state: FL

facility_name: Okaloosa Youth Academy

summary: QI Residential - FY24-25 - 3 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Okaloosa Youth Academy
Gulf Coast Treatment Services
(Contract Provider)
4455 Straightline Road
Crestview, Florida 32539
Review Date(s): March 11-14, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Patrick M McKinstry, Office of Accountability and Program Support, Lead Reviewer (Standard 1,
6, and interviews)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 2
and Interviews)
Shyron Johnson, Developing Opportunities through Vocation and Education Academy,
Assistant Program Director, (Standard 5)
Ken Myers, Office of Education, Northwest Education Coordinator, (Standard 6)
James Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Okaloosa Youth Academy MQI Program Code: 830
Provider Name: Gulf Coast Treatment Center Contract Number: 10760
Location: Okaloosa County / Circuit 1 Number of Beds: 77
Review Date(s): March 11-14, 2025 Lead Reviewer Code: 144
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Educational
Serices, which are included in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
3.14 Suicide Prevention Training *
4.16 Medication Management
6.01 Contract Specific CTE Services (Residential Contract)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 65 (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 Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 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 65 (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 and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 65 (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 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Failed
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Non-Applicable
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 65 (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 Failed
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 65 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 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 65 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Failed
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 65 (Revised September 2022)
Program Overview
Okaloosa Youth Academy is a seventy-seven bed program, for thirteen- to nineteen-year-old
males, located in Crestview, Florida. The program is operated by Gulf Coast Treatment Center,
through a contract with the Department. The program provides the following services: Mental
Health Overlay Services (MHOS), Substance Abuse Treatment Overlay Services (SAOS), and
Juvenile Sexual Offender Treatment Services. In addition, the program fosters each youth by
providing Aggression Replacement Treatment, Pathways, Impact of Crime, Healthy Sex
Offender Sexuality Treatment, The Change Mental Health Curriculum, Skill-streaming the
Adolescent, and Seven Challenges. Additional treatment services provided includes family and
individual therapy and interventions, along with a continuum of group and recreational therapy
modalities on an on-going basis.
Program administration is comprised of a program director and an assistant program director.
Case management services are provided by a case management supervisor, four case
managers, a transition manager, and a recreation therapist. Mental health staff at the program
include a clinical director who is the designated mental health clinician authority, a psychiatrist,
an assistant clinical director, and six therapists. Medical services are offered daily and are
provided by a medical doctor who is the designated health authority (DHA), a clinical manager,
four registered nurses, and one licensed practical nurse. The DHA is required to be on-site
weekly for two hours. Educational services are provided by the Florida Scholars Academy
through a contract with Florida Virtual School. The layout of the program includes three youth
housing units, an administration building, and an education building which houses the program’s
dining and kitchen area. The program has 112 operating security cameras providing coverage
and all were working during the time of the annual compliance review. The program currently
has three vacancies for direct care staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 65 (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.
A total of twenty-six staff were applicable and reviewed for completion of a background
screening since the last annual compliance review. Each staff had a background screening
completed prior to contact with youth and confidential records. As part of the hiring practices at
the program, a criminal history report is reviewed for all staff. None of the staff required an
exemption prior to working with youth. A pre-employment assessment tool was administered to
all staff. Additionally, a passing score was documented in each staff member’s record. The
program has a written policy and procedures addressing volunteers, mentors, and interns;
however, the policy denotes if a volunteer, mentor, or intern serves on a continuous basis, or
volunteers ten hours or more each month they would require a background screening. All other
volunteers, mentors, and interns must remain under the supervision of a certified staff. The
program had an Annual Affidavit of Compliance with Level 2 Screening completed on
December, 2024. The Department of Education had an annual affidavit of compliance for level 2
screening completed on January, 2025.
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.)
A total of two staff required a five-year background rescreening since the last annual
compliance review. Both staff had a rescreening completed every five years, which was
submitted to the Department’s Background Screening Unit at least ten business prior to the
staff’s five-year anniversary.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 65 (Revised September 2022)
▪ 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.
A total of five incidents since the last annual compliance review were reviewed to ensure the
program provides for an environment in which youth, staff, and others feel safe, secure, and not
threatened by any form of abuse or harassment. Each of the incidents indicated contact was
either made to the Florida Abuse Hotline and/or the Department’s Central Communications
Center (CCC) as required. There were no incidents which indicated there was any potential
human trafficking victims, child sexual exploitation, or labor trafficking. The program had nine
reported incidents related to physical, psychological, or emotional abuse since the last annual
compliance review. There were two of the nine found to be documented with substantiated
findings.The remaining seven CCC were noted to be either unsubstantiated or still under review
at time of the annual compliance review.
A review of twenty-six staff personnel records documented staff review and sign a code of
conduct. A program tour revealed the Florida Abuse Hotline and the CCC telephone numbers
were posted throughout the program. The program’s written policy and procedures addresses
steps to report abuse. The program completed a trauma responsive and caring environment
(TRACE) self-assessment on July 8, 2024.
Nine youth were interviewed. All youth report being safe at the program. None of the youth
reported ever having been stopped from reporting abuse to the Florida Abuse Hotline or CCC.
Each youth reported staff are respectful when talking with them. Two of the nine youth reported
having heard use of a curse word while speaking to them or other youth. One of the two youth
said it was directed at them after staff had repeatedly asked them to be quiet. The remaining
youth said they heard it directed at another youth. All nine youth said they have never
exchanged any type of contact information with staff.
Nine staff were interviewed. All staff were able to identify the process for allowing youth to call
either the Florida Abuse Hotline or CCC. None of the staff have ever observed another staff
telling a youth they could not call the Florida Abuse Hotline. None of the staff have ever heard
another staff using profanity while speaking with youth.
The program director was interviewed and reported all staff have had formal training on the
Code of Conduct. Additionally, all staff receive trauma-informed care. The staff at the program
are educated on youth's safety plans and how to implement them in their interactions. Staff
have also had formal training in abuse reporting and it is reviewed in team meetings and
briefings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 65 (Revised September 2022)
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.
A total of five incidents since the last annual compliance review were reviewed for evidence of
management taking immediate action to address incidents of physical, psychological, and or
emotional abuse. Documentation was reviewed to confirm applicable corrective action was
taken by the program. The program director was interviewed. When addressing management
response to allegations of abuse, staff will be removed immediately from contact and an
investigation will be initiated.
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 had a total of thirty-eight incidents reported to the Department’s Central
Communications Center (CCC) during the annual compliance review period. Five incidents were
reviewed to ensure the program notified the CCC within two hours of the incident occurring, or
within two hours of any program staff becoming aware of the reportable incident; each of the
incidents were addressed accordingly. There were no additional internal incidents or grievances
which should have been reported. The program has experienced an increase of four reportable
incidents since the last annual compliance review.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had one Right Interactions (RI) report during the annual compliance review period.
A review of this report indicated the report had not been completed by the staff involved or by
the end of the staff workday, as the staff was terminated the same day of the report, all other
elements of the report were completed as required. Monthly summaries are maintained by the
program of any RI incidents submitted to the Department. The program’s RI plan was updated
on December 13, 2024. The program’s RI plan was approved by the Department on January 17,
2025. The program did not have an increase in right interaction reporting; the program had only
one report the previous annual compliance review period. The program’s RI rate during the
previous quarter was 0.57, which is below the statewide Residential RI rate of 1.71.
Nine staff were interviewed. Three staff reported having utilized RI and each of these staff were
able to explain the process/purpose of RI. The program director was interviewed. All RI
incidents will be reviewed within forty-eight hours of incident to ensure appropriateness.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 65 (Revised September 2022)
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
A review of nine staff pre-service training and certification requirements was completed. Each
staff reviewed had completed all pre-service and certification requirements within 180 days of
hire. All pre-service training was found documented in the Department’s Learning Management
System (SkillPro). Maintenance and kitchen staff may supervise a youth on occasion; however,
these staff are not counted in staff-to-youth ratio. The program submits a pre-service training
plan prior to implementation. Additionally, the pre-training plan was approved by the program
director, the assistant secretary for the Department’s Office of Residential Services, and the
director of the Department’s Office of Talent, Leadership, and Culture. Instructors are qualified
to deliver training provided to program staff
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.
A review of nine staff records for annual in-service training was completed. Each staff reviewed
had completed at a minimum twenty-four hours of mandatory in-service training as required. A
review of three supervisory staff revealed each supervisor had completed a minimum of eight
additional hours on either coaching, leadership, and or personal accountability training. All
reviewed in-service training was found documented in the Department’s Learning Management
System (SkillPro). The program has an annual in-service plan which is updated as any change
might occur. The program submits an in-service training plan prior to implementation. The in-
service training plan was approved by the program director, the assistant secretary for the
Department’s Office of Residential Services, and the director of the Department’s Office of
Talent, Leadership, and Culture. All instructors are qualified to deliver trainings provided.
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 not had any youth grievances during the annual compliance review period. A
review of the program’s written policy and procedures pertaining to grievances did not indicate
any training requirements for grievance practices. The procedures included an informal, formal,
and appeal phase.
Nine youth were interviewed. Each youth reported knowing the process for submitting a
grievance. Nine staff were interviewed and each were able to explain the youth grievance
process. The program director was interviewed and indicated youth write a grievance, the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 65 (Revised September 2022)
supervisor responds to the grievance, and program director resolves grievance in the appeal
phase if not yet resolved.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a written policy and procedures which addresses life and social skills. The
procedures indicate all youth at the program will be provided with social and life skills training
daily, either informally through casual, everyday conversation with and observation of staff and
providers who role model and reinforce appropriate social skills, and/or through more structured
and intentional counseling. The program’s only life skill groups are considered primary services;
therefore, they are not applicable for the annual compliance review. The program incorporates
additional life skills for youth by providing recreational therapy, skills streaming groups, and
outings with hands on activities. Additionally, all curriculums facilitated at the program
incorporate life and social skill training.
Nine youth were interviewed and were able to articulate those services which provide them
each with life and social skill type activities. The program director was interviewed and reported
all youth participate in daily groups unless circumstances such as illness or a doctor
appointment prevent them from attending. In this instance, they are given a supportive session
by a therapist to ensure daily contact with the mental health team. The therapists are trained in
LGBTQIA+ juvenile populations and cater to each youth in the program based on their specific
gender and identity. The PATHWAYS curriculum is tailored and provided to the male population
served by the sex offender program. Each youth is housed in their own room. The designated
mental health clinical authority was interviewed, and stated skills are reinforced through the
program behavior management system, when giving an opportunity to practice skills learned in
groups.
1.12 Restorative Justice Awareness for Youth <---Update--->
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Okaloosa Youth Academy program. For details related specific to IOC service
delivery, please refer to the annual SPEP report.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 65 (Revised September 2022)
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 written policy and procedures addressing how alerts are identified,
documented, updated, and communicated to staff. A review of nine youth records was
completed for a total of twenty alerts found entered into the Department’s Juvenile Justice
Information System (JJIS). One of the twenty youth alerts was found to have a note entered two
months after the youth arrived. The inclusion of the note did not hinder the youth’s medical
treatment; the prescribed treatment was for pro re nata (PRN) purposes only. The review of
alerts varied by alert type and were found to be removed and or updated by appropriate
program staff. Applicable alerts were found to match in JJIS along with the programs internal
system. Additionally, necessary notification was documented in the program’s logbook or shift
report.
Nine staff were interviewed and were able to identify ways they are informed of youth alerts
while at the program. The program director was interviewed and stated medical issues are
reviewed during Department head meetings. Additionally, youth staffing for mental health is
completed weekly and with psychiatric services bi-weekly. The program director is responsible
for entering the safety and security alerts. The clinical director reviews and enters suicide risk
alerts. The medical team is responsible for medical and allergy alerts, which are reviewed by the
clinical director. The nursing staff was interviewed and indicated the health services
administrator oversees and finalizes medical 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 Case Management Record
The program has a written policy and procedures addressing youth records. The program does
maintain separate youth records for healthcare, mental health, and case management with
appropriate sections. Each record was labeled confidential and secured in either a locked file
cabinet and or a locked room. The location of records was marked as confidential.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
Florida Department of Juvenile Justice Residential Annual Compliance Report
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A review of program documentation revealed a community advisory board meeting was
conducted at least every ninety to 120 days since the last annual compliance review. The
program director’s community advisory board is evident of participation by law enforcement,
judiciary, business, school board, other community partners, along with the faith-based
community. Additionally, the program had representation from a victim service advocate, along
with a parent/guardian of a youth previously involved in the juvenile justice system. An informal
interview was conducted by telephone with one of the program’s community advisory board
members. The board member praised the program for all the assistance provided at the church.
The board member confirmed their participation in the regular meetings.
The program director was interviewed and reported the board meets quarterly, membership
involvement is off and on, and they are continuously doing work for the community.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
A review of the program’s written policy and procedures revealed the program has practices for
evaluating staff, performance standards, and frequency of evaluations. A total of five separate
job descriptions were reviewed, which clearly identified staff’s performance standards, three of
which specifically dealt with implementation of the program’s behavior management system. A
total of nine performance evaluations were reviewed to ensure evaluations were conducted
annually. Performance standards appeared to match those applicable job descriptions
reviewed. A review of the contract between the provider and Department was reviewed. The
required positions pursuant to contract appear to be maintained and performed as outlined. The
program has three direct care vacancies. The program contract requires a recreational therapist
position. A review of the provider’s staffing roster, along with recreational therapist credentials
reveal the program contract requirements were met.
The program director was interviewed and stated turnover is at twenty percent and morale is
good. The program does cookouts, gift cards, employee of the month, and birthday celebrations
for staff appreciation. Each staff receives an annual evaluation. Nine staff were interviewed.
Five staff had not been at the program a year. The remaining four staff had annual evaluations
completed.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of contract conditions along with the memorandum of negotiation were addressed,
aside from those services reviewed in contract specific career and technical education. The
program had two specific services to review for the annual compliance review period: forklift
operator certification and assisting youth in paying court cost/fees when applicable. According to
the program, no youth who have been employed while at the program has required any court
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fees be paid. The program has had eighteen youth successful complete certification in forklift
operation, trained through East2West Safety Plus.
The program director was interviewed and reported contract negotiated items offered at the
program are Occupational Safety and Health Administration (OSHA)-10 and forklift training.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
A review of program data trend analysis reveals administration staff monitor and review data in
monthly supervisor meetings. As needed, outcomes are disseminated to staff in meetings
and/or as training. The program shares pertinent information with stake holders in quarterly
community advisory board meetings. As needs arise with identified trend data, discussions are
held with program department heads, supervisors, and staff to address possible revisions to
practices and or policies.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
Nine youth case management records were reviewed for initial parent/guardian contacts and
court notifications. Seven of the nine records included documentation the program did notify the
parents/guardians of each youth within twenty-four hours of admission. Two records did not
have documentation the parents/guardians were notified by telephone within twenty-four hours
of admission. All nine records included documentation the program notified the
parents/guardians in writing within forty-eight hours of the admissions. All juvenile probation
officers (JPOs) and committing courts were notified within five working days of each youth’s
admission as evidenced by the letters in the youth records stamped “mailed” and dated.
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.
Nine youth case management records included documentation the program provided each
youth with an orientation which started on the date of admission. An orientation was observed
during the annual compliance review week. It was observed the assigned case manager went
through the following required elements with the youth: services available, daily schedule,
expectations and responsibilities of the youth, the behavioral management system, positive and
negative consequences for behavior, availability of and access to medical and mental health
and substance abuse services, access to the Florida Abuse Hotline and/or the Department’s
Central Communications Center (CCC), the Prison Rape Elimination Act (PREA) rights and
documentation, the right to be free from sexual misconduct, items considered contraband,
performance planning process involving the development of goals for each youth to achieve,
dress code and hygiene practices, procedures on visitation, mail, and use of telephone,
expectations for release from the program, community access, grievance procedures,
emergency procedures, and assignment to a living unit and room. The case manager explained
to the youth they would find out what dorm and room they would be assigned to after meeting
with the nurse and a facility tour would be conducted throughout the day. Nine youth were
interviewed, and all reported they received an orientation within twenty-four hours after arriving
at the program.
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.
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Nine youth case management records were reviewed for written consent of eighteen years or
older. None of the selected youth were applicable. Three additional records were provided for
review. All three records included documentation the written consent was obtained for all three
youth who were eighteen years or older at the time of admission.
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.
A review of the program’s classification form showed it included all required elements. Nine
reviewed youth case management records included initial classification forms which were
completed on the date of admission. Two youth had suicide risk factors, two youth had medical
risk factors, none of the youth had an escape risk, and one youth had a security risk. Five youth
had risks for the Prison Rape Elimination Act (PREA), one had a risk factor due to a violent
history, and one had a risk factor based upon criminal history. All seven youth with risk factors
affecting classification had corresponding alerts in the Department’s Juvenile Justice
Information System (JJIS). Six of the nine reviewed admission classification forms included the
youth’s assigned living area and sleeping room. Two classification forms did not include this
documentation and one form was only missing the room number. Seven of the nine youth had
additional risk factors added in JJIS after the classification process. Seven of the nine youth had
updated risk assessments which allowed for an increase in the youth’s privileges or freedom of
movement and participation in work projects. Six of the nine youth had updated risk
assessments to participate in off-campus activities. The program’s written policy and procedures
clearly outline the classification system which promotes safety and security, as well as effective
delivery of treatment services, based on determination of each youth’s individual needs and risk
factors, which addresses, at a minimum, items outlined in Administrative Rule. The program’s
policy also outlines what steps must be completed by the youth to earn privileges of freedom
and movement. The program director was interviewed regarding classification and reported the
youth are assigned a room upon intake. The youth are also provided assessments to evaluate
mental health status, physical health status, and cognitive performance. Age and prior
victimization are entered into JJIS by case management staff. Staff are made aware of risks
associated with youth and therapists to develop safety plans which target the areas of concern.
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 written policy and procedures addressing gang identification which include
notification to law enforcement. The program assesses each youth at intake for suspected gang
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involvement.The program has not had any youth who were identified as a gang associate or
gang member during the annual compliance review period.
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 not had any youth who were identified as a gang associate or gang member
during the annual compliance review period. The program provides Impact of Crime (IOC)
groups to all the youth in the program, which has been identified as a gang prevention and
intervention curriculum. When there are youth identified as a gang member or associate, the
program utilizes the gang workbook along with IOC. Impact of Crime is a primary service and is
reviewed by the technical assistance unit. The youth meet for IOC groups two times a week for
one hour. The program’s written policy and procedures address providing youth an opportunity,
if they desire, to develop a plan to disaffiliate with a criminal street gang as evidenced by review.
The program director was interviewed regarding gang prevention and intervention activities. The
program director also reported the youth are provided exercises out of the Gang Workbook.
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.
Nine youth case management records were reviewed for the Residential Assessment for Youth
(RAY) and reassessments. Seven of the nine records included documentation the initial RAY
assessments were completed within thirty days of each admission. Two RAY assessments were
completed late, one was thirteen days late and one was one day late. The RAY which was
thirteen days late was originally completed on a paper RAY form. There was no date on the
paper form to determine when it was completed; therefore, the official date of the initial RAY
was when it was entered into the Department’s Juvenile Justice Information System (JJIS). A
review of nine records indicated the RAY reassessments were completed, at least, every ninety
days after completion of the initial RAY. All RAY assessments and reassessments were
maintained in the youth’s official case records.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
Nine youth case management records were reviewed for the Youth Needs Assessment
Summary (YNAS). All nine records included documentation the YNAS reports were completed
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within thirty days of admission and all were documented in the Department’s Juvenile Justice
Information System (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.
Nine youth case management records were reviewed for performance plans and transmittals.
All nine records included documentation the Individualized Performance Plans (IPP) were
developed within thirty days of youth admissions. All IPPs reviewed were developed after the
initial Residential Assessments for Youth (RAY) and Youth Needs Assessments Summaries
(YNAS). The following intervention and treatment team members signed all nine IPPs: treatment
team leader, youth, administrative representative, living unit representative, treatment staff,
educational staff, and all other parties who had significant responsibility in goal completion. All
signature pages were sent to the parents/guardians for signature, but none were returned. Eight
out of nine IPPs included the top three criminogenic needs included based upon the risk and
protective factors identified during the initial assessment process. One IPP did not include two
of the top three criminogenic needs and there was no explanation as to why. Subsequent IPPs
were reviewed, and the two missing criminogenic needs were not included also with no
explanation. Eight of the nine reviewed IPPs included delinquency interventions and one did
not. Four of the nine youth had court-ordered sanctions which could be completed at the
program and were included in the reviewed IPPs. Eight of the nine IPPs included transition
activities targeted for the last sixty days of the youth’s anticipated stay. All nine reviewed IPPs
included each youth’s responsibilities to accomplish the identified goals, program staff
responsibilities, and appropriate target dates for completion. Seven of the nine records included
documentation the IPP was sent with a transmittal letter to the committing courts, juvenile
probation officer, and parents/guardians. Two records did not include this documentation. Nine
youth were interviewed regarding the participate in the development of the IPPs. All nine
reported they participated in the development of their IPP.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
Nine youth case management records were reviewed for performance plan revisions and
incorporation of other plans. Four of the nine had revised performance plans due to Residential
Assessment for Youth (RAY) reassessment results, four were revised due to newly acquired
information and a demonstrated lack of progress toward completing a goal. All nine youth had
revised performance plans which included demonstrated progress toward completing a goal.
One youth record included documentation an Individualized Performance Plan (IPP) was
updated to facilitate transition activities during the last sixty days of the youth’s stay. One
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youth’s revised IPPs did not include transition activities. All nine youth records included IPPs
which included references to the education plans and treatment plans.
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.
Nine youth case management records were reviewed for performance summary and transmittal
documentation. Eight of the nine youth records included documentation an initial performance
summary was completed ninety days after the signing of the initial performance plan. One
performance summary was completed two days late. All nine records included documentation
additional performance summaries were completed every ninety days after the initial
performance summary. Two youth were applicable for having performance summaries
completed prior to release from the program and both reviewed records had release summaries
completed timely. The reviewed performance summaries included the following elements for all
nine records: youth’s status on performance plan goals, overall treatment progress, academic
status, youth’s behavior, interaction with peers and staff, overall behavior adjustments to the
program, and significant positive and negative events. Five of the nine reviewed performance
summaries included the level of motivation and readiness to change for each youth; however,
four performance summaries did not include this documentation. All reviewed performance
summaries reflected the youth were allowed to read and add comments prior to signing and
each youth was provided a copy of their performance summary. This was evidenced by a
sticker attached to each summary stating the youth received a copy of their performance
summary and each youth initialed the sticker. All original performance summaries were filed in
the youth case management records. All reviewed performance summaries were signed by the
treatment team leader, program director, and youth. Four of the nine records included
documentation a copy of the performance summaries was sent to the committing court and
parents/guardians. Eight of the nine performance summaries reviewed were sent to the juvenile
probation officers (JPOs).
Three closed case management records were reviewed for release summary documentation. All
three records included documentation the original release summary included the justification for
release and was sent with the Pre-Release Notification (PRN). The release summaries and
PRNs were sent at least forty-five days prior to release. A signed copy of the summaries and
PRN were retained in the closed records for all three youth. All three closed records included
written notification to the parents/guardians of the youth’s planned release once the PRN was
approved. An exit Residential Assessment for Youth (RAY) was completed upon the youth’s
release from the program. None of the youth were applicable for completing a victim notification
letter.
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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.
Nine youth case management records were reviewed for parent/guardian involvement. The
program encourages parent/guardian involvement in the assessment process, participation in
the development of the youth’s performance plan, progress reviews, provides advanced notice
of formal treatment team meetings days and times, and transition planning. If the
parents/guardians are unable to attend the program they are provided an opportunity through
telephone and/or video conferencing to participate. A review of youth records revealed the
program consistently sends letters to parents/guardians about family days, treatment team
meetings, and telephone calls. The program director was interviewed and reported the case
managers stay in constant contact with the parents through letters, telephone calls, and emails.
Nine youth were interviewed and reported their parents/guardians participate during treatment
team meetings, family days, telephone calls, family video conference sessions, visitation, and
letters.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
Nine youth case management records were reviewed for treatment team members and
meetings. All nine records included documentation formal reviews were held every thirty days
and informal reviews were held during alternating weeks. All reviewed treatment team meeting
documentation included the youth’s name, date of review, required attendees, comments from
treatment team members, brief synopsis of the youth’s progress, performance plan revisions,
progress on performance plan goals, positive and negative behaviors, an opportunity for the
youth to demonstrate skills acquired in the program, treatment progress, and Residential
Assessment for Youth (RAY) reassessment results. All treatment team documentation was
contained in the youth’s case management record. A treatment team was not observed during
the annual compliance review due to the meetings not being held during the review week. Nine
youth were interviewed. All nine-youth reported they are provided feedback on their
performance by staff to include progress on performance plan goals, positive and negative
behaviors, and treatment progress. All nine youth reported they can demonstrate what they are
learning in the program during treatment teams. They stated they can express concerns and
ask questions, are provided an opportunity to share what they have been doing at the program,
talk about what is learned in groups, discuss grades and education status, and have learned to
speak up for themselves.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
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identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Three closed youth case management records were reviewed for transition conference and
Community Re-Entry Team (CRT) meeting documentation. All three records included
documentation the transition conference was held sixty days prior to each youth’s targeted
release. The following intervention and treatment team members attended each transition
conference: youth, treatment team leader, program director, juvenile probation officers (JPO),
parents/guardians, education staff, and any other pertinent parties. A review of documentation
showed during the transition conferences the following was reviewed: transition activities, and
target completion dates. The treatment team leader obtained attendees’ dated signatures as
evidenced by a review of the transition conference documentation. All three transition plans
were sent with a request for return with signature for those not in attendance. Two of the three
transition plans were submitted to the JPOs electronically as evidenced by an
acknowledgement receipt email. All three youth and their case managers attended the CRT
meetings. All three closed files included documentation of an invitation to attend.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed youth case management records were reviewed for exit portfolio documentation.
All three records included documentation the exit portfolios were discussed during the transition
conference. The following items were included in all three closed records: copy of the youth’s
transition plan, calendar with dates, times, and locations of upcoming community appointments,
educational and/or vocational certificates, educational records, school transcripts, resume, and
sample employment application. One of the three closed records included the youth’s state-
issued identification card. All three closed records included a letter sent to the parents/guardians
requesting the youth’s birth certificate and social security card in order to obtain a state
identification card for the youth. None of this documentation was provided to the program. One
of the three youth had already obtained a state identification card, and a copy was in the record
reviewed. Each exit portfolio was verified during the three exit conferences. All three records
included a signed form showing the youth received a copy of the completed exit portfolio upon
release. All three records also included documentation the exit portfolios were forwarded to the
assigned juvenile probation officers.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth case management records were reviewed for exit conference
documentation. All three records included documentation the exit conferences were held after
the program notified the assigned juvenile probation officer (JPO) of each youth’s approved
release. The exit conferences were held fourteen days prior to each youth’s release. The
reviewed documentation revealed the dates and signatures of those in attendance of the exit
conference was obtained along with a summary of any pending transition goals. All three dates
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of admission and release correlated with the Department’s Juvenile Justice Information System
(JJIS). The status of transition activities was finalized during the exit conference along with
provisions for education and employment. The parents/guardians, JPOs, youth, education
representative, case manager, and other pertinent parties were aware of the plan, documents,
and post-release plan as evidenced by signatures on the exit conference documentation. All exit
conferences were held separate of the transition conference and community re-entry team
meeting.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program’s formal process to promote constructive input includes Town Hall Meetings, Peer
Advisory Board, and utilization of request to speak forms. The youth can complete a request to
speak to a staff member when wanting to provide feedback or make suggestions for the
program. The forms are in the dining hall. Town Hall Meetings are held on all three dorms
monthly as evidenced by a review of meeting agendas for each month of the annual compliance
review period. Nine youth were interviewed and all nine youth indicated they can provide
feedback and what staff they can talk to if there is an issue or if they have a suggestion for the
program. The program director was interviewed and reported the youth are involved in Town
Hall Meetings, Peer Advisory Board, and can utilize request forms.
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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 employs a designated mental health clinician authority (DMHCA) who is a licensed
clinical social worker and holds a valid and active license in the State of Florida. The DMHCA’s
license expires on March 31, 2025. The DMHCA was on-site weekly during the annual
compliance review period and ensured appropriate coordination and implementation of mental
health and substance abuse services were taking place as required. The program provides
specialized treatment services and the DMHCA is the single licensed health professional
responsible for the coordination and implementation of mental health and substance abuse
services. The DMCHA’s position description was reviewed and included all required information.
The program has a back-up DMHCA who has an active and valid license which expires March
31, 2025.
The DMHCA was interviewed and reported their role as overseeing the provision of all services
provided within the program. The DMHCA delivers training in, and fills in for, all services
provided within the program. The DMHCA reported having daily communication with clinical
staff and weekly supervision held with all clinical staff.
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 currently employs one licensed mental health and substance abuse clinical staff in
addition to the designated mental health clinician authority (DMHCA). The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on their education, training, and experience. The licensed mental
health professionals are all licensed under the appropriate Florida statutes chapter with
expiration dates of March 31, 2025, for the DMHCA and March 31, 2025, for the remaining
licensed mental health professional. Copies of licenses were available on-site. All licensed
mental health professionals and licensed qualified professional’s licenses were reviewed with no
noted issues.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
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The designated mental health clinician authority (DMHCA) serves as the clinical supervisor in
the program. The DMHCA ensures all non-licensed staff are performing services they are
qualified to provide based upon education, training, and experience. Weekly supervision records
were provided by the DMHCA for review. Based on documentation reviewed, all non-licensed
therapists received one hour a week of face-to-face direct supervision. All direct supervision
was recorded on a form developed by the program and included all required elements form the
Department’s Licensed Mental Health Professionals and Licensed/Certified Substance Abuse
Professional Direct Supervision Log form. The program has a Chapter 397 license located in the
front lobby of the administration building. The Chapter 397 license expires on October 30, 2025.
All non-licensed mental health and substance abuse clinical staff licensure was in accordance
with contract guidelines. The program employed six non-licensed clinical staff during the annual
compliance review period. All six hold a master’s-level degree from an accredited university in
the field of counseling, social work, psychology, or related human services field. The program
maintains a chapter 397 license and the staff are working under the direct supervision of a
qualified professional. Documentation review confirmed all non-licensed mental health clinical
staff who conduct Assessments of Suicide Risk (ASR) received the required twenty-four hours
of training and were supervised in assessing suicide risk, mental health crisis intervention, and
emergency mental health services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Nine youth records were reviewed for mental health and substance abuse admission screening.
All nine youth were administered a Massachusetts Youth Screening Instrument – Second
Version (MAYSI-2) upon admission. All nine records included documentation the screener
reviewed available information to include the commitment packet and existing reports for
documentation of mental health and/or substance abuse problems. There were five different
staff who conducted the MAYSI-2 screenings, and all were trained based on a review of the
Department’s Learning Management System (SkillPro). All nine screenings were completed in
the Department’s Juvenile Justice Information System (JJIS) on the day of admission. Eight of
nine screenings were completed in full. The remaining screening contained an empty referral
check box which indicated a need for further assessment. Seven of the nine screenings
required further assessment. All eligible screenings requiring further assessment were referred
to the DMHCA. The program director ensured an Assessment of Suicide Risk (ASR) was
completed within twenty-four hours for all seven youth. Three of the nine youth were placed on
Precautionary Observation because off the ASR upon admission to the program. Seven of nine
youth records included a MAYSI-2 assessment referral form which indicated the youth were
referred for an ASR along with the reason for each referral. All records contained a referral for a
comprehensive evaluation. The program director developed a policy and procedures for the
implementation of standardized admission/intake mental health and substance abuse screening
process. The policy included the standardized screening process which also included a review
of the commitment packet information, reports, records, administration of the MAYSI-2 in JJIS,
referrals identified by screenings, staff training in mental health and substance abuse issues
and the administration of the MAYSI-2, and a standardized process for referrals of the youth
when identified as in need of further mental health and/or substance abuse evaluation to an
appropriate service provider, or when immediate attention is needed to a hospital or Baker Act
or Marchman Act receiving facility. The program director was interviewed and stated if a youth
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arrives on suicide precautions an ASR is completed. A comprehensive evaluation is also
completed within thirty days of intake outlining all mental health, substance use and self-harm
risks.
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.
Nine youth mental health and substance abuse records were reviewed for the mental health and
substance abuse assessment and evaluation. Documentation review confirmed all nine records
contained a new and combined mental health and substance abuse evaluation for the youth
upon admission. All nine evaluations were completed within thirty calendar days of admission.
All nine records included signed consents for substance abuse services. An informal interview
with the designated mental health clinician (DMHCA) was conducted and they stated consent
for substance abuse services is completed on all youth entering the program. Non-licensed staff
completed the mental health and substance abuse evaluations for eight of nine youth. The
remaining mental health and substance abuse evaluation was completed by a licensed mental
health clinical staff. The eight evaluations completed by non-licensed staff were reviewed and
signed by the designated mental health clinician authority (DMHCA) within ten calendar days
after the evaluation was conducted. All reviewed evaluations included identifying information of
the youth, reason for the evaluation, relevant background information, behavioral observation,
mental status exam, documentation of an interview being administered, discussion of findings,
diagnostic impression which included the Diagnostic and Statistical Manual of Mental Disorders-
Fifth Edition (DSM-V), patterns of alcohol and other drug abuse, risk factor of continued alcohol
and other drug use, and recommendations.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Nine youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All nine reviewed initial treatment plans were developed within
seven days of initiation of treatment. All initial treatment plans were documented on an initial
treatment plan form which included all required elements from the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Three of the nine youth entered the program on
psychotropic medications and all three initial treatment plans included psychiatric needs. Eight
of nine reviewed initial treatment plans were signed by the clinical staff completing the form. The
remaining initial treatment plan was unsigned by clinical staff completing the form. Eight of the
nine initial treatment plans were completed by non-licensed clinical staff, and all were reviewed
and signed by the clinical supervisor within ten days of completion. The remaining initial
treatment plan was developed by a licensed mental health and substance abuse clinical staff.
All initial treatment plans reviewed were signed by the youth, treatment team leader, and
program management. All nine Individualized Treatment Plans and reviews included psychiatric
services. Three youth were admitted to the program on psychotropic medications and the
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remaining six youth were prescribed psychotropic medication after admission. All individualized
treatment plan reviews were completed on a form which contained all elements from the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form.
Eight of nine records contained documentation of treatment plan reviews being completed every
thirty days as required. The remaining record contained a treatment plan review which was
conducted three days late. All reviewed treatment plans and reviews included signatures from
the youth, treatment team leader, program management, living unit representative education,
and medical staff. None of the youth were involved with the Department of Children and
Families. The treatment plan reviews did not contain parent/guardian signatures or signatures of
juvenile probation officers (JPO). Documentation review confirmed parents/guardians and JPOs
participated in the treatment plan reviews by telephone. All dates of the treatment teams
matched the treatment plan review dates. All individualized treatment plans included prescribed
services, goals, and objectives which were individualized for each youth. A review of three
groups on video was observed and revealed all required groups were being held on the
scheduled days at the scheduled times for the correct length of time.
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.
Nine youth mental health and substance abuse records were reviewed for treatment. All nine
records contained documentation confirming the youth was assigned a treatment team upon
arrival to the program. Documentation review confirmed the treatment teams were comprised of
the youth, administration, a representative from the living unit, a medical representative, a
representative from mental health, a representative from education, and parents/guardians. Six
of the nine reviewed youth records indicated the youth required substance abuse treatment
services. The remaining three were not applicable for substance abuse services. All applicable
youth contained a properly executed Authority of Evaluation and Treatment (AET). All youth
receiving substance abuse treatment services had a signed Youth Consent for Substance
Abuse Treatment. All reviewed mental health treatment notes included all elements of the
Department’s Counseling/Therapy Progress Notes form. All nine youth were receiving individual
psychotherapy and/or counseling and psychosocial skills training. A review of the progress
notes revealed all six applicable youth were receiving substance abuse services as stipulated in
the Individualized Treatment Plans. Three closed youth mental health and substance abuse
records were reviewed for discharge planning. Documentation review confirmed all three closed
records contained a discharge plan which was documented on the Department’s Mental Health
and Substance Abuse Treatment Discharge Summary form, all discharge summaries contained
documentation of future services needed, the discharge plan was discussed with the youth,
parents/guardians, and juvenile probation officers (JPO) during the exit conference, and a copy
of the discharge summaries was provided to the youth, JPOs, and parents/guardians.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program is contracted to provide Sex Offender Treatment Services (SO), Mental Health
Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services (SAOS) for those
youth who are assessed and determined to be in need. Juvenile SO treatment groups are
conducted five days a week. MHOS and SAOS treatment groups are conducted four days a
week. Individual therapy is conducted once a month at minimum. Family therapy and psychiatric
services are once a month, or as needed. Documentation review confirmed all nine records
contained the number of times a youth received individual, group, and family counseling on the
individualized treatment plans. Sex offender evaluations, as well as mental health and
substance abuse evaluations are provided to the youth upon admission. Daily therapeutic
activities are provided by mental health clinical staff. Youth with co-occurring substance abuse
disorders receive substance abuse services. The counselor caseloads are limited to twelve
youth. Mental health treatment groups are limited to ten and substance abuse treatment groups
are limited to fifteen youth. The designated mental health clinician authority (DMHCA) is on-site
for forty-hours a week and clinical staff are on-site seven days a week. Sex offender treatment
planning, therapy, crisis interventions, and therapeutic activities are currently provided to the
youth. A licensed psychiatrist provides psychiatric evaluations, medication management, and
participates in treatment planning.
Nine youth were interviewed. Each reported participating in family and/or group therapy. Nine
staff were interviewed. Each staff reported they do not facilitate any mental health or substance
abuse groups. The DMHCA was interviewed and reported individual counseling, family
counseling and group services are provided at the program. The program provides special SO
treatment by a certified juvenile sex offender therapist.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program maintains a policy and procedures addressing psychiatric services. The program
utilizes a psychiatrist who is board certified and has a clear and active license which expires
March 31, 2026. The program also employs a psychiatric Advanced Practice Registered Nurse
(APRN) who holds a clear and active license which expires on April 30, 2026, and is on-site six
hours a week. The psychiatrist is available for emergency consultation twenty-four hours a day,
seven days a week. The psychiatrist provides services and shares information with the
treatment team regarding the status of each youth receiving psychiatric services. The
psychiatrist and psychiatric APRN provide evaluation and treatment recommendations for the
youth in the program. All recommendations are incorporated into the youth treatment plans. The
psychiatric APRN’s credentials were reviewed and matched the information on the Department
of Health website. The Collaborative Practice Protocol is kept on-site and was reviewed with no
issues. A review of the sign in and out logs confirmed the psychiatrist and APRN were on-site
as required by contractual agreement. Nine youth records were reviewed for psychiatric
services. All nine were applicable for review. Three of the nine youth had psychotropic
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medications when they were admitted to the program. The remaining youth were prescribed
psychotropic medications subsequently to admission. All youth were referred for a psychiatric
interview. The Initial Psychiatric Interview was conducted within fourteen days of admission for
all three-youth admitted with psychiatric medications. All nine Initial Psychiatric Interviews
included the youth history, mental status examination, the Diagnostic and Statistical Manual of
Mental Disorders – Version Five (DSM-5) diagnosis, treatment recommendations. Eight of nine
Initial Psychiatric Interviews included youth’s prescribed medications, the explanation for the
need of the medication, target symptoms, initial treatment goals, potential side effects, risk and
benefits of taking the medication, and frequency of medication monitoring and management.
The remaining youth was not prescribed any medications at the time of the Initial Psychiatric
Interview but later requested psychiatric services and was prescribed medications. All nine
interviews were documented on the Department’s Clinical Psychotropic Progress form and
included all information on the Clinical Psychotropic Progress Note (CPPN). The form was
clearly marked “Initial Psychiatric Interview” on each of the interviews reviewed. One of nine
youth had a medication change which was reflected on page three of the CPPN and five of nine
had medications prescribed for a total of eight youth receiving psychotropic medication and
services upon admittance or following the Initial Psychiatric Interview with the remaining youth
receiving prescribed medications later upon request for psychiatric services for a total of nine
youth eventually receiving psychotropic medications. All nine youth received medication reviews
by the psychiatrist or psychiatric APRN every thirty days or as prescribed. Page three of the
CPPNs included the prescription of psychotropic medications for five of nine youth and changes
made to the youth’s medication after the review for one of the nine youth reviewed. All elements
were included on the CPPN forms reviewed for eight of nine youth. The remaining CPPN did not
contain the signature date of the psychiatrist or psychiatric APRN conducting monthly review.
Two of the nine youth applicable for psychotropic medications while at the program are
screened for Tardive Dyskinesia, as required, which was documented in the individual health
care records. The program does not utilize tele-psychiatry. The psychiatrist was interviewed and
reported their role as supervising the APRN. The psychiatrist reported being on-site monthly.
The psychiatrist reported overseeing the APRN’s clinical work as services provided to the
program. The psychiatrist reported meeting with the designated mental health clinician authority
(DMHCA), and program staff as needed and the formalized procedure in place to review
important issues pertaining to youth receiving psychiatric services. are provided as needed and
in person. Face to face or telephonic communication with representatives from the treatment
team is conducted as needed.
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 maintains a policy and procedures addressing the adherence to a suicide
prevention plan which safely assess and protects youth with elevated risk of suicide. The plan
details suicide prevention procedures and incorporates required elements such as identification
and assessment of youth at risk of suicide, staff training, suicide precautions, levels of
supervision, referrals, communication, notifications, documentation, immediate staff response
and a review process. The plan’s review process for suicide attempts and mortality reviews
contains required elements such as circumstances surrounding the event, relevant facility
procedures, all relevant training of involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors and recommendations for change in policy,
training, medical or mental health services and operating procedures if warranted. The suicide
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prevention plan was reviewed and signed by the program director and designated mental health
clinician authority on July 8, 2024.
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.
Nine youth mental health and substance abuse records were reviewed for suicide prevention
services. Six of the nine youth were applicable for review. Two of six youth were determined to
be at-risk through staff observation, two were determined to be at risk through self-reporting,
and the remaining two were determined to be at risk upon admittance. All six youth received an
Assessment of Suicide Risk (ASR), which was documented on the Department’s form. All youth
were placed on constant supervision. Five of six initial ASRs included documentation the
parents/guardians were notified of the youth’s potential suicide risk. The remaining youth was
admitted to the program on constant supervision and was moved to standard supervision upon
completion of the ASR. Documentation review of the ASR’s confirmed all the assigned juvenile
probation officers (JPO) were notified of the risk status for five of the six applicable youth. It was
documented the mental health staff provided supportive services. All six ASRs were completed
by non-licensed staff who work under a licensed mental health professional, and each was
reviewed within twenty-four hours by a licensed clinical staff. One youth was moved to close
supervision after the initial ASR, two youth were moved to standard supervision, and the
remaining three youth were continued on constant supervision. All six ASRs were completed
within twenty-four hours of screening and/or behaviors observed. The non-licensed mental
health staff conferred with the designated mental health clinician authority (DMHCA) and
program director prior to the youth being moved to close supervision. A follow-up ASR was
completed for all three eligible youth prior to each youth being removed from precautionary
observation (PO) and transitioned to close supervision. The reviewed follow-up ASRs were
documented on the Department’s form. All three youth were maintained on the level of
supervision until a follow-up ASR was completed and noted the level of supervision could be
discontinued and stepped down to close supervision. Close supervision was maintained for all
three youth until it was determined to be no longer necessary by the DMHCA and a conference
was held with the program director. Documentation review confirmed the program is following
the written suicide plan. A review of the Department’s Juvenile Justice Information System
(JJIS) revealed all three youth had an alert entered when the youth was placed on PO. This
alert was also closed properly in the system. Documentation review confirmed the program’s
logbooks contained instructions related to the ASR findings and decisions. All youth were
allowed to participate in specific activities while on PO, which was documented in the
designated safe housing portion of each ASR and follow-up ASR. Video observation was not
able to be conducted to ensure youth were being properly observed while on suicide risk due to
the observations occurring outside of the recording capabilities of the surveillance equipment.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
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The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a policy and procedures addressing suicide prevention observation logs
and the proper supervision levels of youth placed on suicide precautions. Nine youth mental
health and substance abuse records were reviewed, and six records were applicable. Each
applicable youth record contained a Suicide Precaution Observation (PO) Log which was
maintained for the duration the youth was on suicide precautions. Appropriate supervision level
and youth behavior was documented in real time and not exceeding thirty-minute intervals for
each youth. Two of six PO logs contained documentation of observed warning signs.
Documentation review confirmed notification for each was provided to the program director and
designated mental health clinician authority (DHMCA). Each PO log was reviewed and signed
by the shift supervisor and mental health clinical staff. Each PO log documented safe housing
requirements.
3.14 Suicide Prevention Training (Critical) Failed 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 maintains three suicide response kits, which include the Knife-for-life, wire cutters,
and needle nose pliers. The kits are in master control. All suicide kits are co-located with first-
aid kits. All eighteen reviewed staff members, nine pre-service and nine in-service staff,
received training for suicide prevention. A review of suicide drills revealed they were reviewed
with staff no less than quarterly on all shifts. None of the drills were simulated with staff during
the annual compliance review period, only reviewed. All scenarios included suicide attempts or
serious self-injury. Due to the drills not being simulated, there has not been practice of
cardiopulmonary resuscitation (CPR) semi-annually.
The program director was interviewed and reported the program provides suicide drills, medical
drills, and safety and security drills. Nine staff were interviewed. Eight of nine staff reported
medical emergency and suicide drills are conducted monthly. The remaining staff reported
having participated in drills one time. An informal follow up interview was conducted with the
program director who reported the program does not conduct simulated drills due to the
sensitivity of the training which may cause emotional distress to some staff members who have
close personal experience as it relates to suicide. This was discussed with the Department’s
Office of Health Services (OHS) and Office of Residential Services who concurred the drills
needed to be simulated.
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3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written Crisis Intervention plan. The crisis intervention plan contains
required elements such as notification and alert system, means of referral, communication,
supervision, documentation, and review procedures.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program maintains a written Crisis Intervention Plan and Emergency Mental Health and
Substance Abuse Plan which outlines the utilization of a Crisis Assessment for evaluation of
youth who are demonstrating acute psychological distress. The program reported having no
youth who were eligible for a Crisis Assessment during the annual compliance review period.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written emergency mental health and substance abuse plan.
Documentation review confirmed the emergency mental health and substance abuse services
plan contains required elements such as immediate staff response, notifications,
communications, supervision, authorization to transport for emergency mental health or
substance abuse services, transport under Baker Act, transport under Marchman Act,
documentation, training, and review.
3.18 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.
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The program did not utilize a Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Nine youth mental health and substance abuse records were reviewed for the safety planning
process for youth. Documentation review confirmed each safety plan was completed within
fourteen days of admission and was jointly prepared by the youth, parents/guardians, and the
program’s clinical staff. Each safety plan incorporated recommendations from previous or
current clinical assessments or screening instruments and incorporated trauma responsive
practices. Seven of nine safety plans were reviewed and updated at least every thirty-days. Of
the remaining two safety plans, one was reviewed six days late and the other was reviewed
fourteen days late on two occasions, ten days late, and three days late. Two of nine safety plans
were eligible for updating after significant behavior or mental health event identified by the
youth’s intervention and treatment team. Each safety plan was reviewed and updated
accordingly. Each safety plan included required elements such as warning signs indicating a
youth was escalating in their behaviors, youth’s baseline behavior gathered from collateral
contacts, parents/guardians, youth history, and evaluations, the youth and program staff’s
perception of verbal and non-verbal stimuli which has positive and negative effects on the youth.
Each safety plan contained jointly developed coping strategies, to include people and healthy
environments as defined by the youth, intervention strategies preferred by the youth, and a
debriefing process. The safety plans were maintained in the youth’s case management record
and within a binder located in master control, easily accessible to all staff.
The program director was interviewed and reported safety plans are updated monthly at
treatment team meetings. Nine youth were interviewed and each of the nine reported
contributing to their safety plans.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a designated health authority (DHA) who is a licensed medical doctor with a
specialty in internal medicine. The DHA holds a clear and active license with a current expiration
date of January 31, 2026. There were no observed disciplinary cases or public complaints on
record. The program does not currently have a backup DHA or an advanced practical registered
nurse; therefore, no requirement for a Collaborative Practice Protocol was applicable. The DHA
is required by contractual agreement to provide services on-site once weekly for two hours. A
review of sign in and sign out logs for the annual compliance review period found evidence the
DHA was on-site as required. The program’s health services administrator (HSA) reported there
is no contract or agreement for tele-medicine or tele-health, and the program has not utilized
this practice for the annual compliance review period. The DHA was interviewed and stated their
role at the program is to conduct sick calls and periodic exams for chronic conditions, as well as
to perform Comprehensive Physical Assessments. They stated they also aid in policy and
procedure development. The DHA reported they are on-site once each week and communicate
with program staff regarding youth medical needs through text and phone. The DHA also stated
the nurse keeps off-site care records on-site and they are reviewed weekly. In addition, weekly
meetings with the nursing staff are performed to review all important medical issues pertaining
to the youth.
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’s medical staff consists of a health services administrator (HSA), who is also a
licensed registered nurse (RN), along with four additional RNs and a licensed practical nurse
(LPN). A review of all nursing licenses found each had a clear and active license, and all within
their date of expiration. The program provides on-site nursing coverage, according to their
contractual agreement, which consists of 120 hours each week. Nursing staff are present 6:00
a.m. until 6:00 p.m. daily. In addition to their current and active licenses, nursing staff records
were reviewed and discovered each held a current certification for Cardio-Pulmonary
Resuscitation (CPR) and First Aid as required.
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 maintains Facility Operating Procedures (FOPs) and medical protocols for all
health-related procedures and protocols utilized at the facility. The designated health authority
(DHA) and program director signed all respective treatment FOPs as required on February 10,
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2025. All additional nursing staff signed indicating a review of all FOPs, healthcare protocols,
and other procedures on February 10, 2025, February 14, 2025, and March 5, 2025. No new
policies or changes in policies were made during the annual compliance review period. A review
of staff records found all newly employed health care personnel hired for the annual compliance
review period received a comprehensive clinical orientation to the Department’s health care
policies and procedures, which were given by the registered nurse as required. All approval of
treatment protocols and standing procedures were written and authorized by the DHA as
required.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of nine medical records were reviewed for Authority for Evaluation and Treatment
(AET) requirements. All contained a copy of the AET filed within the records. For one youth who
was in the custody of the Department of Children and Families (DCF), there was an active court
order which provided legal authorization for medication administration and authorization for
treatment and procedures. All applicable records included evidence the parent/guardian signed
the AET as required. All AET’s included evidence of a signature by a representative from the
Department. All AET’s were valid. The health services administrator (HSA) was interviewed and
stated obtaining a new AET for youth is done so through contact with the youth’s juvenile
probation officer (JPO). In addition, for youth who are eighteen years of age, the assigned case
manager will have the youth complete consent forms as needed.
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.
Nine total healthcare records were reviewed for parental notification/consent requirements. Two
of nine records were applicable for requiring notification for over the counter (OTC) medications
beyond those covered by the Authority for Evaluation and Treatment (AET). Both applicable
records contained documentation of the required parental notification or these medications.
Consent was provided by the parent/guardian. For eight of nine youth, there was evidence for
any new medication ordered and there was documentation of attempted contact to the
parent/guardian in the progress notes. For the one remaining record, there was no
documentation of contact attempts made. All written notifications were sent utilizing the
Department’s Parental Notification of Health-Related Care: General or Parental Notification of
Health-Related Care: Medication forms. In addition, the Acknowledgement of Receipt of the
Clinical Psychiatric Progress Note (CPPN) page three form was also used for all applicable
records reviewed. For all applicable records reviewed, there was evidence staff witnessed all
telephone call attempts and conversations for psychotropic medications. Whenever a new
psychotropic medication was prescribed, discontinued, or dosage change made, there was
evidence page three of the CPPN was completed and utilized as required for all youth reviewed
when providing parental notification. For all nine records reviewed, there was evidence each
youth vaccinations were verified by nursing staff upon admission to the program. No further
vaccinations were required for any of the youth reviewed thus no consent was required to be
obtained. None of the youth reviewed were applicable for religious exemption from
immunization. The health services administrator (HSA) was interviewed and stated
vaccinations/immunization records are verified through a review of Florida Shots. The HSA
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stated most youth who enter the program have their immunization records sent with them, if not,
nursing staff will review Florida Shots to obtain the information. The timeframe for reviewing the
immunization records is to be done within thirty days form admission.
The HSA was interviewed and stated parental notifications are made if any changes in
medication or status of the youth, and any new orders received. Management of timely
notifications are made by oversight from the HSA. If emergency medical services are required,
9-1-1 may be contacted and the youth is transported to the emergency room. The
parent/guardian is then contacted as well as the designated health authority (DHA). When
obtaining consent for a new psychotropic medication, discontinuance, or adjustment,
parent/guardians are contact by phone and a witness is required. This is then documented in
the progress note and a parental notification form is sent to the parent/guardian. The process for
documenting parent/guardian exemption from immunizations is made on the immunization form.
Generally, only thirty minutes may pass prior to a nurse seeing a newly admitted youth. Nursing
staff are notified of a youth admission by the case manager who provides the commitment
packet.
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.
Nine youth healthcare records were viewed for Healthcare Admission Screening and Re-
Screening requirements. All nine youth records contained a Facility Entry Physical Health
Screening Form (FEPHS) completed on each youth’s date of admission. All were completed by
a registered nurse (RN). Three of nine youth required a new FEPHS form due to a change in
physical custody greater than twenty-four hours. For each of these youth, there was evidence
the program completed a new FEPHS re-screening as required. The health services
administrator was interviewed and stated, in the event there is a change in the physical custody
of a youth, the FEPHS is completed again.
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.
Nine youth healthcare records were reviewed for orientation to healthcare services and
healthcare education. Healthcare orientation topics included all required healthcare orientation
information. Youth sign all orientation sheets which were included in their healthcare record. In
addition, the program utilizes an education/orientation binder to ensure all required orientation
topics were reviewed with the youth. Eight of nine reviewed records found evidence of the
signed form by the youth. For the one exception, the youth signature page was not included in
the record. A review of the program’s contractual agreement determined health education is
conducted monthly in recurring cycles. The program’s health services administrator (HSA)
stated every youth receives all required health education/orientation upon admission, and then
every month a topic is selected and discussed in a group setting with all youth on monthly
recurring cycles. A review of health education topics included all required information with the
exception of seatbelt usage. The topic of prenatal, postpartum, and parenting education was not
applicable for the all-male population serviced by the program.
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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.
Nine youth healthcare records were reviewed for notification requirements for the designated
health authority (DHA). According to an interview with the health services administrator (HSA),
for all youth upon admission, regardless of their medical condition, notification to the DHA is
made by the nursing staff on-site, and documentation of this notification is made in the progress
notes of the healthcare record. For all nine records reviewed there was evidence the DHA was
notified upon each youth admission. For all applicable youth with suspected chronic condition,
there was evidence a referral was made to the DHA. None of the nine reviewed youth needed
emergency care upon their admission. Three of nine youth were applicable for taking
psychotropic medication upon admission. For these three youth, there was documentation the
psychiatrist was notified upon their admission. The HSA was interviewed and stated the DHA is
notified by nursing staff upon admission for all youth. These notifications are documented in the
progress notes.
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.
Nine youth healthcare records were reviewed for Health-Related History (HRH) completion
requirements. All youth had a completed HRH done at the time of their admission. Each HRH
was completed prior to the youth’s Comprehensive Physical Assessment (CPA) focused
evaluation as evidenced by signature and date. The health services administrator was
interviewed and stated the HRH is completed by nursing upon each youth admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
Nine youth healthcare records were reviewed for completion requirements of the
Comprehensive Physical Assessment (CPA). All CPAs were completed using the Department’s
CPA form. Each of the nine records contained a completed CPA form. The health services
administrator (HSA) was interviewed and reported the designated health authority (DHA)
completes a new CPA for all youth. Each of the nine youth records reviewed had a current CPA
on file at the time of their admission; however, a new one was completed by the program’s DHA
within seven calendar days of admission to the program for eight of the nine youth reviewed.
For one youth, the CPA was completed eight days after the youth admission. The medical grade
for each youth was documented on the CPAs reviewed as required. No missing elements were
noted on the forms completed. All sections of the CPAs reviewed were marked with an “O” or an
“X” and completed as required. Further details of items marked with an “X” were noted in the
applicable sections by the DHA. Parts of the exam which were refused by the youth were noted
as required on the CPA. All nine youth records indicated the youth refused a portion of the CPA
exam, which matched the exam dates. The required refusal forms were found in each of the
nine records reviewed. Each record contained a Problem List which was updated as required.
For all nine records, there was evidence there was at least one verified Tuberculosis Skin Test
(TST) documented within the last year. Results of each TST documented on the CPA and
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Office of Accountability and Program Support Page 40 of 65 (Revised September 2022)
Infectious and Communicable Disease (ICD) forms matched for all nine reviewed records. The
HSA was interviewed and stated the DHA completes a new CPA every two years for youth with
a medical grade of one, and one year for youth with a medical grade of two through five. TST
screenings are to be done annually. Youth are screeded for Sexually Transmitted Infections
(STI) diseases using the STI screening form. If screening indicates the need for further
evaluation, this is indicated on the STI form and admitting order from the DHA.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
Nine youth healthcare records were reviewed for Sexually Transmitted Infection (STI)
Screening/Human Immunodeficiency Virus (HIV) screening requirements. Each record
contained evidence the youth were all screened and evaluated for STIs. Each youth was
referred to the designated health authority (DHA) as required. Referrals were documented on
the STI screening tool. Screening was completed by the DHA for all nine youth. Testing was
ordered and performed for eight of nine youth. For one remaining youth, the testing was not
required and not ordered by the DHA. Documentation indicated the youth had recently been at
the detention center and had been recently screened and refused to be screened again.
Screening and testing results for the eight applicable remaining youth were documented using
the Infectious and Communicable Disease (ICD) form and filed in the lab section of their
healthcare records. None of the nine reviewed youth required re-screening. There was evidence
in eight of nine records the youth were offered counseling, testing, and treatment (if indicated)
for HIV. For one remaining record, the consent form was not discovered. For all nine
interviewed youth, each youth confirmed they can ask for and receive testing for HIV if they
choose. Only one of nine reviewed youth consented to the HIV testing. For this one record,
there was evidence the youth received the HIV testing. Documented consent from the youth
was obtained and located within the record. The health services administrator (HSA) stated HIV
pre/post-test and counseling services are provided by an agreement with Oasis. HIV results
were filed confidentially as required. Documentation of the pre/post-test counseling was noted in
the healthcare records and in the progress notes. Youth confidentiality was protected by not
including the youth’s HIV status and any other STI diagnosis based on a review of the
program’s internal medical alert system. The program has a policy and procedures which
notates youth confidentiality and disclosure of test results. The policy indicates confidentiality of
the youth's request for actual testing and/or results is of paramount importance. All paperwork
associated with this process initiated in the facility will be maintained in the youth's permanent,
confidential, and locked medical record. Specifically, the DHA’s, written contractual agreement
prohibits them from divulging confidential information on any mutual client. Any transgression of
the confidentiality agreements by staff or providers will result in immediate termination of any
contractual obligation or employment. The health services administrator was interviewed and
stated STI screenings are documented on the Infectious and Communicable Diseases (ICD)
form. In the event a youth is out of the Department’s physical custody for more than thirty days,
a new Comprehensive Physical Assessment (CPA) and admission packet is completed. HIV
testing results are noted in the lab tab of the youth healthcare record. Youth verbalize they want
to be tested for HIV and Oasis comes to the program to provide the service, which includes
testing and pre/post-test counseling. This process is documented in a nursing note. Each of the
nine interviewed youth all confirmed they are able to ask for and receive testing for HIV.
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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.
Nine youth healthcare records were reviewed for sick call process. Four of the nine youth
reviewed had not ever completed a sick call or participated in the formal sick call process. The
five remaining records were reviewed for completion requirements. For all five applicable youth,
there were a total of thirteen sick calls reviewed. None of the five reviewed records indicated the
youth presented with similar sick call complaints three or more times in a two-week period. For
all five records, the youth completed the Sick Call Request forms. Licensed nursing completed
each sick call form as required. For one sick call reviewed, the program’s licensed practical
nurse (LPN) conducted the sick call, and a review was conducted after by the registered nurse
(RN). Sick Call Request forms were filed in the youth’s healthcare records in reverse
chronological order. No youth were noted as being in restricted housing. Sick call forms were
documented in accordance with Health Services Rule as required. The program’s sick call index
dates corresponded with the completed sick call forms in the records. The sick call index
documented sick calls as required with one exception. For one youth, the sick call index noted a
sick call occurring on July 3, 2024, but the sick call form was not found for the date in question.
The progress notes did, however, notate the youth was seen on July 3, 2025, by medical staff
and treated for a medical complaint. The program’s health services administrator (HSA)
reported the youth was brought up to medical by staff and did not place a formal written Sick
Call Request form. The program maintains a sick call referral log in a separate binder. A review
of this log found sick calls were documented with the following exceptions: For one youth, the
sick call was documented as conducted on one date, but the sick call referral log notates it as
three days later. One of thirteen sick call incidents reviewed was not documented on the sick
call referral log. Sick calls are provided between 11:00 a.m. and 2:00 p.m. daily, as confirmed by
an interview with the HSA. The HSA stated youth complete a Sick Call Request form and turn it
into the staff and the staff bring the youth to medical to be seen. Sick Call Request forms were
observed in the cafeteria in a marked box, along with a drop box for youth to place completed
forms. The box is checked daily by staff. The provider’s contractual agreement indicates sick
calls are provided twice daily and seven days a week and may not conflict with school hours.
The program’s HSA stated only licensed nursing staff conduct sick calls for youth. Sick call
instructions were observed to be posted in each of the youth living area dayrooms. Nine youth
were interviewed. One of nine reported they have not requested a sick call. Two of nine
reported they can be seen immediately by nursing staff once a sick call is requested. Five of
nine reported they are seen within one day. One of nine reported they are seen within three
days. A sick call was observed during the annual compliance review week. The youth was
escorted to the medical area by direct care staff. The medical provider was a registered nurse
(RN) who identified themselves and stated why the youth was there. The youth was seen in the
medical office with the direct care staff sitting outside around the corner of the room with no
other youth present and able to hear or see the examination. The youth was examined by the
RN.
The HSA was interviewed and stated healthcare staff routinely conducts sick calls for youth.
Youth can complete a sick call request. The designated health authority (DHA) may conduct
sick call when they are on-site. Sick calls are conducted in the nursing area of the program. If a
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Office of Accountability and Program Support Page 42 of 65 (Revised September 2022)
youth is presented with repeated sick call requests, they are placed on a list to see the DHA. If a
youth is in restricted housing, nursing will go to the area with direct care staff.
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.
Nine youth healthcare records were reviewed for episodic/first aid/emergency care. Five of the
nine records were applicable for having had an indication the youth required on-site first-aid or
episodic care. In each of the five sampled incidents, the youth were provided care by the
licensed medical professional and not a non-healthcare staff. On-site care was documented
using standard narrative charting. The program has a policy and procedures for Episodic and
Emergency Care. The program’s health services administrator (HSA) stated the facility has a
total of six first aid kits. One is used for each vehicle when transporting youth. All kits are
located in master control. Kits were stocked with all designated health authority (DHA) approved
items. A total of three kits were opened and inventoried. All three had all items as indicated on
the inventory form. All items were within their date of expiration. The HSA stated nursing staff
checks all first-aid kits and the automated external defibrillator (AED) monthly and documents
these checks on the corresponding monthly checks form which are compiled in a binder located
in the nurse’s office. The program has one AED which is also located in the master control
room. The instructions were observed within the device. Both the device’s pads and battery
were within their date of expiration. The nursing staff was observed conducting a self-test on the
AED, with no issues observed. The last date the battery and pads were changed was
documented for May 27, 2024. The current date of expiration on the battery is September 30,
2028. The expiration date for the pads is January 26, 2026. The medical office contains a list of
emergency numbers, including the Poison Information Center, posted and accessible for non-
licensed staff, but inaccessible to youth. The HSA trains approved staff for use of the
epinephrine auto-injector. Nine of nine in-service staff training records indicated all staff were
trained regarding episodic first aid and emergency care. The program provided documentation
of quarterly medical drills completed for both shifts for the scope of the annual compliance
review. A video of the medical drill was unable to be completed due to no drill having been done
for the last thirty-days. Reviewed drills indicated usage of the epinephrine auto-injector,
cardiopulmonary resuscitation (CPR) and AED. Direct care staff participated in at least one drill
which included the use of CPR annually. An episodic care event was unable to be reviewed
during the annual compliance review week. All staff with direct contact on a day-to-day basis
could participate in at least one emergency man-down drill annually. The HSA reported the
program currently has no Narcan on-site. The program also has no current policy and
procedures addressing Narcan. The program has contacted the Department’s Office of Health
Services (OHS) and are in the process of working to get policy approval in this area. Nine staff
were interviewed. Seven of nine confirmed they are authorized to call 9-1-1 in the event of an
emergency. The remaining two staff reported they would contact either master control personnel
or the supervisor as they do not carry telephones with them. Nine of nine interviewed youth
each confirmed they can see both the doctor and dentist if needed. The HSA was interviewed
and stated on-site episodic care is documented in the progress note in subjective, objective,
assessment, plan format. Non-healthcare staff complete the Non-HealthCare Staff form. Youth
are tracked on shift-to-shift nursing reports when youth are sent off-site for emergency care. The
HSA stated medical drills are done quarterly at a minimum.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Nine youth healthcare records were reviewed for off-site care or referrals. Three of nine were
applicable, showing indication the youth required off-site care. For all three, the Summary of Off-
site Care Consultation Report form was utilized and filed in the record. None of the three
incidents were regarding emergent care. Parental notification efforts were observed
documented as required in the records reviewed. Discharge and other applicable
documentation were also filed within each applicable record. There was evidence the program’s
designated health authority (DHA) reviewed and initialed all off-site care findings, instructions,
and information. For youth who required follow-up testing and appointments, there was
evidence in the records where these were tracked, and the youth made all appointments as
required. The health services administrator was interviewed and stated ensuring the DHA is
reviewing and initialing all off-site care findings is made though chart audits. Nursing staff track
follow-up testing, referrals, and appointments using a master roster.
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.
Nine youth healthcare records were reviewed for chronic conditions and periodic evaluations.
Three of the nine were applicable for having been identified on the Facility Entry Physical Health
Screening (FEPHS) form with a current chronic condition. All were classified as required with
the current medical grade. All three youth were placed on the program’s chronic illness list.
Each youth record contained documentation of periodic evaluations at least every ninety-days
as required. None of the youth were applicable for requiring anti-tuberculosis (TB) medication.
None of the periodic evaluations were conducted off-site. There were no lapses in care or
missed periodic evaluations. The Department’s Problem List for all three youth were
documented and updated as required with one exception noted. For one youth, the youth was
identified with seasonal allergies and asthma; however, only the asthma was noted on the
Problem List. The designated health authority (DHA) was interviewed and stated the nursing
staff tracks chronic conditions, and the youth is seen every ninety-days or less. The program
director was interviewed and stated medical issues and formalized procedures regarding
medical concerns are reviewed with medical staff, along with medical notes and charts as well
as juvenile justice information system daily. The health services administrator was interviewed
and stated youth with chronic conditions are monitored through the chronic clinic.
4.16 Medication Management Failed 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.
Nine youth healthcare records were reviewed for medication administration and medication
management requirements. The Facility Entry Physical Health Screening (FEPHS) forms were
reviewed. Five of nine youth did not enter the program on medication, according to their
FEPHS. Three of nine FEPHS forms correctly identified youth who came into the program
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already on prescription medication. One remaining youth entered with medication; however, it
was not noted on the youth’s FEPHS as required. All prescription verifications were included in
each youth’s progress notes. For all applicable records, there was documentation the
designated health authority (DHA) ordered the specific medications to be resumed upon
admission. All nine youth healthcare records indicated all the youth currently are taking
prescribed medications at the time of the annual compliance review. All nine youth are currently
classified as a medical grade five. All medications have a current, valid order, and administered
pursuant to a current prescription. Orders are placed on the practitioner order form. None of the
youth were applicable for restricted housing. Two of the nine youth records were applicable for
having had administered over the counter (OTC) medications not listed on the Authority for
Evaluations and Treatment (AET). For these two records, there was evidence the OTC
medications were administered according to approved protocols. The program uses the pre-
printed pharmaceutical Medication Administration Record (MAR).
MARs were reviewed for all nine youth from the date of their admission to the current date of
review during the annual compliance review week. None of the reviewed MARs contained the
youth’s medical grade, and not all MARs included clear and consistent start and end dates for
all medications. The MARs included all remaining required elements. One of nine youth records
had evidence some medications were administered to youth by trained non-healthcare staff. For
this one applicable youth, ibuprofen was given by the non-healthcare staff on three occasions.
The staff completed the Report of On-Site Health Care by Non-Healthcare Staff form, which was
filed in the youth’s healthcare record. There were no initials on the MAR itself by the youth or
staff for this medication administered any of the three times given.
Undocumented lapses in medication administration were observed in a total of three of the nine
youth records reviewed. Thirteen total lapses were identified for the combined three records.
Two youth had one each on their MAR and one youth had a total of eleven. A review of these
MARs found either a gap in medication delivery schedule with nothing marked, or a “O” marked
in the designated area, but no refusal noted or staff initials. No refusal forms were found in the
records for these identified lapses. The program’s health services administrator (HSA) was
asked about the lapses and stated this was due to youth refusal of medication; however, no
refusal forms were found and no “R” was noted in the designated areas for the dates in
question. Weekly side-effect monitoring was documented consistently for seven of nine youth
records. Two youth had exceptions identified where the weekly side-effect monitoring was not
consistently documented for two months. None of the nine youth records indicated youth
required parenteral medication. All nine youth currently have psychotropic medication
prescribed. Documentation found the designated health authority (DHA) was notified for each
youth admission. Three of the nine youth reviewed were noted as taking psychotropic
medication at the time of their admission to the program. For these three youth, there was
evidence an initial diagnostic interview was conducted by the psychiatrist within fourteen days of
admission. For all nine youth currently taking psychotropics, there was evidence each received
medication monitoring/review every thirty days as required.
The HSA reported they have no standing orders, pro re nata (PRN) orders, or emergency
treatment orders for psychotropic medication. An observation of a medication pass was made
during the annual compliance review. Youth consent was obtained prior to observations being
made. The youth was escorted to the medical area by a supervisor floor staff. The youth was
seen approaching the nurse individually and the nurse identified themselves and stated shy the
youth was there. The same nursing staff verified the youth’s allergy and alert status and
provided medications. The youth was observed to ensure medication was swallowed. The Six
Rights of Medication Delivery/Administration was verified. Each of the nine interviewed youth
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confirmed the nurse gives them their medication. All nine were able to summarize the
medication administration process. The HSA was interviewed and stated nursing verifies youth
medications during admission by contact with parents/guardians, detention centers, and the
FEPHS. Non-healthcare staff may provide medication to youth with permission once they are
trained to do so by nursing staff. The list of authorized staff is posted in the nursing area.
Medication pass times are at 7:00 a.m. and 5:00 p.m. All medications are received from a
community pharmacy. The program uses a psychiatrist who is on-site bi-weekly.
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.
The program’s medical office areas were observed for medication management, inventory, and
storage processes. A review of inventories found medical equipment classified as sharps were
secured and inventoried utilizing a routine perpetual inventory descending count as each sharp
was used and disposed of. All medications were identified and secured in the locked area
designated for storage of medications. Different medications such as injectables, topicals,
drops, and liquids were stored separate. The program’s medication cart was clean and
organized with stock items separate form youth-specific medications. All controlled substances
have a perpetual inventory and were stored separately from other medications. All medications
were stored in a locked area inaccessible to youth. Controlled medications were stored behind
two locks as required. Medications requiring refrigeration were stored in a secured refrigerator
used for medication only. The program has a procedure for destruction and disposal of expired
or discontinued medications; whereas, two registered nurses (RN) verify the medication has
expired or been discontinued and document the amount remaining prior to disposal. If the
medication needing disposal is a controlled medication, the RN and pharmacist must verify,
document, and sign prior to disposal. Pursuant to Board Pharmacy regulatory requirements,
there is a documented shift-to-shift inventory count of all controlled substances documented on
the youth’s Individualized Controlled Medication Inventory Record. Each of the nine non-
healthcare in-service staff training records were reviewed and determined these staff have been
trained in the delivery and oversight of medication self-administration. Training was provided by
the RN. An inventory of three controlled medications, three over-the-counter medications, and
three sharps was completed and determined the final count for each, matched the actual count
observed on documentation provided. There were no discrepancies identified. Shift-to-shift
counts were made for controlled substances inventoried. In the event a count discrepancy is
determined, the RN stated they will be responsible to re-count the medication and review the
Medication Administration Record (MAR) to see if the medication or item was used during the
previous shift, then notify the health services administrator (HSA). The HSA stated a copy of the
pharmacy consultant license is maintained on-site in the nursing area. The pharmacy consultant
is on-site quarterly.
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.
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The program has infection control procedures in place which include prevention, containment,
treatment, and reporting requirements related to infectious diseases, as according to
Occupational Safety and Health Administration (OSHA) federal regulations and Center for
Disease Control (CDC) guidelines. These were documented as reviewed by the program
director and designated health authority (DHA) on February 10, 2025. The program’s infection
control procedures include all required elements. Staff have access to protective equipment
such as gloves, masks, and spill kits. Items were identified in first aid kits provided at the
program. The program had no related instances for the scope of the annual compliance review
in which the local county health department, CDC, and the Department’s Central
Communication Center (CCC) should have been notified of an infectious disease. The program
director reported they have had no incident where a facility occupational exposure occurred for
the scope of the annual compliance review, but in the event, this occurs, they have a separate
filing area to include the information. The program has an exposure control plan which is written
in accordance with OSHA standards. The plan is made available to all staff. The plan was
reviewed and signed by all required parties on February 10, 2025. In the event of a needle-stick
exposure, the plan indicates notification to the supervisory staff immediately, complete an
incident report, and obtain the name and date of birth of the youth. Employees are to report the
incident to Worker’s Compensation to receive the Hepatitis B vaccine within twenty-four hours of
exposure. There have not been three or more cases of any reportable infectious diseases which
needed to be reported to the local county health department or CDC. The program director was
interviewed and stated the program’s exposure control plan in made available to staff in the
control room. The HSA was interviewed and stated infection control training is facilitated by the
training coordinator. The HSA was interviewed and stated the Exposure Control Plan is
available for staff. Infection control training is provided to youth upon their admission.
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 writtepolicy and procedures which indicates staff shall promote safety and
security by maintaining active supervision of youth to include interacting positively with youth,
engaging youth in a full schedule of constructive activities, closely observing behavior of youth
and changes in behavior, and consistently applying the program’s behavior management
system. Supervision of youth was observed each day of the annual compliance review week.
The program was adhering to the daily activity schedule. Youth were observed in line
movements, participating in recreational activities, sitting in education classes and groups, and
being searched by staff. One observation was made witnessing a youth being escorted back to
school by the nursing staff and no program staff. This was discussed with program
administration and determined it was not a normal practice. Youth were seen engaged in
activities. Staff to youth ratio was at, or within, the required ratio of one staff to every eight
youth. Three staff were randomly asked the number of youth they were currently supervising, all
three staff were able to provide the exact number of youth under their supervision. The program
has a daily activity schedule which was observed posted in each youth living unit. Video
observation of youth supervision indicated the youth were watched while inside their dorm
rooms at night sleeping. Observation of youth rooms did not indicate any window coverings or
obstructions.
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 behavior management system (BMS) which was developed and
implemented by all appropriate parties. The program’s written policy and procedures include
protocols where staff are provided feedback regarding implementation of the BMS. The program
has an agreement between them, and the education Department related to BMS. The program’s
licensed clinical social worker (LCSW) provided documentation which reflected refresher
training for all staff, to include education staff, in the BMS. Each of the nine reviewed case
management records included documentation of orientation for each youth on the program’s
BMS. A sample of five different position descriptions were reviewed which confirmed staff job
functions included implementation of the BMS. Each of the nine staff training records reviewed
also included evidence each staff received training in the program’s BMS. Postings of the
program’s BMS was observed in youth living areas and student handbooks. Youth handbooks
include rules governing conduct and positive and negative consequences. The BMS is operated
under a token economy system where youth earn points and increase their levels in the
program, thus earning various rewards and privileges. Copies of completed point sheets for
youth were observed in each of the nine youth case management records reviewed. According
to the program director, the BMS has not changed. The BMS includes all required information
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such as protecting youth rights, and promoting safety, respect, and fairness, and providing a
process for explaining to youth the reasons for any sanctions imposed and giving youth the
opportunity to explain their behavior. The program’s BMS does not include increased length of
stay, promotion of group discipline, disciplinary confinement, or punishment of youth by other
youth. The program’s BMS includes rewards and incentives such as movie night, token store,
bingo night, snacks, special meals, and off-site trips. An incentive calendar was observed
posted in each youth living area which showcased different incentives and rewards for each day
of the month. The program director was interviewed and stated the program uses a token
economy system based on positive rewards for good behavior. All youth have an opportunity to
earn points through time periods of the day, and once the points are earned, they cannot be
taken away. Each youth is given tokens based on these points, if they are not on suspension,
which can be used to purchase things such as point store items and game/movie attendance.
The program director and clinical director monitor all rewards and consequences. The have
larger incentives at a minimum of four times a week. All consequences are reviewed by the
program director. The program director further stated the monitoring of staff implementation of
the BMS is done through a review of point sheets, real time review of token distribution, training,
evaluations, and briefings. Nine staff interviews were conducted. All staff confirmed they have
received training in the BMS. Eight of the nine staff were able to summarize the program’s BMS,
the remaining one staff was newly hired and stated they are still learning the process. All nine
staff were able to give examples of rewards youth may earn such as point store, risk outings,
special meals, and work out times. All nine staff reported nothing is taken away from youth as
result of a consequence received. Youth are informed of consequences through disciplinary
review court, verbal warnings by staff, where youth can explain their behaviors. Nine youth were
interviewed concerning the program’s BMS. All nine were able to give examples of
consequences, as well as rewards through the program’s BMS. Each youth was able to
summarize the program’s BMS and level system. Eight youth stated they are never allowed to
punish other youth, one youth stated other youth can punish youth through the peer advisory
board where they may recommend a youth receive a disciplinary referral. Eight of the youth
stated the staff is consistent with BMS, while one youth stated staff favor other youth.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a total of 112 cameras, all of which were reported to be working at the time of
the annual compliance review. Video recordings are stored for up to thirty days. The program
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staff are required to conduct youth observations for each youth while in their assigned room
every ten minutes at a minimum. Staff utilize a flashlight when making rounds conducting these
ten-minute observation checks of youth. Nine staff interviews were conducted. Eight staff
reported these checks were done at ten-minute increments; one staff reported the checks were
completed every two to three minutes. A review of nine separate dates and times of video
observations were made to confirm the fidelity of these checks. All corresponding visual
observation logs for these selected times were also reviewed and compared with the video. All
nine were observed with staff conducting the checks as required. Staff were seen pausing
briefly, using a flashlight, to observe the youth when in their rooms. In addition to video
observations, visual observation check sheets were reviewed for a thirty-minute increment from
each month of the annual compliance review period. There were no issues observed for the
samples reviewed. Documentation of ten-minute checks were completed as required. Staff
initialed beside the times noted for each entry.
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 written policy and procedures addressing census, counts, and tracking of
youth. The program conducts formal, unscheduled, and emergency counts of youth, as well as
documents all youth movement in the master control logbook. Observations of formal
headcounts were observed during the annual compliance review period. The master control
operator was observed calling for a headcount on the radio. All staff responded, and the master
control operator was observed clearing the headcount and documenting this in the logbook. A
review of all logbooks for the scope of the annual compliance review was conducted. One full
day each month of the annual compliance review period was reviewed, which confirmed counts
are done as required. Counts of youth were observed to be documented at the beginning of
shifts, after outdoor activities, during emergency situations, upon new admissions or releases,
and when youth were temporarily away from the program. Youth movement is documented
when youth move from one location to another within the program. Nine interviewed staff all
confirmed counts are made throughout each program day. All nine staff were also able to
explain when emergency counts are conducted, such as times of escape, power outage, or
inclement weather conditions. Three informal staff interviews were also done, where each staff
was able to give the exact number of youth under their direct supervision at the time they were
questioned.
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.
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The program maintains one master logbook which is in the master control room. The master
control room operator is responsible for documenting daily activities, census information, and
other pertinent information in the logbook. A review of logbooks for the annual compliance
review period was done, which confirmed this practice. All entries were made in ink with no
erasures or white-out areas. Errors were drawn through with a single line. Entries were made
with dates and times of the events with the name of youth involved, brief descriptions of the
events, and either the staff initials or signatures at the end signifying who made the logbook
entry. No pages were observed to be destroyed or removed. Logbooks were bound with
numbered pages. A review of the logbook documented activities were completed as scheduled.
In addition to the logbook, the program maintains a shift pass on report which is used for shift
briefings prior to shift change. These reports were observed for the scope of the annual
compliance review, which confirmed the practice. Shift pass on forms are maintained in the
administration building, as well as in each living unit. A review of these reports found incoming
staff are briefed on the daily events such as youth population counts, remarkable/significant
events, youth on special precautionary status, transports schedules, admissions/releases, and
number of staff on duty. Observations of staff signatures were made for these forms indicating
the staff had been briefed on these program events.
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 written policy and procedures addressing key control, to include key
assignment and usage, inventory of keys, secure storage of keys, and reporting procedures for
replacement and damaged or missing keys. The program maintains a list of staff who have
been issued/assigned permanent keys. These staff include the program director, assistant
program director, human resources staff, and maintenance staff. All other program keys are
maintained in a locked key box within master control. Upon arrival to the program, the master
control operator receives the staff’s personal keys, and they are exchanged for their work keys.
These keys are assigned and documented by the key account number on the Daily Key Log
form. The form indicates who received the keys, the key number, and the date and time in and
out of the keys. In addition, visitor keys were also observed taken up each day of the annual
compliance review. The visitor keys are also stored in the key lock box. The master control
operator was interviewed and stated in the event a key is broken, it is turned in to the
maintenance staff for replacement. Should a key go be missing, the supervisor and
maintenance are notified immediately. Master control also stated restricted keys include mental
health and medical keys and supervisory keys. A review of the Department’s Central
Communications Center (CCC) report information for the annual compliance review period
found no incidents of missing or lost keys being reported. Program keys were all on a tamper-
resistant key ring with a chit, which includes an engraving showing the key assignment number
and number of keys on each ring. A sample of five key rings were reviewed and compared with
the daily key inventory and the key chit number on each ring. Each of the five sets of keys were
present on the inventory and included the correct number of keys which corresponded with the
number on the chit. Three random staff were asked to present their work keys for review. Each
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staff had the set of keys assigned to them, which corresponded with the Daily Key Log form for
the shift the keys were assigned. Each set of keys matched the number of keys engraved on the
key ring. Each staff was familiar with the usage of each key on the ring. Nine interviewed staff
were able to summarize the program’s key control process and stated youth do not have access
to any keys.
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 written policy and procedures which addresses contraband and searches of
staff, youth, and facility grounds and areas for contraband related items. The program provides
youth with a list of contraband through their student handbook. Each youth receives a copy of
the handbook as part of their orientation process. The program’s system to prevent contraband
also includes searching youth incoming and outgoing mail. The search of mail was also
confirmed by the case manager supervisor. The program’s policy and procedures also address
any staff who is found in possession of contraband in the program will be subject to disciplinary
action up to and including dismissal, which will include all supervisors and administrators. In the
event illegal contraband is discovered, law enforcement will be contacted. The program
delineates all required items considered contraband. The program documents confiscation of
contraband on Search Reports. These searches are done by administrators and supervisors
randomly and multiple times each month, covering all program and youth living areas.
Documentation of these completed Search Reports were observed for the annual compliance
review period which confirmed the program’s practice. Confiscation of contraband is
documented on these forms. In addition, a review of logbooks found perimeter checks were also
documented. Checks are done in the morning by assigned program staff. A review of the
Department’s Central Communications Center (CCC) report information for the scope of the
annual compliance review found no incidents with illegal contraband discovered; however, there
was one incident reported where a vape pen was reported to be in the possession of a youth
and brought into the facility by staff. Law enforcement was contacted at which time the vape pen
was disposed of, and the staff was terminated. The items were reportedly discarded by
administration. Nine interviewed staff all confirmed youth room searches are conducted at
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various times in the program. The program director was interviewed and stated all reportable
contraband is reported to the CCC and law enforcement. All other contraband is discarded.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures addressing searches of youth and staff in the
program. Youth searches are conducted prior to youth moving from one location to another
throughout program areas. During the annual compliance review, youth searches were
observed to be conducted by a staff of the same gender. Youth were treated with dignity and
respect. These searches were done prior to youth moving from the classroom to the recreation
yard area. Each of the nine interviewed staff confirmed youth searches are done at every
movement. Each of the nine interviewed youth reported these searches are done at times such
as returning from off campus activities, after outdoor activities, after visitation, after meals, and
after work detail. Video observations indicated all youth, staff, and visitors were searched upon
entering into the facility. Pat searches of the person, bag searches, and a wand device used to
detect metal was observed being utilized.
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 two vehicles used to transport youth. The annual safety inspection was
completed for one of the two vehicles. . Both vehicles were secured when not in use. Both had
approved fire extinguishers, seat belt cutter, window punch, and appropriate number of seat
belts. An approved first aid kit accompanies staff in the vehicle during transport. These kits are
maintained in the master control room when no transports are occurring. Both vehicles were
observed to be clean. A random inspection of five staff personal vehicles was also done and
found each was secured as required. Each of the nine interviewed staff all reported they use
seatbelts to secure youth within the vehicle during transports. Nine youth were interviewed.
One stated they have not been in a vehicle. Two did not provide a response during the
interview. The remaining six interviewed youth reported they use seatbelts during transports.
Three of the interviewed youth also reported they also wear shackles while transported.
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 written policy and procedures regarding the transportation of youth. Youth
are not permitted to drive staff or program vehicles. Program staff are provided a cellular phone
when transporting youth off campus. At least one staff of the same gender as youth is required
to be present during transporting youth. The program’s policy indicated a one staff to five youth
ratio when transporting youth. A transport was unable to be observed during the annual
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compliance review week. The program’s human resources staff was interviewed. The human
resources staff maintains the driver licenses for all staff. A driver list is also maintained by
administration. A review of staff records found all staff listed as drivers had a current and active
driver license. Nine staff were interviewed. All nine staff reported youth are secured in the
vehicles using seatbelts.Eight of nine reported they receive a communication device such as a
radio or cell phone when transporting youth. One staff reported they have never been on a
transport. Eight of nine staff gave examples of safety equipment provided in the transport
vehicle such as a first aid kit, seat belt cutter, and window punch. One staff stated they were
unaware as they have not been on a transport. All nine interviewed staff reported they are not to
use personal vehicles when transporting youth. All nine reported the transport vehicles are to be
searched for contraband prior to and after each use. All nine interviewed staff gave the ratio
requirement of one staff to five youth for transports. Eight of nine summarized the emergency
response during vehicle transports such as contacting 9-1-1, calling the program, and
contacting the Department’s Central Communications Center (CCC). One staff reported they
were unaware as they have not been on a transport. Nine youth were interviewed. All nine
denied ever seeing anyone place contraband in a transport vehicle. All nine reported staff drive
the vehicles safely when transported.
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 written policy and procedures which addresses Weekly Safety and Security
Audits. The program director was interviewed and confirmed the program utilizes the Facility
Security Audit form as its way of identifying and tracking safety and security issues. The
program’s maintenance staff is responsible for conducting the Preventive Maintenance
Checklist and Facility Safety and Security Audit, which addresses all required audit and
inspection information. Documentation of this information was provided which confirmed the
program’s practice. During the annual compliance review week, telephone contact was made
with the Department’s North Region Safety and Security Specialist (SSS), who confirmed the
program provides documentation of completed Facility Safety and Security Audit information
weekly as required. The Department’s SSS also reported the program had no outstanding
deficiencies at the time of the annual compliance review period.
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 written policy and procedures which addresses tool inventory and
management. Machetes and bowie knives were prohibited in accordance with the program’s
policy, which was verified through an interview with the maintenance staff. In the event a tool is
discovered missing, the policy indicates immediate notification to the program director and
provider’s chief executive officer. Youth movement is then restricted, and a commencement of
search for the item is made. All tools were observed to be secured and inaccessible to youth.
Maintenance tools were kept in the maintenance office. A sign in-out tool form was posted on
the inside of the maintenance office door which reflected dates and times of each tool exiting
and then re-entering the maintenance office area. Class B tools such as mops and brooms are
in secured cleaning closets in each living area. An inventory of these items was also observed.
Kitchen knives were secured in a clear locked cabinet. All items were accounted for on the
inventory form. Knives are accounted for twice daily by the dietary manager. The maintenance
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staff was interviewed and confirmed all dysfunctional tools are disposed of and replaced as
needed.
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 written policy and procedures which addresses youth tool handling and
supervision. Vocational tool usage by youth requires supervision of one staff to five youth ratios.
Observations were made of youth in the kitchen using kitchen utensils and tools. The staff to
youth ratio was observed at two staff to six youth. The dietary manager was present, but when
asked, was unaware of the staff to youth ratio requirement. The program director was notified of
this and provided documentation of refresher training for the dietary manager in the staff to
youth ratio requirement during the annual compliance review week. All youth are to have a
completed risk assessment which approves or disapproves any tool usage. A review of nine
youth case management records found each of the nine youth had an updated risk assessment
completed. In addition, nine of nine pre-service and nine of nine in-service staff training records
found each staff had received training in Tool and Sensitive Item Control training. Youth at the
program can work in vocational training programs such as ServSafe and Forklift operation
training. A review of training documentation found evidence youth receive training and
certification in these areas as required. Nine interviewed staff reported youth are allowed to use
cleaning items such as mops and brooms. One staff indicated some youth also may use the
kitchen knives. in Nine interviewed youth all reported they can use mops and brooms.None of
the interviewed youth reported using any class A tools such as screwdrivers, hammers, saws, or
axes.
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 written policy and procedures addressing guidelines required for outside
contractors, which includes information regarding tool control and restrictions. The policy
indicates the shift supervisor or designee will inspect the tools and conduct an inventory of the
items prior to entering and upon exiting for the outside contractor. According to the program’s
maintenance staff, the maintenance person is primarily responsible for inventorying the items,
as well as escorting and remaining with any outside vendor entering the secure area. The
guidelines for repairmen and external workers include tools checked in and out, tool restrictions
while in the facility, restriction of youth from work areas, and missing tool follow-up procedures.
Outside vendor sign in sheets were reviewed and compared with three random project invoice
forms. All three matched the sign in-out form for the approved vendors. The sign in-out forms
included evidence each tool was accounted for prior to entering, and upon exiting the facility. An
observation was conducted of an outside contractor entering the facility. The maintenance
worker was observed searching and inventorying all tools and completed documentation in the
logbook.
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5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has an approved Continuity of Operations Plan (COOP) which addresses fire,
safety, and evacuation drills. The program currently is operating on two shifts. A review of drill
documentation discovered fire drills were completed at a minimum of once a month for both
shifts for the annual compliance review period. There were no discrepancies found. Drill
documentation includes the type of drill, date and time, participants, brief scenario, and findings
and recommendations. A walk-thru of program areas found exit signs clearly visible in all
program areas, as well as egress routes posted. The program has a total of twenty-two fire
extinguishers. All received their annual inspection August of 2024 by an outside provider. Nine
staff were interviewed. All nine reported they have participated in various drills over the past
year, to include weather-related occurrences, fire drills, suicide, medical, chemical spills, and
flooding. Nine interviewed youth reported they have been instructed as to what to do in the
event of a fire and have participated in a drill. The program director was interviewed and
reported the program conducts fire drills monthly.
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 has a Continuity of Operations Plan (COOP) available in the program’s
administration building and accessible to staff. The COOP was last submitted on April 25, 2024
and approved by the Department’s Residential Services on May 2, 2024. The program’s COOP
addresses alternative relocation sites. Emergency supplies and equipment are in the walk-in
pantry, closet area of the kitchen and include batteries, radios, clothing, non-perishable food
items, rain jackets. According to the program director, in the event of an evacuation, the
program will evacuate with all youth records, to include mental health, medical, and case
management records. All required information for each youth was observed within these
individual youth records reviewed. Youth demographic information, victim information,
medication and physician orders, legal information, and list of contact information was included.
The program director was interviewed and confirmed the program’s COOP was in the master
control room of the administration building and a copy in the program directors office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
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The program has a written policy and procedures addressing the storage and inventory of
flammable, poisonous, and toxic items, and materials. A walk-thru of program areas revealed all
chemicals and toxic items were secured and inaccessible to youth. Items were observed kept
and secured in both living unit storage closets, kitchen storage closet, the maintenance supply
closet, and the maintenance office. A review of ten random items within those areas was done
and found no discrepancies. Each item was present on the program’s perpetual inventory,
which matched the actual count of the item observed. Each item also had a corresponding
Safety Data Sheet (SDS) in a SDS binder. These SDS binders were found in each area used to
store or maintain the chemicals and toxic items.
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 written policy and procedures addressing the storage and inventory of
flammable, poisonous, and toxic items, and materials. The policy also prohibits youth usage of
these items. Youth are not authorized to handle or dispose of hazardous items and cleaning
products. The program maintains strict control of toxic items and chemicals. All areas used to
store these items were observed secured and inaccessible to youth. An observation of youth
cleaning was conducted. One staff and two youth were cleaning living quarters. The youth did
not have cleaning solutions accessible to them, the staff sprayed the cleaner and youth wiped it
with a rag. Nine interviewed youth stated they have not handled any chemicals or cleaning
items.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
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• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a written policy and procedures addressing visitation and communication
protocol for youth while in the program. According to an interview with the case manager
supervisor, all youth who enter the program are assigned a case manager who contacts the
youth’s juvenile probation officer (JPO) to confirm the youth’s contact list and create a telephone
and visitation contact. The correspondence is documented in the chronological section of the
youth’s case record. According to youth alert information reviewed, and further interview with
the case manager supervisor, the program did not have a youth with a verified human trafficking
history for the annual compliance review period. Each youth’s assigned case manager
maintains the youth’s approved telephone, mail, and visitation list. The telephone schedule for
youth is every day from 9:00 a.m. to 9:00 p.m. Each youth is afforded one ten-minute call a
week. In addition, the case manager supervisor reported youth can send out unlimited amount
of mail each week to approved contacts. All outgoing and incoming mail is searched in the
presence of each youth by their assigned case manager. Visitation and communication
procedures were observed to be posted in the youth’s student handbook which they receive
during orientation to the program. The visitation rules were seen posted in youth living areas
and administration. Visitation is on the weekends from 10:00 a.m. until 12:00 p.m. The master
control person also maintains the approved visitation list and log, which includes evidence of
visitors signing in and out. The log sign in sheets were compared, and matched, to the approved
visitation list provided. The case manager supervisor and program director reported they have
two bilingual staff on-site to assist as with language services for youth where english is not their
primary language, along with an agreement with Okaloosa District Schools for further
assistance with a multitude of language interpretation. Nine of nine interviewed youth confirmed
they can call their parent/guardian or send letters while in the program.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a posted daily activity schedule in all living units. The schedule documents a
range of supervised and structured indoor and outdoor recreation and leisure activities for the
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youth at least one hour daily. Activities offered promote social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. During the
annual compliance review week, youth were observed each day outside during recreation times
and physical education classes. Staff to youth supervision ratios were maintained at the one to
eight required ratio. Staff were observed interacting positively with youth during these times. A
review of the program’s logbook documented recreation activities occurring as scheduled. In the
event of inclement weather conditions, the program director stated the program will follow the
Department’s protocols related to weather issues, to include monitoring of the heat index to
prevent overexertion, heat stress, and dehydration. The program has one full-time recreational
therapist as a requirement of their contractual agreement, in addition to one part-time
recreational therapist. A review of the recreational therapist’s credentials revealed the staff met
all contract requirements for credentials. Nine interviewed staff were able to provide examples
of indoor and outdoor activities provided to youth, which include ping pong, basketball,
volleyball, cards, football, indoor bard games, weightlifting, and volleyball. Each of the nine
interviewed youth all confirmed recreational activities are provided for at least one hour daily.
Youth also gave similar examples of activities provided, to include football, basketball, and
exercise equipment.
5.23 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 written policy and procedures addressing the search and release
procedures and overall usage of controlled observation. Observations of the program’s
controlled observation room revealed the room met all requirements. The program director
reported having only one incident of a youth being placed in controlled observation for the scope
of the annual compliance review period. The documentation provided noted the staff conducted
an inspection of the controlled observation room prior to the youth’s placement. In addition, a
staff of the same gender as the youth conducted the search of the youth prior to their
placement. There were no discrepancies identified.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a written policy and procedures addressing the search and release
procedures and overall usage of controlled observation. The program director reported having
only one incident of a youth being placed in controlled observation for the scope of the annual
compliance review period. The documentation noted the placement was authorized by a
supervisory staff. The controlled observation was authorized due to the youth becoming
aggressive towards others and exhibiting behaviors which would likely result in immediate injury
or harm to self, others, or substantial property damage. Documentation also indicated staff
advised the youth of placement and expected behavior for removal. There were no complaints
or injuries noted. The youth was placed in controlled observation for forty-six minutes.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
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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 written policy and procedures addressing the search and release
procedures and overall usage of controlled observation. Staff designations for controlled
observations are indicated in the policy. The program director reported having only one incident
of a youth being placed in controlled observation for the scope of the annual compliance review
period. Documentation indicated the staff member making the placement completed the first
page of the controlled observation report and submitted the documentation to the supervisor.
Safety checks were documented as required at least every fifteen minutes to observe and
document the youth’s behavior. All checks were documented on the Controlled Observation
Safety Checks form. The supervisory staff provided written approval before releasing the youth
from controlled observation. No internal alert was required. The Controlled Observation Report,
Health Status Checklist, and Controlled Observation Safety Checks forms were completed as
required and maintained in an administrative record. Documentation was noted for the written
approved release of the youth by the program director/designee. The program director approved
the controlled observation report within fourteen days of the youth release, determining the
placement was appropriate.
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Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education Services
Failed Compliance
(Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
The program has a contract with the Department which specifies career and technical education
services required. The services are employability and career-themed courses based upon youth
need and interest. The program has not provided any Florida Ready to Work soft skills spanning
the annual compliance review period as required. The program has not had any contact with
Florida Ready to Work since last annual compliance review. The program is currently providing
ServSafe and Safe Food Handler Certifications, training in cardiopulmonary resuscitation
(CPR), first aid, and automated external defibrillator (AED) through American Heart Association,
Occupational Safety Hazard Administration (OSHA) certifications, and forklift operator
certifications through East2West Safety Plus. A review of youth certifications supports the
program has provided career and technical education services in ServSafe, CPR, First Aid,
AED, OSHA, and forklift operations. Career and technical education services are provided in
tandem with the program’s activity schedule. Services are rendered by qualified staff or a
company holding necessary certifications to train youth at the program. The following are
identified industry certifications and provided by the program on an on-going basis; ServSafe,
OSHA, and forklift operations. The following indicates career and technical education services
provided and how many youth were in receipt of a certification: SafeServ, forty-six youth, CPR,
forty-five youth, OSHA, sixty-one youth, and forklift operations, eighteen. Currently there are ten
youth enrolled in OSHA. Course work for CPR is completed when there are enough youth to
participate and typically takes a day to complete. Forklift operations will take place when there
are enough eligible youth to participate.
Nine youth were interviewed. All youth agreed educational services are being provided to them.
The program director was interviewed. The program director agreed education services are
available and provided to youth according to the school schedule. Additionally, the program
director verified the program is providing the following contract specific vocational services:
ServSafe, OSHA, and forklift operations.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
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The program shall integrate educational instruction (career and technical education, as well as
academic instruction) into their daily schedule in such a way ensuring the integrity of required
instructional time.
The program has a written policy and procedures to provide educational access. The center
provides education services through Florida Virtual School (FLVS). A review of the program’s
activity schedule and the daily academic schedule indicated the program’s activity schedule
incorporates the daily school schedule. No discrepancies were found. The interview with the
lead teacher indicated all the youth receive credit for completing a course. They also reported
the school schedule is adhered to. Nine youth were interviewed; nine indicated there are no
interruptions during school. A review of randomly selected days in the logbook throughout the
past year indicated education classes started and ended on time or within a few minutes of the
schedule. Observations of the program video on three days showed the youth arrived at class
on time and left on time. On one day the youth were in the dining hall for a special award
presentation until the end of class.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The educational provider shall integrate educational instruction (career and technical education,
as well as academic instruction) into their daily schedule in such a way ensuring the integrity of
required instructional time. Education services are provided through a contract with Florida
Virtual School (FLVS). The 250-day calendar is distributed over twelve months and includes
twenty days for teacher training and planning. A review of the daily school schedule revealed
education provides six fifty-minute classes from 8:30 a.m. through 2:45 p.m. with a sixty-minute
lunch break from 12:05 p.m. through 1:05 p.m., fulfilling the weekly requirement of twenty-five
hours of instructional time. The interview with the lead teacher indicated all the youth receive
credit for completing a course. They also reported the school schedule is adhered to.
Observations of the program video for three days showed teachers were present during
scheduled classroom time.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The career education program is appropriate for the educational abilities and goals of each
youth at the program. Additionally, the career education program is appropriate for length of
stay and classification of each youth at the program. The program’s career educational
programming is a Type 2. The career education programming includes communication,
interpersonal, and decision-making skills.
The program director was interviewed and reported Career Source and Jobs Plus are education
services provided to youth at the program. The interview with the lead educator indicated youth
are provided with individualized instruction in an online platform. Career technical and education
courses and certifications are available to youth. The general education degree (GED)
essentials program is provided for students who are on the GED Track. The Florida Scholars
Academy has recently established a mobile GED testing site at the program.
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6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
Upon admission, staff and youth develop an education transition plan to include provisions for
the continuation of education and/or employment. The educational provider’s contract requires
the provider to develop an Education Transition Plan for each youth upon admission. Three
closed youth records were reviewed and none contained an education transition plan. The
program had no additional applicable youth as none of the remaining youth were applicable for
an Education Transition Plan . FLVS has recently developed an education plan template and
trained its staff to implement an Education Transition Plan for each youth moving forward. The
interview with the instructional leader indicated exceptional student education (ESE) services
are provided for students with disabilities, English language learner (ELL) services for language
learners, and intervention groups for those below grade level in reading and/or math. The
Instructional leader reported an Educational Transition Upon Entry form is completed with each
student and discusses their educational needs and goals after leaving the program. Nine youth
were interviewed; five indicated they participated in the development of their respective
Education Transition Plan. The remaining four youth indicated no they had not participated in
their Education Transition Plan. Two youth indicated the program has equipped them very well
when it came to preparation for a GED, high school, vocational school, employment, and/or
college. Five of the nine youth felt the program readied them well in preparing them for GED,
high school, vocational school, employment, and/or college. The remaining two youth indicated
the program did not well for preparing them.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The Superintendent is responsible for ensuring qualified instructional personnel are provided to
teach and provide exceptional education and related services to students in the program.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has a policy and procedures in place to provide qualified
instructional personnel. In reviewing the educational instructional staff for the program, including
flex teachers who provide virtual education at the program, it indicated all the teachers have an
active certification, according to the Florida Department of Education website. Flex teacher
certifications suggest all are currently certified in their teaching subjects. Four teachers were
teaching in their field and were also teaching courses out of their field. FLVS provided parent
notification for those teachers who were also teaching out of their field; however, the letter did
not indicate which subjects were taught out of their field. One teacher was providing Exceptional
Student Education (ESE) services at the program, and FLVS provided their certification as an
ESE instructor.
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6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
Three closed youth records were reviewed to determine if the education provider completed the
Florida Youth College referral process for each youth who has earned a high school diploma or
general education degree (GED). Each reviewed youth included a referral to the Florida Youth
College. The program does not have a post-secondary program on-site.
Nine youth were interviewed, and all indicated they are not participating in any post-secondary
education services. The lead educator was interviewed and indicated Florida Scholar Academy
works in conjunction with Florida Youth College. Florida Scholar Academy enters youth names
on the survey for Florida Youth College.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Three closed youth records were reviewed to determine if the post-secondary provider, upon
receiving the referral for services, has assigned a Florida Youth College (FYC) Career Navigator
to each youth. Each youth record reviewed included documentation to support Florida Youth
College orientation. Additionally, each youth was in receipt of a career plan based upon the
youth’s interest and aptitude initiated by the programs transition case manager. Each youth was
included on a spreadsheet provided for by FYC documenting thirty, sixty, ninety, and 180-day
follow-up sessions. Two of three youth experienced a delay for the thirty-day follow-up by a few
days. One of the three youth received the sixty-day follow-up approximately sixteen days late.
One of the three youth experienced a delay of a few days for the ninety-day follow-up. One of
the three youth did not receive a 180-day follow-up. A note was found which indicated this youth
was a direct release from the program, whereas FYC would be unable to pay for courses the
career navigator indicated they would provide support and scheduled a later appointment with
the youth; however, the youth was a no-show for the session.
To qualify to enroll in FYC, the youth must have a high school diploma or the equivalent. The
youth can be admitted if they are within the final semester of completing a high school diploma
or have passed at least one of the four GED subject area exams. Currently there is no on-going
support to youth in classrooms to continue academic and credential progress as there is no on-
site program offered.
Nine youth were interviewed, and all indicated they are not participating in any post-secondary
education services. The lead educator was interviewed and indicated Florida Scholars Academy
works in conjunction with FYC. Florida Scholars Academy enters youth names on the survey for
FYC.
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Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 65 (Revised September 2022)

source: DJJ

report_type: QI Residential

program_name_raw: Okaloosa Youth Academy

rule: Indicator 3.14

excerpt: Suicide Prevention Training (Critical)

rating: Failed Compliance

rule: Indicator 4.16

excerpt: Medication Management

rule: Indicator 6.01