state: FL

facility_name: Okaloosa Youth Academy

summary: QI Residential - FY23-24 - 3 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Okaloosa Youth Academy/Okaloosa Sex Offender Program
Gulf Coast Treatment Services
(Contract Provider)
4455 Straightline Road
Crestview , Florida [32539
Review Date(s): March 12, 2024 - March 15, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Jessica Gibson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cio’nna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Ken Myers, Office of Education, Northwest Education Coordinator (Standard 2, Education)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Cedric Prince, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Okaloosa Youth Academy/Okaloosa Sex Offender Program
MQI Program Code: OYA 830/ OSOP 1161
Provider Name: Gulf Coast Treatment Center Contract Number: 10760
Location: Okaloosa County / Circuit 1 Number of Beds: 72
Review Date(s): March 12, 2024 - March 15, 2024 Lead Reviewer Code: 210
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
4.15 Chronic Illness/Periodic Evaluations 4.13 Episodic/First Aid Care/Emergency Care
5.04 Ten Minute Checks *
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 Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 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 Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 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 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 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 Failed
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Limited
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 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 * Limited
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 65 (Revised September 2022)
Program Overview
Okaloosa Youth Academy/Okaloosa Sexual Offender Program (OYA/OSOP) is a seventy-two
bed program, separated into two sides with thirty-eight beds for Mental Health Overlay Services
(MHOS), sixteen beds for Substance Abuse Overlay Services (SAOS), and eighteen beds with
Juvenile Sexual Offender Treatment Services (JSO) serving males between the ages of thirteen
and nineteen, located in Crestview, Florida. The program is operated by Gulf Coast Treatment
Services, through a contract with the Department. The program provides services including
SAOS, MHOS, and JSO. In addition, the program fosters youth by providing Impact of Crime
(IOC) curriculum. The program also provides Pathways, Aggression Replacement Training,
Seven Challenges, Skillstreaming the Adolescent, Forward Thinking, and Healthy
Sexuality/Sexual Education Process. Program administration is comprised of a program director
(PD) and an assistant PD. Case management services are provided by a case management
supervisor, four case managers, and two transition managers. Mental health staff include a
clinical director who serves as the designated mental health clinician authority (DMHCA), an
assistant clinical director, and six therapists. Medical services are provided by a designated
health authority (DHA) and three nurses. The DHA is required to be on-site weekly for two
hours. Educational services are provided by the Okaloosa County School District. The layout of
the program includes one youth housing unit for the OSOP side and two housing units for the
OYA population. The program has two additional buildings for administration, medical,
education, and dining. The program has 108 operating security cameras providing coverage
and all were working at the time of the annual compliance review. At the time of the annual
compliance review, the program had six vacancies for youth care workers.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 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.
The program has a written policy and procedures for staff, volunteers, contracted staff, and
interns to receive a background screening in accordance with Level 2 Screening Standards to
be eligible for employment or to provide services to the youth. The Annual Affidavit of
Compliance with Level 2 Screening Standards was completed and sent to the Department’s
Background Screening Unit (BSU) on December 6, 2023. The teachers who are paid by the
Okaloosa County School Board received an annual screening on January 11, 2024. Twenty-six
staff were applicable for initial background screenings. All twenty-six staff had a background
screening completed prior to contact with youth and confidential records. None of the reviewed
staff had a criminal history report to review. Two of the twenty-six staff had a break in service
and did receive a new background screening. Eighteen of the twenty-six reviewed staff
completed a pre-employment assessment tool. The pre-employment assessment tool was only
provided to direct care applicants. All eighteen staff had a passing score on the pre-employment
assessment tool. Twenty-four of the twenty-six staff were added to the staff Clearinghouse
employment roster. One staff was not employed long enough to be added to the Clearinghouse
roster and the other staff is contracted and not required to be added. One of the twenty-six staff
had a background screening after being previously hired by the Department.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a written policy and procedures for five-year background rescreenings to be
conducted every five years. All five-year rescreenings are to be submitted within twelve months
of the five-year date. Nine staff were applicable for five-year background rescreenings. All nine
five-year rescreenings were completed every five years as required. Eight of the nine
rescreenings were submitted to the Department’s Background Screening Unit/Clearinghouse at
least ten business days prior to the five-year anniversary or retained prints expiration date. One
staff had a background rescreening completed July 15, 2021, due to the staff’s fingerprints
expiring.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 65 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a written policy and procedures for reporting and investigating suspected or
alleged child abuse. Nine staff personnel records were reviewed, and all records included
documentation the staff reviewed and signed a code of conduct. The Florida Abuse Hotline and
the Department’s Central Communications Center (CCC) numbers are posted throughout the
program, which were observed during the program tour. The program’s steps to report abuse
include any staff with the knowledge or suspicion of an incident of child abuse is occurring or
has occurred has the obligation as a mandated reporter to report the incident to the Florida
Abuse Hotline. The staff will complete an Information Report regarding the incident and forward
the Information Report to the program director. The steps for a youth requesting to report
alleged abuse include the shift supervisor will escort the youth to a private area and grant the
youth access to a phone to contact the Florida Abuse Hotline or the CCC if the youth is eighteen
years of age or older. Upon completion of the youth’s call, the youth will be returned to the
designated location they were scheduled to be at. The youth shall not suffer any consequences
or reprisal for calling the Florida Abuse Hotline or CCC. The shift supervisor will complete an
entry in the Alleged Abuse Log. The form will be completed with as much detail as possible to
include the youth’s name, date, time, and any details of the complaint. If the youth refused to
complete the call, the youth will be requested to complete an Abuse Call Refusal Form. The
shift supervisor will notify the program director. The program had a total of five incidents related
to physical, psychological, or emotional abuse since the last annual compliance review. One of
the five incidents were closed as a substantiated incident. The program completed a Trauma
Responsive and Caring Environment (TRACE) self-assessment on April 27, 2023.
Nine youth were interviewed and all reported feeling safe in the program. Seven youth reported
they have not been stopped from calling the Florida Abuse Hotline or CCC when requested.
Two youth have not had to call the Florida Abuse Hotline or CCC. One youth reported they did
not feel staff would stop them from calling if needed. All nine youth reported during their
interviews, staff are respectful when they speak with the youth. Seven youth reported never
hearing staff use profanity. One youth reported hearing the staff use profanity and went on to
explain it was when no one was listening. The youth also reported it was a general statement
and not directed toward anyone specific. The youth could not remember when this occurred.
One youth reported not remembering the situation when they heard staff use profanity. Nine
staff were interviewed, and all staff were able to correctly summarize the process for allowing
staff and youth to call the Florida Abuse Hotline or CCC to report any suspected abuse. None of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 65 (Revised September 2022)
the staff reported observing a coworker telling a youth they could not call the Florida Abuse
Hotline. All nine staff reported they have never observed a coworker using profanity, threats,
intimidation, or humiliation when interacting with youth. One of the nine staff knew the Florida
Abuse Hotline number. The other eight staff were able to describe where they could find the
Florida Abuse Hotline number. The program director reported all staff received Trauma-
Informed Care training. The program utilizes TRACE surveys and action plans to actively
integrate changes and to consistently evolve based upon the presenting need of youth and staff.
The program director reported the program follows CCC reporting guidelines and abuse
reporting guidelines. The program director reported all staff have formal training in abuse
reporting which is also reviewed in team meetings and briefings.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a written policy and procedures for staff misconduct and consequences of
misconduct. The program had five incidents where there were allegations of physical,
psychological, or emotional abuse during the annual compliance review period. In all five
incidents there was evidence management took immediate action to address allegations of
physical, psychological, and emotional abuse. Documentation was reviewed to identify
applicable corrective actions by management. The program director reported one staff received
disciplinary action due to allegations of abuse towards a youth and the disciplinary
documentation was reviewed. The program director went on to report, if there are allegations of
abuse, management removes the staff from youth contact and an investigation is 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 has a written policy and procedures for incident reporting. The program had a total
of thirty-four reports to the Department’s Central Communications Center (CCC) during the
annual compliance review period. Five of the thirty-four incidents were reviewed. All five
incidents were reported within two hours. Three of the five incidents were documented in the
program logbook. One incident was reported by residential operations staff and not the
program; therefore, it was not documented in the logbook. The remaining incident was reported
by the assistant program director from their home. The assistant program director reported the
program master control staff were instructed to document the incident and CCC call in the
program logbook but failed to do so. No other additional incidents were discovered which should
have been reported to the CCC during the annual compliance review week.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 65 (Revised September 2022)
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program has a written policy and procedures for Protective Action Response Right
Interactions model (PAR/RI) reporting. The Okaloosa Sex Offender Program (OSOP) did not
have any PAR/RI incidents during the annual compliance review period. Okaloosa Youth
Academy (OYA) had one PAR/RI incident during the annual compliance review period. The
documentation reviewed for the PAR/RI incident revealed the report was completed by the end
of the staff’s workday and included statements from all staff involved. No mechanical restraints
were used during the PAR/RI incident. The PAR/RI did result in an injury to the youth. The
Department’s Central Communications Center (CCC) was contacted following the incident;
however, it was not reported within the two hours of the incident as required. The youth did
receive a medical review post-PAR/RI and a follow-up doctor’s appointment was made for the
youth. The PAR/RI Report was reviewed by a supervisor and administrator within seventy-two
hours of the incident. A copy of the PAR/RI Report was placed in the program’s centralized file.
Monthly summaries were maintained by the program and submitted to the Department. The
PAR/RI plan was updated November 27, 2023. The PAR/RI plan was approved by the
Department on December 15, 2023. The program director approved and signed the PAR/RI
plan on November 27, 2023. The program PAR/RI rate during the previous quarter was 0.00 for
OSOP and 0.14 for OYA, which are below the statewide Residential PAR/RI rate of 1.76. The
program director was interviewed regarding PAR/RI incidents and reported all PAR/RI incidents
will be reviewed within seventy-two hours of the incident to ensure appropriateness of the
intervention. Seven of the nine interviewed staff reported they have used PAR/RI. Two of the
staff reported they have not use PAR/RI techniques. The seven staff who have used PAR/RI
were able to appropriately summarize how PAR/RI techniques are used.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a written policy and procedures for pre-service training and certification which
state all direct care staff shall receive orientation training and the required pre-service training.
The program staff considered to be direct-care staff who are counted in the staff-to-youth ratio
include maintenance, case managers, transition managers, recreational therapists, and control
room operators. All instructors were qualified to deliver training. Nine staff training records were
reviewed. All nine staff completed the required trainings prior to youth contact including child
abuse recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), emergency procedures, program operating procedures,
Prison Rape Elimination Act (PREA), professionalism, interpersonal communication, and ethics,
and suicide awareness and prevention. Eight of the nine staff completed Protective Action
Response Right Interactions (PAR/RI). One staff was not required to take this training. All nine
staff completed the additional trainings including active shooter preparedness, adolescent
development and behavior, balanced approach to restorative justice, the Department’s Central
Communications Center (CCC), civil rights, communication, Confidentiality and Health
Insurance Portability and Accountability Act (HIPAA), Department of Juvenile Justice Legacy,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 65 (Revised September 2022)
equal employment opportunity, gang awareness, human trafficking intervention, infection
control/bloodborne pathogens, information security awareness, mental health and substance
abuse, quality report writing, safety, security, and supervision of youth, sexual harassment,
effective and respectful treatment of youth, and trauma responsive practices. One staff had not
completed Motivational Interviewing (MI), however, this staff is a therapist and is not required to
complete MI training. All nine staff also completed the contract required trainings including
behavior management modification and positive reinforcement techniques and strategies. All
nine staff completed the trainings as required by Florida Administrative Code including
grievance process, infection control, exposure control plan, behavior management system, and
the intended and safe use of tools. All nine staff completed the additional training of juvenile sex
offenders. Four of the nine staff were still within their initial 180-days of hire. One of the four staff
had not completed the initial 120 required training hours at the time of the annual compliance
review. This staff was still in need of stress management for staff, adolescent healthcare, and
balanced approach to restorative justice. The two new therapists completed the required
therapy-specific training which included treatment plans, suicide precautions, trauma
responsiveness, group, and individual sessions.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written policy and procedures to comply with in-service training
requirements. Nine staff training records were reviewed for in-service training. All nine staff had
completed the required twenty-four hours of in-service training. All nine staff completed active
shooter preparedness, cardiopulmonary resuscitation (CPR)/First-Aid/automated external
defibrillator (AED), human trafficking, information security awareness, mental health and
substance abuse, Prison Rape Elimination Act (PREA), professionalism, interpersonal
communication, and ethics, sexual harassment, suicide awareness and prevention, trauma
responsive practices, and stress management for staff. Four staff had not yet completed the
Protective Action Response (PAR)/Right Interactions (RI) model training. Three of those four
staff are currently certified in PAR/RI. One of the staff is not required to take PAR/RI training.
One therapist had completed therapy specific training. Two case managers had completed the
case management specific training. Three supervisors were selected to review additional annual
supervisory training. All three staff had completed eight or more hours of supervisory training.
All nine staff completed infection control, bloodborne pathogens, and exposure control plan.
None of the staff completed emergency response and emergency drills; however, this is
addressed in standard four. The three required staff completed the mental health overlay
services training. The list of in-service trainings were approved by the Department’s regional
director on December 14, 2023. The program director approved the training plans on November
27, 2023. The program maintains an annual in-service training calendar.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 65 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a written policy and procedures for the grievance process and includes the
training requirements for staff. The program’s grievance process includes the informal phase,
formal phase, and appeal phase. The program’s informal process states if a youth decides they
wish to grieve a situation which has occurred, they may approach the staff on duty at the time of
the situation and informally attempt to resolve the grievance; however, if a grievance involves
allegations of sexual abuse the youth may forego this avenue. The program director reported
the program did not have any grievances during the annual compliance review period; however,
one youth did report during their interview they filed a grievance and it was not resolved. The
program director was asked about this situation and reported the situation was handled during
the informal phase. The informal phase is not documented on a grievance form. The youth was
re-interviewed and reported the issue had been dealt with and resolved. Nine interviewed youth
were able to describe at least part of the process for filing a grievance. Eight of the nine youth
reported never having to file a grievance. Nine interviewed staff were able to accurately
summarize the grievance process for the program. Six of the nine staff reported the program
director reviews the grievances. The program director was able to accurately describe the
phases of the grievance process.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
Eight clinical staff training records were reviewed for facilitator training documentation. The
clinical director and assistant clinical director provide backup facilitator coverage for all groups.
Only clinical staff were reviewed due to case management staff only facilitating primary
services, which are reviewed by the Department’s Office of Programming and Technical
Assistance. All eight staff received training in the non-primary services provided and all had the
appropriate level of education. A review of group documentation revealed the groups are being
held in accordance with the schedule and outlined in the contract table. The program’s activity
schedule was reviewed and reflected the program is providing structured, planned
programming, or activities for the appropriate amount of time. The program director provided the
list of staff along with what groups those staff facilitated during the annual compliance review
period. The designated mental health clinician authority (DMHCA) reported the trained clinicians
provide all mental health and clinical groups for the program. The DMHCA reported the youth
are placed in primary service groups based upon their assigned program component. A
comprehensive mental health/substance abuse evaluation is conducted by a clinician within
thirty days of admission to determine appropriate treatment goals and additional treatment
interventions to adequately address the individualized needs of each youth.
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1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures addressing life and social skills training
provided to the youth. It is the policy of the program to provide youth with training in social skills,
skills for dealing with feelings, positive alternatives to aggressive behavior, skills for responding
effectively to stress, and life skills. Social and life skills training is included in the performance
plan. The staff will reinforce and model appropriate social skills. The life skills interventions are
mental health groups and one delinquency intervention. The delinquency intervention is a
primary service and reviewed by the Department’s Office of Programming and Technical
Assistance; therefore, was not reviewed for the annual compliance review. The interventions
being provided by the mental health staff address communication, interpersonal relationships
and interactions, non-violent conflict resolution, anger management, critical thinking, problem-
solving, and decision making. The program also addresses the needs of the youth through
health and hygiene training, the physical environment, life and social skills training, and leisure
and recreational activities. The services are provided through group meetings. All life and social
skills services and activities are provided to the youth as required as evidenced by reviewed
sign-in sheets. Nine youth were interviewed and reported a list of various activities and groups
they are participating in at the program. The program director was interviewed and reported the
therapists are trained to provide specialized services to cater to each youth in the program.
Each youth is also housed in a room by themselves. The designated mental health clinical
authority (DMHCA) listed out what groups are being held on a regular basis at the program and
which staff facilitate those groups. The DMHCA reported skill implementation is integrated into
the behavior management system. Youth are reinforced by staff, therapists, and case managers
to implement skills into their daily interactions. They are rewarded for positive implementation
and redirected and coached when failing to appropriately implement skills. Youth also practice
learned skills in individual and family therapy sessions.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s restorative justice service is Impact of Crime (IOC). Impact of Crime is a primary
service for all components of the program and is reviewed by the Department’s Office of
Programming and Technical Assistance. The program’s restorative justice activities are
provided through the IOC groups, which include community service activities. The program
director was interviewed and reported the youth attend IOC groups as well as enhanced
therapeutic interventions which focus on victim empathy and reconciliation. The youth complete
a series of activities including written essays, journal prompts, group role plays and
presentations, and one-on-one discussions with their therapists and case managers which
encourage integrity and restorative justice. Youth are also encouraged to participate in activities
based on the token economy and through their reintegration phase of treatment where they are
able to identify their plans for going back to the community, completing letters of apology,
community service hours, and essays proving their understanding of their charges and damage
caused. The designated mental health clinician authority (DMHCA) was interviewed and
reported IOC groups are held two times a week by case management staff. Nine youth were
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interviewed, and eight of the nine youth reported participating in IOC groups and community
service activities. One youth was not sure which restorative justice groups and activities they
had participated in. It should be noted this specific youth was quiet during the interview and did
not provide much information.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures for internal alerts which included
information on how alerts are identified, documented, updated, and communicated to staff.
There were youth identified with alert risks in the program. These youth were placed on the alert
system as specified in the program’s written procedures. Nine youth were reviewed for internal
alerts. These nine youth had a total of forty-eight alerts for review. All alerts were documented
on the alert list and in the Department’s Juvenile Justice Information System (JJIS) on the same
date. All alerts matched JJIS and the internal alert system. The program director reported the
program’s formalized procedures regarding the review of important medical issues pertaining to
the youth include sharing the information during department head meetings and during staffing
with all staff, which are completed weekly with mental health staff. Staffing with psychiatric and
medical staff occur bi-weekly. The nursing staff was interviewed and reported the nursing
department is responsible for updating the medical alert system. Nine staff were interviewed
and reported they are informed of the youth alerts to include medical, mental health, and
security through master control, nursing staff, debriefings, therapists, alert board, case
management staff, safety plans, JJIS, and in the kitchen, where medical alerts are listed.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains a written policy and procedures for youth records. The youth records will
be maintained in a neat and orderly manner consistent with the Department’s requirements.
Nine healthcare records and nine case management records were reviewed. All records
included the youth’s name, Department identification number, date of birth, county of residence,
and committing offense. All records included sections for legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and miscellaneous. All records were marked “Confidential,” and all were stored in a secured
room. The filing cabinets are marked “Confidential”.
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1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program maintains a written policy and procedures for community advisory board meetings.
The program’s community advisory board meets every ninety to 120 days. Members are
solicited from other member recommendations and the executive director of the local Chamber
of Commerce was recently added. The program director has attended the Chamber of
Commerce meetings and spoke about becoming an advisory board member in August of 2023.
All meetings are held in person. The program director was interviewed and reported advisory
board meetings are held quarterly. The members of the board assist with community service
projects and mentorship opportunities. An advisory board member was interviewed and
reported having been involved with the program for three years and visits the program on a
monthly basis. The advisory board member stated they have nothing but great things to say
about the program. The youth appear to be happy, and they have a great program director. The
youth have visited the church the member is a part of to complete community service.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures for staff performance expectations.
Performance evaluations are conducted between the program director or designee and the staff
in January of each year. Five job descriptions were reviewed to ensure each staff’s performance
standards were clearly identified. A sample of five performance evaluations were reviewed to
ensure the evaluations were completed as outlined in policy and annually. All performance
standards reviewed on the evaluations matched the job description for each staff.
The program director was interviewed and reported the program turnover is low and morale is
good. The program provides cookouts, gift cards, employee of the month recognition, and
birthday celebrations for staff. Staff also receive performance evaluations on an annual basis.
Nine staff were interviewed. Five of the nine staff reported communication is very good between
staff. Four of the nine staff reported communication is good amongst the staff. Nine staff also
reported they receive formal evaluations on a yearly basis. Three of the nine staff reported the
supervisors and the program director provide weekly verbal feedback consistently.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract and Memorandum of Understanding (MOU) were reviewed for special
contract conditions. The required conditions include having a post-secondary educational
specialist available to the youth to complete educational goals, sixty percent of awake hours
shall be structured, the youth are to receive three snacks a day, the youth are provided
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opportunities seven days a week to spend their tokens and visit a reward zone, independent
living arrangement assistance and follow-up services, financial assistance for families with
hardships for gas cards and hotel costs, Narcotics Anonymous/Alcoholics Anonymous
meetings, parent support groups, special visitation for Fathers-In-Training, a program for youth
to pay off court costs, staff incentive programs, Saving the Soul puppy program, and equine
assisted therapy and learning. The program director was interviewed and reported all contract
negotiated items are offered to the youth and provided at the program. This was confirmed
through a review of documentation to include sign-in sheets and observations. Nine youth were
interviewed and eight of the nine youth reported they had participated in or are participating in
ServSafe, Florida Ready to Work, Occupational Safety and Health Administration,
cardiopulmonary resuscitation/first-aid/automated external defibrillator, Full Kitchen Program,
puppy program committee, Information Technology (IT) certification, three snacks are provided
each day, independent living, Fathers-In-Training, parent support, and forklift training. One of
the youth would not talk during the interview and would not provide much input regarding the
special conditions of the contract.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program’s contract was reviewed for contract-required career and technical education
requirements. A Memorandum of Understanding (MOU) with East2West (E2W) Safety Plus,
who will be providing the Forklift Operator certification training once a week was reviewed.
Forklift training has not yet started at the program; however, documentation was provided
between the program and the provider they are renting the equipment from to demonstrate
progress toward implementation. Employment opportunities would be provided to youth with
E2W upon completion of certification training. Information Technology (IT) certifications in
Microsoft Office and Java Coding, Florida Ready to Work, Jobs4U Work Readiness Class,
ServSafe food handler certifications, Occupational Safety and Health Administration (OSHA)
certifications, cardiopulmonary resuscitation (CPR), first-aid, and automated external defibrillator
(AED) certifications are all being offered and/or provided. Thirty-eight youth completed
vocational classes for work readiness, thirty-three youth have served on the puppy committee,
nine youth have met with an Army recruiter, one youth completed the
business/entrepreneurship course, eleven have completed the Forklift certification, sixty-three
youth completed ServSafe, sixty-three have completed OHSA, and sixty-three have completed
CPR/first-aid. Two youth are participating in post-secondary educational goals. Two youth were
applicable for independent living and follow-up services at the time of the annual compliance
review. All youth are able to participate in services once they are approved through risk
assessments. The services are provided during school hours. Independent people from the
community are providing career and technical services. One is a job coach and employment
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specialist and one is a forklift certified trainer. Youth were observed during the annual
compliance review week in the kitchen working on their ServSafe certifications. Nine youth were
interviewed, and two reported they are currently only attending school. Three youth reported
participating in CPR, first-aid, and AED certifications, ServSafe, Forklift certification, work
readiness, high school equivalency diploma (GED), kitchen, and commercial driver license
program. One youth did not want to answer. Two youth reported not being able to think of
anything and one youth reported having a GED and is interviewing for jobs. The program
director was interviewed and reported Florida Ready to Work, CPR/first-aid, ServSafe, IT
certification, OSHA, and entrepreneur and small business certifications are being provided at
the program.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program’s data trend analysis is based upon the program’s performance measures. The
information gathered is shared monthly during all staff meetings. The youth satisfaction surveys
are shared during monthly all staff meetings. All staff meetings are mandatory. The program has
an agreement with neighboring residential programs and shares their data trend analysis
information with them. Documentation of completed quarterly meetings and program director
meetings were reviewed. The program continues to monitor staff to gather data and improve
their processes.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures regarding initial contact to a youth’s
parent/guardian and addressing court notification upon each youth’s admission. Nine youth
case management records were reviewed. All records indicated the youth’s parent/guardian
was notified by telephone within twenty-four hours of the youth’s admission. The program
notified the parent/guardian in writing within forty-eight hours of each youth’s admission. The
youth’s committing court, juvenile probation officer, and post-residential services counselor, if
applicable, were notified within five working days of the youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a written policy and procedures regarding youth orientation. A review of nine
records found the program provided an orientation for each youth within twenty-four hours of
admission. The orientation included services available, daily schedule, expectations and
responsibilities of the youth, written information on the program’s behavior management system,
access to medical and mental health services, zero-tolerance regarding sexual misconduct,
access to the Florida Abuse Hotline or the Department’s Central Communications Center if the
youth is over eighteen years of age, and items considered contraband. The youth orientation
also included information on the performance plan process, dress code and hygiene
requirements, procedures regarding visitation, mail, and use of the telephone, expectations for
release from the program, community access, grievance procedures, emergency procedures,
physical design of the facility with a tour, and assignment to a living dormitory. Each reviewed
record documented a signed checklist acknowledging the youth received an orientation packet,
including a copy of the youth handbook. A youth admission was observed during the annual
compliance review week which verified orientation is completed on the day of admission and
included all elements in the program’s policy. Nine interviewed youth stated they received an
orientation to the program within twenty-four hours of admission and included program rules,
procedures, schedules, and all other pertinent information.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a written policy and procedures which address obtaining written consent of
youth who are eighteen years of age or older. Nine youth records were reviewed, and three
were applicable for written consent of youth over the age of eighteen before providing or
discussing information with the parent/guardian. All applicable youth records contained consent
forms signed by the youth allowing the program to share, with the parent/guardian, any
information related to the youth's physical or mental health screenings, assessment, or
treatment.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program’s policy and procedures outlined the classification process and included a
classification system which promotes safety and security, as well as effective delivery of
treatment services, based on the determination of each youth’s individual needs and risk
factors. The factors included physical characteristics of the youth, age, maturity level, identified
special needs, history of violence, gang affiliation, criminal behavior, sexual aggression or
vulnerability to victimization, criminal behavior, and human trafficking history. The policy also
addresses when re-assessment is warranted based upon changes in the youth’s supervision
status, new and updated alerts, relevant information available to the treatment team, and/or
behavioral concerns. Nine youth records were reviewed. Eight youth records had an initial
classification completed on the same day of admission to the program. One youth record
indicated the completion of initial classification one day late. The initial classification forms
included all required elements. Documentation confirmed a new screening for Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB) was completed for each youth. All nine
youth were classified for the purpose of assigning them to a living area, sleeping room, and
youth group or staff mentor. The case manager conducts a risk assessment during the intake
process for each youth and reviews alerts for any issues affecting classification. An interview
with the program director revealed each youth is assigned a single room only upon admission.
The Department’s VSAB is used to assess mental health status, physical health status,
cognitive performance, age, and prior victimization and the results are entered into the
Department’s Juvenile Justice Information System (JJIS) by the case managers. Staff are made
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aware of any risks associated with the youth, and the therapists develop safety plans targeting
the youth’s 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
involvement. Nine youth records were reviewed, and none were applicable for youth suspected
of gang involvement. Three additional records were reviewed, and all three youth were
applicable for gang identification and notification of law enforcement. The program notified local
law enforcement, prior to the seven-day notification of the annual compliance review, as well as
education staff of each youth’s gang involvement. Each youth was identified as having gang
involvement prior to admission to the program by their juvenile probation officer, who entered
the alert into the Department’s Juvenile Justice Information System (JJIS). The program
maintains an internal alert list for all youth, including gang affiliation.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures to ensure youth who are identified as or are
suspected gang members are provided intervention services and activities. Nine youth case
management records were reviewed for gang identification, prevention, and intervention
activities. None of the nine youth were applicable; therefore, three additional records were
selected for review. All three records had evidence each youth was identified as a gang member
or affiliated with a gang. Each youth record included evidence of the youth’s participation in
gang prevention and intervention strategies. Intervention strategies implemented at the program
include Gang Rescue, the Impact of Crime (IOC) curriculum, and Individual Performance Plan
goals. A review of sign-in sheets confirmed the youth’s group participation. The program
provides youth information for gang prevention through assignments pertaining to disaffiliation.
The program director was interviewed and stated the youth are expected to participate in Gang
Rescue.
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 records were reviewed for Residential Assessments for Youth (RAYs). Each record
contained an initial RAY completed within thirty days of the youth’s admission to the program.
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All initial RAYs were completed and maintained in the Department’s Juvenile Justice Information
System (JJIS). All nine reviewed records were applicable for a RAY Reassessment.
Documentation maintained in each youth’s record supported each RAY Reassessment was
completed within ninety-days of the initial RAY. The program maintained all reassessments in
each youth’s record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
Nine youth records were reviewed for a Youth Needs Assessment Summary (YNAS). All nine
YNASs were completed within thirty days of the youth’s admission to the program. Reviewed
documentation supported each YNAS was 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 records were reviewed for Individualized Performance Plan (IPP) development. All
nine records contained an IPP completed within thirty days of the youth’s admission to the
program and after the initial Residential Assessment for Youth (RAY) and Youth Needs
Assessment Summary (YNAS). Each IPP was developed and signed by the treatment team
leader, youth, administrative representative, living unit representative, treatment staff,
education, and all parties who have significant responsibility in goal completion. Reviewed
documentation confirmed a copy of the IPP was sent to each of the youth’s parent/guardian
along with a signature page to return. Each of the parents/guardians signed the signature sheet
and sent it back to the program, which was maintained with the IPP in the youth’s record.
All nine reviewed IPPs documented the youth’s top three criminogenic needs and individualized
goals based upon the prioritized needs reflecting the risk and protective factors identified in the
assessment process. Each youth’s IPP included specific delinquency interventions with
measurable outcomes, which will decrease criminogenic risk factors and promote strengths,
skills, and support reducing the likelihood of the youth reoffending. All nine IPPs included court-
ordered sanctions, which can be initiated and/or completed while the youth is in the program,
transition activates targeted for the last sixty days of the youth’s stay, the youth’s responsibilities
to accomplish each goal, and staff responsibilities to enable the youth to complete the goals. All
nine reviewed records documented a transmittal letter and a copy of the plan was sent to the
committing court, parent/guardian, and juvenile probation officer (JPO) within ten working days
of the IPP being completed. Nine interviewed youth reported they participated in the
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development of their IPP. Two youth indicated they were provided a copy of their IPP, and
seven youth indicated they did not receive a copy. A review of documentation confirmed all
youth had a signed copy in their file indicating they had received a copy of IPP.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
Nine youth case management records were reviewed for performance plan revisions. All nine
youth records were applicable and included evidence of Residential Assessment of Youth
(RAY) Reassessments as required. Each applicable record contained evidence of each youth
demonstrating progress on goal completion. Documentation showed each performance plan
included transition goals to facilitate transition activities when they reach the last sixty days of
their stay in the program.
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 records were reviewed, and each youth was applicable for Performance Summaries.
Each applicable youth record documented a Performance Summary was completed within the
required ninety-day time frame following the signing of the Individualized Performance Plan
(IPP) as well as prior to release. All summaries included the youth’s status on each IPP goal,
youth’s overall treatment progress based on their treatment plan, and the youth’s academic
status, including performance and behaviors in school. In addition, the youth’s behavior,
interactions with peers and staff, overall behavior, and the youth’s adjustment to the program
was included in the performance summary. Each Performance Summary included significant
positive and negative events and justification for release, when applicable. Reviewed
Performance Summaries supported each applicable youth was provided the opportunity to
review and add comments prior to signing and receiving a copy. Six of the nine Performance
Summaries were signed by the treatment team leader. Three Performance Summaries were not
signed by the treatment team leader. Reviewed records documented the original completed
Performance Summary was filed in each applicable youth record and was sent to the youth’s
committing court, juvenile probation officer (JPO), and parent/guardian within ten working days.
A review of three closed youth records supported an original release summary, along with the
justification for release and Pre-Release Notification (PRN), was sent to each youth’s assigned
JPO. All three release summaries and PRNs were sent at least forty-five days prior to the
planned release date and a signed copy was retained in each youth’s closed record. None of
the releases were objected by the court. Reviewed documentation in each closed record
verified, once the PRN was approved, the program provided written notification to the youth’s
parent/guardian regarding the planned release and completed an exit Residential Assessment
for Youth (RAY). None of the three closed youth records were applicable for Sexually Violent
Predator Program (SVPP) consideration or a Victim Notification of Release letter as none of the
closed youth records were for youth discharged from the sex offender side of the program.
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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.
The program has a written policy and procedures which address the encouragement of
parent/guardian involvement in the case management process. The program encourages
parent/guardian involvement in the case management process. This involvement includes the
assessment process, participation in the development of the youth’s performance plan, progress
reviews, formal treatment team meetings, and transition planning. Case management utilizes
telephone conferences for the formal treatment team meetings and web-based video calls for
the transition conferences. Case managers send letters, emails, and telephone calls to remind
parents/guardians of these meetings. Treatment teams were not being held during the week of
the annual compliance review; therefore, no formal treatment team meetings were observed.
The program director was interviewed and stated case managers stay in constant contact with
the parents/guardians by letters and/or phone calls, and in some cases emails. Letters are also
mailed to inform parents/guardians of the date and time of formal meetings. Nine youth were
interviewed, and all confirmed their parents/guardians participate in their treatment team
meetings.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
Nine youth case management records were reviewed for incorporation of other plans into
performance plans. The program incorporates all treatment and academic progress monitoring
plans into each youth’s Individualized Performance Plan (IPP). The program has a separate
treatment plan for mental health. Each IPP references the youth’s mental health plans. None of
the reviewed youth were applicable for a plan from another entity.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
Nine youth records were reviewed for treatment team meetings. Each record documented
formal treatment team reviews were conducted at least once every thirty days. Informal reviews
were held bi-weekly. The program utilized a Performance Plan Review form for both the formal
and informal treatment team meetings which included the youth’s name, date of review, meeting
attendees, comments from treatment team members, youth’s progress, and any revisions. The
treatment team leader reviews the progress of each youth’s goals, behaviors, physical
interventions, treatment progress, and Residential Assessment for Youth (RAY) Reassessment
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results. Youth are provided the opportunity to demonstrate skills acquired in the program.
Reviewed documentation confirmed formal treatment team meeting attendees consisted of the
youth, case management staff who act as the treatment team leader, clinical staff, education,
living unit representative, and a program administration representative for each of the nine
applicable youth. Each youth’s juvenile probation officer (JPO) and parent/guardian were invited
to participate in person, by telephone/video conference, and/or provide written input. Reviewed
documentation confirmed informal treatment team meeting attendees consisted of the youth and
case management staff, with relevant information being provided by treatment team members.
No observations of formal treatment teams were conducted during the annual compliance
review week. Nine interviewed youth reported staff review their performance through progress
on performance plan goals, positive and negative behavior, and treatment progress. Each youth
reported they are given an opportunity to demonstrate any skills they have learned in the
program during treatment team.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
Three closed youth records were reviewed regarding transition planning, conferences, and
Community Re-entry Team (CRT) meetings. Documentation showed all required treatment
team members, youth, parent/guardian, education staff, and juvenile probation officer (JPO)
were invited and participated in the transition conference held at least sixty days prior to the
youth’s targeted release date. All closed youth records documented the transition conferences
were conducted and documented on the Transition Conference form which included attendees
and signatures acknowledging the transition goals and accountability for completion. During the
transition conference, participants reviewed the transition activities outlined on each youth’s
Individualized Performance Plan (IPP) or revised IPP, additional identified transition activities,
target completion dates, and each person’s responsibility for goal completion. Each youth
record contained documentation a copy of the transition plan was sent with a request to return
the signature sheet to anyone not in attendance who had a responsibility for completion of
transition goals, as well as documentation a copy of the plan was sent electronically to the JPO.
Documentation in all three closed records supported the program received an invitation to the
CRT meetings. Reviewed documentation supported the program, youth, and parent/guardian
participated in the CRT meetings.
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2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program maintains a written policy and procedures for the assembly of the exit portfolio for
each youth to assist once released back into the community. Exit portfolios are to include a
state-issued identification card, Social Security card, birth certificate, all educational
documentation, school transcripts, résumé, sample employment applications,
educational/vocational certificates earned in the program, along with a calendar of upcoming
appointments. Three closed youth records were reviewed all records contained all required
elements except for the state-issued identification card. There was evidence of the program
attempting to obtain this information by mail. All three closed records included the Social
Security cards and birth certificates. All three closed youth records indicated the exit portfolio
was discussed and initiated during the transition conference and verified during the exit
conference. Documentation supported the exit portfolio was completed and given to each youth
upon release. Documentation showed the program forwarded each youth’s juvenile probation
office (JPO) a copy of the exit portfolio.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth records were reviewed for completion of the exit conference. Reviewed
documentation found each exit conference was conducted at least fourteen days prior to the
youth’s release and after notifying the juvenile probation officer (JPO) of the youth’s release.
Reviewed documentation supported the youth, case manager who also acted as the treatment
team leader, the program director or designee, educational staff, mental health staff, and
medical staff all participated and signed the exit conference, with the parent/guardian and JPO
participating by telephone. Transition activities and target dates were reviewed and finalized
during the exit conference. Documentation showed a copy of the exit conference was
electronically sent to each JPO and mailed to each parent/guardian. All exit conferences were
separate from the transition and Community Re-Entry Team meetings. All three of the reviewed
youth records showed the date of admission and release coincided with the dates entered in the
Department’s Juvenile Justice Information System (JJIS).
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures to promote constructive input by youth.
Reviewed documentation verified the program solicited input from youth through treatment
teams, grievances, the Peer Advisory Board, and Town Hall Meetings. The program director
was interviewed and confirmed the program’s formal process to solicit input from youth. Nine
youth were interviewed. Three youth reported they do not provide input about what happens in
the program. Three youth reported they were not sure or had not heard of providing input. One
youth reported they would provide input through town hall meetings. One youth reported never
providing input but they could talk with the program director. One youth reported the living units
have peer advisors, but this youth was not involved.
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2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to address Career and Technical Education (CTE).
The career educational programming is Type 2. The program has personal accountability skills
and behavior appropriate work habits for employment incorporated into the programming.
Programming includes communication, interpersonal skills, and decision-making skills. Youth
can earn ServSafe, Florida Ready to Work Soft Skills, first-aid/cardiopulmonary resuscitation
(CPR), Occupational Safety and Health Administration (OSHA 10), and Forklift certifications.
Three reviewed youth case management records had samples of completed employment
applications and a résumé summarizing education, work experience, and/or career training.
None of the youth records contained a Department of Highway Safety and Motor Vehicles state-
issued identification card; however, a request to the parent/guardian for the documentation was
located within the records. Each youth record contained other documents essential to obtaining
employment. Two of the three youth had Career Source Center Information. Documentation
indicated the youth’s parent/guardian and juvenile probation officer (JPO) were aware of the
youth’s educational plan. The interview with the lead educator indicated that the Educational
Transition Plan was shared during a treatment team meeting.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide for educational access for the
youth. Educational services are provided by the Rader Group which is contracted by the
Okaloosa School District which approves the 250-day school calendar. A review of the daily
education schedule revealed youth are provided with a minimum of twenty-five hours of
instruction each week, incorporating six, fifty-minute class periods, as indicated on the daily
school schedule provided by the lead educator. The youth are receiving 240-days of instruction,
the calendar allows for the teachers to utilize ten days for training and teacher planning
throughout the school year. The lead educator was interviewed and reported the daily schedule
is followed with minimal interruptions and school is not canceled for any reason. The program
director indicated there are minimal interruptions during the school day. Nine youth were
interviewed. Four youth reported there were interruptions and five youth reported there were no
interruptions throughout the school day. The interruptions the youth provided were to go to the
nurse or restroom or graduates talking while others are working. One youth could not provide
examples. One youth reported there are interruptions only when youth are acting out. Three
days were reviewed in the logbooks and three days from the past thirty days were reviewed on
video, and each showed no issues pertaining to the daily school schedule. The reviewed
logbooks showed on the three days the youth arrived and left during the expected times. A
review of the video showed the youth began class and ended as expected. The interview with
the lead educator indicated the youth were arriving to school on time and left at the appropriate
times.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a written policy and procedures requiring an Educational Transition Plan
to be developed upon each youth’s admission. Three closed youth case management records
were reviewed. The youth records included an individual Education Transition Plan developed
upon entry and included the youth’s post-release goals. Three closed case management
records contained an exit plan indicating the case manager, parent/guardian, and youth were all
aware of the plan. Nine youth were interviewed. The youth reported they were involved in the
development of their transition plan. Each youth also reported they felt the program was
preparing them very well or well when it came to preparing them for high school equivalency
diploma (GED), high school, career and technical school, employment, and/or college.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a full-time designated mental health clinician authority (DMHCA) who is a
licensed clinical social worker (LCSW) under Chapter 491 Florida Statute. The DMHCA is a full-
time staff and is on-site seven days a week, for forty hours a week. The DMHCA provides
oversight to all therapists delivering mental health overlay services, substance abuse overlay
services, and juvenile sex offender treatment services; and provides weekly clinical supervision
to all therapists. In addition to providing oversight to all therapists, the DMHCA is certified to
facilitate and provide back-up coverage for all groups conducted by the clinical staff. The
DMHCA provides the twenty-hour training to non-licensed staff on the Assessments of Suicide
Risk (ASRs), as well as reviews the ASR assessments completed by non-licensed staff. The
DMHCA’s license expires March 31, 2025. The program has a licensed mental health clinician
(LMHC), who serves as the back-up DMHCA. The back-up DMHCA is licensed under Chapter
491, Florida Statutes, with a license expiration date of March 31, 2025. The DMHCA was
interviewed and described their role as overseeing all services provided at the facility. The
DMHCA conducts comprehensive case reviews of all youth at admission and on an on-going
basis to ensure appropriate services are provided to all youth and treatment needs are
adequately met. The services provided are group counseling, individual counseling, family
counseling, crisis intervention services, and Baker Act assessments. The DMHCA stated they
have daily communication with all clinical staff and weekly clinical supervision where therapists
are encouraged to bring issues or concerns as they arise. Communication is on-going through
face to face and virtual meetings.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has one full-time licensed assistant clinical director other than the designated
mental health clinician authority (DMHCA). The full-time licensed clinical staff is a licensed
mental health clinician (LMHC), who serves as the back-up for the DMHCA. The LMHC has a
clear and active license under Chapter 491, Florida Statutes, which expires on March 31, 2025.
The DMHCA ensures all licensed clinical staff working under their supervision are performing
services they are qualified to provide based upon education, training, and experience. The
licensed mental health and substance abuse clinical staffing is in accordance with the current
contract and Florida Administrative Code. Licensures of clinical staff, along with the program’s
Chapter 397, Florida Statutes licensure were posted within public view. The program’s Chapter
397, Florida Statutes, licensure is site-specific, with an expiration date of October 30, 2024.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The current designated mental health clinician authority (DMHCA) is responsible for ensuring all
six non-licensed therapists work under their supervision. The non-licensed clinical staff perform
services which they are qualified to provide based on education, training, and experience. A
review of the program’s contract found the juvenile sex offender non-licensed clinical staffing is
in accordance with the contract and Florida Administrative Code. Documentation was found
both non-licensed mental health and substance abuse non-clinical staff were receiving at least
one hour a week of on-site face-to-face direct supervision by the DMHCA for the annual
compliance review period. Supervision was documented as required on the Department form.
All six non-licensed clinical staff hold a master’s-level degree from an accredited university or
college in the field of counseling, social work, psychology, or related human services field. Each
of the non-licensed mental health and substance abuse clinical staff provide mental health and
substance abuse services as a staff of the service provider, licensed under Chapter 397, Florida
Statute. There are three sex offender certified therapists at the program, which includes both
licensed clinicians and one non-licensed clinical staff. The program provided documentation
confirming five non-licensed mental health staff completed the twenty-hour training and
supervised experience to complete the Assessments of Suicide Risk (ASRs) for youth and one
staff is in the process of getting the ASR training. The ASR training was documented on the
Non-Licensed Mental Clinical Staff Person’s Training in Assessment of Suicide Risk form.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Nine youth records were reviewed for a mental health and substance abuse admission
screening. Each contained a completed Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2) administered in a confidential manner upon the youth’s admission to the
program. The screening tools documented the trained staff completing the screening, along with
the date and time of the initial screening. During the screening process, all available information
was reviewed, which included the review of the commitment packet, reports, and records from
existing documentation of mental health and/or substance abuse assessments. The MAYSI-2s
were completed in the Department’s Juvenile Justice Information System (JJIS). In eight of the
nine youth records reviewed, regardless of the MAYSI-2 findings, a referral was made for the
youth to receive the Assessment of Suicide Risk (ASR). All nine reviewed records included a
Comprehensive Assessment. Seven of the nine youth were applicable for a referral for further
assessment based on the MAYSI-2 results. Two records did not document a referral was
required on the MAYSI-2. In one record a referral was marked as the result of the MASYI-2, but
the youth did not have any needs on the MAYSI-2 determined for referral. Each completed ASR
documented the program director was notified and the ASR was conducted within twenty-four
hours. Reasons for referrals were documented on seven of the nine referrals. One youth did not
require an ASR. The second youth received an ASR and comprehensive evaluation, but no
referral was documented. One youth record did not have a completed ASR, however; there was
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no suicide risk marked on the MAYSI-2. There were other administrative assessments used to
determine the youth’s referral needs which also did not indicate a suicide need. The program
director was interviewed and reported the MAYSI-2 is conducted at intake and reviewed by the
clinical team.
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 records were reviewed for mental health and substance abuse assessments and
evaluations. All nine reviewed records were applicable for completion of a new mental health
and substance abuse evaluation. The evaluations were completed within thirty calendar days
from the youth’s admission to the program. Eight of the nine mental health and substance abuse
evaluations were completed by a non-licensed clinical staff person and signed off by the
designated mental health clinician authority (DMHCA) and one evaluation was completed by the
DMHCA. All nine mental health and substance abuse evaluations contained demographics,
reason for evaluation, relevant background information, behavioral observations, Mental Status
Examination, discussion of findings, clinical impression, and recommendations. All nine
reviewed youth records included a new, completed substance abuse and sexual offender
assessment. The substance abuse assessment was completed under the program’s licensure;
Chapter 397, Florida Statute. All nine youth records contained a signed consent for substance
abuse services. The substance abuse assessment contained a reason for assessment, relevant
background information, behavioral observation, methods of assessment, patterns of alcohol
and other drug abuse, impact of alcohol and other drug abuse on major life areas, risk factors of
continued alcohol and other drug abuse, clinical impressions, and recommendations. The
DMHCA was interviewed and reported all incoming documentation is reviewed by the clinical
director and assigned therapist prior to admission. This information, in conjunction with all
screenings and assessments conducted at intake, are integrated into the comprehensive mental
health/substance abuse evaluation. Presenting behaviors are documented in the
comprehensive mental health/substance abuse evaluation and for any significant behavioral
changes which occur following the completion of the evaluation, an update will be conducted.
Should the youth be behaviorally non-compliant with the evaluation, collateral information will be
utilized for the evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
Nine youth records were reviewed for youth treatment planning. Each youth record contained an
initial treatment plan, and each was developed within seven days of the youth’s admission to the
program. The initial mental health treatment plans were site-specific, which included similar
elements to the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. The
initial treatment plans were signed by the mental health clinical staff completing the form. Eight
of the nine were completed by a non-licensed clinical staff and signed by the licensed clinical
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supervisor within ten days of completion, with the designated mental health clinician authority
(DMHCA) completing one of the initial treatment plans. All nine initial treatment plans were
signed by all members of the treatment team with documentation of a letter to the
parent/guardian when they could not be reached. Psychiatric needs were included in the initial
treatment plan for the two applicable youth who were admitted to the program on psychotropic
medications. All nine reviewed individual treatment plans were developed within thirty-days of
admission. Eight of the plans were completed by a non-licensed mental health clinical staff and
signed by the licensed clinical supervisor within ten days of completion, with the DMHCA
completing one of the individualized treatment plans. The nine individualized treatment plans
reviewed were developed on a site-specific form, which contained similar elements to the
Department’s Individualized Mental Health Treatment Plan form. Five of the nine youth were
applicable and included psychiatric services in their individualized treatment plans. The plans
included psychotropic medication and frequency of monitoring by the psychiatrist. Each
treatment plan review was conducted and documented on a program specific form which
contained similar information to the Department’s Individualized Mental Health/Substance
Abuse Treatment Plan Review form. Each of the youth’s individualized treatment plans
documented their prescribed services to include individual therapy, group, family, and
psychiatric services when needed. A review of each youth’s progress notes determined youth
were in receipt of services, both stipulated and not stipulated on the treatment plans, such as
individual therapy group therapy, family therapy, and psychiatric services when needed. Forty-
seven total individualized treatment plan reviews were completed and documented, with three
reviews being one day late from the required thirty calendar days. Video observations of three
treatment groups were made and compared with the corresponding sign-in sheets and logbook
entries and no issues were observed. In the DMHCA’s interview, they reported the clinical
director and clinical supervisor monitor the implementation of all services provided. This occurs
through fidelity monitoring and review of documentation.
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 records were reviewed for mental health and substance abuse treatment. Reviewed
records indicated each of the youth were assigned a treatment team upon arrival to the
program. Each youth is assigned to an on-site therapist and case manager upon intake to the
program. The multidisciplinary treatment team was comprised of the youth, program
administration, staff from the residential living unit, and other staff responsible for delinquency
intervention and treatment services for the youth. Each of the nine records contained treatment
team documentation, which validated it is comprised of representatives from administration,
education, vocational training, medical staff, mental health staff, substance abuse staff, youth,
and when possible, the youth’s parent/guardian. Provided treatment consisted of individual,
group, and psychiatric services when applicable. Each of the nine youth had a properly
executed Authority for Evaluation and Treatment (AET) form on file. Each youth in receipt of
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mental health services had a documented diagnosis. Seven of the nine youth were applicable
for needing substance abuse treatment and all records included a signed Youth Consent for
Substance Abuse Treatment and Youth Consent for Release of Substance Abuse Treatment
Records forms. Each youth in receipt of substance abuse services had a documented
diagnosis. Mental health treatment and substance abuse treatment notes were documented on
the provider’s form, which contained all the required information within the Department’s
Counseling/Therapy Progress Note form. According to the clinical director and sign-in sheets for
mental health treatment groups, documented groups were limited to ten or fewer youth and for
substance abuse treatment groups, documented groups were limited to fifteen or fewer youth.
The nine reviewed youth records contained documentation youth were involved in individual
psychotherapy or counseling. Youth were engaged in therapeutic activities designed specifically
to address skill deficits or maladaptive behaviors. On-site sex offender groups were provided by
certified, non-licensed sex offender therapists with additional coverage from the certified and
licensed sex offender therapist. Mental health and substance abuse groups were provided by
the non-licensed clinical staff, who are staff of the service provider under Chapter 397, Florida
Statute. Three additional youth records were reviewed for Discharge Plans. Each of the three
Discharge Plans were documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Plan form. None of the three reviewed youth records required any type of
notification for suicide alert or precautions. The three Mental Health and Substance Abuse
Treatment Discharge Summaries documented the services needed for daily maintenance of
positive improvement in behavioral, emotional, and social skills made by youth during treatment.
Each of the three Discharge Plans contained documentation the plan was mailed home to the
youth and family. Two of the three discharge summaries contained signatures from all members
of the treatment team. An informal interview with the designated mental health clinician authority
(DMHCA) confirmed the one record was of the youth who left the week of the annual
compliance review and the paperwork confirming the Discharge Plan was sent to the
parent/guardian and juvenile probation officer (JPO) had not been attached to the record. Nine
youth were interviewed, and eight youth reported they participated in counseling once a week,
one youth reported every month, and one youth shook their head no and said nothing. The
program was made aware of the final youth’s response. Nine direct care staff were interviewed,
and all stated they did not facilitate mental health groups. The DMHCA was interviewed and
reported the processes for individualized mental health and substance abuse treatment
planning are the clinicians integrate feedback from the youth, family, internal and external teams
to develop a treatment plan based upon the youth’s individualized needs.
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 Juvenile Sex Offender Treatment Services (JSO), Mental
Health Overlay Services (MHOS), and Substance Abuse Treatment Overlay Services (SAOS)
for those youth who are assessed and determined to be in need. The program provided JSO
treatment groups five days a week, MHOS and SAOS treatment groups four days a week,
individual therapy once a month at a minimum, family therapy services once a month, and
psychiatric services once a month or as needed. All nine records documented the number of
times a youth receives individual, group, and family counseling on the individualized treatment
plans. JSO 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.
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The program arranges for a psychologist to provide services when needed. The counselor
caseloads are limited to twelve youth and have an average of ten youth. Mental health
treatment groups are limited to ten or fewer youth and substance abuse treatment groups are
limited to fifteen or fewer youth. Clinical staff are on-site seven days a week. JSO treatment
planning, therapy, crisis interventions, and therapeutic activities are provided to the youth. The
program is licensed under Chapter 397, Florida Statute. The program has three full-time
certified JSO therapists, with two licensed clinicians and one non-licensed clinician who provide
coverage seven days a week and facilitate the JSO treatment groups. A licensed psychiatrist
provides psychiatric evaluations, medication management, and participates in treatment
planning. All nine interviewed direct care staff confirmed they do not facilitate treatment groups.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
A total of nine youth records were reviewed for psychiatric service delivery. Two of the nine
youth were admitted with psychotropic medications and referred for an initial psychiatric
interview, which was conducted within fourteen days of admission. An additional three of the
nine youth were referred for a psychiatric interview after admission and the initial psychiatric
interview was conducted within thirty-days of the referral. The five initial diagnostic psychiatric
interviews included the youth’s history, Mental Status Examination, a diagnosis from the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), applicable
treatment recommendations, applicable prescribed medications, explanation of the need for
psychotropic medication, and frequency of medication monitoring. Each of the initial diagnostic
interviews with the psychiatrist were documented on the Department’s Clinical Psychotropic
Progress Note (CPPN). Each conducted psychiatric evaluation reflected the elements specified
in Florida Administrative Code. Seven youth did not enter the program on psychotropic
medications, three of whom were prescribed medications after the initial psychiatric interview
was completed and the remaining four were not prescribed medications. The two youth who
entered the program on medications were continued on the medications. All five youth
applicable for psychotropic medications while at the program were screened for Tardive
Dyskinesia, as required, which was documented in the Individual Healthcare Records. All five
youth on psychotropic medications received the monthly psychiatric reviews. Out of thirty-one
monthly psychiatric reviews, all were done within thirty days. Each of the psychiatric evaluations
completed were documented on the CPPN. Psychiatric services are provided by a licensed
psychiatrist whose license expires March 31, 2024. The program does not employ or have a
contract with a psychiatric advanced practice registered nurse (APRN). The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist provides input to a representative of the treatment team on the psychiatric status of
each youth in receipt of psychiatric services. In addition, the psychiatrist’s evaluation and
recommendations for youth are incorporated into the mental health clinical staff’s evaluations of
the youth and the youth’s Individualized Mental Health or Substance Abuse Treatment Plan. A
review of sign-in sheets for the psychiatrist confirmed on-site visits occurred every two weeks
for the required two hours throughout the annual compliance review period. The psychiatrist is
ultimately responsible for the prescription and monitoring of psychotropic medications at the
program. The psychiatrist actively participates in, manages, and supervises psychotropic
medication services within the program. The psychiatrist’s interview revealed the psychiatrist
described their role as providing psychotropic medication management with associated
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consultation and routine follow-up. The psychiatrist stated they are on-site twice a month for two
hours. The psychiatrist meets with the program’s designated mental health clinician authority
(DMHCA) as needed. The DMHCA interview confirmed the DMHCA meets with the psychiatrist
bi-weekly.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written Suicide Prevention Plan, which details suicide prevention
procedures. The written Suicide Prevention Plan included identification and assessment of
youth at risk of suicide, staff training, suicide precautions, levels of supervision, referral,
communication, notification, documentation, immediate staff response, and a review process.
The program director has an established review process for every suicide attempt or serious
self-inflicted injury, along with a mortality review for a completed suicide. The established review
process included the circumstances surrounding the event, program procedures relevant to the
incident, training received by all involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations, if any, for changes in
policy, training, physical plant, medical or mental health services, and/or operational
procedures. The program’s written Suicide Prevention plan was reviewed and was last
approved by the designated mental health clinician authority (DMHCA) and program director on
July 11, 2023.
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.
Eight of the nine youth records reviewed were applicable for suicide prevention services. Five of
the eight did not have a precautionary observation (PO) placement or removal at the program,
but received an Assessment of Suicide Risk (ASR) upon admission. The remaining three youth
were admitted to program on PO but were reduced to standard supervision after receiving the
ASR, which was within twenty-four hours of being placed on PO. The ASR was completed
utilizing the Department’s ASR form. The on-site mental health staff conducted the ASR and
provided supportive services to each of the youth. In seven of the eight ASRs reviewed, a
trained non-licensed therapist completed the ASR and reviewed by a licensed staff within
twenty-four hours. One ASR was completed by the designated mental health clinician authority
(DMHCA). The results of the ASR were recorded in all youth records reviewed, as required. In
all ASRs reviewed, the youth was placed on standard supervision and the suicide alert was
closed for the three youth admitted on PO. The other five youth records did not require an alert
in the Department’s Juvenile Justice Information System (JJIS). Placement on PO allows the “at
risk” youth to participate in select activities with other youth in designated safe housing and/or
observation areas of the program. Placement of a youth on PO does not limit the youth’s activity
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to an individual cell or restrict them to their sleeping room. Each non-licensed clinical staff
completing ASR screenings completed the required twenty hours of training by a licensed
professional documented on the Department’s Non-Licensed Mental Health Clinical Staff
Person’s form. Each of the youth had documentation on their ASR where the licensed mental
health professional conferred with the program director or designee on all ASRs. Documentation
of the actual date and time the clinician conferred with the program director or designee was
found in the appropriate sections on all ASRs. None of the youth assessed for suicide risk were
found to be in crisis. None of the youth required an ASR to be conducted outside of the
program. There have been no youth at the program requiring secure observation for the annual
compliance review period. The program has suicide response kits on-site. Camera footage and
corresponding documentation for one applicable youth on PO was reviewed with no issues.
Nine staff were interviewed regarding response needed for a youth who expressed suicidal
thoughts. All nine staff reported they would notify mental health, search the youth’s room for
sharp objects, place the youth on constant sight and sound supervision, and document
supervision. Two staff said they would place the youth in a locked room. All five staff knew the
suicide kits were kept in master control and two staff reported suicide kits were in the vehicles.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Three of the nine youth records were applicable for the review of precautionary observation
(PO) logs with three youth admitted to the program with placements on PO. Logs were
documented on the Department’s Suicide Precautions Observation Log form. The appropriate
level of supervision and observations of youth behaviors were documented in real time, at a
minimum of thirty-minute intervals. There were no noted warning signs documented on any of
the reviewed logs. In the three applicable youth records reviewed, all the logs were reviewed
and signed by each shift supervisor and reviewed and signed by mental health clinical staff. All
completed logs were reviewed to determine supervision, supervisory reviews, response to
warning signs, and safe housing requirements were met. Each log documented the safe
housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
A total of eighteen staff training records (nine pre-service and nine in-service) were reviewed for
completion of suicide prevention training, with no noted issues. A review of training included
simulated suicide drills, which were held no less than quarterly on each shift for staff who
encounter youth. The program has three suicide response kits with one in master control and
one in each of the two vehicles. The suicide response kits contained a knife-for-life, wire cutters,
and needle nose pliers. The program director reported suicide drills are mandatory and if staff
miss a drill, they get a write up and have to review the drill with the program director. The
reviewed suicide drills included the use of cardiopulmonary resuscitation (CPR) annually. An
interview with the program director revealed the program provides training or “mock” drills for
staff covering medical, suicide, and emergency drills. Nine staff were interviewed, and each staff
shared how often medical emergency and suicide drills are conducted on their respective shifts.
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3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written Crisis Intervention Plan. The plan included the required information
of a notification and alert system, means of referral, including youth self-referral,
communication, supervision, documentation, and a review process.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program did not have any youth requiring a Crisis Assessment since the last annual
compliance review was conducted. The program has a written Crisis Intervention Plan and
Emergency Mental Health and Substance Abuse Plan, which address the practices necessary
to effectively handle youth in need of a Mental Status Examination and a Crisis Assessment.
The program utilizes the Department’s Crisis Assessment form to document reasons for
assessing a youth demonstrating acute psychological distress.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written Emergency Mental Health and Substance Abuse Plan. The plan
includes immediate staff response, notification, communication, supervision, authorization to
transport for emergency mental health services or substance abuse services, transport for
emergency mental health evaluation and treatment under Chapter 394, Florida Statute (Baker
Act), transport for emergency substance abuse assessment and treatment under Chapter 397,
Florida Statute (Marchman Act), documentation, training, and a review process.
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3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Nine youth records were reviewed for a safety planning process for youth. Each of the reviewed
safety plans contained warning signs necessary in the identification of a youth escalating in their
behaviors. Each safety plan included the youth’s baseline behavior in addition to the youth’s and
staff’s perceptions of verbal and nonverbal stimuli which may have positive and negative effects
on the youth. The plans included coping strategies, to include people and healthy environments,
along with intervention strategies preferred and defined by the youth. All nine safety plans
included the debriefing process. All nine safety plans were completed within fourteen days upon
the youth’s admission to the program and included the inclusion of or attempts to include the
parent/guardian or a family member for the preparation of the plan. Each of the plans
incorporated recommendations from previous or current clinical assessments or screening
instruments. Forty-seven safety plan updates were reviewed with five plans updated late. Three
updates were three days late each and the remaining were two and nine days late. The safety
plans are stored in master control for easy access to staff. An interview with the program
director revealed safety plans were being reviewed monthly or as any changes occur. Nine
youth were interviewed, and one youth said they did not contribute to their safety plan, three
said they did, two said they were not aware of it, and two reported they were not sure. One
youth reported they get asked to change it, but the youth does not change it. Nine staff were
interviewed, and three staff reported they do not look at safety plans. One of those staff went on
to report the supervisors or mental health look at them. One staff reported reviewing them two-
to-three months ago. Two staff reported they reviewed them a month ago. One staff reported
reviewing them in November. Two staff reported reviewing them two weeks ago. One of these
staff went on to report they reviewed the safety plan for a youth who was upset and they used
the safety plan to help calm the youth down.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The designated health authority (DHA) is a licensed medical doctor (MD). The DHA holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The DHA has a license, which expires January 31, 2026. The DHA has
specialty training in family practice. There was no indication the DHA had any disciplinary cases
and/or public complaints on record. The program does not have a physician’s assistant (PA) or
advanced practice registered nurse (APRN) employed. A review of sign-in/out logs during the
annual compliance review period confirms the DHA was on-site at least once a week, with no
observed issues. The contract requires the DHA to be on-site at a minimum of two hours each
visit. There was no indication the DHA had any vacations and or scheduled absences during the
annual compliance review period. The program does have a back-up medical doctor who holds
an unrestricted license and meets all requirements for independent and unsupervised practice
in the State of Florida. The back-up medical doctor’s license expires March 31, 2024. There was
no indication the program used any type of tele-medicine services during the annual compliance
review period. The DHA was interviewed. The DHA confirmed their role in performing duties at
the program.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a total of five licensed nurses to include on-site nursing coverage provided by
registered nurses (RNs) and licensed practical nurses (LPNs). The program has four RN’s and
one LPN. When LPNs are used, the RNs provide direction to the LPN, which includes reviewing
all medical cases daily when necessary. All nurse licensure credentials were clear and active,
according to Florida Department of Health (DOH). All nursing staff have a current
cardiopulmonary resuscitation (CPR) certification. According to contract, the required on-site
hours for nursing are one health service administrator for forty hours, and two RNs for a total of
eighty hours weekly.
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 designated health authority (DHA) conducted an annual review of all respective treatment
facility operating procedures (FOPs). The DHA last signed and dated on January 22, 2024. The
program director also conducted an annual review, signed, and dated treatment FOPs on
January 5, 2024. In addition, the psychiatrist completed an annual review, signed, and dated the
respective treatment FOPs on January 19, 2024. A review of nursing staff found each had
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reviewed, signed, and dated a cover page on which medical FOPs were listed. There was no
indication of any new or changed FOPs during the year reviewed. Each of the newly employed
healthcare staff received a comprehensive clinical orientation to the Department’s healthcare
FOPs, which were given by a registered nurse. A review of approved treatment protocols and
standing procedures indicated they were authorized by the DHA only.
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 youth Individual Healthcare Records (IHCRs) was conducted for completion of
an Authority for Evaluation and Treatment (AET) form. Eight of the nine youth had a completed
AET filed within their IHCR. One remaining youth turned nineteen prior to being admitted to the
program. An AET or court order for this youth was not required since the youth is responsible for
authorizing their own physical and mental health care. Each applicable youth AET’s had the
youth’s parent’s/guardian’s signature. There was no indication where a parent/guardian refused
to sign the AET. The applicable AET’s were signed by a Department representative. All the
AET’s were observed to be valid. There were no cases of youth in the care of the Department of
Children and Families.
An interview with nursing staff was conducted, and they indicated the AET will come with the
youth in the face sheet when admitted. An AET is valid for as long as the youth is under
supervision with the Department or for one year after it was signed by the parent/guardian
whichever comes later. In addition, if a youth is in the program and reaches eighteen years of
age and has the capacity, the youth is responsible for authorizing healthcare and release of
their healthcare records. Youth who are eighteen can give verbal consent at the point of contact.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
parental/guardian notification/consent. Seven of the nine youth were applicable for
parental/guardian notification of over the counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET). In each of the seven applicable youth
records, there was documentation of consent provided by the parent/guardian. Documentation
was noted within progress notes of an attempt made to contact the parent/guardian when
medication was ordered. Written notifications were sent to parent/guardian utilizing the
appropriate Department forms. Two of the nine youth were applicable and admitted to the
program on psychotropic medication. Three of the remaining seven youth were applicable for
being prescribed psychotropic type medication after admission to the program. For each of the
youth prescribed psychotropic type medications, staff witnessed all telephone call attempts to
parent/guardian. Each of the youth on psychotropic medication, whether new, discontinued, or
significantly changed had parental/guardian verbal consent was documented on page three of
the Clinical Psychotropic Progress Note (CPPN). There were no youth reviewed who were
under the care of the Department of Children and Families (DCF). Seven of nine youth had
documentation where the program verified the youth’s vaccinations within thirty days of
admission. The remaining two youth were missing a date of when medical staff conducted a
verification. None of the youth were applicable for requiring new vaccinations or requesting
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religious exemption. An informal interview with on-site nursing confirmed the program utilizes
the Florida Shots website for verification of youth vaccinations.
The nurse explained parental/guardian notifications occur when any medications are added,
changed, or discontinued, when there has been a significant change in youth condition, and/or
there are any medications not covered by the AET. In addition, vaccination or immunizations not
consented for on the AET. Parents/guardians are also notified for any off-site emergency care,
hospitalizations, non-routine dental procedures, or whenever a youth is taking off-site for
medical treatment. Any verbal notification will be followed-up by a written parental/guardian
notification. Attempts to contact parents/guardians by telephone or in person are made, then a
note is added in progress notes. When a new psychotropic medication is prescribed,
discontinued, or the drug dosage is significantly changed, parental/guardian verbal consent for
psychiatric meds is documented through the CPPN. Written consent is documented on the
acknowledgement of receipt of the CCPN form. For immunizations where there is a religious
conflict, the parent or guardian will complete the Religious Exemption from Immunization Form.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
healthcare admission screening and rescreening form. Each of the IHCR’s contained a Facility
Entry Physical Health Screening (FEPHS) form, which was completed on the date of admission.
All the FEPHS forms were completed by a registered nurse (RN). None of the FEPHS forms
were completed by direct care staff. One youth was applicable for a change in custody greater
than twenty-four hours, whereas a FEPHS re-screening was completed for each returning date
after the change in custody.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
youth orientation to healthcare/education services. All youth had documentation for completion
of orientation to healthcare services upon admission to the program. The youth’s orientation
included all necessary topics and was signed by each youth on a separate healthcare/education
form.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
notification to the designated health authority (DHA) and/or designee. One youth was applicable
for known or suspected chronic conditions. Two of the nine youth were applicable for taking
psychotropic type medications upon admission. The program’s facility operating procedures
indicate the DHA and/or designee will be notified for all newly admitted youth. All nine youth had
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documentation of a referral being sent to the DHA within twelve hours of the youth’s admission.
The two applicable youth admitted on psychotropic type medications had documentation of the
psychiatrist being notified.
An interview with nursing staff was conducted for those youth admitted with a chronic condition.
Nursing staff will immediately notify the DHA. The contact between nursing staff and the DHA is
documented on the nursing admission form.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
the Health-Related History (HRH) form. All nine reviewed youth records contained a HRH
completed within seven calendar days of admission. Each reviewed HRH was completed prior
to completion of the Comprehensive Physical Assessment (CPA); as evidenced by signature
and date. All the HRHs were reviewed by the designated health authority (DHA); this was
indicated by the checkbox on the CPA.
An interview with nursing staff was conducted and confirmed nursing staff completes the HRH
upon the 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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
a Comprehensive Physical Assessment (CPA) form. All the CPAs reviewed were completed on
the Department’s CPA form. All the reviewed CPAs were completed within seven calendar days
of the youth’s admission to the program. Each of the new CPAs were completed by the
Designated Health Authority (DHA). Eight of the nine reviewed CPAs documented the correct
Medical Grade. The remaining one record did not contain documentation of the youth’s Medical
Grade on the CPA. Evidence of the youth’s Medical Grade was found documented within the
IHCR. Each section of the CPA was marked respectively with an “O” or an “X” accordingly. All
nine youth refused the genital examination. Eight of the nine records did not contain a refusal
form completed on date of the actual examination. The program conducted a review and had
each youth sign a refusal for the genital examination upon admission. The one remaining youth
signed a refusal on date of the genital examination. Each of the youth reviewed did receive
medical services; a medical assessment was conducted as required. Five of the nine youth
reviewed were applicable for updating the Department’s problem list. Four of the five had
required information updated on the problem list. The one remaining youth was missing required
documentation on the problem list. All nine youth had at least one verified tuberculosis skin test
(TST) documented in the IHCR. The TSTs were found documented on the CPA and Infectious
and Communicable Disease (ICD) forms.
An interview with nursing staff was conducted and confirmed the CPA is completed within seven
days of youth admission. If the youth is a Medical Grade two through five, a CPA is completed
yearly thereafter, and if the youth’s Medical Grade is one, a CPA is completed every two years.
In addition, the process and time frame for tuberculosis screenings is every year and a new one
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completed within seventy-two hours of admission if a screening has not been completed within
the past twelve months.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
sexuality transmitted infection (STI) screening. All nine youth were clinically screened and
evaluated for STIs. In each case, the youth were all referred to the designated health authority
(DHA). The youth had documentation of the referral on the STI form. In each of the cases,
testing was ordered and performed. In seven of nine youth records, the results from testing
were found documented on the STI form. The remaining two youth did not have the results
documented on the STI form, although lab results were found in the IHCR.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for human
immunodeficiency virus (HIV) testing. Each of the youth were offered HIV counseling, testing,
and/or evaluation. One of the nine youth consented for HIV testing. All the documentation for
this one youth was completed in accordance with Florida Administrative Rule with no
exceptions. The remaining eight youth had documented refusal forms found in the IHCR.
Pursuant to Florida Statute, Chapter 381, the program had a policy and procedures which
addressed HIV testing results which are only disclosed to youth and statutorily identified entities.
All HIV pre and post-test counseling services are provided by a local testing center.
An interview with nursing staff was conducted and confirmed youth are screened for STIs upon
admission which is then documented on the infectious disease form and the DHA reviews the
results. If necessary, medical will get an order from the DHA to collect a urine to test for STIs.
Upon receipt of the results, medical will contact the DHA to determine what is next. The test
results will be recorded on the Infectious and Communicable Disease (ICD) form. For those
youth who want HIV testing, they will receive HIV education upon admission and will be offered
to attend a class, provided by an outside agency for education, testing and results, if interested.
Youth will sign consent for testing or sign they are refusing the testing/education and will be
placed in the IHCR under consents. Youth HIV results are kept in the IHCR in a sealed
confidential envelope and will be sent with the youth when released from program. All education
for youth is documented on the health education record, which youth sign they attended the
course. An interview with nine youth was conducted, each of the youth agreed they can ask for
an HIV/AIDS test if they want one.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
the sick call process. Four out of the nine youth records were applicable for sick call review.
None of the reviewed youth presented with any similar sick call complaints three or more times
within a two-week period. All sick calls were reviewed; the individual youth completed a sick call
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request form. In each of the sick calls, the nurse completed the sick call request form. None of
the sick calls reviewed were completed by a licensed practical nurse (LPN). The sick calls were
each found filed in the IHCR in reverse chronological order. None of youth had been in
restricted housing during the annual compliance review period. The reviewed sick call forms
were each documented in accordance with Florida Administrative Code. Each sick call reviewed
was found documented on the program’s sick call index. The sick calls were documented on the
program’s sick call referral log. The dates listed on the sick call index corresponded to the
completed sick call form located in each IHCR.
A review of the daily schedule, along with posted schedule, and nurses’ interview, confirmed
sick call was conducted as required. Sick call hours were posted outside the medical clinic. Sick
call is seven days a week at 11:00 a.m. and 2:00 p.m. A review of sick call documentation
supported only licensed nurses conduct sick call. The program has a policy and procedures,
which allow for a shift supervisor to review any sick call request when there are no licensed
healthcare staff on-site. The review of sick call occurs as soon as possible and within four hours
after the request is submitted. Observations of sick call forms were made and found in each
dormitory and in the dining area of the program. The medical clinic has an exam table and
equipment to perform sick call if necessary. A sick call request was made by a youth and
subsequently observed during the annual compliance review week. The youth was escorted to
medical by direct care staff. The healthcare staff identified themselves and upon review of the
sick call, articulated the purpose for the youth’s visit. The youth was seen in the medical clinic
with no other youth present. The youth was examined by a licensed healthcare staff. The direct
care staff was observed outside the medical clinic door, affording the youth and healthcare staff
privacy.
An interview with nursing staff was conducted and confirmed sick call practices; whereas, if a
youth needs to see the nurse, the youth fills out a sick call slip, and signs the bottom. The
nursing staff log the sick call entry and enter it in the IHCR under nursing progress notes and file
the sick call sheet. Sick calls are routinely conducted by a RN, if the LPN is on, sick call will be
reviewed by the RN. If sick call completed by the LPN, it will be reviewed daily either by
telephone or in person by the DHA or RN. If needed, youth will be placed on the DHA’s list for
the next time he is in the facility, when a youth presents with similar sick call complaints three or
more times within a two-week period.
An interview with nine youth was conducted regarding sick call and five said they are seen
immediately, three said within a day, and one said they had never requested a sick call. An
interview with nine staff was conducted, and all confirmed nursing staff review sick calls. Two of
the nine staff also stated the supervisor gives the request to nursing. In addition, each of the
staff confirmed nursing conducts sick calls.
4.13 Episodic/First-Aid and Emergency Care Failed Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
an episodic, first-aid, and/or emergency care situation. Six of the nine youth reviewed were
applicable for completion of episodic, first-aid, and/or emergency care. Each of the six medical
incidents were conducted by licensed healthcare staff. The healthcare staff documented each
case in subjective, objective, assessment, and plan (SOAP) format. There were no cases of an
episodic, first-aid, and/or emergency scenario having been provided for by non-healthcare staff.
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There is a total of seven first-aid kits, two of which are utilized for transportation. First-aid kits
are in master control, construction building, kitchen, nurses’ station, and program vans. On-site
healthcare staff confirmed a monthly review of first-aid kits is conducted to ensure contents are
maintained and stored in accordance with guidelines to prevent expiration and replenished as
needed. A review of three first-aid kits confirmed the kits are fully stocked with designated
health authority (DHA)-approved contents. Additionally, a review of monthly tracking sheets
demonstrated on-going monitoring of first-aid kits occurred as required.
The program has one automated external defibrillator (AED), which is kept in master control.
The operating procedures for the AED are located with the AED. On-site nursing checks the
AED to ensure batteries and pads are operable monthly. The medical staff conducted a self-test
of the AED with no issues. The AED batteries are due to expire May 2024. The AED pads are
due to expire January 2026.
The program has not conducted any announced or unannounced emergency medical during the
annual compliance review period.
Emergency numbers were observed in the medical clinic and master control. The emergency
numbers are accessible to all staff and inaccessible to any youth. Staff authorized to administer
the epinephrine auto-injector, were designated in writing; training was last conducted on
January 19, 2024, by a registered nurse. A total of nine staff training records were reviewed,
which documented the completion of episodic, first-aid, and emergency care. An episodic care
event was not able to be observed during the annual compliance review week.
The program does not have any written policy and procedures which address the use, access,
and inventory of Narcan. Narcan was found stored in master control with the AED and in the
medical clinic in the medication cart. The program conducts monthly inventory of Narcan. Staff
were last trained on Narcan use February 21, 2024.
An interview with nursing staff was conducted and confirmed the location of the AED and first-
aid kits. In addition, the nurse confirmed the AED pads and batteries expiration dates. An
interview with nine youth was conducted, all youth agreed they can see a doctor and/or dentist if
necessary. An interview with nine staff was conducted and asked if allowed to call 9-1-1 if a
youth has a medical emergency; five of the staff stated yes, three staff would contact another
person to make contact, and the last staff said they never had an emergency situation but would
call 9-1-1 if it is a big emergency.
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.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
off-site care referrals. Three of the nine IHCRs reviewed were applicable and required some
type of off-site care. In each of the off-site care instances provided, a Summary of Off-Site Care
Consultation Report form was found filed in the youth’s IHCR. The off-site care cases were each
found documented of the episodic care log. Each case had documentation of parental/guardian
notification efforts. Only one of the three off-site cases were applicable for discharge
documents. In the one applicable case, the designated health authority (DHA) reviewed and
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signed the off-site care findings. Only one of the three youth required follow-up appointments.
The one youth received the appropriate follow-up care.
An interview with nursing staff was conducted and confirmed they track youth who are sent off-
site for first-aid or emergency care needs. Documentation for these events is completed on the
off-site summary sheet. The DHA will document the review of all off-site care findings,
instructions, and information. The program will ensure actual documents are requested from the
outside provider, all follow-up testing, referrals, and appointments require documentation
indicting the youth received appropriate care and timely follow-up care as needed.
4.15 Chronic Conditions/Periodic Evaluations Failed Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
chronic condition periodic evaluations. One of the nine youth were found applicable for having a
chronic condition. Two additional youth records were requested. A total of three youth were
reviewed for having a chronic condition. Two of the three youth were applicable and identified
on the Facility Entry Physical Health Screening form upon admission. The remaining one youth
was later identified with a chronic condition. None of the youth had been identified as having a
communicable disease. Two youth were taking medication on an on-going basis. One youth
was undergoing treatment for a physical health condition. Each of the youth were classified with
a Medical Grade between two and four; however, one of the three youth did not have the proper
Medical Grade annotated on the Comprehensive Physical Assessment (CPA) form. The CPA
documented a Medical Grade one, when the Medical Grade should have been at a minimum
two. All three youth were placed on the chronic illness list. One of the three youth were
applicable for needing to receive a periodic evaluation every ninety-days. The remaining two
youth had not been at the program long enough to need a periodic evaluation.
The one applicable youth did not have any documentation of having completed a ninety-day
periodic evaluation. There was no indication of any youth requiring anti-TB medication. None of
the youth required an evaluation to be conducted off-site. For two of the three applicable youth,
the Department’s problem list was not updated in accordance with Florida Administrative Code.
The one remaining youth had the problem list updated as required.
An interview with nursing staff was conducted and confirmed the program monitors youth with
chronic conditions, by the youth’s Medical Grades, no less than every three months. An
interview was conducted with the program director who indicated the medical issues are noted
in the Department’s Juvenile Justice Information System. The program director and medical
staff meet daily. An interview was conducted with the DHA where they confirmed periodic
evaluations for youth with chronic conditions are completed and tracked no more than every
ninety days. In addition, they ensured all youth with a chronic condition receive a periodic
evaluation as required, as a result of nurses tracking the timing of visits.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of nine youth Individual Healthcare Records (IHCRs) was conducted for completion of
medication management. Two of the nine youth reviewed were admitted to the program on
medication. Each youth had a completed Facility Entry Physical Health Screening (FEPHS)
form. In addition, prescription verification was included in each of the youth’s progress notes.
The designated health authority (DHA) and psychiatrist were contacted to resume specified
medications prescribed prior to admission. During the annual compliance review period, five
youth from the sample of nine were prescribed medications, for a total of seven youth taking
medications. All prescribed medications for each of the seven applicable youth, had a current,
valid order, and were administered according to valid prescription. All medications prescribed
had a practitioner order form completed by the DHA, which was documented on the practitioner
order form. There no youth observed as having been in restricted housing. All seven youth were
applicable for being prescribed either over-the-counter (OTC) and or psychotropic medications.
The program documents all medication administrations on pre-printed pharmacy medication
administration records (MAR), which included all information required by Florida Administrative
Code. There were no instances of trained non-healthcare staff administering medications. There
were no observed undocumented explanations for a lapses or errors in medication
administration. Each youth reviewed had minimum weekly side-effect monitoring documented
on the MAR. One of the seven youth were applicable for having refused taking medication. In
this case, the youth signed a refusal of treatment form. The refusal form was found in the
youth’s IHCR. Each of the seven youth MARs reviewed for the annual compliance review period
had all required elements. None of the reviewed youth required parenteral medication.
Two of the nine youth reviewed were applicable for having prescribed psychotropic medication
upon admission to the program. There was documentation in the IHCR where the psychiatrist
was notified of the youth’s admission. The youth were in receipt of an initial diagnostic
psychiatric interview within fourteen days of admission. There were three youth during the
annual compliance review period who were prescribed psychotropic medication after admission.
Each of these youth had an initial diagnostic psychiatric interview conducted. All five youth
prescribed psychotropic medications were in receipt of medication monitoring every thirty days
as required. There were no standing orders for psychotropic medications observed. There was
no indication of any emergency treatment orders for psychotropic medications observed. There
was no indication of any pro re nata (PRN) orders for psychotropic medications observed.
A medication administration pass was observed during the annual compliance review week. The
youth was escorted to the medical clinic by direct care staff. The medical staff identified
themselves and the purpose for the youth’s visit. In addition, the medical staff asked for the
youth to identify themselves. The medical staff also prepared the medications and reviewed with
the youth any allergies and alerts. The Six Rights of Medication Administration were observed to
have been conducted by the medical staff administering the medication. The medical staff gave
the youth water and medication. The youth took the medication along with the water and
swallowed the pill. The medical staff had the youth open their mouth and did a visual check. The
medical staff gave the youth a cracker and had them chew it up, take another drink of water,
then did another visual check of the mouth. The medication pass was documented on the
youth’s MAR. There is a list of program staff who are trained in administering medication to
youth posted on the medical clinic wall.
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An interview with nursing staff was conducted and confirmed the process for nursing staff to
verify a youth’s medication regimen when a youth is admitted with medications is to document
on the transport packet. The program uses pre-printed pharmacy MARs to document youth
medication administration. In addition, the nurse confirmed medication pass times are 7:00 a.m.,
and 5:00 p.m., every day. An interview with nine youth was conducted, and seven youth said
the nurse administers medication, the remaining two youth stated they do not get medication.
An interview with nine staff was conducted and all confirmed the nurse dispenses medication to
youth. Two of the staff remarked either supervisor or trained staff could dispense medication to
youth.
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 equipment in the medical clinic classified as sharps were secured and inventoried utilizing a
routine perpetual inventory. Three sharps were observed and counted including scissors, toenail
clippers, and suture removal kit. The final count listed on the program’s inventory matched the
actual count observed. All observed medications were identified and secured in locked area
designated for storage of medications. The medication cart was observed to be clean and
organized. Three over-the-counter (OTC) medications were observed and counted. The final
count listed on the program’s inventory matched the actual count observed. All observed
narcotics and controlled substances had a perpetual inventory, were stored separately from
other medications, and stored behind two locks. The program only had two controlled
substances at time of observation, and both were counted. The final count listed on the
program’s inventory matched the actual count observed. A shift-to-shift inventory count of all
controlled substances was found documented on the youth’s Individualized Controlled
Medication Inventory Records.
All medications were found stored in a separate, secured area, inaccessible to youth.
Medications which required refrigeration were stored in a secured refrigerator used for
medication storage only. Medications are destroyed by the pharmacist, and two nurses, using
the RX Destroyer solution. The nurse will document any medications being destroyed. There is
a list of program staff who are trained in administering medication to youth posted on the
medical clinic wall. Training is delivered by a registered nurse (RN). An informal interview with
the RN was conducted to ascertain practices for reporting medication inventory discrepancies.
The RN will check the count, if an issue with count and/or inventory exists, the program director
will be immediately notified, and documentation provided concerning the discrepancy.
An interview with nursing staff was conducted and confirmed the process for disposal of
medication where destruction of medications is done with three people, two being nurses and
the auditor from the program’s pharmacy provider. The substances will be destroyed and will be
written on the pharmacy destruction log. The medication will be counted by the auditor and the
nurse, while the other nurse will destroy the medication by placing them in the bottle of liquid
destroyer. The nurse also stated the program secures controlled medication, has a perpetual
inventory of the medications, and stores them separately from other medications. Controlled
substances will be maintained behind two separate locks with two separate key accesses.
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4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program’s infection control procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to federal regulations and the
Centers for Disease Control and Prevention (CDC) guidelines. The infection control procedures
were reviewed last by the designated health authority (DHA) January 8, 2024, by the program
director January 5, 2024, and by the health services administrator January 5, 2024. The
infection control practices included all required elements. There were no instances in which the
local county health department, CDC, and/or the Department’s Central Communications Center
had to be notified for an infectious disease during the annual compliance review period. The
program has an exposure control plan. The written exposure control plan included all required
elements, and in addition addresses a process for post-needle stick exposure. The exposure
control plan is available to all staff and located in the medical clinic. The plan was last reviewed
and singed annually by the program director on January 5, 2024. The program director has an
established separate file maintained for any youth or staff who may have experienced a facility
and/or occupational exposure.
An interview with nursing staff was conducted and confirmed the program has an exposure
control plan, which is available to staff located in the medical clinic. Nursing conducts infection
control training for staff. Infection control training is provided to youth within seven days of
admission into the program.
An interview with the program director confirmed the exposure control and infection control
plans are kept in the control room.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures which indicate 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, working in the dining hall, sitting in education classes and
groups, and being searched by staff. No youth were seen unsupervised and walking around
alone. 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 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. The program has a daily activity schedule which was observed to be
posted in each youth living unit. Nine interviewed staff reported when a count cannot be
reconciled, a recount in conducted and movement of youth restricted.
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 staff 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. The training was documented as
complete on October 24, 2023. 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. Nine staff training records reviewed also included evidence each staff received
training in the program’s BMS. Postings of the program’s BMS were observed in youth living
areas and youth 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 nine youth case
management records reviewed. The program utilized the same BMS as in the previous year.
According to the program director, the BMS has not changed. The BMS includes all required
information 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
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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, and special meals. An incentive calendar was observed to be 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 throughout the day, and once the points are earned, they cannot be taken away. Each
youth is given tokens based on these points, as long as 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. A youth has the opportunity
to receive reinforcement fourteen times a day, with additional incentives built into each day. The
youth 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. Each staff was able to summarize the
program’s BMS. 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 and verbal warnings by staff, and youth have
the opportunity to explain their behaviors. Nine interviewed staff also reported they are given
feedback of their implementation of the BMS through informal discussion, team meetings, and
shift briefings. Nine youth were interviewed and all 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. None of the youth reported youth are ever
allowed to punish other youth. Seven of nine youth stated staff use rewards the same. Two
youth reported this can vary depending on the staff. When asked to rate the program’s BMS,
three youth stated it was fair, two stated it was good, and four rated it very good.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program does not utilize room restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Limited 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 108 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
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 interviewed staff all reported these checks were
done at ten-minute increments. A review of nine separate dates and times of video observations
was 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. Eight of the 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. One of nine reviewed checks contained
exceptions. On February 29, 2024, the staff was observed performing a check at 4:26 a.m. and
then at 5:03 a.m. There were no checks observed made in between these two times. The
corresponding visual observation check sheets were observed and found the staff documented
they performed checks at ten-minute increments during these times, which resulted in
falsification by the staff. The program was made aware and notified the Department’s Central
Communications Center (CCC) to report the incident. 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 was 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 conducted during the annual compliance review week. 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 annual compliance review period was conducted. One full day
each month of the annual compliance review period was reviewed, which confirmed counts
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were 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 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. Five of nine staff reported the day’s formal census was forty-seven youth, one stated
fifty, one stated fifty-seven, and two staff reported it was forty-eight.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains one master logbook which is located 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 confirmed 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 annual compliance review
period, 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.
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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 week. The visitor keys were taken prior to the visitor entering the secure
area. 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 keys, 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 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.
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 address 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 youth 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 incoming and outgoing youth mail. The search of mail was also confirmed by
the case manager supervisor. The program’s policy and procedures also address any staff who
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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 perimeter check was observed conducted in the
facility parking lot on a morning of the annual compliance review week. A review of the
Department’s Central Communications Center (CCC) report information for the annual
compliance review period found no incidents with illegal contraband discovered; however, there
were two incidents reported where vape pens were discovered during searches of youth
returning from a home visit. Law enforcement was contacted, but the program director reported
they chose not to respond. The items were reportedly discarded by administration. Nine
interviewed staff all confirmed youth room searches are conducted at 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 week, 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. Nine interviewed staff confirmed youth searches are done at every movement. 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.
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. The other vehicle is a brand-new vehicle, reportedly
acquired during the annual compliance review period and has not had an annual safety
inspection completed as of yet. Both vehicles were secured when not in use. Both had approved
fire extinguishers, a seatbelt cutter, window punch, and appropriate number of seatbelts. 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
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found each was secured as required. 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. Nine interviewed staff all
reported youth are secured in the vehicles by using things such as seatbelts and shackles.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures regarding the transportation of youth. Youth are not
permitted to drive staff or program vehicles. Program staff are provided a cellular telephone
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
compliance review week. The program’s human resources staff was interviewed. The human
resources staff maintains the driver licenses for all staff. A driver’s 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. Eight of nine reported they receive a communication
device such as a radio or cellular telephone 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, seatbelt 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 address 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 are 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.
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5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a written policy and procedures which address 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
located 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 staff was interviewed and confirmed all dysfunctional tools are disposed of and
replaced as needed. During the annual compliance review period, a fire occurred near the
outside maintenance sheds. Two maintenance sheds were destroyed in the fire. The program
reported the incident to the Department’s Central Communications Center (CCC) and the
incident was investigated. As a result, some maintenance tools and lawn equipment were
destroyed. The remaining tools were relocated to the program’s vocational storage shed inside
the secure facility. This area was secured and inaccessible to youth. An inventory of all tools in
each tool storage area was completed. Eighteen random tools and eight kitchen knives were
observed. Each item was accounted for and was noted with the corresponding inventory sheet
provided. All but one tool had an identifying mark or numerical engraving for easy identification.
One utility knife, located in the vocational storage building did not have a numerical mark on the
item, but was secured and on the inventory sheet.
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 address youth tool handling and
supervision. Vocational tool usage by youth requires supervision of one staff to five youth.
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 have the opportunity to 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. Eight of nine interviewed youth all reported they can use mops and
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brooms. Two youth also mentioned they can use a rake. One of eight interviewed youth stated
youth are not allowed to use any tools. 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 the contractor entering and upon exiting. 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.
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 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-through 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 2023 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, major disturbances, chemical spills, and
flooding. Eight of 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. One stated they have not participated in a fire
drill. The program director was interviewed and reported the program conducts fire drills
monthly.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a Continuity of Operations Plan (COOP) available in the program’s
administration building and accessible to staff. The COOP was last approved by the
Department’s Office of Residential Services February 2023. According to the program director,
Residential Services provided notification to the program, advising the program to postpone
submitting a new COOP at this time due to some changes being made with the template. The
program’s COOP addresses alternative relocation sites approved by the Department.
Emergency supplies and equipment are located in the walk-in pantry and closet area of the
kitchen. 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 were included. The program director
was interviewed and confirmed the program’s COOP was located in the control room of the
administration building.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures addressing the storage and inventory of flammable,
poisonous, and toxic items and materials. A walk-through 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 five random items within each of these areas
was done and no discrepancies were found. 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.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures addressing the storage and inventory of 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 to be secured and inaccessible to youth. Youth cleaning times were
unable to be observed during the annual compliance review week. One of nine interviewed
youth reported they only use paint in the facility when working on projects, and under staff
supervision. Eight of nine interviewed youth stated they have not handled any chemicals or
cleaning items. Youth reported the staff spray the item and they wipe it off when cleaning.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a written policy and procedures which address the disposal of all flammable,
toxic, caustic, and poisonous items. Grease is maintained in a grease vat located outside the
secure fencing area. Grease is disposed of through an agreement with a local disposal
company. Dirty mop water is disposed of through standard plumbing drains. Waste
management services comes to the program weekly to dispose of general waste from the
facility. The program director was interviewed and reported only the maintenance staff are
responsible for disposal of other chemicals or cleaning products. The program director reported
maintenance staff follow the program’s policy regarding disposal. The maintenance staff was
interviewed and confirmed any disposal is done through program operating procedures. In
addition, the maintenance staff reported there have been no disposals of chemicals done
throughout the annual compliance review period. The medical staff dispose of biohazardous
waste through an agreement with a local disposal company. The nursing staff was interviewed
and reported the biohazardous waste company comes to the program every six months to
dispose of these items. Invoices were observed for this practice, which were maintained in the
biohazardous waste disposal binder. All biohazardous waste is maintained in a marked
container located in the medical office closet. The program’s Continuity of Operations Plan
(COOP) includes all required action regarding notification and cleaning of chemical spills in the
program.
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5.21 Elements of the Water Safety Plan, Staff Training, and
Satisfactory Compliance
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
According to the program director, the program has not participated in any water-related
activities for the annual compliance review period. The program has a water-safety plan which is
addressed in their policy and procedures. The program director reported they do not have a
certified lifeguard. Nine interviewed youth all reported they do not participate in water activities
at the program.
5.22 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 makes contact
with the youth’s juvenile probation officer (JPO) to confirm the youth’s contact list and create a
telephone and visitation contact list. The correspondence is documented in the chronological
section of the youth’s case record. For youth who have a history of human trafficking or are an
endangered person, the JPO is contacted to verify the parent/guardian and the contact for the
youth. According to youth alert information reviewed, and a 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
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youth’s approved telephone, mail, and visitation list. The telephone schedule for each youth
varies by the case manager schedules. Each youth is afforded one ten-minute call a week.
Telephone calls for youth were observed being completed during the annual compliance review
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 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 staff 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. Eight of nine interviewed staff reported they would notify the supervisor or
administration if a youth does not speak English as a primary language. One stated they would
locate a translator for them. Nine interviewed youth confirmed they can call their
parent/guardian or send letters in the program. Eight of nine youth reported they were unaware
what services the program has for youth where English is not their primary language. One youth
stated the assistant program director could assist in translating.
5.23 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
youth at least one hour daily. Activities 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 confirmed it 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 a
recreational therapist as a requirement of their contractual agreement. 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. 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.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a 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
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reported having only one incident of a youth being placed in controlled observation for the
annual compliance review period. The documentation 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.
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a 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 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 under two hours.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has a policy and procedures 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 annual compliance review period. Documentation
indicated the staff 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.
Five of nine interviewed youth denied ever being sent to their room for getting in trouble. Four of
nine stated they have been sent to their room for a few minutes for a cool down period. One
youth stated he’d been sent to his room for a couple of hours once, but was unable to give
dates and time frames for this. Follow-up discussion was made with the program director who
stated this youth has never been sent to his room for controlled observation.
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source: DJJ

report_type: QI Residential

program_name_raw: Okaloosa Youth Academy

rule: Indicator 4.13

excerpt: Episodic/First-Aid and Emergency Care

rating: Failed Compliance

rule: Indicator 4.15

excerpt: Chronic Conditions/Periodic Evaluations

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)