BUREAU OF MONITORING AND QUALITY IMPROVEMENT

S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E

BUREAU OF MONITORING AND QUALITY IMPROVEMENT

Annual Compliance Report

Okaloosa Youth Academy Gulf Coast Youth Services

(Contract Provider) 4455 Straightline Road

Crestview, Florida 32539

Review Date(s): December 8-11, 2020

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:

Satisfactory Compliance

No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions which do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated.

Limited Compliance

Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator which result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically.

Failed Compliance

The absence of a component(s) essential to the requirements of the indicator which typically requires immediate follow-up and response to remediate the issue and ensure service delivery.

Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Patrick M McKinstry, Office of Accountability and Program Support, Lead Reviewer (Standard 1 & Interviews) Jill Foy, Office of Accountability and Program Support, Operation Review Specialist (Standard 4 and Interviews) Tara Frazier, Office of Accountability and Program Support, Operation Review Specialist (Standard 2) Lea Herring, Office of Accountability and Program Support, Operation Review Specialist (Standard 3) James Ken Phillips, Office of Accountability and Program Support, Operation Review Specialist (Standard 5)

Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support of 67 (Effective 07/01/2020

Program Name: Okaloosa Youth Academy MQI Program Code: 830 Provider Name: Gulf Coast Youth Services Contract Number: 10288 Location: Okaloosa County / Circuit 1 Number of Beds: 60 Review Date(s): December 8-11, 2020 Lead Reviewer Code: 144 This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, 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.

1.14 Internal Alerts System and Alerts (JJIS)*

Limited Ratings Failed Ratings

Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support of 67 (Effective 07/01/2020)

Standard 1: Management Accountability Residential Rating Profile

1.01 Satisfactory1.02 Satisfactory1.03 Satisfactory1.04 Satisfactory1.05 Satisfactory1.06 Satisfactory1.07 Satisfactory1.08 Satisfactory1.09 Satisfactory1.10 Satisfactory1.11 Satisfactory1.12 Satisfactory1.13 Satisfactory1.14 Limited1.15 Satisfactory1.16 Satisfactory1.17 Satisfactory1.18 Satisfactory1.19 Satisfactory

1.20 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).

Staff Performance

Protective Action Response (PAR) and Physical Intervention Rate Incident Reporting (CCC) *

Standard 1 - Management Accountability Initial Background Screening *

Five-Year RescreeningProvision of an Abuse-Free Environment * Management Response to Allegations *

Indicator Ratings

In-Service Training

Advisory BoardYouth Input

Delinquency Intervention and Facilitator TrainingLife Skills Training Provided to Youth

Recreation and Leisure Activities

Gender-Specific ProgrammingRestorative Justice Awareness for Youth

Grievance Process

Pre-Service/Certification Requirements *

Youth Records (Healthcare and Management)Internal Alerts System and Alerts (JJIS)*

Program Planning


Standard 2: Assessment and Performance Plan Residential Rating Profile

2.01 Satisfactory2.02 Satisfactory2.03 Satisfactory2.04 Satisfactory2.05 Satisfactory2.06 Satisfactory2.07 Satisfactory2.08 Satisfactory2.09 Satisfactory2.10 Satisfactory2.11 Satisfactory2.12 Satisfactory2.13 Satisfactory2.14 Satisfactory2.15 Satisfactory2.16 Satisfactory2.17 Satisfactory2.18 Satisfactory2.19 Satisfactory2.20 Satisfactory2.21 Satisfactory2.22 Satisfactory

Exit PortfolioExit Conference

Performance Plan Development, Goals and Transmittal *Performance Plan Revisions

Performance Summaries and Transmittals

Education Transitions PlanTransitions Planning, Conference, and Community Re-entry Team Meeting (CRT)

Gang Identification: Prevention and Intervention Activities

Members of Treatment TeamIncorporation of Other Plans Into Performance Plan

Treatment Team Meetings (Formal and Informal Reviews)Career Education

Educational Access

Safety Planning Process for Youth

Residential Assessment for Youth (RAY)Youth Needs Assessment Summary (YNAS)

Indicator Ratings

Standard 2 - Assessment and Performance PlanInitial Contacts to Parent/Guardian and Court Notification

Youth OrientationWritten Consent of Youth Eighteen or Older

Classification Factors, Procedures, and Reassessment for ActivitiesGang Identification: Notification of Law Enforcement

Parent/Guardian Involvement in Case Management Services





Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile

3.01 Satisfactory3.02 Satisfactory3.03 Satisfactory3.04 Satisfactory3.05 Satisfactory3.06 Satisfactory3.07 Satisfactory3.08 Satisfactory3.09 Satisfactory3.10 Satisfactory3.11 Satisfactory3.12 Satisfactory3.13 Satisfactory3.14 Satisfactory3.15 Satisfactory3.16 Satisfactory3.17 Non-Applicable

Treatment and Discharge Planning * Specialized Treatment Services*

Psychiatric Services *

Suicide Prevention Training * Mental Health Crisis Intervention Services *

Crisis Assessments * Emergency Mental Health and Substance Abuse Services *

Baker and Marchman Acts *




Suicide Prevention Plan * Suicide Prevention Services *

Suicide Precaution Observation Logs *

Standard 3 - Mental Health and Substance Abuse ServicesDesignated Mental Health Clinician Authority or Clinical Coordinator

Licensed Mental Health and Substance Abuse Clinical Staff *Non-Licensed Mental Health and Substance Abuse Clinical Staff

Mental Health and Substance Abuse Admission ScreeningMental Health and Substance Abuse Assessment/Evaluation

Mental Health and Substance Abuse Treatment

Indicator Ratings


Standard 4: Health Services Residential Rating Profile

4.01 Satisfactory4.02 Satisfactory4.03 Satisfactory4.04 Satisfactory4.05 Satisfactory4.06 Satisfactory4.07 Satisfactory4.08 Satisfactory4.09 Satisfactory4.10 Satisfactory4.11 Satisfactory4.12 Satisfactory4.13 Satisfactory4.14 Satisfactory4.15 Satisfactory4.16 Satisfactory4.17 Satisfactory4.18 Non-Applicable4.19 Satisfactory

Indicator Ratings

Standard 4 - Health Services

Authority for Evaluation and TreatmentParental Notification/Consent

Designated Health Authority/Designee *

Off-Site Care/Referrals

Facility Operating Procedures

Episodic/First Aid Care/Emergency CareSick Call Process

Comprehensive Physical Assessment/TB Screening

Healthcare Admission & Rescreening FormYouth Orientation to Healthcare Services/Health Education

Designated Health Authority/Designee Admission NotificationHealth-Related History

Sexually Transmitted Infection & HIV Screening

Medication ManagementChronic Illness/Periodic Evaluations




Infection Control/Exposure Control

Licensed Medical Staff*

Medication/Sharps Inventory and Storage Process

Prenatal Care/Education


Standard 5: Safety and Security Residential Rating Profile

5.01 Satisfactory5.02 Satisfactory5.03 Satisfactory5.04 Satisfactory5.05 Satisfactory5.06 Satisfactory5.07 Satisfactory5.08 Satisfactory5.09 Satisfactory5.10 Satisfactory5.11 Satisfactory5.12 Satisfactory5.13 Satisfactory5.14 Satisfactory5.15 Satisfactory5.16 Satisfactory5.17 Satisfactory5.18 Satisfactory5.19 Satisfactory5.20 Satisfactory5.21 Non-Applicable5.22 Satisfactory5.23 Satisfactory5.24 Satisfactory5.25 Satisfactory

Ten Minute Checks *

Logbook Entries and Shift Report Review

Weekly Safety and Security Audit

Contraband ProcedureSearches and Full Body Visual Searches

Vehicles and MaintenanceTransportation of Youth

Behavior Management System Infractions and System Monitoring

Storage and Inventory of Flammable, Poisonous, and Toxic Items and MaterialsYouth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials

Disposal of all Flammable, Toxic, Caustic, and Poisonous Items

Tool Inventory and ManagementYouth Tool Handling and Supervision




Census, Counts, and Tracking

Key Control*

Controlled Observation Safety Checks and Release Procedures

Outside ContractorsFire, Safety, and Evacuation Drills

Disaster and Continuity of Operations Planning (COOP)

Visitation and CommunicationElements of the Water Safety Plan, Staff Training, and Swim Test *

Search and Inspection of Controlled Observation RoomControlled Observation

Indicator Ratings

Standard 5 - Safety and SecurityYouth Supervision *

Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training


Program Overview

Okaloosa Youth Academy (OYA) is a non-secure residential commitment program which may serve up to sixty male youth between the ages of thirteen and nineteen years old. The program is contracted through the Department of Juvenile Justice with Gulf Coast Youth Services, Inc. The OYA program is located in Crestview, Florida and is co-located with Crestview Sex Offender Program (CSOP). The management team consists of a program director, two assistant program directors, a clinical manager, two registered nurses (RN), a designated mental health clinical authority (DMHCA), one licensed clinical staff, five non-licensed clinical staff, one food service manager, five dietary workers, one maintenance person, a transition specialist, and four case managers. In addition, the provider has an agreement with a designated health authority (DHA) and a psychiatrist. The DHA is contracted to be on-site for a minimum of two hours weekly and is on-call twenty-four hours a day, seven days each week. The psychiatrist is required to be on-site twice monthly and is on-call twenty-four hours a day. The program had a total of one therapist and nine youth care worker vacancies at time of the annual compliance review. The program offers Mental Health Overlay Services (MHOS) and Substance Abuse Overlay Services (SAOS). The OYA contract offers a variety of delinquency intervention groups; Life Skills Training (LST), Thinking for a Change (T4C), Anger Management Life Skills (ARISE), Impact of Crime (IOC), Moral Reconation Therapy (MRT), and Seven Challenges. In addition, Boys Council and Fathers in Training (FIT), which are gender-specific interventions. The educational services are provided by the Okaloosa County School District. Youth attend school five days a week and have the opportunity to earn credits as well as certifications within the vocational component; Home Builders Institute, Inc. (HBI). The program is comprised of three youth housing units; two are designated to house the Okaloosa Youth Academy population. The remaining housing unit is for the CSOP youth. The program has two additional buildings; one designated for administration and medical practices and the other designated for education and dinning. The program has 108 cameras, with 107 currently operating at the time of the annual compliance review.


Standard 1: Management Accountability

1.01 Initial Background Screening (Critical) Satisfactory Compliance

Background screening is conducted for all Department employees and volunteers and all contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth and confidential youth records. A contract provider may hire an employee to a position which requires background screening before the screening process is completed, but only for training and orientation purposes. However, these employees may not have contact with youth or confidential youth records until the screening is completed, the rating is eligible and the employee demonstrates he or she exhibits no behaviors which warrant the denial or termination of employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually.

There were eight staff which required an initial background screening. Each of the reviewed initial background screenings were completed prior to contact with youth. In addition, a criminal history report was reviewed as part of each staff members hiring requirements. None of the eight staff reviewed, required an exemption prior to working with youth. None of the staff had a break in service as indicated within the Staff Verification System (SVS). Three out of the eight staff reviewed, were direct care applicants. The three applicable staff were reviewed for completion of a pre-employment assessment. Each of the direct care staff reviewed, had a passing score on the pre-employment assessment tool and was documented in their respective employment record. The provider added each applicable employee to their Clearinghouse employment roster. None of the eight staff reviewed were applicable for completion of a background screening, when a provider employee is hired by another contracted provider company. None of the employees were hired and provided orientation prior to receipt of determination. Due to the current COVID-19 pandemic, the program has not had any person on-site who assist or interacts with youth on an intermittent basis for less than ten hours and/or may have access to confidential information. The program does have written facility operating procedure (FOP), which outlines practices necessary should there be a need to submit a background screening for volunteers, mentors, and/or interns interacting with youth on an intermittent basis. An Annual Affidavit of Compliance with Level 2 Screening Standards was completed and sent to the Background Screening Unit and signed December 23, 2019. The teachers who are paid by the school board or Department of Education, received an annual screening, which was completed and signed on January 7, 2020. The program has a written FOP, which outlines the hiring authority process for employment. Each of the employee applicants contained documentation, where the hiring authority reviewed the Central Communications Center (CCC) Person Involvement History Report, SVS module, and Florida Department of Law Enforcement (FDLE) Automated Training Management System (ATMS) results.


1.02 Five-Year Rescreening Satisfactory Compliance

Background rescreening/resubmission is conducted for all Department employees and volunteers and all contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth and confidential youth records. Employees and volunteers are rescreened every five years from the initial date of employment. When a current provider staff member transitions into the Clearinghouse, the rescreen/resubmission date starts anew and is calculated by the Clearinghouse. (Note: For the new date, see the Retained Prints Expiration Date on the applicant’s personal profile page within the Clearinghouse.).

The program had two staff who required a five-year background rescreening during the annual compliance review period. The staff member’s five-year rescreening was completed every five years. The resubmission was sent to the Background Screening Unit (BSU)/Clearinghouse, at least ten business days prior to the staff member’s five-year anniversary date. The program reported not having any volunteers, mentors, and/or interns who required a five-year rescreening since the last annual compliance review.

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 residential program shall post the Florida Abuse Hotline telephone number for youth under the age of eighteen and the Central Communications Center telephone number for youth 18 years of age and older telephone number.

• 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 who 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 shall complete or schedule a TRACE self-assessment.

There was a total of forty-four Central Communications Center (CCC) calls reported since the last annual compliance review. A minimum sample of five CCC incidents were reviewed. Three of the forty-four CCC were allegedly related to physical, psychological, or emotional abuse. The remaining two other reports reviewed dealt with an arrest of a staff and a failure to report. The three CCC allegedly related to physical, psychological, or emotional abuse had no substantiated findings and were still under investigation at time of the annual compliance review. Staff personnel records contained a signed copy of the code of conduct. During the tour of the program, staff observed the numbers for the CCC and the Florida Abuse Hotline posted throughout the program.


The program has a written facility operating procedure (FOP), which addresses abuse reporting. The steps to report abuse, are as follows: All youth shall have unimpeded self-reporting access to the Florida Abuse Hotline and/or the Department of Juvenile Justice CCC. According to FOPs, the youth does not need permission from anyone to call the Florida Abuse Hotline and does not need to provide an explanation to make the call. No attempt to discourage or intimidate the youth from calling the Florida Abuse Hotline shall be made, and the youth shall not suffer any consequence or reprisal for making a call. All youth over the age of eighteen will be allowed to report alleged abuse to the CCC. Youth are informed, at the time of admission, of the limits of confidentiality related to staff reporting abuse, security issues, and threats of harm. This is documented on the new youth admission checklist. If the youth makes a request to a youth care worker (YCW) to make an abuse call, the YCW will contact the shift supervisor immediately to inform them of the request by the youth to make an abuse call. The shift supervisor will, for those youth under the age of eighteen, escort the youth to a private area and grant the youth access to a phone to contact the Florida Abuse Hotline. For those youth over the age of eighteen, the shift supervisor will escort the youth to a private area and grant the youth access to a phone in order to contact the CCC. Upon completion of a youth’s call, the youth will be returned to the designated scheduled location. The shift supervisor will complete an entry into 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 known. Should a youth refuse to complete a call after asking or reconsiders the request, then staff request the youth to complete an Abuse Call Refusal form. No retaliation will be brought upon any youth or staff member reporting alleged incidents of child abuse. The program environment appears to be free of physical, psychological, and emotional abuse. The program completed a Trauma Responsive and Caring Environment (TRACE) self-assessment on January 21, 2020.The program has had three alleged incidents related to either physical, psychological, and or emotional abuse since the last annual compliance review. A sample of five youth were interviewed, each of the youth stated they felt safe at the program. None of the youth reported ever having been stopped from reporting abuse to the Florida Abuse Hotline or CCC (if eighteen years or older), since they have been at the program. The youth state, staff are respectful when talking with them and other youth. The youth were asked if they had heard staff use profanity when speaking with them or other youth and how often; Three of the five youth replied, never. One of the youth replied once and the other youth replied occasionally. Each of the two youth were asked if they could provide examples for these occurrences; one youth stated while in a classroom he heard a staff say something; although he could not recall when or which staff member. The other youth stated, while on the recreation yard he had heard staff yell something directed at another youth; the youth could not recall a date or the staff member who said these things. A discussion was held with program management concerning these findings. The program director indicated and provided documentation of meetings, where they have an on-going agenda item for staff meetings which addresses: “No using profanity at or around any youth”. The program director will immediately address with any staff, if he becomes aware of staff using profanity around or at youth. A total of five staff was interviewed and were able to explain the process for allowing staff and youth to call the Florida Abuse Hotline or CCC. Each of the staff reported they have never observed a co-worker tell a youth they could not call the Florida Abuse Hotline. The same staff reported they have never observed a co-worker using profanity when speaking to youth, using threats, intimidation, or humiliation when interacting with youth. The program director states actions are taken if allegations of physical abuse, threats, or profanity towards a youth is used. The program director reports all staff adhere to the staff code of conduct and any substantiated cases of abuse of any form will be met with immediate and swift corrective action up to and including


termination. All incidents, whether CCC or Florida Abuse Hotline calls, are reported to the program director or assistant program directors. If the incident is reportable, it will be called into the CCC before the two-hour time frame. If abuse is reported, this will immediately be called into the Florida Abuse Hotline and the CCC. Additionally, all staff are trained in the abuse reporting criteria, as well as all youth are notified, and it is posted on all dorms. Youth will have complete access to the Florida Abuse Hotline or the CCC.

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 had three Central Communications Center (CCC) calls, which were allegedly related to physical, psychological, or emotional abuse since last annual compliance review. None of the reviewed incidents had any substantiated findings related to physical, psychological, or emotional abuse. Two of the three alleged incidents reviewed were still under investigation. The third incident was turned over to the Department’s Office of Inspector General for investigation. Although no findings have been determined at the time of the annual compliance review, the program has conducted their own internal investigations. The program provided internal investigations for each of the incidents reviewed. There is evidence based upon documentation provided, which supports management takes immediate action to address incidents of physical, psychological, and emotional abuse. The program director states any allegations of abuse are reported to the Florida Abuse Hotline, called into the CCC, and staff is immediately removed from contact with youth until the investigation is completed.

1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance

The program shall notify the Department’s Central Communications Center (CCC) within two hours of the incident occurring, or within two hours of any program staff becoming aware of the reportable incident.

The program had a total of thirty-eight Central Communications Center (CCC) calls within the last six months. A minimum sample of five CCC reports were reviewed. In each of the reports reviewed, the CCC was notified within two hours of the program becoming aware of the incident, when required. Each of the applicable incidents were documented within the program’s logbook. There were no internal incident reports and/or grievances which should have been reported to the CCC. The program has seen an increase in the total number of reportable incidents to the CCC. In review of the previous six months and this past six months of reported CCC incidents, the increase is largely attributed to COVID-19 reporting. When asked to explain the program’s incident reporting process, the program director reports all incidents, whether CCC or Florida Abuse Hotline calls, are reported to the program director or assistant program directors. If the incident is reportable, it will be called into the CCC before the two-hour time frame. If abuse is reported, this will immediately be called into the Florida Abuse Hotline and the CCC. Additionally, all staff are trained in the abuse reporting criteria, as well as all youth are notified, and it is posted on all dorms. Youth will have complete access to the Florida Abuse Hotline or the CCC.


1.06 Protective Action Response (PAR) and Physical 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 had a total of four Protection Action Reports (PAR) interventions during the scope of the annual compliance review period. Each of the reviewed PAR intervention reports were completed by the end of the staff member’s workday. The PAR reports included statements from all staff involved. None of the PAR interventions reviewed required the use of mechanical restraints. None of the PAR interventions resulted in injury to youth or staff. One of the four PAR interventions documented an allegation of abuse made by the youth. All of the PAR reports had a review completed by a PAR certified instructor or supervisory staff. None of the reports required any type of a PAR medical review. The reports indicated a Post-PAR interview was conducted with the youth by the administrator, or designee, as soon as possible, but no longer than thirty-minutes after the incident. All of the PAR reports were reviewed by the administrator, or designee, within seventy-two hours of the reported incident, excluding weekends and holidays. A copy of the PAR reports is placed in the program’s centralized file within forty-eight hours of being signed by the administrator. Monthly summaries of all PAR incidents are submitted to the Department by the fifteenth of each month. The program’s PAR plan was approved by the Department. The program has had an increase in the total number of PARs since the last annual compliance review. The program provided the following synopsis: Okaloosa Youth Academy has experienced an increase in PARs due to four newer youth struggling during the acclimation process into the program. Rather than adjusting, they experienced increased agitation and aggression during this time, which is not abnormal when adolescents with pre-existing behavioral issues are introduced to and attempting to adjust to a new environment. Program staff responded in those situations with PAR techniques which were immediately necessary to ensure the safety and security of the youth, staff, and program. Youth were then individually addressed to reinforce program rules, norms, and expectations while also assisting them in their acclimation. The program’s quarterly PAR rate during the annual compliance review period was 0.60, which is below the statewide residential PAR rate of 2.10. The program director states, all PAR incidents are reviewed by the program director or designee within seventy-two hours. Additionally, all PAR incidents are reported to the Department for their review as well. Video of PAR incidents are stored for review as well.

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.

A sample of five staff training records were reviewed for pre-service training requirements. Three out of the five staff reviewed were certified within 180 days of their respective hire dates. The remaining two staff still have time remaining to complete the required minimum 120 hours of pre-service training. Each of the three applicable staff who completed training within 180 days had documentation of a minimum of 120 hours of pre-service training. All five staff reviewed did complete the following pre-service training: cardiopulmonary resuscitation (CPR), first aid, and


automated external defibrillator (AED). Three of the five staff have completed Protective Action Response (PAR) training. The two remaining staff are scheduled to complete PAR in January 2021; these two staff have not had any contact with youth. Each of the five staff reviewed have completed professionalism and ethics (to include standards of conduct), suicide prevention/intervention, emergency procedures, child abuse reporting, Prison Rape Elimination Act (PREA), and human trafficking training. In addition, there was evidence each of the five staff reviewed have completed contract specific training. The five staff reviewed completed the necessary enhanced specialized training for staff; Mental Health Overlay Services (MHOS) and Substance Abuse Overlay Services (SAOS). Those applicable staff training records reviewed indicate completion of training requirements within the Department’s Learning Management System (SkillPro). Pre-service training is documented into SkillPro within thirty-days of completing training. All instructors are qualified to deliver training provided for by the program. The program submitted, in writing, a list of pre-service training to the Office of Staff Development and Training, which included course names, descriptions, objectives, and training hours for any instructor-led training based on the above topics. The list of pre-service training submitted was missing contract specific training. The pre-service training plan was submitted April 6, 2020 and signed April 29, 2020.

1.08 In-Service Training Satisfactory Compliance

Residential contracted provider staff 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 completes eight hours of training (as part of the twenty-four hours of annual in-service training) in the areas specified in Florida Administrative Code.

A sample of five staff training records were reviewed for in-service training requirements. The staff reviewed received a minimum of twenty-four annual training hours. Each of the staff were in receipt of cardiopulmonary resuscitation (CPR), first aid, automated external defibrillator (AED) and Protective Action Response (PAR) update training, for calendar year 2019. In addition, staff had training in professionalism and ethics and suicide prevention training. Three supervisory training records were reviewed. The supervisor’s training included a minimum of eight hours of additional training in areas specific to management, leadership, personal accountability, employee relations, communication skills, and fiscal training. Those applicable staff training records reviewed, indicated completion of training requirements within the Department’s Learning Management System (SkillPro). All in-service training was documented into SkillPro within thirty-days of completing training. All instructors are qualified to deliver training provided for by the program. The program submitted in writing, a list of in-service training to the Office of Staff Development and Training, which included course names, descriptions, objectives, and training hours for any instructor-led training based on the above topics on October 2, 2018 (which is applicable for calendar year 2019). The program has an annual in-service training calendar, which is updated as changes occur. The provider hires youth care workers (YCW) and YCW IIs, which are considered to be direct-care staff and included in the staff-to-youth ratio. Supervisory staff and food service manager may occasionally supervise youth; however, are not counted in daily staff-to-youth ratio requirements. The program currently has three licensed nursing staff, each had a current certification in CPR with AED.


1.09 Grievance Process Satisfactory Compliance

Program staff shall be trained on the program’s youth grievance process and procedures. The program adheres to their grievance process and shall ensure it is explained to youth during orientation and grievance forms are available throughout the facility. Completed grievances shall be maintained by the program for a minimum of twelve months.

The program has a written facility operating procedures (FOP), which includes training requirements of the grievance process. A sample of five staff training records reviewed determined staff have received required training on the program’s grievance process and procedures. The program’s grievance process includes an informal phase, formal phase, and appeal phase. The program’s written FOP outlines the steps/process for each phase, to include time frames. The program maintains copies of the grievances for the past twelve months. The program had only two grievances since their last annual compliance review. Each of the grievances reviewed include the nature of the grievance. The grievances reviewed documented the informal phase, date of the grievance, and date of response conducted at the formal phase. Only one of the two grievances went through to the appeal phase and was resolved at this phase. Each of the reviewed grievances were responded to within the specified time frames. A sample of five youth were interviewed concerning the program’s grievance process. Three of five youth interviewed, reported never submitting a grievance; however, all the youth were able to identify how they would submit one if necessary. All youth reported they could ask for assistance in completing a grievance form. A sample of five staff were interviewed concerning the youth grievance process. Each of the staff were able to explain the program’s youth grievance process. The program director was interviewed, he was able to explain the program’s 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.

There were nine staff who have all been trained in a delinquency intervention model as required. Training reviewed, included the staff’s date of training, level of education (degree or diploma), and number of years of experience working with adult or juvenile offenders. A staff member’s level of education and work experience are considered when determining staff delivery of delinquency intervention services. A review of the provider’s contractually required services was conducted. The program is completing all groups listed on the contract table. A review of Mental Health Overlay Services (MHOS) and Substance Abuse Overlay Services (SAOS) was conducted. The program is completing groups according to schedule. The program’s contract offers a variety of delinquency intervention groups; Life Skills Training (LST), Thinking for a Change (T4C), Anger Management Life Skills (ARISE), Impact of Crime (IOC), Moral Reconation Therapy (MRT), and Seven Challenges. In addition, the program offers The Boys Council and Fathers in Training (FIT), which are gender-specific interventions. LST is an evidence-based practice curriculum. Seven Challenges, T4C, IOC, and MRT are promising practice type curriculums. The ARISE curriculum is a practice with demonstrated effectiveness curriculum. A review of the program’s activity schedule determined the program provides structured, planned programming, or activities at least seventy-six percent of the youths’ awake


hours. A review of ten sample staff training records was conducted, each of the staff had training on evidence base-based strategies. A sample of five youth were reviewed for delinquency intervention service delivery. Each of the youth reviewed, were involved in either an evidence-based, promising practice, and or a practice with demonstrated effectiveness intervention. The youth were involved in a delinquency intervention addressing an identified priority need (as identified by the Residential Assessment for Youth). The individual youth performance plans addressed an identified priority need. The program director states each staff member who is chosen to deliver delinquency intervention groups, have degree’s and have been trained on how to facilitate groups.

1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance

The program shall provide instruction focusing on developing life and social skill competencies in youth.

The youth at the program receive life and social skill intervention services, which specifically address, at a minimum: communication, interpersonal relationships and interactions, non-violent conflict resolution, anger management, and critical thinking skills. The program develops performance plans and match youth to specific delinquency interventions based on the most serious needs indicated on the Residential Assessment for Youth (RAY) and mental health/substance abuse evaluations. These evaluations/assessments are reviewed and conducted at the time of admission to the program. The program’s contract offers a variety of life and social skills intervention, which are Life Skills Training (LST), Thinking for a Change (T4C), Anger Management Life Skills (ARISE), Impact of Crime (IOC), Moral Reconation Therapy (MRT), and Seven Challenges. In addition, Boys Council and Fathers in Training (FIT), which are gender-specific interventions present the youth with applicable life and social modalities. A review of both the program’s written facility operating procedures (FOP) and activity schedule was conducted, which revealed how the life and social skills were administered to youth on-site. A review of sign-in sheets for Mental Health Overlay Services (MHOS) and Substance Abuse Overlay Services (SAOS) was conducted, along with other life and social skills intervention services provided. Additionally, the program ascertains each youth are provided with a variety of opportunities to apply the skills learned in groups through participation in community outings and other structured activities. Also, the healthy demonstration of life and social skills are embedded into the program’s behavior management practices for all youth. The clinical director was interviewed about what type of specialized services are delivered consistent with contractual requirements and reports MHOS and SAOS. In addition, the clinical director provides random audits of clinical documentation on a weekly basis, weekly clinical supervision, and meets with clinicians daily. A sample of five youth were interviewed; each youth was able to discuss the delinquency intervention groups they have participated in and what skills they had learned.

1.12 Restorative Justice Awareness for Youth Satisfactory Compliance

The program shall provide activities or instruction 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 provider’s contract of required services was reviewed. The program’s contract offers a variety of services; Life Skills Training (LST), Thinking for a Change (T4C), Anger Management


Life Skills (ARISE), Impact of Crime (IOC), Moral Reconation Therapy (MRT), and Seven Challenges. In addition, Boys Council and Fathers in Training (FIT), which are gender-specific interventions. Due to COVID-19 pandemic restrictions, the program director stated, no community service outings have been completed recently; however, the program did conduct rock painting, which were donated to the nursing homes in the community and victim cards were sent to community shelters. The program’s restorative justice activities are designed to assist youth in accepting responsibility for harm they have caused by their past criminal actions. In addition, the restorative justice activities teach youth about the impact of crime on victims, their families, and their communities. These activities expose youth to each victims’ perspectives through victim speakers and provide opportunities for youth to plan and participate in reparation activities intended to restore victims and communities. A sample of ten staff training records were reviewed, each had required training for restorative justice awareness. A review of the program’s activity schedule outlines youth being scheduled for restorative justice awareness groups and activities. Group sign-in sheets for the program’s life and social skills were reviewed; groups are being delivered according to the program’s group/activity schedule.

1.13 Gender-Specific Programming Satisfactory Compliance

A residential commitment program shall provide delinquency interventions and treatment services which are gender-specific and focus on preparing youth to live responsibly in the community upon release from the program.

The provider’s contractual agreement for gender-specific programming is Boys Council and Fathers in Training curriculums. The program demonstrates a model which addresses the needs for a male population. The program designs services based upon the common characteristics of the male gender population. The program’s activity schedule provides gender-specific programming. A review of sign-in sheets for gender-specific programming confirms groups are being delivered according to the program’s group/activity schedule. An interview with the program director revealed the needs of the male youth at the program are addressed with Boys Council and Fathers in Training gender-specific curriculums.

1.14 Internal Alerts System and Alerts (JJIS) (Critical) Limited Compliance

The program shall maintain and use an internal alert system easily accessible to program staff and keeps them 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 subsequent to the classification process, the program immediately enters this information into its 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 subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued.

The program has a written facility operating procedure (FOP) which determines how alerts are identified, documented, updated, and communicated to staff. The program’s alerts were inconsistent with the alerts which were entered into the Department’s Juvenile Justice Information System (JJIS). Four out of the five sample youth reviewed had an identified issue with alert being entered within JJIS timely. One youth was admitted on medication and subsequently the alert was entered within JJIS approximately three months later. Another youth


had a similar occurrence, whereas the youth arrived at the program and the alert was entered within JJIS late; approximately two and half months. One youth was seen for medical concerns over several dates; five of the entries for this medical incident were documented within JJIS late. The same youth was seen by a psychiatrist, five out of the six encounters where medication documentation was necessary, the entries were entered within JJIS late. Those instances where a late JJIS entry was discovered, there was a lapse in the program’s internal alert system as well. Each of the alerts appeared to have been removed or downgraded by the appropriate staff. Most of the alerts which were lacking timely entry were found in medical, other areas, such as mental health and case management, did not appear to have any issues with timely entries into JJIS. A sample of five staff were interviewed, each provided information on how they are made aware of the youth’s alerts, which include mental health, medical, and security. An interview with the program director regarding what the formalized procedure is in place pertaining to the important medical issues for youth are conveyed confirms daily meetings are held with nursing staff to discuss any youth issues and updated internal alerts. In addition, all alerts are posted in main control, case management opens and closes out alerts, and management is updated weekly or as needed as alert statuses change. Nursing staff commented they are responsible for updating the medical alert system.

1.15 Youth Records (Healthcare and Management) Satisfactory Compliance

The program maintains an official case record, labeled “Confidential,” for each youth, which consists of two separate files:

• An individual healthcare record. • An individual management record.

The program separates youth records into three separate files; healthcare, mental health, and case management. The individual management record contained file tabs at a minimum with the youth’s name, Department of Juvenile Justice identification number, date of birth, county of residence, and committing offense. The individual management record contained at the minimum the following sections: legal information, demographic and chronological information, correspondence, case management and treatment team activities, and miscellaneous section. Each of the youth records are labeled “Confidential.” The official youth case records are secured in a locked file cabinet or a locked room. The program clearly identifies filing cabinets used to store official youth case records as “Confidential.”

1.16 Youth Input Satisfactory Compliance

The program has a formal process to promote constructive input by youth.

The program solicits input from youth through peer advisory boards, which is the program’s formal process to promote constructive input from the youth. In addition, the program conducts town hall meetings and has request forms each youth can access to provide input into the program. A sample of five youth were interviewed; each stated they are able to provide input about what happens at the program through peer advisory boards. The program director states the formal process to solicit input from youth is through peer advisory board, town hall meetings, and request forms.


1.17 Advisory Board Satisfactory Compliance

The program has a community support group or advisory board meeting at least every ninety to 120 days. The program director solicits active involvement of interested community partners.

The program has a community advisory board (CAB) which has met one time since the last annual compliance review conducted in May 2020. The program was unable to conduct formal CAB meetings due to COVID 19 restrictions and other issues which arose due to active cases within the program. Beginning in April of 2020, restrictions were placed on the program, which did not allow outside visitors to enter the program. Subsequently, the program discontinued face-to-face CAB meetings at this time. Ongoing active cases of the virus occurred on a regular basis from July through December 2020, with the last active case occurring during the week of November 30, 2020. This made it unsafe to resume contact with outside visitors at any point during this time frame. Despite these challenges, the program director continued consistent contact with members of the CAB to maintain relationships and remain informed. The program believes these contacts by telephone, should be counted as meetings and/or efforts to maintain community relationships. An on-site supplemental visit was conducted in November 2020, whereas a CAB review was conducted and noted no physical meetings had occurred. The program took action and conducted an on-site CAB meeting December 8, 2020. A review of sign-in sheets, agendas, and minutes from CAB meeting was reviewed. There is documentation to support where the program director actively solicits active involvement from law enforcement, judiciary community, other community partners, business community, school board, and the faith community. The program director recruits victim advocates and a parent/guardian whose child was previously involved in the juvenile justice system. The annual compliance review team were on-site at time of the CAB meeting and were able to ascertain the community partners involvement with the program. The program director was interviewed, he stated the CAB consist of members from the community (law enforcement, faith community, and private business), these members provide suggestions, feed-back, and community involvement opportunities.

1.18 Program Planning Satisfactory Compliance

The program uses data to inform their planning process and to ensure provisions for staffing.

The program maintains copies of youth and parent/guardian surveys, which allows for input and development into program planning. The Monitoring and Quality Improvement Annual Compliance Report, along with the Comprehensive Accountability Report (CAR), are published reports related to the program. These reports and surveys are incorporated into program planning, whereas, results are shared with staff during staff meetings. Staff input and/or feedback is achieved through the program’s all staff meetings. These type meetings occur monthly, which allow for staff to communicate with management. In addition, the program conducts a bi-annual employee engagement survey; which addresses program planning input. Staff retention efforts include, recognition of employee birthdays, recognition of all employee years of service, and an employee of the month. Another avenue for which the corporation is handling employee retention, is by hiring qualified candidates. This is accomplished through Selecting Traits and Acquiring the Right Talent (START); this program is a process to ensure the program is hiring ideal staff. In addition, the program conducts an assessment prior to interview, in order to identify applicant strengths, which includes likelihood of retention. Some past activities provided to maintain employee recognition/retention include, employee cook-out, water day (for youth and staff), all staff given a choice of a turkey or ham in November 2020, and an employee Christmas party. The program’s written facility operating procedures (FOP) addresses incentives and retention planning; to minimize turnover and improve employee


morale. A review of sign-in sheets demonstrate staff are in attendance to staff meetings conducted at a minimum monthly. The program currently has one therapist and nine youth care worker positions vacant. A discussion with the human resource director reveals the program is actively recruiting through social media platforms and career websites. The number of vacancies is largely attributed to the current COVID-19 pandemic. The program conducts monthly all staff meetings. Supervisor meetings are held at a minimum monthly, with management meetings being conducted weekly. A sample of five staff interviewed all agree staff meetings are held monthly. In addition, staff find the meetings to be valuable and informative. Each of the staff confirm they are briefed on annual reports, youth, and/or parent/guardian survey results. All the staff believe communication amongst staff is good at the program. The staff were able to articulate their individual abilities to provide input and feed-back concerning the program operations. The program director explains turnover is low and staff morale is high. The program does impromptu gift card giveaways, luncheons, cookouts, and holiday parties to improve staff morale. The program director explains about how reports and surveys are shared for program planning purposes. The data is captured and shared with each department. The facility utilizes the results to help serve the youth and maintain a positive culture. Program staff are kept informed through daily shift meetings, monthly team meetings, and supervisor meetings.

1.19 Staff Performance Satisfactory Compliance

The program ensures a system for evaluating staff, at least annually, based on established performance standards.

A review of the program’s written facility operating procedures (FOP) was conducted. The FOP addressed a system for evaluating staff, performance standards, and frequency of evaluations. The FOP identifies staff evaluations will occur annually. A review of staff position descriptions confirms performance standards are clearly identified. A review of staff performance evaluations confirms each were completed as outlined in the program’s FOP, which is annually. Performance standards reviewed match job descriptions for each staff. A comparison between the program’s staffing roster and contract, along with applicable amendments was conducted. Each staff position is being maintained and performed as required. A recent contract amendment was signed to suppress the need for a recreational therapist until June 30, 2021. A sample of five staff were interviewed, each were able to validate time frames for completion of formal evaluations based upon time at the program. The program director confirms performance evaluations are completed annually to ensure staff meets and exceeds expectations.

1.20 Recreation and Leisure Activities Satisfactory Compliance

The program shall provide a variety of recreation and leisure activities.

The program activity schedule was reviewed. The program offers large muscle activity for a minimum of one hour daily to include both indoor and outdoor type activities. Review of program logbook demonstrates the activity schedule is being followed as posted. The program’s written facility operating procedures (FOP), provide activities based on the developmental levels and needs of the youth in the program. Scheduled activities include a choice of leisure and recreation options. Youth are encouraged to explore individual interests. Youth are encouraged and engaged in constructive use of leisure time. Observed on several occasions during the annual compliance review, youth were engaged in activities which promoted social, cognitive skill development, creativity, teamwork, healthy competition, mental stimulation, and physical


fitness. During the annual compliance review, outside temperatures were moderate, affording youth to participate in scheduled activities. The program does take precautionary measures to prevent over-exertion, heat stress, dehydration, frostbite, hypothermia, and exacerbation of existing illness or physical injury. A recent contract amendment was signed to suppress the need for a recreational therapist until June 30, 2021. A sample of five youth performance/treatment plans were reviewed and noted therapeutic activities are incorporated. There is evidence the program has a formal process to promote constructive input from youth. This is accomplished through peer advisory boards, which is how the promotes constructive input from the youth. In addition, the program conducts town hall meetings and has request forms each youth can access to provide input into the program. A sample of five youth were interviewed, each youth agrees the program allows them the opportunity to exercise, play outside, or have down time to read a book, or play a board game. The youth reports physical activities provided, are for at least one hour. A sample of five staff were interviewed, each staff was able to articulate types of indoor/outdoor activities provided to the youth and for a minimum of one hour.


Standard 2: Assessment and Performance Plan

2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory Compliance

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, and notify the youth’s committing court, assigned juvenile probation officer (JPO) and post residential services counselor (if applicable) in writing within five working days of any admission.

Five case management records were reviewed to determine when the program made initial contact with the parent/guardian and notification to the court. All five records indicated each youth’s parent(s)/guardian(s) were notified by telephone within twenty-four hours of admission. Each of the parent(s)/guardian(s) were notified in writing within forty-eight hours of the youth’s admission. All notifications were sent to each juvenile probation officer (JPO) within five working days of the youth’s admission. All youth case management records included documentation in the case notes of these notifications.

2.02 Youth Orientation Satisfactory Compliance

The program shall provide each youth an orientation to the program rules, expectations, goals of the program, and services applicable to youth, to begin within the day of, or prior to, the youth’s admission.

A review of five youth case management records found all received an orientation on the date of their admission. The orientation included the following: services available, daily schedule, expectations and responsibilities of the youth, written behavioral management system (BMS) which is posted in the youths’ dormitory as well as in the student handbook, availability and access to medical, mental health, and substance abuse services, access to the Florida Abuse Hotline and/or Central Communications Center (CCC), Prison Rape Elimination Act (PREA), contraband items, the performance planning process, dress code and hygiene practices, procedure on visitation, mail and use of the telephone, expectations for release, community access, grievance procedures, emergency procedures, facility tour, assignment to a living unit, and medical topics as outlined in Chapter 63M-2. During the week of the annual compliance review, the program did not have a youth admission to observe the orientation process. Five youth were interviewed and confirmed their orientation occurred within twenty-four hours of admission and all were familiar with the orientation process.

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 screening, assessment, or treatment.

A review of five youth case management records found two were applicable for written consents of youth eighteen years of age or older. An additional record was requested for review. All three applicable youth case management records had documentation of a written consent form signed by the youth to provide or discuss information related to physical or mental health screening, assessment, or treatment with the parent/guardian.


2.04 Classification Factors, Procedures, and Reassessment 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.

The program has written policy and procedures in place which outlines the program’s classification process. A review of five youth case management records found all had the initial classification conducted on the day of each youth’s admission. The factors considered for this initial classification are as follows; physical characteristics, age, maturity level, identification of any special needs, history of violence, gang affiliation, and criminal behavior. Two of the five youth had and a new Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) completed in the Department’s Juvenile Justice Information System (JJIS). The program identifies risk factors for each youth to include suicide, medical, escape, and security risks. The treatment team leaders utilize each youth’s face sheet, commitment packet, and JJIS alerts to determine living area and sleeping room assignments for the youth. According to the program director, youth are assigned to a dorm based on the program placement. Documentation in all five youth records confirmed a reassessment was completed every two weeks. These reassessments were completed to determine if each youth was eligible for an increase in privileges or freedom of movement, participation in work projects or other activities including the use of certain tools, and participation in off-campus activities. The program has their internal alerts displayed in the administration building’s copy-room and in master control. These alerts are checked daily and updated as needed.

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.

A review of five case management records found none were applicable for gang affiliation; therefore, three additional active records were requested for review. None of the three records had notification to the local law enforcement of these youths suspected gang activity. The program did send a letter to all three youths’ home county law enforcement agencies notifying them of the suspected gang activity. The program shared this information with the education department and juvenile probation officer for all three youth. One of the three youth’s post-residential counselor was also notified. The other two youth are recent admissions at the program and their post-residential counselor have not been identified, therefore, notification has not been sent.


2.06 Gang Identification: Prevention and Intervention Activities Satisfactory Compliance

A residential commitment program shall implement gang prevention and intervention strategies. The residential commitment program shall provide intervention strategies when youth are identified as being a criminal street gang member, are affiliated with any criminal street gang, or are affiliated with any criminal street gang, or are at high risk of gang involvement.

The program has written policy and procedures in place for early detection, deterrence, and speedy reporting to local law enforcement agencies. The policy does not address the opportunity for a youth to develop a plan to dis-affiliate with a criminal street gang. A review of five youth case management records were reviewed for gang prevention and intervention activities. None of these youth records were applicable; therefore, three additional active records were requested for review. All three youth have been identified as a gang member or have a gang affiliation. One of the three youth is currently participating in a gang prevention and intervention strategies, as well as the youth’s performance plan includes a goal and objective relating to gang intervention strategies to complete. The other two youth are recent admissions at the program and have not completed their initial performance plans. The program implemented Gangs: 50+ Stories of Fractured Lives Workbook and Impact of Crime as the gang intervention strategies. Prior to COVID-19, a faith-based church volunteered weekly to provide the youth with the gang prevention/awareness program called Gang Rescue.

2.07 Residential Assessment for Youth (RAY) Assessments and Re-Assessments


The program shall ensure an initial assessment of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the initial assessment process in JJIS. The program shall ensure a reassessment of each youth is conducted within ninety days. The program shall ensure any other updates or reassessments are completed when deemed necessary by the intervention and treatment team to effectively manage the youth’s case. The program shall maintain all reassessment documentation in the youth’s official youth case record.

Five youth case management records were reviewed for compliance with initial Residential Assessment for Youth (RAY) assessments and reassessments. All youth records had documentation the RAY was completed within thirty days of admission and maintained in the Department’s Juvenile Justice Information System (JJIS). All youth records had documentation the RAY reassessment was completed within ninety days of the initial RAY. Four of the five youth were eligible for additional RAY reassessments and each were completed within the required time frame. The remaining youth only qualified for the first reassessment. Each of the five youth case management records included all of the reassessments.

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.

Five case management records were reviewed for completion of the Youth Needs Assessment Summary (YNAS). Each of the youth records contained documentation the YNAS was completed within thirty days of the youth’s admission. All YNASs were completed in the Department’s Juvenile Justice Information System (JJIS).


2.09 Performance Plan Development, Goals and Transmittal (Critical)


The intervention and treatment team, including the youth, shall meet and develop the performance plan, based on the findings of the initial assessment of the youth, within thirty days of admission. For each goal, the performance plan shall specify its 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 committing court, the youth’s juvenile probation officer (JPO), the parent/guardian, and the Department of Children and Families (DCF) counselor, if applicable.

Five case management records were reviewed performance plan development, goals and transmittal. All youth had their individualized performance plan developed within thirty days of admission, following the initial assessment. The following members were present during all five youths’ development of this plan; treatment team leader, youth, administrative representative, treatment staff, parent/guardian, and for one applicable youth the Department of Children and Families (DCF) caseworker. Two of the five youth records included input from education for the development of the plan. If the parent/guardian participates in the development of this plan, the program does not send the signature sheet to the parent/guardian with a request for signature and return. All reviewed individualized performance plans included the following elements; individualized goals based upon the prioritized needs reflecting the risk identified during the initial assessment process, the three top criminogenic needs, specific delinquency interventions, target court-ordered sanctions, transition activities targeted for the last sixty days of each youth’s anticipated stay, youth and staff responsibilities, and target dates for goal completion. All reviewed youth records had a transmittal letter and a copy of the plan sent to the committing court, juvenile probation officer, parent/guardian, and the DCF caseworker, on the one eligible youth, within ten working days of the plan being completed. Five youth were interviewed and confirm they each participated in the development of their performance plan and received a copy. Four of the five were able to identify goals on their plan, while the remaining youth indicates not being able to recall what goals were on the performance plan.

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.

A review of five case management records found each had a performance review completed every ninety days based upon each youth’s Residential Assessment for Youth (RAY) reassessment and each record documented demonstration of progress or lack of progress toward completing a goal. Two of the five records were applicable for revisions to the individualized performance plan to facilitate transition activities during the last sixty days of the youth’s stay. Each of the youth completed one transition goal and are currently working on additional transition goal. The remaining three youth were not eligible.


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 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 its signing.

A review of five case management records found each had a Performance Summary completed every ninety calendar days following the signing of the initial performance plan. All performance summaries included the youth’s status on each goal, overall treatment progress, academic status and credits earned, behavior, level of motivation/readiness to change, interaction with peers and staff, overall behavior adjustment to the program, and significant positive and negative events. Two of the five youth records had performance summaries prepared prior to the youth’s release and included justification for the release. In all five performance summaries, each youth is allowed to read and add comments prior to signing, each youth is provided a copy of the summary, and the original is filed in each youth’s case management record. All five performance summaries documented the treatment team leader, program director, and youth signatures. All summaries were sent to the committing court, juvenile probation officer (JPO), parent/guardian, and the Department of Children and Families (DCF) caseworker, for the one eligible youth, within ten working days. Two of the five case management records were eligible for review of the release summary, so an additional closed record was selected for review. All three youth had the original summary, along with justification for release, sent with the Pre-Release Notification (PRN) to each youth’s JPO at least forty-five days prior to the planned release. The program has received two youths’ signed PRNs, which are retained in the case management record, while the program has yet to receive the third youth’s signed PRN. The two youth who have signed PRNs, the program sent written notification to the DCF caseworker and parent/guardian of each youth’s planned release. The program completed a Residential Assessment for Youth (RAY) exit for the closed record but has not completed the RAY exit on the active youth. Five youth were asked if they were provided a copy of their performance summary sent to the court and the two applicable youth confirmed they have.

2.12 Parent/Guardian Involvement in Case Management 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 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 a video conferencing platform for the transition conferences. Case managers send letters, emails, and telephone calls to remind parents/guardians of these meetings. A formal treatment team


meeting was observed where the case manager attempted to contact the parent/guardian by telephone and left a voicemail message. Five interviewed youth confirm their parent(s)/guardian(s) are involved in their treatment. The program director added they encourage parent/guardian involvement through treatment teams, family group sessions, family days, and parent/guardian surveys.

2.13 Members of Treatment Team Satisfactory Compliance

The team includes, 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.

The members of the program’s treatment team include the following; treatment team leader, youth, administrative representative, treatment staff, juvenile probation officer (JPO), parent/guardian or Department of Children and Families (DCF) caseworker, program’s gang prevention specialist, and transition services manager. The living unit representative, and education staff are not always physical present but do provide verbal or written input. Medical staff participate in treatment team if the youth is on medication. In all five case management records reviewed, all pertinent parties were invited and participated in the treatment team meetings.

2.14 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.

Five youth case management records were reviewed for incorporation of other plans into performance plans. The program incorporates all treatment goals into each youth’s performance plan. One of the five youth had a Department of Children and Families (DCF) care plan. This youth has completed the DCF care plan and only has to maintain contact with the DCF caseworker.

2.15 Treatment Team Meetings (Formal and Informal Reviews) Satisfactory Compliance

A residential commitment program shall ensure the intervention and treatment team meets every thirty days to review each youth’s performance, to include RAY reassessment results, progress on individualized performance plan goals, positive and negative behavior, including behavior resulting in physical interventions. If the youth has a treatment plan, review their treatment plan progress.

Five youth case management records were reviewed for formal and informal treatment team meetings. All five performance reviews included the youth’s name, date of review, any comments, brief synopsis of youth’s progress, performance plan revisions, progress on performance plan goals, positive and negative behaviors, behaviors resulting in physical interventions, treatment progress, Residential Assessment for Youth (RAY) results, and an opportunity for the youth to demonstrate a skill learned at the program. All five youth had a formal treatment team review held at least every thirty days. All five youth had informal reviews conducted bi-weekly with the youth and treatment team leader. All five informal reviews included the same information as the formal review, excluding the RAY reassessment results.


A formal treatment team meeting was observed during the week of the annual compliance review. The youth, treatment team leader, therapist, were all in attendance and the juvenile probation officer participated by telephone. An attempt to call the youth’s parent/guardian was made; however, unsuccessful and the treatment team member left a message by voicemail. Prior to this meeting, education provided the treatment team leader with this youth’s grades and progress in school. During the formal treatment team meeting, the treatment team leader discussed the youth’s progress on performance plan goals, positive and/or negative behaviors, and treatment progress. Five interviewed youth confirm staff review their overall progress in the program and they are all given the opportunity to demonstrate skills learned in the program.

2.16 Career Education Satisfactory Compliance

Staff shall develop and implement a vocational competency development program.

None of the original five case management records were applicable for career education; therefore, three additional closed youth records were reviewed. Each of the three youth had provisions for continuing education as one of their goals on their performance plans. All youth had a completed employment application, a résumé, documentation indicating the location and business hours of a local Career Source Center, appropriate documents essential to obtaining employment, documentation of each youth’s parent/guardian, juvenile probation officer (JPO), and treatment team leader being aware of the vocational plan, and post-release discharge plans. Two of the three youth records contained evidence of a valid Florida identification card. The program offers a Type 2 educational programming. The career education programming includes communication, interpersonal, and decision-making skills. The vocational and career education program provided is appropriate for the age of the youth, as well as appropriate for the educational abilities and goals of the youth in this program. Additionally, the career education program is appropriate for the length of stay and custody characteristics of the youth in the program. According to the principal, every youth in the program utilizes Florida Ready to Work. During the intake and assessment process, the program uses My Florida Shines program. For those youth who qualify, the program offers a Home Builders Institute (HBI) program as well. The program director was confirmed career education services are offered to the youth such as HBI, ServSafe certifications, first aid, and cardiopulmonary resuscitation.

2.17 Educational Access Satisfactory Compliance

The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time.

The program operates the educational services through the Rader Group, Inc. under the supervision and direction of the Okaloosa County School District on a year-round basis. The program provides 250 days of educational and vocational instruction over a twelve-month time frame, with a minimum of twenty-five hours of weekly instruction. The teachers utilize ten days for teacher planning/training. A review of the program’s logbook and school schedule reflected the youth are attending school as scheduled. Interviews with five youth confirm there are no interruptions during education instruction.


2.18 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.

Five case management records were reviewed for education transition plans. None of the five records were applicable; therefore, three additional closed case management records were requested for review. Key personnel related to transition activities include the youth, parent/guardian, instructional personnel in the juvenile justice education program, department personnel for youth in the program, certified school counselor from the program, and a transition plan developed with youth, program education, and aftercare staff with specific plans for continuation of education for all three youth. None of the three youth had involvement from personnel from the post-release school district. In each of the three youth records, the Education Transition Plan addressed the following: services and intervention based on each youth’s assessed education needs and post-release education plans, recommended education placement for post-release must be based on individual needs and performance, and specific monitoring responsibilities by individuals who are responsible for the reintegration and coordination of the provision of support services. Five youth were interviewed regarding how well the education received was preparing them for the future and all agreed they are well prepared. Each of the five youth were interviewed to determine if they were involved in the development of the education transition plan. Two of the five confirm they are involved and the other three are non-applicable.

2.19 Transition Planning, Conference, and Community Re-entry Team Meeting (CRT)


A residential commitment 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 them 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 attendees’ 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.

Five youth case management records were reviewed for transition plans, transition conferences, and Community Re-entry Team (CRT) meetings. Only two of the five records were applicable; therefore, the review team requested an additional record for review. Each of the three youth transition conferences were held at least sixty days prior to the targeted release date. The following intervention and treatment team members attended the transition conference for all three youth, treatment team leader, program director or designee, transition specialist, therapist, education, juvenile probation officer, youth, and parent/guardian or Department of Children and Families (DCF) worker. Two of the three youth were involved in Project Connect, who also attended the conference. For all three youth, the following was discussed during the conference;


transition activities on each youth’s performance plan, identify target completion dates, and identity persons responsible for completion. In all three records, the treatment team leader obtained dated signatures of attendees representing acknowledgement of the transition goals and accountability for completion. All three records included documentation of an invitation to participate in the CRT meeting, which was conducted prior to the youth’s release. In all three CRT meetings, the youth and treatment team leader participated.

2.20 Exit Portfolio Satisfactory Compliance

The residential commitment program will assemble an exit portfolio for each youth to assist the youth once he/she is released back into the community.

Five case management records were reviewed for exit portfolios. None of the case management records were applicable; therefore, three closed youth records were requested for review. All Exit Portfolios were discussed and initiated at the transition conference. Each of the portfolios included a copy of the youth’s transition plan, a calendar with upcoming community appointments, educational and/or vocational certificates, educational records, school transcripts, a résumé, and completed employment applications. Two of the three youth records had documentation of a Department of Highway Safety and Motor Vehicles state-issued identification card. The third youth’s parent/guardian did not provide the proper documentation for the program to take this youth to get his identification card. Two of the three youth had a copy of his Social Security card and birth certificate. The third youth’s parent/guardian informed the program the youth already had this documentation but did not provide the program with a copy. All Exit Portfolios were verified at each youth’s Exit Conference. Documentation was provided confirming all three youth were provided a copy of their Exit Portfolio upon release. Each of the youth’s Exit Portfolio information was discussed with the juvenile probation officer during the Community Re-entry Team (CRT) and Exit Conference.

2.21 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.

A review of five case management records reviewed for and Exit Conference found none were applicable; therefore, three closed youth records were requested for review. All three Exit Conferences were conducted after the program notified the juvenile probation officer (JPO) of the release. All three conferences were conducted at least fourteen days prior to each youths’ release and contained documentation in the case record, including the date, signature, and a summary pending transition goals. A review of the Department’s Juvenile Justice Information System (JJIS) admission and release dates correlated with the program’s date for all three youth. The following were participants for all three youth in the Exit Conference, treatment team leader, parent/guardian, education, JPO, youth, therapist, and transition specialist. One youth had a member of Project Connect participate as well. All three youth had the Exit Conference, Community Re-entry Team (CRT), and Transition Conference held separately.


2.22 Safety Planning Process for Youth Satisfactory Compliance

A residential program shall conduct an on-going safety planning process for each youth. The safety plan shall be designed to identify stimuli which have both positive and negative effects on the youth.

The program maintains all youth safety plans in master control. Five interviewed staff confirmed the location of the safety plans. The safety plans including the following; warning signs, youth’s baseline behavior, crisis recognition, jointly developed coping strategies, intervention strategies preferred by the youth, and debriefing preferences. Five case management records were reviewed for this indicator. All five youths’ safety plans were completed the day of admission. Four of five of the youth’s parents/guardians were contacted and jointly prepared the safety plan. The program attempted to contact the Department of Children and Families (DCF) caseworker for the remaining youth and left a voicemail message. All five safety plans incorporate any recommendations from previous or current clinical assessments and incorporate trauma responsive practices. The program begins working on these safety plans prior to each youth’s arrival. Three of the five youth had their safety plans updated and reviewed by the therapist every thirty days. The fourth youth had one thirty-day review missed, while the fifth youth had three consecutive thirty-day reviews missed. Five youth confirmed they were involved in development of their safety plans. Five staff were interviewed regarding the process for reviewing the safety plans. All staff replied they review these plans after a new youth arrives, as needed, or if there are difficulties with a youth and ideas on how to handle them or help them. These same five staff were asked when the last time they reviewed a safety plan and the answers varied from last week, last month, to a couple of months ago.


Standard 3: Mental Health and Substance Abuse Services

3.01 Designated Mental Health Clinician Authority or Clinical Coordinator


Each program director is responsible for the administrative oversight and management of mental health and substance abuse services in the program. Programs with an operating capacity of 100 or more youth, or those 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 facility/program. Programs with an operating capacity of fewer than 100 youth or those not providing specialized treatment services, may have either a DMHCA or a Clinical Coordinator.

The program has a licensed clinical social worker who serves as the designated mental health clinician authority (DMHCA), licensed under Chapter 491, Florida Statute. A copy of the license and position description was available and reviewed. The DMHCA is on-site forty hours a week and on-call on the weekends, to provide oversight of mental health and substance abuse treatment. A review of the licensed clinical social worker’s (LCSW) license through the Florida Department of Health (DOH), Division of Medical Quality Assurance, reveals the license is clear and active through March 31, 2021. The DMHCA interview described their role in the coordination and implementation of mental health and substance abuse services at the program. The DMHCA delivers clinical supervision to all non-licensed therapist. In addition, audits clinical charts for compliance to standards. The program provides mental health and substance abuse overlay specialized services. The DMHCA provides communicates daily with other clinical staff at the program. The designee who serves as back-up for the DMHCA is also a LCSW, with a license which expires March 31, 2021.

3.02 Licensed Mental Health and Substance Abuse Clinical 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 they are qualified to provide based on education, training, and experience.

The designated mental health clinical authority (DMHCA), ensures the one licensed clinical staff working under his supervision, works full time and is performing services which they are qualified to provide, based on education, training, and experience. The licensed clinical social worker (LCSW) license is clear and active with an expiration date of March 31, 2021. A review of the program’s contract found the mental health and substance abuse clinical staffing was in accordance with contract and Florida Administrative Code 63N-1 and 64B19-18.0025. The program’s Chapter 397 license, with a correct physical address of the program, expires January 29, 2021.


3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff


The program director is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure clinical staff working under their supervision are performing services they are qualified to provide based on education, training, and experience.

The designated mental health clinical authority (DMHCA), assures the five non-licensed clinical staff working under their supervision, are performing services which they are qualified to provide, based on education, training, and experience. A review of the program’s contract found the mental health and substance abuse non-clinical staffing was in accordance with contract and Florida Administrative Code 63N-1. Documentation was found where each of the five 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. Documentation of the direct supervision was recorded on a similar form, including all information of the Department’s Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log (MHSA 019). All five 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 substance abuse clinical staff provide substance abuse services as an employee of a service provider, licensed under Chapter 397, Florida Statute. The program provided documentation for three of the five non-licensed mental health staff who have conducted Assessments of Suicide Risk (ASR). The three non-licensed mental health staff have received twenty hours training and supervised experience in the completion of an ASR and the two staff are still in training and not completing the assessments. The training included administration of at a minimum, five assessments of the ASR or Crisis Assessments conducted on-site in the physical presence of a licensed mental health professional. The training was documented on Non-Licensed Mental Clinical Staff Person’s Training in Assessment of Suicide Risk form (MHSA 002). The program is certified under Chapter 397, Florida Statute, and expires January 29, 2021.

3.04 Mental Health and Substance Abuse Admission 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.

Five 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 upon the youth’s admission to the program and in a confidential manner. The screening tools documented the trained staff complete the screening, along with the date and time of the initial screening. During the screening process, all available information was reviewed, which included review of the commitment packet, reports, and records from existing documentation of mental health and/or substance abuse problems. The MAYSI-2 screenings were completed in their entirety in the Department’s Juvenile Justice Information System (JJIS). Three of the five MAYSI-2 reviewed, indicated further assessment was required. For each of the five youth records reviewed, regardless of the MAYSI-2 findings, a referral was made when the staff believed the youth assessed to have either a mental health need, substance abuse problem, and was a suicide risk. The five youth had a referral for further


evaluation generated. Four of the five applicable youth reviewed for completion of an Assessment of Suicide Risk (ASR), the program director was notified the ASR was conducted within twenty-four hours or other information obtained at intake suggested potential suicide risk. In all five youth records, a referral was generated for completion of a comprehensive evaluation. A reason for referral was documented in each of the all records reviewed. The residential program director has a written Facility Operating Procedures (FOP), which addresses the implementation of a standardized admission and intake for mental health and substance abuse screening process. The written FOP includes a standardized screening process; review of commitment packet information, reports, and records. In addition, administration of the MAYSI-2 on the Department’s Juvenile Justice Information System (JJIS). Each screening administered is conducted by a “qualified professional,” and a referral made for youth identified in need of further evaluation or immediate attention when necessary. The FOP identified staff training in mental health and substance abuse issues and administration of the MAYSI-2. In addition, the program’s FOP identified standardized process for referral of youth identified as in need of further mental health and/or substance abuse evaluation to an appropriate service provider or professional or, when immediate attention is needed, to a hospital or Baker Act or Marchman Act receiving program. The observation of five youth records, demonstrated the program staff conducting screening, reviewed youth’s commitment packet information, reports, and records for existing documentation of all mental health and/or substance abuse problems, needs, or risk factors. An interview with the program director was conducted. The program director reports all youth admitted to the program have a MAYSI-2 completed upon admission.

3.05 Mental Health and Substance Abuse Assessment/Evaluation


Youth identified by screening, staff observation, or behavior after 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.

Five youth records were reviewed for mental health and substance abuse assessment and evaluations. All five records reviewed were applicable for completion of a new mental health evaluation. The evaluations were completed within thirty calendar days of the youth’s admission to the program. Each of the mental health evaluations were completed by a non-licensed mental health clinical staff person. The evaluations were subsequently reviewed and signed within ten days by a licensed mental health professional. The five mental health evaluations conducted contained demographics, reason for evaluation, relevant background information, behavioral observations, Mental Status Examination, discussion of findings, clinical impression, and recommendations. Five youth records reviewed for completion of a substance abuse assessment. Each of the five youth records reviewed were applicable for completion of a new substance abuse assessment. The substance abuse assessments were completed under the program licensure; Chapter 397, Florida Statute, and contained a signed consent for substance abuse services, by each of the youth. The assessments reviewed were completed within thirty calendar days of admission. The substance abuse assessments 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 impression, and recommendations. Each of the substance abuse assessments conducted, addressed the youth’s original referral reason.


3.06 Mental Health and Substance Abuse Treatment Satisfactory Compliance

Mental health and substance abuse treatment planning in Departmental facilities focuses 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.

Five youth records were reviewed for mental health and substance abuse treatment. Records reviewed indicated each of the youth were assigned a treatment team upon arrival to the program. Each of the youth are assigned to an on-site therapist and case manager upon intake to the program. The multidisciplinary treatment team were 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 five records contained treatment team documentation, which validates 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. Two of the five youth were applicable for needing substance abuse treatment and admitted to the program for substance abuse treatment. Treatment provided consisted of individual, group, and family counseling, which is provided for by non-licensed substance abuse staff, who is an employee of a service provider licensed under Chapter 397, Florida Statute. Each of the applicable youth had a properly executed Authority for Evaluation and Treatment (AET) form on file. Each youth in receipt of mental health services had a documented diagnosis. All five youth reviewed had a signed Youth Consent for Substance Abuse Treatment forms (MHSA 012) and Youth Consent for Release of Substance Abuse Treatment Records (MHSA 013). 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 (MHSA 018). According to the designated mental health clinician authority (DMHCA), mental health treatment groups were limited to ten or fewer youth and substance abuse treatment groups were limited to fifteen or fewer youth. This was confirmed with the review of treatment group sign-in sheets and billing documents, as well as length of time for each group provided. The five youth records reviewed, contained documentation youth were involved in individual psychotherapy or counseling. As noted within each individual mental health and/or substance abuse treatment plan, youth were engaged in therapeutic activities designed specifically to address skill deficits or maladaptive behaviors. On-site substance abuse group is provided for by a licensed qualified professional or a non-licensed substance abuse clinical staff, who are employed by the service provider under Chapter 397, Florida Statute. Interviews were completed with five youth who all indicated they were participating in individual and family counseling at a frequency dictated by their treatment plans. Five direct care staff were interviewed, all stated they did not facilitate mental health groups. An interview with the designated mental health clinician authority (DMHCA) confirmed the program provides both mental health and substance abuse overlay specialized services.


3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance

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. All youth who receive mental health and/or substance abuse treatment while in a residential 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 facility.

Five youth records were reviewed for youth treatment planning. All records contained an initial treatment plan and each were developed on the date of the youth’s admission to the program. The Initial Mental Health Treatment Plans were site-specific, which included all the information contained within the Department’s Initial Mental Health/Substance Abuse Treatment Plan form (MHSA 015). Two of the five records reviewed were applicable for completion of an initial substance abuse plan. Each of the Initial Substance Abuse Treatment Plans were site-specific, which included all the information contained within the Department’s Initial Mental Health/Substance Abuse Treatment Plan form (MHSA 015). Each of the reviewed Initial Mental Health Treatment Plan or Substance Abuse Treatment Plans were developed within seven days of admission to the program. The Initial Treatment Plans were signed by the mental health clinical staff person or substance abuse clinical staff person completing the form. All five individual treatment plans reviewed, each were developed within thirty-days of admission and completed by a non-licensed mental health clinical staff person. The seven individualized treatment plans reviewed, were developed on a site-specific form, which contained all the elements of the Department’s Individualized Mental Health Treatment Plan form (MHSA 016). Those plans were each signed by the licensed clinical supervisor, within ten days of completion. All five youth were applicable for the inclusion of psychiatric services into each of their individualized treatment plans. These plans include psychotropic medication and frequency monitoring by the psychiatrist. Each treatment plan review was conducted and documented on a program specific form which contained all the information in the Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form (MHSA 017). Each of the youth’s individualized treatment plans documented prescribed services; individual, group, family, or psychiatric. Review of the youth’s progress notes determined youth were in receipt of services stipulated on the treatment plan. Thirty-eight individualized treatment plan reviews were documented and completed, for each of the five reviewed youth records. Three additional youth records were reviewed for discharge planning. Each of the three discharge plans were documented on the Department’s Mental Health/Substance Abuse Treatment Discharge Plan form (MHSA 011). None of the three-youth reviewed required any type of notification for suicide alert or precautions. The three Mental Health and Substance 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 had been discussed with the youth, parent/guardian, and juvenile probation officer (JPO) during the Exit Conference. A copy of the Mental Health and Substance Abuse Treatment Discharge Summary were provided to the youth, JPOs, and parents/guardians in each of the three reviewed youth records.


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 Mental Health Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services (SAOS). The program provides treatment services at least seven days a week. In addition, therapeutic activities are provided by a mental health clinical staff person seven days a week. Psychiatric services are provided on-site at least bi-weekly. Youth with co-occurring substance abuse disorders receive substance abuse services, which is prescribed according to their individual treatment plans. A psychologist is available to provide services, as needed. Therapist caseloads average ten youth for MHOS services. The SAOS program provides urinalysis during intake, upon return from home visits, and random monthly screening. The program provides treatment services at least seven days a week. SAOS groups never exceed more than fifteen youth in a group. Youth with co-occurring mental health disorders receive mental health treatment. The program is licensed under Chapter 397, Florida Statute, and a qualified licensed professional is on-site at least five days a week. A licensed psychiatrist provides psychiatric evaluations, medication management, and participates in treatment planning. Substance abuse clinical staff are on-site seven days a week. Therapist caseloads are no more than ten youth for SAOS. A review of five pre-service training records indicate each staff was in receipt of MHOS and SAOS training. An interview with the program director confirms specialized services are provided for at the program and all youth admitted to the program receive MHOS or SAOS services. An interview with the designated mental health clinician authority (DMHCA) confirmed the program provides both MHOS and SAOS services.

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. ***Tele-psychiatry is not currently approved for use in Residential Programs***

A total of five youth records were reviewed for psychiatric service delivery. All five youth were referred for an initial psychiatric interview. Each of the five youth were seen within fourteen days of the psychiatric referral. The initial diagnostic psychiatric interviews included, youth history, Mental Status Exam, a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), treatment recommendations (if applicable), prescribed medications (if applicable), explanation of the need for psychotropic medication, and frequency of medication monitoring. Each of the five initial diagnostic interviews with the psychiatrist were documented on the Clinical Psychotropic Progress Note (CPPN). Four of the five youth reviewed, entered the program with psychotropic medication currently prescribed and received a psychiatric evaluation within thirty days of admission. Each of the psychiatric evaluations conducted reflect the elements specified in Florida Administrative Code 63N-1. In the five youth records, twenty-four months of psychiatric evaluations were reviewed. Of the five records reviewed three youth had psychiatric reviews just outside of thirty-days, for five reviews. Two youth had two late psychiatric reviews and one youth had one late psychiatric review. According to a registered nurse at the program, the psychiatrist’s contract requires two site visits each month, which cause psychiatric reviews to be a few days late in months which have five


Wednesdays. Each of the psychiatric evaluations completed were documented on the CPPN. Psychiatric services are provided by a psychiatrist licensed under Chapter 485 or 459. The program holds a physician services agreement with the psychiatrist to render on-site and on-call services. The program does not employ or have a contract with a psychiatric advanced practiced 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 evaluation and recommendations for youth, is 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, confirms on-site visits during the past six months as required by contract. A copy of the psychiatrist license was reviewed and is current. 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 service within the program. The interview with the program’s psychiatrist revealed the psychiatric services includes the doctor’s responsibility for initial evaluations utilizing data supplied by members of the mental health therapy team and interview with youth, as well as monthly therapy with youth prescribed appropriate medications and evaluation of effectiveness. Psychiatric evaluations, individual therapy with youth, and medication monitoring are conducted by the psychiatrist. The psychiatrist states he is on-site twice a month. A review of the sign-in sheets confirmed the psychiatrist was on-site every fourteen days during the annual compliance review period. The psychiatrist meets with the program’s designated mental health clinician authority (DMHCA) as needed. The psychiatrist process is for the nurses, case managers, and therapists at the program, to communicate with each other regarding the youth's progress. The nurse, youth, and psychiatrist discuss the youth's issues, medications, and side-effects. Other discussion topics include the youth's feelings on medication's effectiveness and how youth feels regarding his therapy.

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 includes 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’s written suicide prevention plan is reviewed annually.


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.

Three of the five youth records reviewed were applicable for suicide prevention services. The three youth were determined to be at risk during the admission screening to the program and two were assessed for suicide risk while at the program. Subsequently, each of the youth were placed on Precautionary Observation (PO) and had an Assessment of Suicide Risk (ASR), completed upon admission to the program. The ASR referral was generated for each of the youth reviewed. The ASR was completed utilizing the Department’s ASR form (MHSA 004). All six youth were screened and subsequently placed on standard supervision at admission. Precautionary Observation was authorized for each youth. The on-site mental health staff conducted the ASR and provide supportive services to each of the youth. One youth was placed on PO while at the program and received a subsequent ASR continuing the PO supervision. The next day a Follow-Up ASR was completed as required by the mental health substance abuse (MHSA) manual and stepped down to close supervision. In each of the youth’s ASR screening, a conference was held with the program director by the licensed mental health professional to reduce level of supervision. In each of the three youth records reviewed, two records included an ASR releasing the youth’s status as PO and one ASR continuing the youth on PO. The parent/guardian or juvenile probation officer (JPO) was not notified of the youth’s ASR status in all three records reviewed. Each of the five ASRs reviewed, were completed by a licensed mental health professional or clinical staff under the supervision of a licensed mental health professional. The result of the suicide risk assessment was recorded as required. Each of the youth had a completed suicide alert initiated within the Department’s Juvenile Justice Information System (JJIS). The alerts were removed from JJIS once the youth was removed from PO. 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. Youth placement on PO does not limit their activity to an individual cell or restrict them to their sleeping room. Each of the non-licensed clinical staff completing ASR screenings documented completion of twenty hours of training by a licensed professional on the Department’s Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of Suicide Risk form. The reviewed ASR screenings were conducted within twenty-four hours of referral. When applicable, the youth reviewed who were a suicide risk were stepped down to close supervision and all youth subsequently determined not to be a potential suicide risk, were transitioned directly to standard supervision. Each of the three youth had documentation on the ASR, to indicate the licensed mental health professional conferred with the program director or designee, prior to revising the supervision level. Documentation of the actual date and time the clinician conferred with the program director or designee was found on the ASR in appropriate sections. 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 since last annual compliance


review. The program has suicide response kits on-site. 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 includes; 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. Five staff were interviewed regarding response needed for a youth who expressed suicidal thoughts. Four staff reported they would notify mental health, place the youth on constant supervision, and document supervision. Three staff report they would notify the supervisor. Each of the interviewed staff identified locations of the program’s suicide response kits.

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 member 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.

Five incidents were reviewed for Precautionary Observation (PO) Logs with three youth applicable for placement on PO. All reviewed PO Logs were documented on the Department’s Suicide Precautions Observation Log form (MHSA 006). 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 or need to document warning signs in any of the six PO logs reviewed. All the PO logs were reviewed and signed by each shift supervisor. All the PO logs were reviewed and signed by mental health clinical staff. All completed PO logs were reviewed to determine supervision, supervisory reviews, response to warning signs, and safe housing requirements were met. Each of the PO Logs documented safe housing requirements. Three youth who had been previously placed on PO were interviewed. All three youth confirm staff were with them at all times while on suicide precautions. All youth confirmed they were never left alone for any period of time while on suicide precautions.

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.

Ten staff training records were reviewed for completion of suicide prevention and implementation of suicide precautions six hours annually. All staff reviewed, completed appropriate annual training requirements. Training included mock suicide drills held no less than quarterly on each shift and the program completed these drills as required. A review of fifty percent of the direct care staff demonstrated participation in quarterly drills. Direct care staff reviewed, participated in at least one mock drill which included the use of cardiopulmonary resuscitation (CPR). Staff members who are not present during a quarterly drill have the opportunity to review each drill scenario and procedures. Interviews with five staff confirm suicide drills were conducted monthly.


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: 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, or by a non-licensed mental health clinical staff person working under the direct supervision of a licensed mental health professional, to determine the severity of 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 intervention, the program director or designee shall be notified of the crisis situation and need for 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 during the annual compliance review period or since the last annual compliance review. The program has a written Crisis Intervention Plan and Emergency Mental Health and Substance Abuse Plan, which addresses those practices necessary to effectively handle youth in need of a Mental Status Exam and a Crisis Assessment. The program utilizes the Department’s Crisis Assessment form (MHSA 023), to document reasons for assessing a youth demonstrating acute psychological distress.

3.16 Emergency Mental Health and Substance Abuse Services (Critical)


Youth determined to be an imminent danger to themselves or others due to mental health and substance abuse emergencies occurring in facility require emergency care provided in accordance with Rule 63N-1 Florida Administrative Code and the facility'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.


3.17 Baker and Marchman Acts (Critical) Non-Applicable

Individuals who are believed to be an imminent danger to themselves or others because of mental illness or substance abuse impairment require emergency mental health or substance abuse services.

The program did not utilize a Baker Act or Marchman Act procedures during this annual compliance review period; therefore, this indicator rates as non-applicable.


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 facility.

The program has a designated health authority (DHA) who is a licensed physician with an unrestricted license and meets all requirements for independent and unsupervised practice in Florida. The DHA’s license expires on January 31, 2022. The DHA’s specialty training is in family practice with experience in adolescent health. The DHA does not designate a physician assistant (PA) or advanced practice registered nurse (APRN). However, during a two-week period in June 2020, the Office of Health Services temporarily (thirty days) approved an APRN to cover during the DHA’s absence due to COVID-19. The DHA does not currently have a back-up, but the DHA and program are actively seeking a doctor of equal licensure to cover for absences of any kind. In the event of the DHA’s absence, youth are sent to the North Okaloosa Medical Center for any medical needs. According to the provider’s contract, the DHA is required to be on-site weekly, for two hours. Sign-in sheets for the previous six months were available for review. A review of the sign-in sheets reflected a three-week period in July and August in which the DHA did not sign in or out on the log; however, the DHA’s visits to the program during this period could be verified by their signature documented on the weekly clinic logs. The failure of the DHA to sign-in during these times was previously identified during a supplemental monitoring visit on September 10, 2020. As of September 14, 2020, the nursing staff have created a new DHA sign-in/out log which is maintained in the nursing station. Since this time, there have been no instances of the DHA not documenting sign-in/sign-out times as required. In addition, the new sign-in/sign-out sheet did not reflect any instances where nine or more days passing between on-site visits. The DHA is available twenty-four hours a day, seven days a week for medical concerns, emergency care, and the coordination of off-site care. The DHA reported he is on-site once a week and is always available to program staff by phone. The DHA explained his role is to review policy and procedure, is on-call for medical problems, provide care for youth during sick call, and new admissions once a week.

4.02 Facility Operating Procedures Satisfactory Compliance

The program shall have Facility Operating Procedures (FOP) for all health-related procedures and protocols utilized at the facility.

The program has written policies and procedures for all health-related procedures and protocols utilized at the program. The designated health authority (DHA) and program director signs and dates all respective treatment protocols. The DHA reviewed and signed the protocols and Facility Operating Procedures (FOP) on January 6, 2020. The program director reviewed and signed the protocols and FOPs on December 31, 2019. The review and development of FOPs, or other protocols related to psychiatric services and psychotropic medication management is performed by the program’s psychiatrist. The psychiatrist reviewed and signed the protocols on January 6, 2020 and FOPs on December 9, 2020. Nursing staff reviews, signs, and dates a cover page on which all FOPs, treatment protocols, and other procedures are listed. New policies or changes in policies made during the year are reviewed, signed, and dated by nursing staff for changes which occur between annual compliance reviews. An annual review of all FOPs and protocols is completed by the program. All newly employed health care personnel receive a comprehensive clinical orientation to the Department’s health care policies and procedures, given by a registered nurse. A copy of the health care staff orientation packet was


provided by the program. Approval of treatment protocols or standing procedures are written and authorized by the DHA and are not delegated to any other person.

4.03 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.

Five youth Individual Healthcare Records (IHCRs) were reviewed for an Authority of Evaluation and Treatment (AET). Four of five records reviewed contained an AET stamped “copy” in red ink. Two of the four youth records reflected each turned eighteen years old subsequent to their admission to the program. The program utilizes a separate form for youth eighteen years of age or older providing consent for release of specific information as noted on the Release of Information Authorization for Youth Eighteen Years of Age and Older form and to whom the information can be released and shared. Each of the records for youth who turned eighteen contained a signed release of information. One of the five youth was applicable for involvement with the Department of Children and Families (DCF) in which the parental rights had been terminated. This record contained a court order authorizing all treatment for the youth while in the Department’s custody. According to the nurse, it is the responsibility of the juvenile probation officer to provide a current AET and the case manager is the point of contact for this form.

4.04 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.

Five youth Individual Healthcare Records (IHCRs) were reviewed for parental consent. Three of five youth IHCRs were applicable for over-the-counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET), in which documentation reflected parental notification. Two of five youth IHCRs reviewed were applicable for significant changes to existing medication and none were applicable for discontinuation of medication prior to entering the program. One youth was applicable of off-site emergency care in which parental notification was made by telephone and in writing. Two of the five youth were applicable for hospitalizations which included parental notifications. Three of the five youth reviewed were applicable for new medications in which verbal attempts were made, to include witnesses, and were documented in all three youth’s progress notes. The program sends out written notifications regardless of telephone notifications. Five of the five youth reviewed were applicable for psychotropic medication. Four of the five applicable records reflected parent/guardian consent on page three of the Clinical Psychotropic Progress Note (CPPN). One of the applicable five youth taking psychotropic medication were applicable for involvement with the Department of Children and Families (DCF), in which a court order for medical treatment was documented in the IHCR. In addition to the court order, a DCF Medical Report for Prescribing Psychotropic Medication to a Child in Out-of-Home Care (5339) form was observed for this youth. Documentation reflected all five reviewed youth records confirm their immunizations were verified through Florida Shots and/or the health department on the day of admission. None of the youth reviewed were applicable for refusing consent or refusing consent due to religious reasons. According to the nurse, immunizations are reviewed on the day of admission through Florida Shots to determine whether they are up to date.


4.05 Healthcare Admission Screening and Rescreening Form (Facility Entry Physical Health Screening Form)


Youth are screened upon admission for healthcare concerns which may need a referral for further assessment by healthcare staff.

Five youth Individual Healthcare Records (IHCRs) were reviewed for the completion of a Facility Entry Physical Health Screening (FEPHS) form. A review of five IHCRs reflected a FEPHS was completed on the day of admission for each youth. All five FEPHS were observed to be completed by a registered nurse (RN). None of the youth reviewed were applicable for a change in custody since being admitted to the program. According to the nurse, admission screenings are completed by the nurse on duty and in the event of a change in custody a new entry form and drug screening is completed.

4.06 Youth Orientation to Healthcare Services/Health Education


All youth shall be oriented to the general process of health care delivery services at the facility.

Five youth Individual Healthcare Records (IHCRs) were reviewed for orientation to health care services. Documentation in all five records reflected youth received general care orientation upon admission to the program, as indicated by the youth and staff signature and date of the healthcare orientation packet. The program’s health care orientation included the following: access to medical care, sick call, medication monitoring, what constitutes an emergency, the right to refuse care, what to do in the event of sexual assault, and the non-disciplinary role of healthcare providers.

4.07 Designated Health Authority (DHA)/Designee Admission Notification


A referral to the facility’s Physician, PA, or ARNP shall be made for youth who are admitted with known or suspected chronic conditions not requiring emergency treatment on admission.

Five youth Individual Healthcare Records (IHCRs) were reviewed for notification to the designated health authority (DHA). The program’s practice is to notify the DHA for all new admissions to the program. None of the five youth reviewed were applicable for chronic conditions or were in need of emergency response upon admission to the program. Documentation in all five youth IHCRs confirm the DHA and psychiatrist (if applicable) notification were made upon admission. The DHA notification was observed in the Chronological Progress Notes for each youth.

4.08 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 DJJ facility.

Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of a Health-Related History (HRH). Documentation in all five records confirm the HRH was completed on the day of the youth’s admission. The program’s practice is to complete a new HRH for each youth, regardless if there is one on record. Each of the five youth’s HRH was subsequently reviewed by the designated health authority (DHA) within seven days of the youth’s admission. According to the nurse, the HRH is completed by the nurse of duty within twenty-four hours of the youth’s admission.


4.09 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance

The standardized Comprehensive Physical Assessment form shall be used for all youth admitted into the physical custody of a DJJ facility.

Five youth Individual Healthcare Records (IHCRs) were reviewed for a Comprehensive Physical Assessment (CPA). The program uses the Department’s CPA form. The program’s practice is to complete a new CPA on each youth, regardless if there is one on record. All records contained a new CPA which was completed for each youth within seven days of admission to the program. All CPAs were observed to be completed by the designated health authority (DHA) who is a medical doctor (MD). Four of five youth reviewed were a medical grade five upon admission and the remaining youth was a medical grade one upon admission. All five CPAs reviewed were observed to be completed in accordance with the Health Services Manual requirements. All sections of the CPA were marked with an “O” or an “X”. Those sections marked with an “X” reflected comments by the DHA in the comments section of the form. All five youth refused the Tanner Stage portion of the exam in which case “refused” was written on this section of the CPA and a corresponding refusal form documented in the IHCR for each youth. This process coincides with the program’s written policy and procedures. The Department’s Problem List was observed to be updated for all five youth. All five IHCRs reflect each youth had a verified Tuberculin Skin Test (TST) completed in the last year. The results of the TST were observed to be documented on the CPA and Infectious Communicable Disease (ICD) forms in all reviewed records. According to the nurse, a new CPA is completed on admission for each youth, if a youth is a medical grade two-five, a new CPA is completed every year thereafter. The nurse reported a Tuberculosis Screening is performed on each youth annually, if the youth has had a positive test in the past, a chest x-ray is performed every year.

4.10 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance

The program shall ensure all youth are evaluated and treated (if indicated) for sexually transmitted infections (STIs) and HIV risk factors.

Five youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted infection (STI) screening. All IHCRs reviewed confirm each youth was clinically screened for STIs. Documentation all records confirm each youth was subsequently referred for testing. Testing, screening, results, clinical evaluation, and diagnosis were found to be documented on the Infectious and Communicable Disease (ICD) form for all youth. None of the youth reviewed were out of custody in which a re-screen was required. Five IHCRs were reviewed for evidence the youth were offered counseling, testing, and if necessary, treatment/referral for human immunodeficiency virus (HIV). Documentation in all five reviewed records reflected youth were offered these services. Three of five youth refused HIV testing/services as indicated on their consent form. The remaining two youth consented to HIV testing/services. Test results were observed filed in a confidential manner consistent with Florida Statute 381.004, a certified HIV counselor conducted the testing, and the youth’s HIV status is never included in the program’s internal alerts. HIV testing is completed by the Okaloosa AIDS Support and Information Services (OASIS). Pre-test and post-test counseling were observed documented in the two of the two applicable youth’s Health Education Record within their IHCR. A copy of the provider’s 500/501 certification was available for review. Five interview youth report they are able to request an HIV test if needed. According to the nurse, medical staff utilize the STI screening form, if further evaluation/testing is ordered, a urine sample is obtained, and results are


documented on the ICD form. The nurse added, consent for HIV testing is first obtained upon admission and OASIS provides HIV related services.

4.11 Sick Call Process Satisfactory Compliance

All youth in the facility shall be able to make Sick Call requests and have their 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.

Five youth Individual Healthcare Records (IHCRs) were reviewed for sick call. One of five youth reviewed was applicable for sick call, the program provided two additional applicable records for review. None of the three reviewed applicable youth presented with a similar complaint three or more times within a two-week period. Two of three youth were applicable for a referral to the designated health authority (DHA). All three youth completed a Sick Call Request form which was placed in a secure box, then provided to the nurse. The completed Sick Call forms for all three youth reviewed and were observed to be filed with the progress notes in the IHCR in reverse chronological order. The program only employs registered nurses (RNs), in which case the sick call was completed by an RN for each of the three youth reviewed. None of the youth reviewed were applicable for restrictive housing. Sick call is conducted twice a day, seven days a week, at 11:00 a.m. and 2:00 p.m. Sick call hours were observed posted outside the nurse’s station and in the cafeteria. Sick Call forms were observed in the cafeteria. In the event a sick call is placed when the nurse is not on-site, staff will contact the clinic manager (RN) or designated health authority (DHA) to determine the appropriate course of action. Sick Call forms were observed to be documented in accordance with the Department’s Office of Health Services Rule 63M-2. All three sick calls reviewed were observed to be documented on the Sick Call Index as well as the Sick Call Referral log. A sick call was observed during the annual compliance review with no issues noted. Five of the five staff interviewed reported the nurses review and conduct sick call. Three of five youth interviewed reported they are seen for sick call immediately after placing a sick call or within one day, two youth reported they have never placed a sick call.

4.12 Episodic/First Aid and Emergency Care Satisfactory Compliance

The facility shall have a comprehensive process for the provision of Episodic Care and First Aid.

Five youth Individual Healthcare Records (IHCRs) were reviewed for Episodic Care. Four of the five youth reviewed were applicable for Episodic Care. Documentation in four reviewed applicable records reflect the youth were provided with on-site first aid/episodic care by licensed health care staff. The Episodic Care Log was reviewed and corresponded with the Episodic Care documentation found in the four applicable records reviewed in addition to the progress notes for each youth. The program has a total of nine first aid kits: one in medical, one in the kitchen, one in maintenance, two in the vocational building, two assigned to the vans, and two assigned to master control. The program’s suicide response kit is located in master control and contains the required items. Three first aid kits were inspected and found to be fully stocked with the contents approved by the designated health authority (DHA). A registered nurse (RN) checks the first aid kits each month and restocks as necessary. The monthly first aid kit check log for the previous six months was available for review and verified this practice. The program has one automated external defibrillator (AED) which is located in master control. Instructions are located inside the AED. Nursing staff inspects the AED once a month. AED inspections for


the previous six months were available for review and verified this practice. The registered nurse (RN) performed a self-test of the AED during the annual compliance review, in which the AED was found to be operational. The AED batteries were last changed in February of 2019 and the current batteries expire in May of 2024. The AED pads were last changed on May 31, 2019 and the current pads expire in September of 2021. A review of drill documentation reflected the program has conducted drills quarterly and on each shift since the last annual compliance review. Documentation further reflected drills included the demonstration of cardiopulmonary resuscitation (CPR)/AED semi-annually. In the event a staff member missed or was not able to participate in a mock drill, they are identified, and nursing staff will review the drill with them individually. A list of emergency numbers (including Poison Information Control Center) are posted in the nursing station, control room, kitchen and are inaccessible to youth. An approved list of supervisory level staff is maintained in the nursing station in the event nursing staff is not available. All staff on the approved list have received appropriate training in the administration of the Epinephrine Auto-Injector. The training was observed to be provided by a RN. Five of the five staff interviewed report they are allowed to contact 9-1-1 in the event a youth has a medical emergency. Five of the five youth reported they can see a dentist or a doctor if needed. The nurse was able to explain the process for episodic care, reported the locations/contents of the first aid kits, suicide response kit, and AED. The nurse added drills are conducted on each shift once a quarter.

4.13 Off-Site Care/Referrals Satisfactory Compliance

The facility 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.

Five Individual Healthcare Records (IHCRs) were reviewed for off-site care. Three of the five records reviewed were applicable for non-emergent off-site care. Parental notifications were documented in all three applicable records. The Summary of Off-Site Care form was observed in each of the three records reviewed. Documentation reflected the Summary of Off-Site Care forms were reviewed by the designated health authority (DHA) and included discharge documents. One of the three applicable youth reviewed required follow-up appointments. The medical staff tracks off-site appointments with an appointment calendar/book. According to the nurse, follow-up testing/appointments are tracked using an appointment book. The nurse added, all paperwork from off-site appointments is reviewed by the DHA and any orders are reviewed and followed.

4.14 Chronic Conditions/Periodic Evaluations Satisfactory Compliance

The facility shall ensure youth who have chronic conditions receive regularly scheduled evaluations and necessary follow-up.

Five youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions. None of the five records were applicable for chronic conditions. The program provided three additional applicable records for review. One of three youths reviewed was identified as having a chronic condition of the Facility Entry Physical Health Screening (FEPHS) form. None of the three youth were applicable for a communicable disease, all three were taking prescribed medication on an on-going basis, and none of the youth were undergoing treatment for a physical health condition which included a Body Mass Index (BMI) greater than thirty. Two of the three youth were classified with a medical grade of two, and one youth was classified with a medical grade of four. All three youth were observed on the program’s chronic illness list. Two of the three


reviewed youth received periodic evaluations at no greater than three-month intervals. One of the three youth had their initial evaluation with the designated health authority (DHA) but has not been in the program long enough to receive the first three-month evaluation. None of the youth reviewed are applicable for tuberculosis medication in the previous six months. Periodic evaluations are tracked on the chronic list roster which include evaluation dates. Periodic evaluations are conducted prior to the renewal of an expired prescription medication. None of the periodic evaluations for the youth reviewed were conducted off-site. No lapses in care or missed periodic evaluations were observed. The Department’s Problem List was updated for each youth as required. The program director interview confirms meetings are conducted daily with healthcare staff to review important medical issues pertaining to youth in the program. The DHA reported periodic evaluations are conducted every three months and the nurses track all chronic conditions.

4.15 Medication Management Satisfactory Compliance

Medication shall be received, stored, inventoried, and provided in a safe and effective manner which shall be demonstrated by observation, review of documentation of procedures and processes.

Five Individual Healthcare Records (IHCRs) were reviewed for medication management. Four of the five records reflected youth were taking prescribed medications upon admission to the program. One of the five records reviewed reflected the youth was prescribed medication subsequent to admission to the program. Prescription verification for all four youth was observed in the Chronological Progress Notes in the record. Documentation further reflected the registered nurse (RN) contacted the designated health authority (DHA) and/or psychiatrist to resume the medications. All medications were observed to have a current, valid order and are given pursuant to a current prescription. Practitioner Order forms were observed for all five youth for continuation of or for newly ordered prescribed medication. None of the youth reviewed were applicable for restrictive housing. Three of the five youth reviewed were applicable for over-the-counter (OTC) medications in which they were administered according to the Practitioner’s Order. The program utilized a pre-print pharmacy Medication Administration Record (MAR). Staff initial each administered medication entry. A review of the MARs, for all five youth, from the previous six months reflected one undocumented explanation for a lapse in medication administration. The nurse failed to initial the p.m. medication entry for one youth on November 29, 2020. A count of the youth’s current prescription (non-controlled) reflected the youth did not missed any doses of medication. Additionally, the youth was interviewed pertaining to any missed medication in which he reported he has never missed any of his prescribed medication since being admitted to the program. No other undocumented lapses or errors in medication administration were noted. Nursing staff document weekly side-effect monitoring on the MAR. The Six Rights of Medication Administration are maintained by both licensed and non-licensed staff. In one of the five youth records, one refusal was observed in which a corresponding refusal form was documented in the IHCR. The Facility Entry Physical Health Screening (FEPHS) form indicted four of five youth were taking prescribed medication upon admission to the program. Appropriate notifications to the designated health authority (DHA) and parents/guardians were made for all four youth. All medications were observed to be in a separate, secure areas inaccessible to youth. Oral medications are not stored with topical medications. Medication requiring refrigeration are stored in a secured refrigerator which is used for medication only. The medication cart was observed to be clean, organized, and stock items are kept separate from specific youth medications. Expired medications are destroyed once a month with Drug Destroyer in the presence of the pharmacist and two RNs. The program’s policy and procedures verified this process. Medication pass was observed during the annual


compliance reviewed with no issues noted. All five interviewed youth report the nurse provides them with their medication and all were able to explain the medication pass process in detail. All five interviewed staff report the nurse give youth their medication. According to the nurse, the program uses a pre-printed MAR (Pharmerica) and medication pass occurs twice a day, at 7:00 a.m. and 5:00 p.m., seven days a week.

4.16 Medication/Sharps Inventory and Storage Process Satisfactory Compliance

Any medical equipment classified as stock medications shall be secured and inventoried by using a routine perpetual inventory descending count as each sharp is utilized and disposed of or when the medication is utilized.

Medical equipment classified as sharps were observed securely stored and inventoried by using a perpetual inventory. All medications are identified and secured in the locked area designated for the storage of medications. Controlled substances are kept separately from other medications and have a perpetual inventory. Additionally, controlled substances are kept behind two locks with two separate keys. The program has a process in place for the destruction and disposal or return of expired or discontinued medications. A perpetual inventory and weekly inventory of all sharps and stock over-the-counter (OTC) medications was observed. Pursuant to the Board of Pharmacy regulatory requirements, a shift-to-shift inventory count of all controlled substances was observed documented on the youth’s Individualized Controlled Medication Inventory Record. A shift-to-shift count of controlled medications was observed. The program maintains an approved list of supervisory level, non-health care staff trained in the delivery of medication self-administration in the event nursing staff is not on-site. Training was observed to be completed for each staff member on the approved list. The number of medication tablets remaining after each administered dosage was observed on the youth’s Individualized Controlled Medication Inventory Record. The reviewer observed the nurse inventory two youth medications, both being a controlled medication, three OTC medications, and three sharps, all of which matched the perpetual inventory. Reporting criteria and procedures for inventory discrepancies are in place. Perpetual inventories of medications and sharps for the previous six months were available for review. All medications were observed to be in a separate, secure areas inaccessible to youth. All non-controlled and OTC medications are stored in a separate, secure, locked area inaccessible to youth. Controlled substances are kept behind two locks. Oral medications are not stored with topical medications. Medication requiring refrigeration are stored in a secured refrigerator which is used for medication only. The medication cart was observed to be clean, organized, and stock items are kept separate from specific youth medications. Expired medications are destroyed once a month with Drug Destroyer in the presence of the pharmacist and two RNs. The program’s policy and procedures verified this process. The nurse was able to explain procedures for inventory discrepancies, secure storage and routine inventories of medication, disposal of medication, and the practice for securing controlled substances.


4.17 Infection Control – Surveillance, Screening, and Management


The program shall have implemented Infection Control procedures including prevention, containment, treatment, and reporting requirements related to infectious diseases, as per 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 infection control shall also be provided at the time of intake and subsequently when the need is identified.

The program’s Infection Control procedures in place to include prevention, containment, treatment, and reporting requirements related to infectious diseases, according to the Occupational Safety and Health Administration (OSHA) federal regulation and the Center for Disease Control (CDC) guidelines. The plan was signed and reviewed by the designated health authority (DHA) on January 6, 2020 and by the program director on December 31, 2019. The program’s Infection Control procedures include the following: common, infection diseases of childhood, self-limiting, episodic contagious illness, viral or bacterial diseases, tuberculosis, hepatitis A, B, C, and HIV, pediculosis and/or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA), food borne illnesses, bio-terrorist agents, and chemical exposure. The hepatitis B immunization is available to staff. Staff have access to personal protective equipment. The program has a comprehensive process for needle stick post-exposure evaluation. The program or designee will maintain a separate file containing all documents for youth and staff who have experienced facility exposure, as necessary. The program’s Exposure Control Plan was found to be written in accordance with OSHA standards. The plan is available to all staff. The plan is reviewed and signed annually by the program director. The plan includes a risk assessment, methods of compliance, and process for needle stick post-exposure. The program has had one instance of a COVID-19 related outbreak (July 2020) in which more than ten percent of the youth were quarantined, and more than six staff members were affected. Between March 2020 and the present, all COVID-19 related cases have been reported as required. There have been no other noted infectious diseases or outbreaks which should have been reported during the annual compliance review period. A review of five pre-service and five in-service records reflected infection control and site-specific exposure control training was completed as required. The program director reported the Infection/Exposure Control Plan is located in the control room; however, did not indicate in the interview how often the plan is reviewed with staff. According to the nurse, the Infection/Exposure Control Plan is located in the medical department. The nurse added, infection control training is provided to youth upon admission to the program and as needed thereafter.

4.18 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 rates as non-applicable.


4.19 Licensed Medical Staff (Critical) Satisfactory Compliance

The Designated Health Authority (DHA) is clinically responsible for all healthcare services provide 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 DJJ Rule as well as Facility operating procedures and nursing protocols approved by the DHA.

The program employs three full-time registered nurses (RN), one of which acts as the clinic manager. The program does not utilize any licensed practical nurses. A review of nursing license credentials reflects each of the three RNs have a clear and active license according to the Florida Department of Health, Division of Medical Quality Assurance website. In addition, all three nurses have current cardiopulmonary resuscitation (CPR) certifications. A review of the provider’s contract reflected compliance with specific duties as outlined as well as the requirement of a RN clinic manager and supplemental RNs.


Standard 5: Safety and Security

5.01 Youth Supervision 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, and consistently applying the program's behavior management system (BMS). Program staff can account for the whereabouts of youth under their supervision at all times.

Supervision of youth was observed each day of the annual compliance review. During this time, observations confirm the program was adhering to the daily activity schedule. The program’s written facility operating procedures regarding supervision of youth defines active supervision by requiring staff to interact positively with youth and engaging them in a full schedule of activities, while closely observing their behavior and changes in their behavior through consistent application of the program’s behavior management system (BMS). During the annual compliance review, youth were observed in line movements, in classrooms, and during search procedures. No youth were seen without direct staff supervision. The staff to youth ratio was maintained each day. Staff were seen interacting positively with youth. Formal and informal counts were observed taking place. Random staff were asked to explain the count procedure as well as explain what the process was in the event a count was not reconciled. All interviewed staff confirmed a recount would occur in the event this happened. If the recount was not cleared, procedures to address a possible youth escape would commence.

5.02 Comprehensive and Consistent Implementation of the 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 behavior management system (BMS) utilized at the program.

A review of the program’s behavior management system (BMS) was completed. The BMS is clearly written and has not changed from the previous annual compliance review. The BMS was observed posted in the youth living areas and included rules governing youth conduct as well as positive and negative consequences for behaviors. In addition, the BMS was explained in the youth handbook. Five of the five youth records had evidence each youth signed for and received a handbook upon admission to the program. Five of the five staff training records reviewed contained evidence each staff are trained in the program’s BMS. The program director reports all teachers are trained in the BMS and utilize this process by issuing points to youth throughout the day for acceptable behaviors exhibited. The program director was interviewed and reports the BMS is developed on a token economy system. The educational department utilizes the same token economy system throughout the day according to the program director. Teachers in the program understand and have been trained in the BMS and can afford or remove points for youth based on their behavior. An incentive calendar was observed in each living unit. The program’s contractual agreement outlines incentive opportunities for youth ensuring rewards outnumber the consequences as a minimum of a four-to-one ratio. Incentive rooms are required according to contract which include movie incentives, video games, barber shop, and a token store. The incentive rooms were located in the A-200 building of the facility.


The program’s BMS includes all required elements, and does not include an increased length of stay, denial of basic rights, promotion of group punishment, or punishment by other youth. Staff interactions with youth, and compliance with the BMS, were observed during the annual compliance review. Five interviewed youth were able to summarize the program’s BMS. All five youth reported they felt the BMS was good. All five were able to summarize rewards and consequences associated with the program’s BMS. Five interviewed staff were able to summarize the BMS process and give examples of rewards the program offers. All five staff reported nothing can be taken from a youth as a consequence for a behavior exhibited. All five staff report they give youth the chance to explain behaviors prior to issuing a disciplinary report.

5.03 Behavior Management System Infractions and System Monitoring


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 behavior management system (BMS), and ensure the use of rewards and consequences are administered fairly and consistently in application among all staff.

The program has a written policy and procedures which ensure a protocol exists where staff are provided feedback regarding their implementation of the behavior management system (BMS). Position descriptions for the case management and direct care staff were reviewed as examples to confirm the program’s BMS is mentioned as a requirement for staff to ensure effective implementation for youth. The program’s BMS includes the process for youth to explain their behaviors if given a consequence. Youth who receive sanctions are given opportunities to explain behaviors in a disciplinary court which is facilitated by the assistant program director. The program director reported they do not utilize room restriction for infractions. Five interviewed youth and five interviewed staff were all able to summarize the program’s BMS. The program director reported youth receive daily incentives, and all sanctions issued are delivered through the treatment team and approved by the program director. In addition, staff training for the BMS is done every six months. Five interviewed staff report supervisors provide to them feedback for their implementation of the BMS. The feedback is given as needed, according to four staff. One staff reported it was given daily. Five youth were interviewed concerning the implementation of the BMS. All stated youth are not allowed to punish other youth. All youth reported staff give rewards equally. All five were able to summarize the BMS process.

5.04 Ten-Minute Checks (Critical) Satisfactory Compliance

A residential commitment program shall ensure staff observe youth at least every ten minutes while they 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 director was interviewed and reported they have a total of 108 cameras, with 107 of them working properly. The one camera not functioning was located in the intake area bathroom and is being addressed by program administration through work order. Video storing can be held for up to thirty days. The program operates on two shifts for direct care staff. Six


randomly selected days and times were observed which included weekends and each youth living area. The sample of video selected for review observed five different staff performing ten-minute observation checks. Each sample reviewed found staff were performing checks of youth in their rooms within the ten-minute required time frame. Staff were seen using flashlights to look into youth rooms. Each of the staff were pausing briefly to observe and account for youth. The ten-minute visual observation sheets confirm the checks were completed in real time, as required. Five interviewed staff confirmed they are to conduct the checks at ten-minute time frames.

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 resident 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 resident counts and census information, the program reconciles immediately and takes follow-up action as needed.

The program’s written policy and procedures were reviewed of census, counts, and tracking of youth. The program requires counts to be conducted formally and at unscheduled times throughout each day. Logbooks for the scope of the annual compliance review found counts were conducted formally at the beginning and end of each shift, as well as another formal count during the middle of the shifts. In addition, informal counts were documented throughout the log at random times of the shifts. Observations of logs found one master control operator had not documented informal counts consistently but had documented all required formal counts as well as documentation of youth movement from one program area to another. Observations of informal and formal counts were made throughout the annual compliance review to confirm the count and youth tracking process. Documentation of logbooks found evidence the master control operator documents when youth are temporarily away from the program. A master control operator was interviewed and stated in the event there is a discrepancy in the count, a recount will occur to see where the missing youth may be. If the youth is unable to be located, escape procedures would then commence. Five interviewed staff all summarized the youth tracking and count process. In addition, each staff indicated youth are counted at each movement.


5.06 Logbook Entries and Shift Report Review Satisfactory Compliance

The program maintains a chronological record of events, incidents, and activities in a central log-book maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures direct care staff, including each supervisor, are briefed when coming on duty.

The program maintains one logbook which is located in the master control room. A review of logbooks for the scope of the annual compliance review was completed. The logbooks were bound with numbered pages. Entries were made in ink with no erasures or white-out areas. Examples of errors were made which indicated errors being struck through with a single line and dated and initialed by the person making the correction. All entries included the date and time of the event, with the name of the staff and youth involved, and a brief description of the event. Logbook entries included all required events, such as emergency situation, population counts, perimeter checks, supervision of youth, and transports of youth away from the facility. In addition to the logbook, the program maintains a shift report named the Shift Pass-On Report. These reports are completed at the beginning of each shift, by the shift supervisor, and are reviewed and signed by incoming direct care staff. The reports include documentation of population counts, significant events, youth on security risk or special supervision levels, and admissions or releases. Samples of these Shift Pass-On Reports were made for the scope of the annual compliance review to confirm the practice. Copies of these reports were observed maintained in the youth living units for forty-eight hours.

5.07 Key Control 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

• Reporting and replacement of damaged keys

The program has a written policy and procedures outlining the key control process. The system includes key assignment and the inventory and tracking of keys, secure storage of keys not in use, and procedures addressing missing or damaged keys. The distribution and collection of staff and personal keys was observed during the annual compliance review. The program keys were observed securely stored in a locked box with master control. Keys are assigned a number and are on a tamper resistant ring with a chit attached. The chit has the assigned number and number of keys on the ring stamped. Staff arriving on duty turn in their personal keys to master control who exchanges those for the staff’s assigned facility keys for each shift. The personal keys are placed on the hook where the staff keys were, and thus are given back to the staff at the end of their shift in exchange for the facility keys used. A sampling of ten sets of keys was selected and compared with the ring number and chit. Each had the accurate ring number and number of keys indicated on the chit engraving. In addition to the collection of keys, the master control operator logs the keys issued in a daily key log with the staff name, key assignment, and time in and out of the key ring issued. Samples of the daily key log were reviewed to confirm the practice. Restricted keys are kept secured in the master control room. The master control operator was interviewed and stated restricted keys include those of medical, case management, therapists, and food service workers. Permanent keys are assigned to designated


staff such as the program administration, and maintenance mechanic. Direct care, maintenance mechanic, and the master control operator were interviewed as to procedures for damaged keys. All reported in the event this occurs, staff are to contact the master control operator who will notify the maintenance mechanic for a replacement. The damaged keys would be discarded. A review of Central Communications Center (CCC) reports for the scope of the annual compliance review found no incidents related to missing keys at the facility. Three random staff were stopped and asked to present their keys. A sampling of these three staff sets of keys, which included two supervisors and one direct care staff, found each had the designated key ring assigned for the shift, and each ring matched the number engraved on the corresponding chit attached. Five interviewed staff all were able to summarize the program’s key control process.

5.08 Contraband Procedure 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, electronic or vaporless cigarettes, non-facility issued electronic equipment or devices, 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 its staff/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 case file. If a confiscated item is not illegal, the program director or designee has the discretion to discard 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 contraband, the program shall turn the item over to local law enforcement and a criminal report filed.

The program has a written policy and procedures to address contraband. Each youth receives a handbook upon admission which outlines contraband in the facility. The program’s procedures address items deemed as contraband. Youth are informed on consequences if found with contraband. The program performs searches of the facility grounds, perimeter, youth, incoming and outgoing mail, and vehicles to help reduce the introduction of contraband. The program’s facility operating procedures addressing staff standards of conduct denotes any staff who is found in possession of contraband in the program will be subject to disciplinary action up to and including dismissal. The policy indicates law enforcement is to be contacted if any found item would be considered illegal as defined by Florida Statutes. A review of Central Communications Center (CCC) reports for the scope of the annual compliance review found no incidents of illegal contraband discovered and reported at the facility. The program’s contraband policy clearly delineates those items considered contraband as required. The program completes a Security Checklist daily by shift supervisors. The checklist documents a search of program areas as well as ensuring security cameras and electronic metal detecting devices are working properly. In addition, the Housing Unit/Room Area Search Summary forms are completed weekly by supervisors. These search forms are completed to capture documentation and findings of searches for youth rooms and living areas. Samples of these forms for the scope of the annual compliance review were reviewed to confirm consistency with the practice. The program director


was interviewed and stated all contraband is recovered and, if applicable, the CCC will be notified as well as law enforcement.

5.09 Searches and Full Body Visual Searches Satisfactory Compliance

The program shall perform searches to ensure no contraband is being introduced into the facility.

Youth searches were observed during the annual compliance review. Searches were completed by staff of the same gender as the youth. Searches were completed prior to youth moving from one program area to another. Youth were seen treated with dignity and respect by staff. Thoroughness of searches were observed. Staff gave youth instructions, explaining the reason for youth searches. Observations confirm searches were conducted according to Protective Action Response (PAR) procedures. Five interviewed youth all reported searches occur at various of times throughout the day and when moving from one location to another. Five interviewed staff all report searches are conducted for youth at every youth movement. Visitor searches were observed during the annual compliance review. Visitors were instructed to remove their shoes and empty pockets while program staff used an electronic wand to scan visitors for any foreign objects. Bags, purses, cases were also searched by staff to ensure contents were authorized prior to entering the facility.

5.10 Vehicles and Maintenance Satisfactory Compliance

The program ensures any vehicle used by the program to transport youth is properly maintained, and maintains documentation on the use and maintenance of each vehicle. Each vehicle being used for transport of 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 transportation, and youth are not attached to any part of the vehicle by any means other than proper use of a seat belt.

The program currently has three vehicles assigned. Two of the three vehicles are used to transport youth for off-campus appointments, according to transportation logs and an interview with the maintenance mechanic. The maintenance mechanic was interviewed and stated one vehicle not being utilized for transports has an issue with the air condition system and has not been repaired. Follow-up was also made with the assistant program director who confirmed the vehicle is not used to transport youth. He stated the program is planning to obtain a new vehicle to replace this one. A review of annual safety inspections was completed for all three vehicles. Documentation of invoices confirm each had an annual safety inspection completed by a certified mechanic in October of 2020. Personal vehicles were checked to ensure they remain secured when not in use and all vehicles were locked. A transport was unable to be observed during the annual compliance review. Each observed vehicle used to transport youth was secured when not in use. Each had an approved fire extinguisher, seat belt cutter, window punch, and appropriate number of seatbelts. The vehicle’s first aid kit is kept in master control and according to the master control operator, it is checked out with the vehicle keys. Observations of the first aid kit contents found they were inventoried as required by the medical department. The program’s procedure does not authorize youth to be attached to any part of the vehicle by any means other than proper use of a seat belt. Each vehicle door to the youth passenger area could not be opened from the inside. Each had a safety screen separating the driver from the rear passenger area.


5.11 Transportation of Youth Satisfactory Compliance

Appropriate minimum staff to youth ratio shall be maintained while youth are transported off facility grounds to ensure the safety and security of youth, staff, and the public.

The program has a written policy and procedures addressing transportation of youth. A youth transport was unable to be observed during the annual compliance review. Three youth and three staff were randomly and informally interviewed, all confirming proper seat belt usage is required for transports. According to the program’s operating procedures, staff are required to bring a cellular telephone with them during transports. In addition, the policy indicates staff are not to leave a youth alone in a vehicle, nor are they authorized to allow youth to drive program vehicles. A ratio of one staff to five youth is required at a minimum for transports, with one staff being of the same gender as the youth. A safety screen separates the driver from the rear passenger area. The program maintains a list of all staff authorized to drive program vehicles for youth transport. The list includes documentation of checks for a valid Florida Driver’s License. The initial check is completed by the human resource person, and annually thereafter by the program’s administrative assistant. All transports occurring are documented on the program’s alert board located in master control. Five youth interviews were conducted and all reported they felt staff drive safely during transports. None of the youth reported ever seeing contraband placed in a vehicle. Five interviewed staff all reported vehicles are searched prior to being used to transport youth. All stated they are able to use a cellular telephone during transports. Each staff was able to explain the safety equipment provided in the vehicle such as first aid kits, knife for life, fire extinguisher, window punch, and seatbelt cutter. None of the staff reported they are able to use personal vehicles when transporting youth.

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 addressing the inspection process of the facility and facility grounds. Weekly security audits are conducted by the assistant program director who completes these on the Department provided weekly safety inspection sheets. The documentation is forwarded to the program director for review then scanned and sent weekly to the Department’s residential operations staff. Telephone contact with the residential operations staff was made and confirmed this practice is completed as required by the program. The assistant program director maintained hard copies of completed forms for review. The documentation included development and implementation of any corrective actions warranted. The form captures inspections of all program areas to include buildings, camera system, doors, bathrooms, locks, perimeter fencing, and facility grounds. Samples of the Weekly Safety and Security Audit forms were reviewed for the scope of the annual compliance review and found no issues with the practice. The program director was interviewed and stated he reviews this documentation each week prior to the documentation being shared with the Department.

5.13 Tool Inventory and Management Satisfactory Compliance

The facility 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 addressing tool inventory and management and youth handling of tools. All tools, to include Class B tools and maintenance tools, were observed secured and inaccessible to youth. The program keeps only Class B tools, such as a


mop, dustpan, mop bucket, broom, and plunger in a locked closet within each living unit. An inventory of these items were posted on the wall of the closets and were checked daily by the maintenance mechanic. All maintenance tools are kept in the maintenance office and in an outside storage shed. Tools were engraved for easier identification. An inventory of ten percent of all tools in each location was done and found each had a corresponding identification code, and all were accounted form. The maintenance mechanic completes a monthly inventory of all tools. Documentation of inventory forms for the scope of the annual compliance review was completed to confirm the practice. Kitchen knives were observed during the annual compliance review. The knives were kept secured in a locked box within the kitchen area. The food service director reported inventory of all kitchen knives and utensils is completed daily at the beginning and end of each shift. An inventory of all knives was completed during the annual compliance review and found each were accounted for. The kitchen uses a shadow board system to account for the kitchen knives. Five of five staff training records reviewed had evidence staff were trained in tool usage. Five interviewed staff reported youth only use mops and brooms when using tools.

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 the youth, other youth, and staff.

The program has a written policy and procedures addressing tool inventory and management and youth handling of tools. The policy addresses ratio requirements, tool distribution and collection, and search criteria during work projects. Youth at the program have vocational opportunities to work in the Home Builder’s Institute vocational classes or in the kitchen. An interview with the program director revealed, the staff to youth ratio when using tools is required to be a minimum of one to five. Youth are searched after every vocational class. Five youth interviews were conducted. Each youth reported they have used vocational tools in vocational classes while at the program. Youth who participate in these classes are required to have an approved risk assessment authorizing them to use vocational tools. A review of five youth records found each had this risk assessment completed, either approving or disapproving them for tool usage. The assessment is completed by the assigned case manager every two weeks. The case manager reviews the youth’s behavior and any disciplinary referrals received during this time.

5.15 Outside Contractors Satisfactory Compliance

The program shall establish guidelines required for outside contractors, which includes information about tool control and restrictions.

The program has procedures outlined for outside contractors entering the facility grounds. An interview with the program director revealed outside vendors sign-in and sign-out on a visitor log. The program director stated personal cellular telephones and recording devices are not allowed; however, could only be authorized by the program director himself if necessary. A search of the contractor’s tools is completed and inventoried by the program staff. The maintenance mechanic is responsible for escorting them on-site at all times while on the facility grounds. This process was observed during the annual compliance review and Peaden Air Conditioning Company was seen on-site. The maintenance mechanic provided documentation showing the tools brought in were accounted for and documented on the sign-in and sign-out log. A review of project invoices was completed to confirm the projects being worked on matched the sign-in sheets provided. The program’s guidelines for outside contractors include


tools being checked upon arrival and departure, tool restrictions while in the facility, and restriction of youth from work areas. The maintenance mechanic was interviewed to confirm the process and stated in the event a tool went missing, the program will follow missing tool procedures outlined in policy.

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 a Continuity of Operations Plan (COOP) which addresses emergency drills. The program director reported the COOP is located in the control room. Unannounced fire drills are required to be at a frequency of one a shift each month. The program operates on two shifts. Copies of drill documentation were reviewed which included the type of drill, date and time, location of the drill, list of participants, scenario, and any comments if applicable. Drill documentation provided for the scope of the annual compliance review revealed the program performed fire drills monthly and on both shifts with the following exceptions: a drill was not completed for the night shift on June, July, and September of 2020. The program is required to perform other safety and evacuation drills at a frequency of once a quarter. Documentation of these drills found them to be completed as required. Observations of program areas and buildings found evacuation routes clearly visible. Fire extinguishers were observed to be inspected annually, as required. During the annual compliance review, the fire marshal was on-site performing an annual inspection. There were no major issues reported by the fire marshal, according to an interview with the program director and maintenance mechanic. Five interviewed staff all report they have participated in fire drills. Staff stated they participate in other various drills such as weather related, medical, suicide, and escape. Five interviewed youth all reported they have been instructed as to what to do in the event of a fire. When asked about the frequency of fire drills, four youth stated they are conducted monthly, and one youth stated every two months.

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. A residential commitment program shall establish and maintain critical identifying information and a current photograph 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) to address basic care and custody of youth in the event of an emergency or disaster situation. The program director was interviewed and stated the plan is kept in master control. The plan was reviewed March 5, 2020. The plan’s annexes are updated as required. The plan addresses alternative housing which is approved by the Department of Juvenile Justice (DJJ) residential director. The residential director signed and approved the program’s COOP on March 5, 2020. The program’s disaster plan is combined with the COOP, in addition, the program has an Emergency Plan Manual for 2020 which addresses disaster preparedness. The program’s dry storage area in the kitchen was observed where emergency supplies of food is maintained. An interview with supervisors for the various program


departments, such as case management, medical, and mental health revealed in the event of an evacuation, all youth hard copy records will be secured and taken along with the youth to alternate housing area deemed within the emergency evacuation procedures. The youth records contain all required information. In addition, the master control room maintains a card file in a box for each youth at the program. The card had a photograph of the youth along with the youth’s Department of Juvenile Justice identification number, name, date of birth, date of arrival, committing county, committing offense, physical description of the youth, and assigned case manager.

5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials


The program director or designee shall maintain strict control of flammable, poisonous and toxic items and materials and a complete inventory of all such items.

The program has a written policy and procedures which addresses the storage and inventory, disposal, and youth handling of flammable, poisonous, and toxic items and materials. Observations made during the annual compliance review found all flammables and toxic chemicals to be secured and inaccessible to youth. There were no chemicals observed in youth living areas. The program’s maintenance mechanic was interviewed and stated chemicals used to clean the living units are kept in storage areas such as outside maintenance sheds and the maintenance office. The maintenance mechanic states she brings the items down to clean and then returns them to their storage location. Youth do not directly handle the chemicals, according to the maintenance mechanic. Chemicals and flammables were observed in the following locations: kitchen closet, maintenance office, and a maintenance shed located outside the facility. A perpetual inventory was maintained in each of these areas. A total of ten percent of each location where the items were stored were reviewed and found all items matched the corresponding inventory list to include containing the appropriate number of chemicals. Each area also had a Safety Data Sheet (SDS) binder which found all chemicals reviewed to have a corresponding SDS present. Only the maintenance mechanic and program director reportedly have access to the maintenance office and outside storage shed. The food service director has access to the kitchen. The program director was interviewed concerning chemicals maintained at the facility. He stated the program does not maintain a list of staff authorized to handle the items, but all staff may handle cleaning products if needed.


5.19 Youth Handling and Supervision for Flammable, 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 clean dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any other person’s biohazardous material, bodily fluids, or human waste. The program shall establish and implement cleaning schedules, a pest control system, a garbage removal system, and a facility maintenance system which shall include maintenance schedules and timely repairs based on visual and manual inspections of the facility structure, grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-annually, yearly, and every three years, as prescribed in the Preventive Maintenance Checklist (RS 123, February 2019.

The program has a written policy and procedures which addresses the storage and inventory, disposal, and youth handling of flammable, poisonous, and toxic items and materials. The program maintains control of flammable, poisonous, and toxic items and materials. Observations made, and interviews with the program director and maintenance staff revealed the program does not keep chemicals stored in youth living units. The areas observed where chemicals and flammables are kept were seen secured and inaccessible to youth. The program’s policy does not authorize youth to directly handle chemicals or to clean or dispose of biohazardous waste. Youth were unable to be observed cleaning during the annual compliance review. The program has a maintenance mechanic who completes a Preventive Maintenance Checklist weekly. A walk-thru of all program areas is done, while a list of repairs is made of areas needing attention. In addition, weekly security audits are conducted by the assistant program director who completes these on the Department provided weekly safety inspection sheets. The documentation is forwarded to the program director for review then scanned and sent weekly to the Department’s residential operations staff. Five youth were interviewed. One youth reported he used a bleach spray bottle to clean with and staff were present. The program administration was made aware of youth and staff interviews during the debriefing process. No response from the program was given. Interviews with the maintenance mechanic found the cleaning products are brought to the living areas for cleaning and then taken back up afterword. The maintenance mechanic states at no time do youth utilize the products directly. In addition, no chemicals were observed accessible to youth during the annual compliance review completed. The remaining four youth reported they do not directly handle any chemicals at the program.

5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items


The maintenance personnel, or other trained staff who have the safety equipment for diluting, handling, and disposing of hazardous waste and/or solid waste, shall be responsible for disposing of hazardous items and toxic materials.

The program has a written policy and procedures which addresses the storage and inventory, disposal, and youth handling of flammable, poisonous, and toxic items and materials. The program director was interviewed concerning chemicals maintained at the facility. He stated the program does not maintain a list of staff authorized to handle the items, but all staff may handle


cleaning products if needed. According to the program director, the program does not have a person responsible for the disposal of all hazardous wastes. The maintenance mechanic was interviewed and stated she primarily handles all flammables and toxic chemicals and has not disposed of any materials within the last six months. In the event disposal is needed, the maintenance mechanic stated disposal would be done so through policy. In the event of a chemical spill, the maintenance mechanic stated she would notify the master control operator and supervisor on duty the handle the situation through the facility operating procedure guidelines. The food service director was interviewed and stated dirty mop water is disposed of through mop sinks. In addition, the program has a contractual agreement with a local company who pumps out used grease in a grease container located outside the kitchen area. Copies of invoices were observed to confirm the practice. The program director was interviewed and stated the maintenance department is responsible for the safe disposal of all items.

5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test (Critical)

Non-Applicable

Programs choosing to participate in water-related activities shall develop and implement a water safety plan to ensure proper supervision and safety of the youth during water related activities. The plan shall also ensure staff are appropriately trained for each specific type of water activity. Programs allowing youth to participate in water-related activities shall have a water safety plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be followed during water-related activities, as follows:

• Determination of the risk level for each participating youth, including whether or not the youth can swim, an assessment of swimming ability, and other factors to include age and maturity, special needs such as physical and mental health issues, and physical stature and conditioning;

• Type of water, such as pool or open water;

• Water conditions, such as clarity, turbulence, and bottom conditions;

• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba diving, and shoreline and offshore activities to include fishing from a bank or pier, fishing while wading, or picnicking close to a body of water.

• Lifeguard-to-youth ratio and positioning of lifeguards;

• Other staff supervision; and

• Safety equipment needed for the activity, such as personal flotation devices when youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and offshore activities.

Programs choosing to participate in water-related activities shall ensure staff are appropriately trained for each specific type of water activity. Programs choosing to participate in water-related activities shall assess each youth's aquatic ability prior to participation in water-related programming.

The program does not participate in water-related activities; therefore, this indicator is rated non-applicable.


5.22 Visitation and Communication Satisfactory Compliance

The program allows visitation and communication for youth while in the program.

The program has a written policy and procedures concerning visitation for youth. The program’s visitation schedule was observed visibly posted for youth and staff. The case managers were interviewed and stated they maintain an approved telephone, mail, and visitation log for the youth. This documentation was observed during the annual compliance review. Youth are afforded opportunities to communicate with family members. Guidelines for mail, visitation, and telephone communication is captured within the student handbook, which each youth receives at admission. Five of the five youth case management records revealed each youth signed for a youth handbook, as well as were given the program’s correspondence procedures at admission. According to the program’s policy, as well as interviews with the case management staff, all youth incoming and outgoing mail is searched for contraband in the presence of the youth. The mail is searched by the assigned case manager. The program reported not having a youth with a history of human trafficking, but in the event this occurs, the case manager would be responsible to follow-up with the youth’s assigned juvenile probation officer to confirm whether the parent/guardian indicated could be allowed to communicate with the youth. Five of the five interviewed youth all report they were able to contact their parent/guardian by telephone or send a letter if needed.

5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance

The program shall conduct youth searches and room inspections prior to placing a youth on Controlled Observation.

The program has a written policy and procedures related to controlled observation for youth. The program has a controlled observation room which is located in the A-200 building of the facility. Observations of the room found it met all requirements. The program reports having no incidents involving a youth placement in controlled observation in over a year. Therefore, there was no further documentation to review for search and inspections of controlled observation rooms.

5.24 Controlled Observation Satisfactory Compliance

Programs shall only place youth in Controlled Observation when non-physical interventions would not be effective.

The program has a written policy and procedures related to controlled observation for youth. The program reports having no incidents involving a youth placement in controlled observation in over a year. Therefore, there was no further documentation to review controlled observation. Five youth were interviewed regarding if they had been sent to their room before for punishment reasons. Three youth stated they have not. One youth stated he was sent to the room with the door shut for a cool off period of about ten minutes. The other youth reports he was sent to his room for about twenty to thirty minutes for an altercation with another youth and the door was shut. Each of the youth stated they were observed by the staff during this time. Results of youth interviews were discussed with program administration during the annual compliance review. Follow-up discussion was made with the program director who stated it is the response of Okaloosa Youth Academy, the program has no knowledge of any youth being placed in their rooms for control purposes for any short or long period of time. The program director further stated, in rare occurrences, youth may be placed in their rooms following an incident so


program staff can conduct proper investigations and to ensure safety and security, but as stated, the program is not aware of any such incidents occurring.

5.25 Controlled Observation Safety Checks Release 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 his or her behavior, the youth is no longer an imminent threat to self or others.

The program has a written policy and procedures related to controlled observation for youth. The program has a controlled observation room which is located in the A-200 building of the facility. Observations of the room found it met all requirements. The program reports no incidents involving a youth placement in controlled observation in over a year. Therefore, there was no further documentation to review controlled observation safety check release procedures.

BUREAU OF MONITORING AND QUALITY IMPROVEMENT

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