, a physical health evaluation, and evaluation for latent or active
tuberculosis. An interview with nursing staff was conducted. The nursing staff confirmed the
DHA completes the initial Comprehensive Physical Assessment (CPA) within seven days of
admission. An annual CPA is also completed as applicable. Youth records are reviewed for
Tuberculosis Skin Test (TST) status prior to admission and upon arrival. A Tuberculosis (TB)
screening is completed by the nurse during the initial nursing assessment. Thereafter, a medical
tracker is maintained to monitor TST due dates. Documentation of TSTs is located on the
Infectious and Communicable Disease (ICD) form. Youth who have not remained in the
program’s custody will receive an annual TST screening.
Orange Youth Academy (OYA)
The program maintains a policy and procedures ensuring each youth admitted shall receive
and/or shall have on record a current CPA and Health-Related History (HRH) form completed
no later than seven calendar days after admission into the program A review of five youth
Individual Healthcare Records (IHCRs) found a new CPA form was completed by the
designated health authority (DHA), on the Department’s CPA form, within seven days of
admission for three of the five youth. The remaining two youth IHCRs included a current CPA.
Each youth’s Medical Grade was documented on their CPA. Each of the CPAs documented the
appropriate Medical Grade for the reviewed youth. There was no indication of any missing or
incomplete elements on any of the reviewed CPAs. All five youth refused a part of the
examination and each form included documentation of the youth refusal. All sections of the CPA
were completed in full, utilizing an “O” and/or applicable “X” markings. The program’s practice is
for the youth not to be placed into general population until their healthcare needs are identified
and deemed not to require immediate medical attention and/or a referral for further assessment
by healthcare staff. The Department’s Problem List was updated, as required for each youth. All
five youth had at least one verified TST completed and documented within a year of their
admission. Each youth’s results were documented on their CPA and on their ICD form, and
each youth’s test results matched on both forms.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of a CPA form. Each of the reviewed records
contained a new CPA, which was completed on the Department’s CPA form. Each of the CPAs
were completed within seven calendar days of admission. All of the CPAs were completed by
the DHA. Each CPA documented the appropriate Medical Grade. There was no indication of
any missing or incomplete elements on any of the reviewed CPAs. All five youth refused a
portion of the examination and documentation of refusals were found in each IHCR. The
Department’s Problem list was updated as required for each youth. Each youth had at least one
verified TST documented in the IHCR. Additionally, the results of the TST documented on the
CPA and ICD forms matched for each youth.
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Office of Accountability and Program Support Page 61 of 86 (Revised September 2022)
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.
An interview of six youth was conducted. Five of the six youth agree they may ask for a human
immunodeficiency virus (HIV) test. The one remaining youth stated they could not. An interview
with nursing staff was conducted. Nursing staff replied youth are interviewed during the initial
nursing assessment to obtain their history and risk factors for sexually transmitted infections
(STIs). According to the designated health authority’s (DHA’s) standing admission orders, all
youth are screened for STIs regardless of their risks. The STI Screening form is reviewed by the
DHA who determines if further evaluation, treatment, or off-site evaluation/treatment is required.
The STI screening form is filed in the infectious and communicable disease information section
of the Individual Healthcare Record (IHCR). STI lab results are filed in the laboratory section of
the IHCR. Youth can be rescreened at any time. Rescreening would be documented on the STI
screening form. HIV test results are kept in the laboratory section of the IHCR in a sealed
envelope marked confidential. Youth are asked if they want HIV testing during the intake
process and it is documented on the HIV consent form. A HIV log is maintained identifying youth
who have requested testing. An order is written by the physician and labs are completed/drawn
by medical staff to be processed by the contracted laboratory services provider. Pre and post-
test counseling is conducted by the DHA on-site and is documented on the youth’s health
education record. The test results are sealed, marked confidential, and filed in the laboratory
section the youth’s IHCR. Confidential results are given to the youth upon discharge.
Orange Youth Academy (OYA)
The program maintains a policy and procedures ensuring all youth entering the program are
clinically screened, evaluated, and treated, if necessary for STIs and HIV. The DHA makes the
decision based on the screening tool and medical evaluation to order testing for STIs. A review
of five youth IHCRs reflected four of five youth were identified as sexually active and were
clinically screened and evaluated for STIs utilizing the STI Screening form. Further evaluation
was required for three of the four applicable youth. All three reviewed youth were referred to the
DHA. Each youth’s referral was documented on their STI form. Testing was ordered for three
youth and performed for two of three youth. The remaining youth refused testing and the refusal
of treatment form was completed. Each youth’s IHCR included documentation of testing,
screening results, clinical evaluations, and diagnoses on the Department’s Infectious and
Communicable Disease (ICD) form, excluding HIV results, and filed within the lab section of the
IHCR. There were no applicable youth who were out of the Department’s custody for over thirty
days and/or who required a rescreening due to presenting symptoms. The program maintains a
policy and procedures ensuring all youth at risk for HIV infection are offered counseling, testing,
education, prevention counseling, and a referral for medical treatment, as indicated. Four of five
youth were offered counseling and testing and one youth received HIV testing. A consent form
in the applicable IHCR reflected the youth was provided treatment/referral for HIV. The youth’s
results were in the IHCR in a sealed envelope marked “confidential,” consistent with Florida
Administrative Code. The envelope was signed by the DHA, indicating their review.
Documentation of pre-test and post-test counseling was contained in the youth’s IHCR. The
youth’s confidentiality was protected, as his HIV status was not included on the program’s
internal alert system.
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Office of Accountability and Program Support Page 62 of 86 (Revised September 2022)
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of STI screening. Only two of the five reviewed
IHCRs were applicable, an additional record was requested and subsequently reviewed. All
three applicable reviewed youth were documented as being sexually active and referred to the
DHA. Each youth’s IHCR reflected the referral appropriately documented on the STI form. All
the youth had necessary testing ordered; however, each youth refused to have STI testing
completed. Each of the youth had a refusal form signed and filed in the IHCR.
Five youth IHCRs were reviewed for HIV testing. All five youth were offered HIV counseling,
testing, and/or evaluation; four of the five did not consent for any services. The one remaining
youth accepted HIV services and was referred accordingly. The one youth had documentation
for consent, which was maintained in the IHCR. The HIV results were filed confidentially in the
youth’s IHCR, which was in a sealed envelope marked “confidential”. The sealed envelope
contained the signature of the DHA, indicating a review was conducted. There was
documentation in the one IHCR confirming the youth had HIV pre and post-test counseling
services completed. The youth’s confidentiality was protected; there was no indication the HIV
status was ever posted on the program’s internal alert system.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures which provide for youth in the program to be able to
submit sick call requests and have complaints treated appropriately through the sick call
system. The program is required to respond in a timely manner, and document all sick call
encounters, as required by the Department. A review of the daily schedule, posted schedule,
and nurse interview confirmed sick call was conducted pursuant to the provider’s contract
requirements. Sick call hours were observed to be posted on the door leading into the medical
clinic. Hours posted are weekdays at 7:15 a.m. and 11:15 a.m., and weekends at 8:30 a.m., and
5:00 p.m. An informal interview with nursing staff confirmed only licensed nurses conduct sick
call. In addition, the program has a policy and procedures, which allow the shift supervisor to
review all sick call requests as soon as possible and within four hours after the request is
submitted. Sick call forms were available to youth in each dormitory. An exam table, along with
other medical equipment, was observed in the medical clinic.
An interview of six staff was conducted. Each staff affirmed nurses conduct sick calls. In
addition, each staff stated nurses respond to sick calls. An interview of six youth was conducted,
and all replied they can be seen by a nurse within one to three days. Four of the six youth said
they have never requested a sick call. An interview with nursing staff was conducted. Youth can
submit a sick call at any time by placing a sick call referral form in the sick call box. The box is
monitored by the nurses at regular intervals throughout the day; at least every two hours and
then prioritized at the scheduled sick call time. Youth are assessed within a twenty-four-hour
time-period. Sick call is conducted by a licensed practical nurse (LPN) and registered nurse
(RN). If conducted by a LPN, a daily review is conducted with either the RN or DHA to obtain
approval for the implemented treatment plan. Sick call is conducted in the medical office to
provide privacy for youth. Youth who have the same complaint three times within fourteen days
or if the protocol treatment appears to be ineffective a referral is made to the DHA.
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Office of Accountability and Program Support Page 63 of 86 (Revised September 2022)
Orange Youth Academy (OYA)
Five youth Individual Healthcare Records (IHCRs) were reviewed and three were applicable for
having requested sick call while in the program. The three applicable youth had copies of the
sick call request forms in their IHCRs. None presented with similar sick call complaints three or
more times within a two-week period. In all instances, the nurse completed the sick call request
forms. One of the records contained a sick call which was completed by a LPN, and this sick
call was reviewed by a RN the same day and documented on the sick call request form. All sick
call forms were documented in accordance with Florida Administrative Code. Each of the
applicable youth’s sick calls were documented on the sick call index and documented on the
program’s sick call referral log. The dates listed on the sick call index corresponded to the
completed sick call forms located in the IHCR for each youth. A sick call was observed during
the annual compliance review week. Verbal consent was obtained by the youth prior to the
annual compliance review team observing the sick call. The youth was escorted to sick call by
direct care staff. The nurse identified themself and verified why the youth was present. The
youth was seen in private, with no other youth present to hear the examination. The direct care
staff stayed just outside the clinic during the sick call encounter to ensure privacy while still
providing supervision.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of the sick call process. One out of the five
youth records were applicable for review. An additional two records were requested and
reviewed. None of the three reviewed youth presented with any similar sick call complaints three
or more times within a two-week period. In each of the sick calls reviewed, the youth completed
a sick call request form. The on-site nursing staff completed the sick call request form for each
youth. Two of the three sick calls reviewed were conducted by a LPN and subsequently
reviewed daily by the RN. All three sick call request forms were found filed in the IHCR in
reverse chronological order. There were no indications of youth having been in restricted
housing during the annual compliance review period. Each of the sick call forms were found to
be documented in accordance with Florida Administrative Code. All of the sick calls reviewed
were found documented on the sick call index. In addition, each youth’s sick calls were
documented on the program’s sick call referral log. Each of the dates listed on the sick call
index corresponded to the completed sick call form located in each IHCR.,
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program maintains a policy and procedures ensuring there is a written plan to provide
twenty-four-hour emergency medical, mental health, and dental care to youth, as needed, in
response to unexpected illnesses, accidents, or conditions requiring immediate attention or an
immediate professional assessment to determine the severity.
The program has eight first-aid kits located in master control, education, cafeteria, copy room,
and four for the program vans, which are kept in master control. An informal interview with
nursing staff confirmed the medical staff conduct weekly checks of first-aid kits and auxiliary
supplies. Checks are performed to ensure contents and inventory match and expiration dates
are good. Three first-aid kits were observed, with no issues noted. A review of the on-site
tracking log for first-aid kits was observed, confirming the program conducts weekly checks as
described. The program had one automated external defibrillator (AED), which was in master
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 86 (Revised September 2022)
control. The procedures for the AED were located with the AED. An on-site check of the AED
was completed with nursing staff during the week of the annual compliance review, no issues
were observed. An informal interview with nursing staff confirmed checks of AED batteries and
pads were conducted monthly by medical staff. Documentation confirmed the AED batteries
expire June 2024 and the pads will expire April 2024.
A review of the program’s drills covering episodic, first-aid, and/or emergency care
documentation were observed. The drills were completed on each of the programs three shifts
at a minimum of quarterly during the annual compliance review period. Each of the drills
consisted of either announced or unannounced episodic, first-aid, and/or emergency care
scenarios. Reviewed drills included the administration of cardiopulmonary resuscitation (CPR)
techniques. This allowed direct care staff to participate in at least one drill which included the
use of CPR annually. Additionally, drills simulated emergent events which allowed for immediate
first-aid and/or administration of CPR techniques to include the use of the AED. A list of
emergency numbers was found in master control and the medical office, which are accessible to
all staff and inaccessible to youth. Training is provided, at a minimum to supervisory staff, in the
administration of an epinephrine auto-injector. Ten staff training records, five from each
program, were reviewed and documented the completion of episodic, first-aid, and emergency
care training.
During the annual compliance review week an episodic care event was able to be observed.
During the event, licensed medical staff provided care, which afforded privacy for the youth
being evaluated. Direct care staff present were located outside the open door adjacent to the
exam room where medical staff rendered care. A review of the program’s episodic and
emergency care policy and procedures confirmed practices observed were followed as written.
The program has policy and procedures which clearly outline the use, access, and inventory of
Narcan. The Narcan is stored in the medical clinic behind a locked door and locked cabinet,
which is accessible by trained supervisory and licensed medical staff. The Narcan is inventoried
weekly along with auxiliary medical clinic supplies and medications.
An interview of six staff was conducted. Four of the six staff agree they are able to personally
call 9-1-1 if a youth has an emergency. The remaining two staff indicated they don’t have a
telephone, yet they would either contact supervisory staff or master control. An interview of six
youth was conducted. All six agreed they can see a dentist or doctor if needed. An interview of
nursing staff was conducted. Nursing staff confirmed the program has eight first-aid kits and
confirmed the locations. In addition, nursing staff indicated they would notate episodic care on
the progress notes and on the episodic care log. Non-licensed staff can complete the On-Site
Health Care by Non-Health Care Staff form to notify nursing staff upon their return to assess
youth who received treatment after hours. Documentation is reflected on the episodic care log
and off-site tracker. Nursing staff stated the program defines regular basis as one drill each shift
each month, for a total of three drills each month. Emergency numbers are posted in the
medical office and in master control. Nursing staff follow a yearly drill calendar and plan drills
accordingly. The drill calendar has various drills which incorporate CPR at least quarterly
throughout the calendar year.
Orange Youth Academy (OYA)
Five youth Individual Healthcare Records (IHCRs) were reviewed and four were applicable for
episodic care. On-site care was provided by licensed healthcare staff for each event. Each
event was documented in the required subjective, objective, assessment, and plan (SOAP)
format. All events were documented on the Episodic Care Log, which corresponded with the on-
site events observed in the IHCRs.
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Office of Accountability and Program Support Page 65 of 86 (Revised September 2022)
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of an episodic, first-aid, and/or emergency care
situation. Four of the five youth reviewed were applicable for episodic, first-aid, and/or
emergency care. Out of the four applicable records, there was a total of eight separate
incidents. Each of the youth who had on-site incidents were provided care by a licensed
healthcare staff. Healthcare staff documented each incident in SOAP format. There were no
incidents of an episodic, first-aid, and/or emergency having been provided for by non-healthcare
staff.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a policy and procedures for the provision of off-site emergency and non-
emergency referrals for medical care and treatment. Evaluations conducted off-site shall be
recorded on the Department’s Summary of Off-Site Care form. The designated health authority
(DHA) reviews, signs, and dates the off-site care instructions. Nursing staff confirmed off-site,
first-aid, and emergency care needs are tracked using the episodic log and off-site tracker.
Coordination occurs among nursing staff and direct care staff; the health service administrator
(HSA) is notified of all medical off-site requirements. Once a youth returns to the program
following a hospital discharge, the discharge documentation is reviewed by the nurse on-site.
The nurse on-site contacts the DHA to review the information by telephone or in-person if on-
site. The DHA reviews and signs the hospital documentation acknowledging it has been
reviewed. The DHA folder is used for weekly review of documents as well as documentation to
be signed being flagged in the youth's Individual Healthcare Records (IHCRs) to be reviewed
during the next scheduled on-site visit. Follow-up testing, referrals, and appointments are
tracked by the internal medical tracker, off-site tracker, and nursing calendar.
Orange Youth Academy (OYA)
Five youth IHCRs were reviewed; however, only two were applicable for off-site first-aid or
emergency care. An additional record was requested and reviewed for off-site care. Reviewed
documentation supported the DHA reviewed the completed Summary of Off-Site Care form and
discharge paperwork as evidenced by signature and date for two of the three applicable youth.
The form was filed within both of the youth’s IHCRs. The remaining youth IHCR did not contain
a Summary of Off-Site Care form. Reviewed documentation supported each parent/guardian
was notified, as required. Applicable discharge documents were found to be filed within each
youth’s IHCR. Two of the three applicable reviewed youth required follow-up testing, referral,
and/or appointments. Each youth completed and/or were still receiving treatment and
appointments, as required.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of off-site care referrals. Two of the five IHCRs
reviewed were applicable. An additional record was requested to make a sample size of three.
The three reviewed youth had a total of four separate incidents requiring off-site care. Each of
the incidents had a completed Summary of Off-Site Care Consultation Report form filed in the
youth’s IHCR. Each of the off-site events were documented accordingly and contained
parental/guardian notification. Each of the youth had necessary discharge and other applicable
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documents filed within the IHCR. In each incident, the DHA reviewed and signed all off-site care
findings. Two of the three reviewed youth required additional follow-up appointments. One of the
two youth had completed appointments documented accordingly. The remaining one youth had
an appointment scheduled; the incident occurred just prior to the week of the annual compliance
review and appropriate care instructions from the DHA were being completed.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The facility administrator (FA) was interviewed pertaining to chronic conditions and periodic
evaluations and stated they meet with healthcare staff daily. The FA indicated medical staff
review youth information prior to admission to identify any medical issues. Sick call is daily, the
youth fill out the sick call form for non-emergency medical issues and place it in the box. The
nurse meets with the youth and schedules them to see the doctor if needed. An interview was
conducted with the designated health authority (DHA) indicated youth with chronic conditions
are seen by the DHA every sixty days and tracked using an internal medical tracker to manage
follow-up dates. Youth are added to an internal medical tracker upon intake to manage follow-up
dates for youth; the internal medical tracker is reviewed by the medical staff daily. Nursing staff
confirmed once a youth is identified upon intake or by the DHA to have a chronic condition, the
youth is then placed on the medical tracker for monitoring and tracking of due dates.
Orange Youth Academy (OYA)
The program maintains a policy and procedures ensuring youth who have been identified with a
chronic illness receive regularly scheduled evaluations and necessary follow-up treatment. The
purpose of the periodic evaluation is to ensure the youth requiring ongoing treatment or who
have experienced changes in condition or treatment regimen are adequately monitored. The
frequency of the periodic evaluation is determined by the youth’s condition, clinical needs, and
clinically appropriate medical standards. A review of five youth Individual Healthcare Records
(IHCRs) indicated two youth were identified with a chronic condition as documented on the
Facility Entry Physical Health Screening (FEPHS) form. None of the youth were identified as
having a communicable disease. One of the five youth was taking prescribed medication on an
ongoing basis. Three youth had an identified chronic health condition, were undergoing
treatment for a physical health condition, and were classified with a Medical Grade two through
four, or a Medical Grade five for youth also taking psychotropic medications. Each youth was
placed on the program’s Chronic Illness List. A review of progress notes found each youth
received periodic evaluations at least every ninety-days. The program maintains a tracking log
for youth with chronic conditions and evaluation dates. The tracking log indicated each youth’s
next scheduled appointment. None of the youth were applicable for taking anti-tuberculosis
medications. Each of the youth had an evaluation completed prior to a prescription renewal,
change, or expiration. None of the five reviewed youth were applicable for an off-site evaluation.
There were no indications of lapses in care or missed periodic evaluations in any of the
reviewed records. The Department’s Problem List for each youth was updated in accordance
with Florida Administrative Code.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of chronic condition periodic evaluations. Three
of five youth were applicable for having a chronic condition. None of the youth had been
identified as having a communicable disease. None of youth were taking medication on an on-
going basis. One of the youth were undergoing treatment for a physical health condition. One
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youth was classified with a Medical Grade between two and four. This youth was later
prescribed psychotropic medication and the Medical Grade changed to a five. Three applicable
youth were placed on a chronic illness list. Two of the three youth were in receipt of periodic
evaluations at least every ninety-days. The remaining one youth had not been at the program
long enough to receive a periodic evaluation. The two applicable youth had documentation of
periodic evaluations filed in the IHCR. One of the periodic evaluations was conducted off-site
and a Summary of Off-Site Care form was filed in the IHCR Chronological Progress Notes.
Subsequently, the DHA provided follow-up with the youth and signed off on the documents.
There was no indication of any lapses in care or missed periodic evaluations. For each of the
three applicable youth, the Department’s Problem List was updated in accordance with Florida
Administrative Code.
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.
Six youth were interviewed, and five said medication is given by the nurse, while one said they
do not take medication. All the youth taking medication were able to articulate the medication
administering process. Six staff were interviewed, and all said medication is dispensed to youth
by a nurse. The nurse was interviewed and advised only nurses complete admissions at the
program. Medications are verified with the records sent from the Department. Medications are
also verified with parent/guardian and youth during the intake process. The nurse also advised
non-licensed healthcare staff are med-tech trained by using med-tech training curriculum which
was approved by the designated health authority (DHA). Non-licensed healthcare staff are
trained by the nurse. The list of approved non-licensed healthcare staff who are med-tech
trained is posted in the medical office. The nurse said the medication pass times are weekdays
at 6:45 a.m., 11:15 a.m., and 5:30 p.m., and on weekends at 8:00 a.m., 12:00 p.m., and 5:30
p.m. The nurse advised a prescription order is written by the physician, reviewed and signed by
the nurse, and then faxed to the pharmacy. The prescription is then filled by the pharmacy and
delivered to the facility by courier. Prescriptions are either filled through a vendor or a
community pharmacy. Nursing staff confirmed the practices for administering medications.
Medications are verified by the Medication Transfer/Disposition forms, Medication
Administration Records (MARs), and physician orders. Preprinted pharmacy MARs are utilized
which include all the components of the Department’s MARs. The psychiatrist is on-site weekly.
Each youth is seen by the psychiatrist after admission for an initial psychiatric evaluation. Each
youth prescribed psychotropic medication is seen by the psychiatrist at least every thirty days
for medication management. The psychiatrist provides education to the youth and staff
regarding medications and associated side effects.
A medication administration pass was observed during the annual compliance review week,
with no noted issues. The youth was escorted to medical by direct care staff. The youth was
sitting in medical at the time of the medication administration. On-site nursing staff identified
themselves and stated the reason for the medication. The nurse prepared and administered the
medication to the youth. In addition, the nurse verified with the youth if there were any allergies.
The Six Rights of Medication Administration were conducted by the nurse administering the
medication. During the process, the nurse gave the youth water and the medication. The nurse
observed the youth take the medication and drink the water and then checked in the youth’s
mouth to ensure the medication had in fact been swallowed. The medication was documented
on the youth’s MAR.
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Office of Accountability and Program Support Page 68 of 86 (Revised September 2022)
Orange Youth Academy (OYA)
The program has a policy and procedures which require medication to be received, stored,
inventoried, and provided in a safe and effective manner. Five youth Individual Healthcare
Records (IHCRs) were reviewed. None of the youth were admitted with medication; however,
four of the five youth had been prescribed medication while at the program, and all of the youth
had taken over-the-counter (OTC) medication while at the program. All youth had a standard
Department MAR to document all medication and treatment. All the MARs clearly indicated
medication start and stop dates. In each instance, staff initialed each administered medication
entry. There were no lapses or errors in medication administration. Nursing staff documented
weekly side-effect monitoring on the MARs for each applicable youth. None of the youth refused
medication. Each of the MARs contained the youth’s name, Department Identification number
(DJJID), date of birth, allergies, precautions, Medical Grade, medical alerts, and a current
picture of the youth. None of the youth required parenteral medication, and none were
prescribed psychotropic medication upon admission or after admission.
Orlando Intensive Youth Academy (OIYA)
Five youth IHCRs were reviewed for completion of medication management. Four of the five
youth reviewed were admitted to the program on medication. The remaining one youth was later
prescribed medications after being referred to the psychiatrist for evaluation. Each of the
applicable Facility Entry Physical Health Screening (FEPHS) forms and progress notes
indicated the youth was admitted with medication. The medication for each youth was verified
during the youth’s admission to the program and documented within the IHCR. The DHA and
psychiatrist were contacted to resume medications prescribed prior to admission. All prescribed
medications had a current, valid order, and were subsequently administered according to the
current prescription. Each youth’s prescribed medications had a practitioner order form
completed by the DHA, which was documented on the practitioner order form. There was no
indication any of the reviewed youth were in restricted housing.
All five youth were applicable for taking either OTC and/or psychotropic medications during the
annual compliance review period. Documentation for administering medications was reviewed,
the program utilizes a pre-printed pharmacy Medication Administration Record (MAR), which
includes all information required by Florida Administrative Code. None of the reviewed MARs
had any medications administered to youth by trained non-healthcare staff. There were no
undocumented explanations for lapses or errors in medication administration. Each of the
reviewed youth had, at a minimum, weekly side-effect monitoring documented on the MAR. Two
of the five youth were applicable for refusing to take medication. On each occasion of refusal,
the youth signed the refusal of treatment form, which were found in each IHCR. In addition,
each medication refusal was found clearly documented on the youth’s MAR. All five youth
MARs were reviewed for the annual compliance review period, each contained all required
elements. None of the youth required parenteral medication.
Three of the five youth reviewed were applicable for having prescribed psychotropic medication
upon admission. Each of the youth had supporting documentation found in the IHCR, where the
psychiatrist was notified upon admission. All the youth were in receipt of an initial diagnostic
psychiatric interview within fourteen days of admission. The fifth youth reviewed was prescribed
psychotropic medication subsequent to admission and had an initial diagnostic psychiatric
interview conducted. Three of the five youth received a medication monitoring every thirty days
as required. The remaining two youth had not been at the program for thirty days by the week of
the annual compliance review. There was no indication of any standing orders for psychotropic
medications. There was no indication of any emergency treatment orders for psychotropic
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medications. There was no indication of any pro re nata (PRN) orders for psychotropic
medications.
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.
An interview of nursing staff was conducted and confirmed medications are destroyed on-site
with the pharmacist (when applicable), a nurse, and/or the facility administrator (FA) or
designee. Other medications are returned to the pharmacy for destruction. Controlled
medications are maintained behind a double locking mechanism, the locked boxed is within the
locked medication cart. They are counted shift-to-shift at least twice daily. The pharmacy
consultant is on-site monthly to complete monthly, quarterly, and yearly reviews to ensure the
program is in compliance with pharmacy policies and procedures.
An observation of medical equipment classified as sharps was completed. These items were
found secured and inventoried utilizing a routine perpetual inventory. All medications were
identified and secured in a locked area designated for storage of medications. An observation of
the medication cart was completed. The medication cart was clean and organized. All the
narcotics and controlled substances had a perpetual inventory, were stored separately from
other medications, and stored behind two locks. The medical clinic, along with medications are
in an area inaccessible to youth. Medications requiring refrigeration would be stored in a
secured refrigerator used for medication storage only; during the week of the annual compliance
review there were no refrigerated medications. All medications aside from controlled substances
are collected then mailed to the pharmacy. Controlled substances are destroyed by program
nursing staff with witnesses, using a compound destroyer. The program has a log documenting
any medications having been destroyed. A review of five staff training records for non-
healthcare staff assisting in the administration of medications was completed. The training for
delivery of medications is conducted by an on-site registered nurse (RN), at a minimum
annually. Three over-the-counter (OTC) medications, three controlled substances, and three
sharp tools were observed and there were no issues with counts matching the inventory. An
informal interview with the RN, confirmed, in the event of a medication discrepancy, they would
first double-check inventory with documented count, ask all medical staff present of any known
issues, then if not reconciled, notify the supervisor, and conduct a call to the Department’s
Central Communications Center (CCC).
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 written infection control procedures in place, to include prevention,
containment, treatment, and reporting requirements related to infectious diseases, according to
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
procedures were last reviewed by the designated health authority (DHA) and facility
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administrator (FA) on June 13, 2023. Additionally, the procedures were reviewed by the
program’s compliance officer on June 23, 2023. The program’s infection control procedures
include all required elements. Hepatitis B immunizations are available for staff as outlined within
the program’s exposure control plan. During the annual compliance review week, staff were
observed using protective equipment, including rubber gloves and face masks. In addition, first-
aid kits are stocked with protective equipment, which are accessible to staff. There was one
instance in which the local county health department, CDC, and/or the Department’s Central
Communications Center (CCC) had been notified of an infectious disease during the annual
compliance review period. The program has a written exposure control plan which includes all
required elements including a process for post-needle stick exposure. The exposure control
plan is available to all staff. The plan was last reviewed and signed by the FA on June 13, 2023.
An informal interview with nursing staff addressing the program’s process for needle-stick
exposure confirmed nursing staff will immediately report any needle-stick to the health service
administrator (HSA) and communicate ir to the FA. Staff will be sent to the local area hospital for
further evaluation and determination made to what extent medical assistance will be required
and follow-up if necessary. The FA had an established file in the event of any experienced
facility and/or occupational exposure. The program did not have any three or more cases of
infectious diseases which needed to be reported. The program did not have any instances
involving quarantining or hospitalization of at least ten percent of the total population of youth
during the annual compliance review period.
An interview with the FA confirmed the facility administrator’s office and medical nursing office
are the location of the program’s exposure control and infection control plans. These plans are
reviewed bi-annually. An interview of nursing staff was conducted and confirmed there is copy
of the exposure control plan available and is in the medical office. Additionally, infection control
training is conducted by the HSA twice a year. Also, infection control training is provided to
youth upon admission as a part of the monthly health education in accordance with the Health
Education Calendar. The HSA provides training on the program’s exposure control plan.
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 describing what the program considers to be active
supervision. The program’s contractually-required staff to youth ratio of one to eight was
observed during the annual compliance review week. Observations included movements,
education, breaks, groups, meals, sleeping, and recreation. Staff were observed actively
supervising youth and positively interacting with them. Three staff were asked how many youth
they were supervising, two were able to indicate the correct number, the remaining one staff
had to count prior to providing an answer. The daily schedule was posted in each module for
youth and staff access indicating a full agenda of activities. Two of six staff interviews indicated
when a youth count cannot be reconciled a recount has to be conducted. The remaining four
stated movement is stopped until all youth are accounted for and the count is reconciled.
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 has a policy and procedures including a protocol where staff are provided
feedback regarding the implementation of the behavior management system (BMS). The
appropriate parties were involved in the development, implementation, and ongoing
maintenance of the BMS. The program’s BMS was changed since the last annual compliance
review and the person responsible for the modification had training/experience in behavior
management techniques or systems. The BMS included promoting safety, respect, and
fairness, promoting and protecting youth rights, positive and negative consequences,
constructive disciplinary actions, opportunities for positive reinforcement, and recognition of
accomplishments and positive behaviors at a four to one ratio. The BMS also encompassed
promoting socially acceptable means for youth to meet their needs, a process for explaining to
youth the reasons for any sanctions imposed, youth having the opportunity to explain their
behavior, opportunities for staff and youth to discuss the impact of behavior on others,
reasonable reparations for harm caused to others, discussions of alternate behaviors, promoting
positive dialogue and peaceful conflict resolution, and ensuring separation of youth from
population is minimized. The BMS did not include increased length of stay, denial of a youth’s
basic rights or services, promoting group discipline, punishment of youth by other youth, and
disciplinary confinement, wherein a youth is isolated in a locked room as discipline for
misbehavior. The program’s BMS has a process wherein staff explain to each youth the reason
for any sanction imposed prior to the end of the staff’s workday, the youth is given an
opportunity to explain their behavior, and the staff and the youth discuss the behavior’s impact
on others, reasonable reparations for harm caused to others, and alternative acceptable
behavior.
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A review of documentation indicated the program has an agreement with the school related to
the BMS. The facility administrator/designee trained the education staff in the jointly combined
BMS plan to include use of BMS during school. All ten case management records reviewed
confirmed youth orientation included a review of the program’s BMS. Twenty-seven position
descriptions were reviewed confirming staff whose job functions include the implementation of
the program’s BMS was documented in each position description. All five pre-service staff
training records indicated each staff completed training in the program’s BMS. The BMS
postings were observed in the modules and are documented in the youth handbook which
includes the rules governing conduct and positive and negative consequences. Staff and youth
interactions were observed during the annual compliance review week, as well as
documentation, which indicated adherence to the required elements of the BMS, including
rewards and negative consequences, as well as negative consequences being in direct relation
to the severity or seriousness of inappropriate behavior exhibited. The program utilizes a variety
of rewards/incentives, such as chips, cookies, toaster pastries, candy, gummies, cinnamon rolls,
chocolate bars, honey buns, cup of noodles, hygiene items, fast food, game room access,
movie and popcorn, video games, music player rental, extra telephone calls, and post-
commitment hygiene items.
All six interviewed staff indicated they received training in the BMS and the program’s BMS is a
point system with a four to one ratio of rewards to consequences. Three staff said it is a level
system, four indicated it is posted throughout the facility, and two said it is included in the youth
handbook which is provided during the orientation process. One staff indicated the point sheet is
completed daily, and the BMS is based on youth behavior and completion of their
responsibilities. The staff indicated canteen/snacks, pizza day, movie night, outings, later
bedtime, Fun Friday, recreation, and other incentives are rewards as part of the BMS. All six
stated youth cannot have anything taken from them, as a consequence. Four of the six staff
interviews indicated youth are informed of the consequences and can explain their behavior
during special treatment team, and the remaining two said the staff will talk to them about it.
Five of the six staff indicated the supervisors provide feedback regarding implementation of the
BMS during shift briefing and one said they are updated daily.
Six youth were interviewed. One of interviewed youth indicated they had not been in trouble.
The remaining five youth stated they get level freeze or early bedtime, lose points, no
incentives, and no canteen as a consequence. One youth stated anything against the rules can
result in a consequence and staff are fair when providing punishment. The six youth stated they
receive canteen, Fun Friday, movie night, pizza night, extra canteen, chips, candy, special
events, and Gotcha ticket as a reward. All six youth were able to provide the different levels of
the BMS (training, rookie, pro, all-star, and hall of fame) and stated to level up they need to
complete the required days of good behavior. Two youth also stated they must fill out an
application to level up. All six said youth are not allowed to punish other youth and all staff use
rewards the same. Four rated the BMS as good and two as fair.
The facility administrator interview indicated the program utilizes a BMS compiled of a series of
levels. The youth complete each level by earning daily points to earn positive days in the
program. Earning positive days allows youth to participate in nightly incentives. Youth who have
a behavioral infraction will not earn points for tasks, which could hinder the youth’s progression
in the BMS. Additionally, youth can receive a special treatment team referral for more serious
behavioral violations. The youth will meet with the treatment team to provide feedback and
share input on the situation, and together will determine an appropriate consequence. All youth
have the equal opportunity to earn daily points towards a positive day. Youth are issued ongoing
prompts to encourage them to make positive choices throughout the day. All youth can earn
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incentives which are provided nightly, weekly, and monthly. Youth also have the opportunity to
utilize their earned points in canteen. The program utilizes a daily tracker to manage each
youth's progress and as means of communication with the staff and youth of where the youth is
at in the program. The point cards are reviewed daily by the shift supervisor and anytime a point
is not earned, the reasoning is explained on the point card, so the youth and other staff are
aware in the event the youth have a question. The daily tracker also reflects if the youth is on
level freeze, and they can monitor their own progress as he earns positive days. Staff are
evaluated from commendable to unacceptable for participation in the maintenance of the
therapeutic milieu of the living unit, enforcement of the level system or other methods of the
BMS. Performance evaluations are completed at ninety days of employment or promotion and
annually. Ongoing informal fidelity is conducted to ensure any issues with the BMS
implementation is addressed timely to avoid systemic issues and re-training is issued as
needed.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, or contract state 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 eighty-nine cameras and eighty-five were operational during the annual
compliance review week. The video recordings are stored for thirty days. A review of ten-minute
check sheets and video observation for three randomly selected dates covering all four modules
indicated all checks were completed in the required frequency and in real time. A review of
check sheets for the annual compliance review period covering all four modules indicated all
checks were documented in real time, and the staff completing the checks initialed or signed the
check sheets. All six staff interviews indicated room checks are conducted when a youth is
placed in their room for sleeping or non-punishment reasons every six minutes and no longer
than ten minutes. The facility administrator interview indicated the program has operational
security cameras, which record for thirty days.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures describing a process for youth census, counts, and
tracking. During the annual compliance review week observations of youth counts were
conducted. The program’s practice is for youth counts to be called out by master control over
the radio, as well as staff calling master control with a head count prior to moving youth from
one location to another. A review of the logbook for the annual compliance review period
indicated counts were conducted at the beginning of each shift, after each outdoor activity,
during emergency situations, for total daily census counts, head counts, youth movement
counts, transfers, and youth temporarily away from the program. The dates reviewed did not
have any youth admissions, releases, or discharges.
Five of six staff interviews indicated youth counts are conducted three times a shift. The
remaining one said at least two times on their shift. The six staff provided various answers
regarding when emergency counts are conducted including after drills, when a youth is missing,
outings, bad weather, transportation, youth being released, cannot clear the count, and during
an emergency. Three of the six indicated the current youth census was fifty-four, one said fifty-
five, one fifty-three, and one forty-six. At the time of the annual compliance review, the census
was fifty youth total.
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.
A review of the master control logbooks for the annual compliance review period for at least one
full day a month indicated the logbooks were bound with numbered pages, no entries were
destroyed or removed, and they included the dates and times of the events, the names of the
staff and youth involved, brief descriptions of the events, and the names and signatures of the
staff making the entries. On four of the nine full days reviewed the program had six entries
which included erasures, and staff scrawling over the writing instead of striking through with a
single line and initialing the error. All other entries were made with ink with no erasures or white-
out areas, and all errors were struck through with a single line, and initialed by the staff
correcting the error. The activity schedule and logbook documented minimal interference of
educational instruction, education classes were conducted as scheduled, and youth arrived to
and departed school on time. The review of the logbook indicated recreation was conducted, as
scheduled. The logbooks documented emergency situations, special instructions for supervision
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and monitoring of youth, population counts, perimeter security checks and other security checks
conducted by direct care staff, requests by law enforcement to access any youth, incidents,
removal of any youth from the mainstream population, and internal incidents reported to the
Department’s Central Communications Center. The reviewed logbook pages did not require
documentation of transports away from the facility, admissions and releases, or information
relating to escapes or attempted escape incidents.
The program does not have a living unit logbook; however, utilizes shift reports. A review of shift
reports for the annual compliance review period indicated the reports summarized the events,
incidents, and activities documented in the program’s master control logbook. Observations
showed the incoming staff signed and dated the shift reports for the previous shift to document
their review or verbal briefing about its contents and confirmed the program supervisor verbally
briefing incoming staff about the contents of the shift report. The shift report is maintained in
master control, for access to all staff, for forty-eight hours.
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 on key control including key assignment and 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 policy also entailed
permanent key assignment, daily tracking, and reconciliation of keys.
Observations during the annual compliance review week indicated the incoming staff provided
their personal keys to master control/designee and received program keys. The staff signed a
key log and documented the number of the keys received, time, and date. One of the
observations included a set of restricted keys, which followed the same process. The staff
provided personal keys and received an assigned key ring, which was documented on the key
log. Observations of the key storage area in master control were conducted; the boxes were
secured and inaccessible to youth. The key storage is divided into two locked boxes. One box
contained the restricted, medical, and permanent issued keys. The other locked box contained
the active general key sets. A random review of keys and the key log indicated all keys had
been signed out as required. A review of the key inventory indicated the inventory matched the
actual key rings in use. The program did not have any key incidents which required a call to the
Department’s Central Communications Center. A sample of five key rings for five staff was
observed. All five staff had the keys in their possession and were able to provide the function of
each key on the key ring. One of the five key rings had one more key as indicated on the key
inventory. The key belonged to a permanent issued key ring and the staff indicated it had just
been added during the annual compliance review week. Three key rings for a staff mentor,
transporter, and the food service director were observed. Each of the three staff were able to
provide the function of each key, and the key rings were documented on the key inventory with
the correct number of keys. An informal interview with the master control operator indicated
restricted keys are assigned to particular individuals and when they come into the facility, they
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will get the assigned key. Six staff interviews explained the program's key control process
including giving a key to get a key, having to sign a key log, key assignment for different
positions, as well as two saying staff keys are given to master control upon entry and a
chit/token is provided to visitors. Six said personal keys are securely stored, three indicated
program keys are assigned to staff, and one said there is daily tracking of keys with the key log.
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 in place regarding contraband. The program’s system
to prevent contraband entering the facility includes defining items/material considered
contraband, as well as exemptions, providing youth with a list of contraband, informing youth of
consequences if found with contraband, searching the physical plant, searching the facility
grounds, searching the youth, searching incoming mail, and searching outgoing mail. The policy
and procedures encompassed any staff who is found in possession of contraband in a program
will be subject to disciplinary action up to and including dismissal, as well as law enforcement is
contacted if illegal items are found or if there is evidence of unlawful activity. The program
clearly delineates items considered contraband, including, but not limited to, sharps, escape
paraphernalia, tobacco products, lighters or matches, electronic or vaporless cigarettes, any
unauthorized article of food or clothing, any intoxicating beverage 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 coins, and non-facility issued keys. A review of random dates for the annual
compliance review period indicated the program documented confiscation of contraband and
disposition, which included disposal of non-illegal contraband. The program maintains
confiscation of contraband in the youth case records. The program did not have any illegal
contraband turned over to law enforcement during the annual compliance review period. The
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facility logbook, incident reports, and search reports were reviewed to determine frequency and
quality of searches and the results of each search.
The facility administrator interview indicated upon entry into the facility, staff and visitors are
searched in an effort to prevent contraband from entering the program. All visitors and staff are
notified of the Florida Statute as it is posted at the entrance doors of the facility. In addition, a list
of items identified as contraband are noted within the program’s parent/guardian and youth
handbooks, and the staff handbook. Weekly room and common area searches are completed,
and findings are documented on the search log. Any unauthorized item/illegal contraband is
documented on the log and disposed of properly; illegal contraband requires
notification/reporting to law enforcement and the Department’s Central Communications Center.
Four of six staff interviews indicated youth room searches are conducted weekly, two stating
daily.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
Observations during the annual compliance review week included youth searches during
movement, after transport, and during admission. The youth were treated with dignity and
respect to minimize the youth’s stress and embarrassment, were conducted by the appropriate
number and gender of staff, were thorough, and the staff provided appropriate instructions, as
required by the Protective Action Response/Right Interactions (PAR/RI) training manual. Due to
visitation occurring on the weekends, youth not utilizing tools, and none of the youth
participating in off-campus activities, observations of those activities could not be conducted
during the annual compliance review week. All six interviewed staff indicated youth searches
are conducted during every movement. Five of six interviewed youth indicated searches are
conducted for every movement; the remaining one said all the time.
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 has one transport vehicle which had an annual safety inspection and maintenance
records documented. The vehicle is secured at all times, had a fire extinguisher, seatbelt cutter,
window punch, appropriate number of seatbelts, and the door to the youth passenger area
could not be opened from the inside. The program maintains an approved first-aid kit, which is
utilized during transports. Nine vehicles in the facility parking lot were checked, and all were
locked when not in use. Two of six interviewed youth indicated they had not been on a
transport. The remaining four stated they must wear seatbelts during vehicle transport, three
also stated shackles, and one said doors are locked to provide secure transport. All six
interviewed staff indicated youth are secured with a seatbelt during transport, five indicated
restraints, and one also mentioned locking the doors as part of securing the youth.
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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 relating to transportation of youth and driver eligibility,
which is in compliance with the Department’s policy. The policy includes youth being prohibited
from driving program or staff vehicles. A review of the program’s policy, observations, and
interviews indicated a cellular telephone or radio is issued by the program to the transporter.
Observations during the annual compliance review week included a youth being transported to
the program as a new admission, and the staff-to-youth ratio was utilized. The transport
included one male youth, one male staff, and one female transporter, and all were wearing
seatbelts. The youth was wearing shackles on his hands and feet. A review of transportation
logs for the annual compliance review period indicated the one staff to five youth ratio was
utilized during all transports. All transports had at least two staff, no matter how many youth
were being transported. A review of documentation indicated all staff operating a program
vehicle have a current driver’s license. The facility administrator interview indicated the vehicle
does not have a safety screen; however, a staff rides in the back of the van with the youth
during transport. All six interviewed staff indicated the staff are provided a cellular telephone
during transports, two also stating a radio. One of the six was not sure what safety equipment is
in the transport vehicle since they have never been on a transport. Four of the remaining five
indicated a first-aid kit and one said a window punch are in the vehicle. Two staff also
mentioned a fire extinguisher. All six stated staff are not allowed to use personal vehicles to
transport youth, the transport vehicles are searched for contraband prior to and after each use,
and a staff rides in the back of the van with the youth during transport. All six staff interviews
indicated they would call the program/master control in case of an emergency during a vehicle
transport. Two staff also stated to call 9-1-1 and one said to pull off the road. The six staff said
the ratio for youth transport is two staff to one youth. One staff also indicated at least one staff
has to be male. All six youth interviews indicated they had never seen anyone place contraband
in a transport vehicle and they all feel staff and staff are driving the transport vehicle safely.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the audit/inspection process, including who
is responsible for conducting the weekly security audits and safety inspections, the development
and implementation of corrective actions warranted as a result of safety and security
deficiencies found during any internal or external review, audit, or inspection, an internal system
to verify the deficiencies are corrected, and existing systems are improved or new systems are
instituted as needed to maintain compliance, and met all requirements.
A review of the weekly safety and security audits for the annual compliance review period
indicated they were completed every week. The program had no deficiencies during the annual
compliance review period regarding weekly safety and security audits. A review of the
program’s Preventive Maintenance Checklist indicated weekly, bi-weekly, monthly, quarterly,
annual, and three-year checks are conducted regarding maintenance and repairs as required.
The facility administrator (FA) interview indicated the program maintenance staff and FA
complete weekly safety and security inspections, which are documented on the weekly safety
inspection report and provided to the FA for review. The report details identification of the issue
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and tracks the correction of the deficiencies. All efforts are made to correct deficiencies in a
timely manner, dependent on the severity of the issue.
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 addressing the issuance, inventory, and control of
equipment and tools, including missing/lost tools, and dysfunctional tool disposal or
replacement. A review of the tool inventory indicated all tools are inventoried prior to being
issued for work, following work activities, and daily, including sharp-edged, pointed tools. Tools
which do not have sharp edges or points are inventoried monthly. The program did not have
machetes, bowie knives, or other long blade knives. A review of the inventory to document the
issuance and return of tools was completed, and indicated it was done for the annual
compliance review period. Fifteen tools were reviewed, and all were secured, had markings,
and were noted on the inventory.
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 including supervision requirements when youth use
tools, issuing tools to youth and staff, an assessment to determine a youth’s risk to self and
others, established ratios, tool distribution and collection, search criteria during work projects, as
well as a ratio of one staff to five youth. The policy did not include disciplinary work project ratio
or vocational training ratio. The program prohibits youth from handling tools; therefore,
observations of youth using tools were not conducted. All ten reviewed case management
records indicated each youth received a training in the intended and safe use of tools and each
youth had a risk assessment completed. All six interviewed staff indicated youth do not use
tools. All six interviewed youth indicated youth are not allowed to use tools.
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 regarding outside contractors, which indicate
contractors shall receive written instructions detailing their responsibilities regarding tool
management and contraband, confine their work to the authorized area of work, and performing
the work with proper security and safety precautions. In addition, upon leaving, these contracted
individuals shall not leave tools at the program. The policy also outlined who is responsible for
providing approval/permission if certain contraband items are required. Four project invoices
submitted to the program by the vendor were reviewed. All had instruction sheets, as well as
sign in and out sheets, which included inventory of the tools utilized during the work project.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 80 of 86 (Revised September 2022)
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.
A review of the program’s Continuity of Operations Plan (COOP) indicated fire drills and COOP
drills are to be conducted once a month on each shift. A review of drill documentation for the
annual compliance review period indicated the program conducted at least one fire drill a shift
monthly and one COOP drill once a month on each shift. All drills contained the type of drill,
date and time, participants, brief scenario, findings, and recommendations. Observations during
the annual compliance review week indicated fire evacuation routes and egress plans were
posted throughout the facility. The program had twenty-five fire extinguishers which received an
annual inspection.
All six interviewed staff indicated they had participated in a fire drill in the last twelve months.
Five said they had partaken in a weather drill, four an escape, and two each a bomb threat and
chemical spill drill. Staff also mentioned participating in cardiopulmonary resuscitation, suicide,
code white, hurricane, medical, evacuation, and COOP drills. Five of six interviewed youth
indicated they had been instructed on what to do in case of a fire. Three youth said drills are
conducted once a month, one said every two weeks, one stated they had never seen a drill
since arriving at the program, and the remaining youth said it is supposed to be once a month;
however, has never seen it happen. The facility administrator interview indicated COOP drills
are conducted monthly and quarterly.
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’s Continuity of Operations Plan (COOP) is a combined plan and was located in
master control and the meeting room readily available to staff members, youth, and visitors, and
disseminated to appropriate local authorities. The COOP was reviewed and updated annually
on February 13, 2024. The COOP addressed alternative relocation sites approved by the
applicable Department regional director/designee and was submitted to the Department for
approval. The program’s equipment and supplies required for continuous operation and services
during emergency or disaster situations were located in the kitchen storage area. Supplies
included, water, cookies, canned fruit, canned vegetables, crackers, juice, and more. The
COOP was a new plan and included fire, fire prevention and evacuation, severe weather,
disturbances or riots, bomb threats, hostage situations, chemical spills, flooding, terrorist threats
or acts, staff roles and responsibilities, any equipment and supplies needed, information about
youth which might be needed, alternative housing arrangements, provisions for continuity of
care and custody of youth, and provisions for public protection.
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Office of Accountability and Program Support Page 81 of 86 (Revised September 2022)
The program has a separate hard-copy record for each youth, which is easily accessible and
mobile in the event of an emergency situation. Ten hard-copy youth records were reviewed. All
ten records included at a minimum each youth’s full name, Department identification number,
admission date, date of birth, gender, race, name, address, telephone numbers for
parent/guardian, as well as name, address, and telephone number of the person with whom the
youth resides, and his or her relationship to the youth. Each record also contained persons to
notify in case of an emergency, juvenile probation officer’s name, circuit/unit, and contact
information, names of committing judge, state attorney, and public defender with contact
information on each, committing offense and judicial circuit where the offense occurred, notation
of whether or not the judge retains jurisdiction, physical description of youth to include height,
weight, eyes and hair color, any identifying marks, overall health status, including chronic
illnesses, current medications and allergies, personal physician name and photograph of youth.
One of the ten youth records also required victim notification contact information. The facility
administrator interview indicated the COOP is available for staff access in master control and
the conference room.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
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 program has a policy and procedures detailing the storage and inventory of flammable,
poisonous, and toxic items and materials. Observations during the annual compliance review
week indicated all flammable, poisonous, and toxic items were secured at all times, inaccessible
to youth in master control, the kitchen, the flammable storage shed and the maintenance shop.
A review of documentation indicated inventories were maintained for the annual compliance
review period. The program has a list of facility positions/titles authorized to handle flammable,
poisonous, and toxic materials. A review of twelve flammable, poisonous, and toxic materials
indicated the actual count of the item observed matched the ending inventory count, each item
was secured and had a Safety Data Sheet present, with one exception. One item in master
control was one less than indicated on the inventory. The program stated the cleaning fluid was
utilized the same day as the observation and the staff had not yet updated the inventory.
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 regarding youth handling and supervision of
flammable, poisonous, toxic items and materials. Observations during the annual compliance
review week indicated the program maintains strict control of flammable, poisonous, and toxic
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 82 of 86 (Revised September 2022)
items, and materials, and does not allow youth to use, handle, or clean-up dangerous or
hazardous chemicals or have youth clean, handle, or dispose of any person’s bio-hazardous
material, bodily fluids, or human waste. The program restricts youth access to areas where
items are used or stored. Observations of youth during the daily cleaning activities were not
conducted due to no youth cleaning while the team was on-site. All six interviewed youth
indicated they do not use any chemicals/cleaning products.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous 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 regarding disposal of flammable, toxic, caustic, and
poisonous items in accordance with the Occupational and Safety Health Administration
standards. The program has a list of positions/titles authorized to of dispose flammable, toxic,
caustic, and poisonous items. The program has a contract with a bio-hazardous waste
contractor. The program did not utilize any bio-hazardous materials during the annual
compliance review period; therefore, the program’s disposal log was not reviewed, and this was
confirmed in an informal interview with the maintenance staff. The program’s liquid waste from
work details is disposed of in the plumbing drains, kitchen liquid waste, except grease, is
disposed of in the kitchen sink, and grease is placed in a grease trap. Based on the program’s
policy and procedures and an informal interview with the facility administrator, the chemical
spills clean-up process includes upon becoming aware of a chemical spill, staff will notify master
control of the location, the shift supervisor/master control will direct the shut-down of all air
handlers and ventilation systems, close all windows and doors at the direction of the on-scene
supervisor/designee, and assistance from outside the facility shall be contacted, as necessary,
consistent with emergency procedures. The facility administrator interview indicated the
program participates in the Division Household Hazardous Waste program, if needed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 83 of 86 (Revised September 2022)
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures related to visitation, youth correspondence, and use
of telephone. The policy includes the availability of alternative visitation arrangements with the
parent/guardian. The visitation schedule was posted in the modules and indicated visitation
occurs Saturdays and Sundays. A review of the visitation log and schedule confirmed
adherence. A review of the telephone log and schedule indicated youth receive telephone calls
once a week. Youth receive two stamps a week to send out correspondence, and can utilize
unlimited mailing to lawyers, legal representatives, and Department of Children and Families
counselors. Youth are given an opportunity to communicate with family members by mail and by
telephone, as indicated through a review of the mail and telephone log. The program does
search all outgoing youth mail. The program did not have any youth with a history of human
trafficking at the time of the annual compliance review. The program has an agreement with a
third-party language service entity for language translation services.
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Office of Accountability and Program Support Page 84 of 86 (Revised September 2022)
Three of six interviewed staff indicated the program utilizes staff to translate if a youth’s primary
language is not English. The remaining three stated they do not have any youth who do not
speak English and one said they are sure the program has something in place in case this
should happen. All six interviewed youth indicated they can call their parent/guardian or send a
letter. Five of the six youth said all youth at the program speak English. The remaining youth
stated they do not know what service the program has in place for youth whose primary
language is not English. The facility administrator interview indicated the program utilizes a
bilingual online program for youth whose primary language is not English.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program’s activity schedule documented a range of supervised and structured indoor and
outdoor recreation and leisure activities for the youth for at least one hour daily, including large
muscle activity. A review of the logbook indicated recreation was conducted as scheduled. The
program’s activities promote social and cognitive skill development, creativity, teamwork,
healthy competition, mental stimulation, and physical fitness. Observations during the annual
compliance review week indicated the program takes precautionary measures to prevent
overexertion, heat stress, dehydration, and exacerbation of existing illness or physical injury. A
review of the program’s contract, staff roster, recreational therapist credentials, schedule, and
services indicated the program has two contractually required recreational therapists with
qualifying credentials and is providing services as mandatory. All ten youth records reviewed
indicated recreational therapy was included in each youth’s individualized performance and/or
treatment plan.
All six interviewed youth indicated the program allows youth the opportunity to exercise, play
outside, have down time to read a book, or play a board game for at least one hour a day. The
six youth stated they play different sports, like football, kickball, basketball, and four square. All
six staff interviews indicated youth are provided indoor and outdoor activities at least one hour
daily, with one staff also stating on the weekends it is two hours a day, and another saying the
youth get one hour twice a day. The six staff said the youth play various sports including
basketball, touch football, kickball, soccer, lift weights, and using a water slide.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a policy and procedures on the requirements of controlled observation rooms.
Since the start of the provider’s contract, the program had one controlled observation. The staff
conducted an inspection of the room prior to placing the youth in the room. The controlled
observation met the required elements and was documented on the controlled observation
report. The youth was searched by a staff of the same gender prior to placement in the room.
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Office of Accountability and Program Support Page 85 of 86 (Revised September 2022)
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a policy and procedures on the placement in controlled observation. Since the
start of the provider’s contract, the program had one controlled observation. A supervisory staff
authorized the placement for the youth. Controlled observation was authorized due to the
youth’s active aggression toward others. Documentation indicated staff advised the youth for the
reason of placement in controlled observation and expected behavior for removal, and a
healthcare professional completed the health status checklist. The staff conducted and
documented safety checks and observed the youth’s behavior. The Controlled Observation
Report, Health Status Checklist, and Controlled Observation Safety Checks forms were
maintained in an administrative office. The youth is no longer in the program; therefore, the
review of the youth’s individual management record was not able to be completed.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
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 has a policy and procedures on the process of release of youth from controlled
observation. Since the start of the provider’s contract, the program had one controlled
observation. Documentation indicated staff advised the youth for the reason of placement in
controlled observation and expected behavior for removal and a healthcare professional
completed the health status checklist. The staff conducted and documented safety checks and
observed the youth’s behavior within the required time frame. The Controlled Observation
Report, Health Status Checklist, and Controlled Observation Safety Checks forms were
competed and maintained in an administrative office. The facility administrator and/or supervisor
who has the delegated authority give written approval before a youth is released from controlled
observation. The staff did not determine if an internal alert was warranted for this controlled
observation. The youth is no longer in the program; therefore, the review of the youth’s
individual management record was not able to be completed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 86 of 86 (Revised September 2022)

report_type: QI Residential

program_name_raw: Orange Youth Academy & Orlando Intensive Youth Academy