Tampa Bay Girls Academy

Limited compliance, DJJ review : Indicator 1.02 Education Transition Plan (Education Contract Provider)

Upon admission, education staff and youth develop an education transition plan which includes provisions for continuation of education and/or employment. According to the contract, the contracted educational provider is required to develop an Education Transition Plan for each youth. Three closed youth records were reviewed, none of the closed records contained an Education Transition Plan. Many youth entered the program before December 12, 2024, when the new education provider, Florida Virtual School, started their initiation of the transition plans, so they would not have had an education transition plan developed by the provider. The youth, parent/guardian, instructional personnel in the program, department personnel for youth in the program, personnel from the post-release school district, and a certified school counselor were all involved with each youth through the education transition activities. Youth services and interventions based on assessed educational needs and post-release education plans were not on each youth’s Education Transition Plan, as none were completed; however, Electronic Education Exit Plans (EEEP) were completed for each youth and the required information was documented on the EEEP for each youth. The recommended educational placement for post-release was documented on the EEEP for each youth and was based on each youth’s individual needs and performance. Specific monitoring responsibilities by individuals who were responsible for the ...

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

The Educational Provider staff shall complete staff training as outlined within the contract. According to the contract, the contracted educational provider is required to provide its assigned staff with professional development/training as specified in their contract. Fourteen training records for educational staff, five facility-based teachers and nine virtual/flex teachers, were reviewed. Each of the facility-based teachers who had the required training with the exception of two staff missing mental health and substance abuse training, and one staff missing adolescence development training. None of the nine virtual/flex teachers had any of the required training which includes behavioral management and de-escalation, child abuse, suicide awareness and prevention, and professionalism, interpersonal communication, and ethics to include standards of conduct. The virtual/flex teachers had additional trainings; however, none were required. It was also noted not all trainings, for any of the fourteen teachers, were reflected in the Department’s Learning Management System (Skill Pro).

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

The Educational Provider shall develop and upload an Exit portfolio at least three school days prior to the youth’s exit from a residential commitment program. According to the contract, the contracted educational provider is required to develop and upload an exit portfolio for each youth. A review of three closed youth case management records found none of the records contained the individual Education Transition Plan. Two of the three youth records included results of district and statewide assessments, the remaining youth was non- applicable for the assessments. Two of the three youth records did not have a Progress Monitoring Plan, the remaining youth was non-applicable for the plan. None of the three youth were applicable for the Section 504 plan, English Language Learner, Behavior Intervention, or Individual Education plan. Two of the three youth had a cumulative transcript in their exit portfolio, the remaining youth was non-applicable. One youth record included a list of courses in progress with grades, the remaining two records did not. None of the youth earned industry certifications and only one youth was applicable for their high school equivalency diploma. All three youth had documents uploaded into the Department’s Juvenile Justice Information System within three school days, prior to the youth’s release.

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

Education staff shall develop and implement a career education competency development program. Florida Scholars Academy (FSA), the education contract provider, is currently in the process of developing the career education curriculum for the educational abilities and goals of youth in the program and appropriate for the length of stay and classification of the youth in the program. At the time of annual compliance review, no documentation of career education was available. Currently, youth at all facilities are working with Career Power Workplace Skills workbooks. A review of program activities confirmed no career exploration services are being provided beyond soft skills instruction. There has been no lead response from Florida Virtual School (FLVS) regarding additional career exploration or coursework options. According to the program schedule, eligible youth participate in Career Power Workplace Skills activities during designated instructional periods Monday through Friday. The instructional leader indicated career education activities are limited to the use of the workbooks, with no additional curriculum or industry-recognized credential instruction currently available. Interviews with youth confirmed the absence of career exploration opportunities beyond the soft skills content provided. To fully meet contractual requirements and promote workforce readiness, the program is encouraged to finalize and implement the career education curriculum and secure additional career ...

Limited compliance, DJJ review : Indicator 1.04 Incident Reporting (CCC) (Critical)

The program shall notify the Department’s Central Communications Center (CCC) within two hours of the incident occurring, or within two hours of any program staff becoming aware of the reportable incident. The program has a policy and procedures to ensure notification of all reportable incidents to the Department’s Central Communications Center (CCC) within two hours of incident or program becoming aware of incident. The program had 160 CCC reports during the annual compliance review period. A random sample of ten percent of all incidents were reviewed for a total of sixteen incidents. Five of sixteen reviewed incidents were not reported within the required two hour time frame. The five late reported incidents were sixty-seven hours and fifty-minutes late, four hours and fifteen minutes late, two hours and fifty-six minutes late, fourteen minutes late, and thirteen minutes late. The remaining eleven incidents were reported within two hours as required. Fifteen of sixteen CCC incidents were applicable for requiring documentation in the program’s logbook. Eleven of fifteen CCC incidents were not documented in the logbook. The remaining four CCC incidents were recorded in the logbook. During the annual compliance review week, the review team determined the program had failed to report an abuse allegation to the CCC. Once the program was notified of this by the review team, the program gave corrective action to the assistant facility administrator who failed to report. This ...

Limited compliance, DJJ review : Indicator 1.06 Pre-Service/Certification Requirements (Critical)

Residential contracted provider staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall have sixteen hours of supervisor training in addition to the required pre-service trainings. The program has a policy and procedures to ensure all staff complete all required pre-service training requirements within 180 days of hire. Policy states only youth care workers and shift supervisors are considered direct care staff and/or counted in staff-to-youth ratio. Documentation confirmed all training instructors were qualified to deliver training for the program and the program submitted a pre-service training plan prior to implementation of pre- service training which was signed on October 25, 2024, by all required parties except the facility administrator. Seven staff training records were reviewed for completion of pre-service training within 180 days of hire. None of the seven reviewed staff completed their required pre-service training or 120 training hours within 180 days of hire. Four of seven staff completed their required pre-service training after the program received the seven-day notification of their annual compliance review. Two of the three remaining staff were missing one training course each and the last remaining staff had supervisory training hours to complete. Three of seven reviewed staff were applicable for supervisory training. None of the three applicable staff ...

Limited compliance, DJJ review : Indicator 1.12 Internal Alerts System and Alerts (JJIS) (Critical)

The program shall maintain and use an internal alert system easily accessible to program staff and keeps staff alerted about youth who are security or safety risks, and youth with health-related concerns, including food allergies and special diets. When risk factors or special needs are identified during or after the classification process, the program immediately enters this information into the internal alert system. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth’s alert status. When risk factors or special needs are identified during, or after, the classification process, the program immediately enters this information into the Department’s Juvenile Justice Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. The program has a policy and procedures to determine how new alerts are identified, documented, updated, and communicated to staff. Any staff can identify and place a youth on alert status; however, only medical, mental health, and facility administrator/designee can update or close medical, mental health, and safety and security alerts. All alerts will be entered and updated in the Department’s Juvenile Justice Information System (JJIS). Suicide alerts will be updated or closed by the mental health clinical staff or a licensed mental health ...

Limited compliance, DJJ review : Indicator 1.16 Special Contract Conditions

The program shall implement all items or services either negotiated or outlined in the contract which are considered Special Contract Conditions or listed within the Scope of Services Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary of Negotiated Points, Special Conditions, or older contract may not have them clearly identified as a special condition. These items typically exceed the minimum requirements outlined in Florida Statutes and Florida Administrative Code. The program has several additional services or items which were negotiated and outlined in the provider’s contract with the Department. These special contract conditions are: providing three snacks to the youth daily; transition specialist manager shall seek court orders for youth to go Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support on outings to establish bank accounts, get identification cards, and other activities as allowed; therapist are to create a relapse prevention plan with all youth; visitation should be taking place every Saturday and Sunday; the program shall provide inspirational murals, individualized comforters, sensory room, game room, and reflection area, faith-based services shall be provided quarterly and quarterly documented attempts to provide religious services and education encompasses all religions. Documentation was provided for snacks and indicated youth are only receiving two ...

Limited compliance, DJJ review : Indicator 2.01 Initial Contacts to Parent/Guardian and Court Notification

The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the youth’s admission, by written notification within forty-eight hours of admission. The program notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post- residential services case manager (if applicable) in writing within five working days of any admission. The program has a policy and procedures establishing guidelines for initial contacts with the parent/guardian, committing court, juvenile probation officer (JPO), and the post-residential service provider, if applicable, for each youth. A review of seven youth case management records was conducted, and each record contained documentation the parent/guardian was contacted by telephone within twenty-four hours of each youth’s arrival to the program. Three of the seven reviewed records also contained documentation the program provided written notification to the parent/guardian with forty-eight hours of admission; two records contained documentation of late notification, one by four days and one by six days; and the remaining two records did not have documentation of the required written notification. Each record shall contain documentation of notification to the committing court, JPO, and the post-residential service provider, if applicable, within five working days of admission. Three of the seven reviewed records had the required JPO notification; one was two days late; and the remaining three ...

Failed compliance, DJJ review : Indicator 2.04 Classification Factors, Procedures, and Reassessment for

Activities Failed Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, promoting safety and security, as well as effective delivery of treatment services. Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and reclassified, if warranted, prior to considering an increase in privileges or freedom of movement, participation in work projects, or other activities involving tools or instruments which may be used as potential weapons or means of escape, or participation in any off- campus activity. All youth admitted to residential commitment programs shall be screened for vulnerability to victimization and sexually aggressive behavior prior to room assignment. Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed. The screening shall be completed in JJIS. The program has a policy and procedures to ensure each youth is properly assessed for treatment services, room assignments, and activities while in the program. The program’s classification process includes youth’s physical characteristics, age and maturity level, special needs, history of violence, gang affiliation, criminal behavior, sexual behaviors and victimization, vulnerability, human trafficking factors, and risk alerts (medical, suicide, escape, and security). A review of seven youth ...

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

Re-Assessments Limited Compliance The program shall ensure an initial assessment of each youth is conducted within thirty days of admission. Documentation of the initial assessment process is to be maintained in JJIS. The program shall ensure reassessments are completed for each youth at least every ninety days from the initial assessment. The program shall ensure any other updates or reassessments are completed, when deemed necessary, by the intervention and treatment team to effectively manage the youth’s case. The program shall maintain all reassessment documentation in the youth’s official youth case record. The program has a policy and procedures to ensure each youth receives an assessment within thirty days of admission to utilize when structuring the performance plan goals while in the program. A review of seven youth case management records was conducted. Each record contained documentation the initial Residential Assessment for Youth (RAY) assessment was completed within thirty days of admission as confirmed in the Department’s Juvenile Justice Information System (JJIS). Five of the seven reviewed records were applicable for re- assessment(s), which are required every ninety days; the remaining two records were not. One of the five applicable records required two re-assessments; and the remaining four records only required one reassessment each. One of the six required re-assessments was completed within the required ninety-days; one re-assessment was missed/not ...

Limited compliance, DJJ review : Indicator 2.09 Performance Plan Development, Goals, and Transmittal

The intervention and treatment team, including the youth, shall meet and develop the performance plan, based on the findings of the youth’s initial assessment, within thirty days of admission. For each goal, the performance plan shall specify the target date for completion, the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth to complete the goal. Within ten working days of completion of the performance plan, the program shall send a transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian, and the Department of Children and Families (DCF) case manager, if applicable. Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support The program has a policy and procedures to ensure each youth is assigned a treatment team containing a treatment team leader, the youth, parent/guardian, administrative representative, living unit representative, treatment staff, education staff, and if applicable medical staff and Department of Children and Families (DCF) case manager; and has an individualized performance plan, which is required to be shared with the parent/guardian, committing court, juvenile probation officer (JPO), and the Department of Children and Families case manager, if applicable. A review of seven youth case management records was conducted, and each contained an initial ...

Failed compliance, DJJ review : Indicator 2.10 Performance Plan Revisions and Incorporation of Other

Plans Failed Compliance Performance reviews shall result in revisions to the youth’s performance plan when determined necessary by the intervention and treatment team. The youth’s performance plan shall reference or incorporate the youth’s treatment or care plan. The program has a policy and procedures to ensure performance plan reviews are conducted and revisions occur as needed, and to ensure all youth plans are incorporated in the performance plan. A review of seven youth case management records was conducted, and there was a total of fourteen revisions. Each revision was due to youth progress on goals; however, there was no documentation within the seven reviewed records to determine if any revisions were based on or warranted from Residential Assessment for Youth (RAY) re- assessment results, newly acquired or revealed information, or lack of progress on goals. Two of the fourteen revised plans had the required treatment teams signatures; the remaining twelve did not have any signatures. One of the seven reviewed records had revisions based on the need to facilitate transition activities in the youth’s last sixty days; the remaining six were not applicable. All reviewed plans incorporated each youth’s additional plans, and none of the youth were applicable for behavior support plans through the Department of Children and Families.

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

The intervention and treatment team shall prepare a Performance Summary at ninety day intervals, beginning ninety-days from the signing of the youth’s performance plan, or at shorter intervals when requested by the youth’s committing court. Additionally, the intervention and treatment team shall prepare a performance summary prior to the youth’s Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support release, discharge, or transfer from the program. The program shall distribute the Performance Summary, as required, within ten working days of signing. The program has a policy and procedures to ensure performance summaries are completed every ninety days. A review of seven youth case management records was conducted. Five of the seven reviewed records required the initial ninety-day Performance Summary; the remaining two were not applicable. One of the five completed performance plans was completed as required; one was not completed as of the annual compliance review week; and the remaining three were completed late: one was four days late, one was twelve days late, and one was eighty-two days late. None of the four completed summaries were completed due to the youth’s release or discharge. All four completed summaries included the status of each youth goal, the youth’s overall treatment progress, behavior status and adjustment, level of motivation/readiness for change, interaction with staff and peers, and ...

Failed compliance, DJJ review : Indicator 2.13 Treatment Team Members and Meetings (Formal and

Informal Reviews) Failed Compliance The treatment team members include, at a minimum, the youth, representatives from the program’s administration and residential living unit, education, and others responsible for providing or overseeing the provision of intervention and treatment services. The program has a policy and procedures to ensure each youth has a treatment team with all required members and informal and formal treatment team meetings are held as required to review the youth’s progress. A review of seven youth case management records was conducted, and a total of forty-one formal meetings and thirty-one informal meetings were required. Thirty-eight of the required forty-one formal treatment team meetings were conducted every thirty days; one was five days late; and the remaining two were not conducted/missed. Fifteen of the thirty-one required informal treatment team meetings were conducted bi-weekly alternating with formal meetings; the remaining sixteen were not conducted/missed. A review of the documentation for each conducted treatment team meeting was completed. The documentation had the youth’s name, date of the review, submitted information/comments from team members, summary of youth’s progress in the program and on goals, positive and negative behaviors, and treatment progress; and not included in the documentation were behaviors resulting in physical interventions, Residential Assessment for Youth results, nor attendance and signature of required treatment ...

Limited compliance, DJJ review : Indicator 2.14 Transition Planning, Conference, and Community Re-Entry

Team Meeting (CRT) Limited Compliance A program shall ensure the intervention and treatment team is planning for the youth’s successful transition to the community upon release from the program, when developing each youth’s performance plan and throughout its implementation during the youth’s stay. During the Transition Conference, participants shall review transition activities on the youth’s performance plan, revise the activities if necessary, and identify additional activities/services, as needed. Target completion dates and persons responsible for their completion shall be identified during the conference. The intervention and treatment team leader shall obtain conference participant’s dated signatures, representing their acknowledgement of the Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support transition activities and accountability for their completion pursuant to the youth’s performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to discharge. The program has a policy and procedures to ensure the treatment team plans for successful transition to the community upon release. Three closed youth case management records were reviewed for transition planning, activities, and required meetings. One of the three reviewed records had a transition conference held at least sixty days prior to release; the remaining two were held late: one was three days late and ...

Failed compliance, DJJ review : Indicator 2.15 Exit Portfolio

The program will assemble an Exit Portfolio for each youth to assist once released back into the community. The program has a policy and procedures to ensure each youth is released with an exit portfolio to assist them with their re-entry into the community. Three closed youth case management records were reviewed. None of the three reviewed records contained an exit portfolio or evidence of one. An exit portfolio is required to include state-issued identification, copy of transition plan, calendar with all dates, times, and locations of upcoming community appointments, social security card, birth certificate, educational and/or vocational certificate(s) earned, resume, and sample employment applications. The program’s contract specifies additional elements will be included in the exit portfolio: all applicable healthcare screenings, health education material, and links to a local Planned Parenthood or health department; Healthcare Determination of Medicaid eligibility and application; contact information for Care Review Teams; a copy of the current insurance information, date of expiration; address mental health, social/behavioral concerns, and problems; making appointments with clinicians and building bridges with community psychiatrists; age-appropriate support groups which continue the twelve-step message learned in Alcoholics Anonymous/Narcotics Anonymous group; services to promote positive use of leisure time, prevent gang involvement, and discourage association with ...

Failed compliance, DJJ review : Indicator 2.16 Exit Conference

An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review the status of goals developed at the transition conference and finalize release plans. The program has a policy and procedures to ensure an exit conference is held to finalize release plans. Three closed youth case management records were reviewed. Two of the three reviewed records had documentation of an exit conference being held; however, neither were held at least fourteen days prior to release: one was one day late, and the other was eleven days late. The remaining record did not have any exit conference documentation. Documentation for both youth who had an exit conference confirmed all required parties were invited by emaiil. Both records were missing the signature of attendees of the exit conference, verification of release date, status of transition activities, education or employment status, a review of the exit portfolio, and parent/guardian and juvenile probation officer awareness of youth’s vocationa plan.

Limited compliance, DJJ review : Indicator 2.18 Educational Access (Residential Contract Provide)

The program shall integrate educational instruction (career and technical education, as well as academic instruction) into the daily schedule in such a way ensuring the integrity of required instructional time. The program has a policy and procedures to ensure youth receive educational services. The program’s daily activity schedule includes the education schedule and times. The reviewed schedule does coincide with the Educational Contract Provider’s scheduled times. A video review of three educational days was conducted and confirmed the youth are receiving educational services as outlined on the schedule. Logbooks were reviewed, one educational Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support day each month of the annual compliance review period, for a total of eight months. One of the eight reviewed days had the start time of school listed accurately to reflect the schedule; one day started thirty minutes late; and the remaining six months did not have any documentation of the start of school. None of the eight months had documentation of the commencement of the school day reflected in the logbook as required. Seven youth were interviewed and all seven youth confirmed they are receiving educational services. Six of the seven interviewed youth stated there are no interruptions during the school day; the remaining youth stated sometimes other youth talk loudly, causing staff to redirect them which is ...

Failed compliance, DJJ review : Indicator 2.19 Contract Specific Career and Technical Education Services

(Residential Contract Provider) Failed Compliance The program shall implement all career and technical education services (formerly referred to as pre-vocational and vocational services) negotiated or outlined in the contract which are considered Contract Specific Conditions or listed within the Scope of Services Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary of Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as a special condition. Career and technical education service instruction shall be provided so the interests, aptitudes, and skills of the youth are developed, while building upon their existing strengths, in a manner supportive of their employability goals which provide an occupational advantage and workforce readiness in their community. These items may exceed the minimum requirements outlined in Florida Statutes and Florida Administrative Code. The program has a policy and procedures which requires the implementation of career and technical education (CTE) services, which are negotiated in the contract. A review of the program’s approved contract reflects the required CTE services are SPARK, Choices, Business Education, ServSafe, Florida Ready to Work Soft Skills, Occupational Safety and Health Administration (OSHA-10), and cardiopulmonary resuscitation (CPR)/first-aid. A review of CTE documentation ...

Failed compliance, DJJ review : Indicator 3.07 Treatment and Discharge Planning (Critical)

Mental health and substance abuse treatment planning in programs focus on providing mental health and/or substance abuse interventions and treatment to reduce or alleviate the youth's symptoms of mental disorder and/or substance abuse impairment and enable youth to function adequately in the juvenile justice setting. The treatment team is responsible for assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or substance abuse treatment while in a program shall have a discharge summary completed documenting the focus and course of the youth's treatment and recommendations for mental health and/or substance abuse services upon youth's release from the program. The program has a policy and procedures addressing treatment and discharge planning. Seven youth mental health and substance abuse records were reviewed for mental health and substance abuse treatment. Six of seven reviewed youth records reflected youth were assigned to a treatment team upon arrival to the program, the remaining youth record did not contain documentation to determine when the youth was assigned to a treatment team. The multidisciplinary treatment teams 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. Six of seven reviewed youth records contained ...

Limited compliance, DJJ review : Indicator 3.08 Specialized Treatment Services (Critical)

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 has a policy and procedures which require specialized intensive mental health treatment services to be provided to youth. A review of the program’s contract and clinical program description indicated the program has five components of treatment to include intensive mental health (IMH), borderline intellectual functioning/borderline developmentally delayed (BIF/BDD), developmentally delayed (DD), mental health overlay services (MHOS), and substance abuse treatment overlay services (SAOS). Seven youth mental health and substance abuse records were reviewed. Two youth were applicable for MHOS, one was applicable for BIF services, and the remaining four youth were designated for IMH services. During the annual compliance review week, the population of the program had zero youth designated as DD and two youth designated as requiring SAOS; DD services were not reviewed due to the program not having any active youth participating in DD services. All specialized treatment services are provided by licensed therapists or non-licensed therapists working under their direct supervision. The program is not licensed under Chapter 397; therefore, all substance abuse services are provided by licensed clinical staff. Group services include Dialectical Behavioral Therapy Skills Manual for ...

Limited compliance, DJJ review : Indicator 3.11 Secure Observation (Critical)

Youth placed on suicide precautions may be maintained on secure observation when less restrictive means are not effective. The program has a policy and procedures to address youth on suicide precautions being placed on secure observations. Seven youth mental health and substance abuse records were reviewed. None were applicable for being placed in secure observation. An additional three youth mental health and substance abuse records were requested for a minimum sample of three. Two of three youth did not have authorization by the facility administrator (FA)/designee and designated mental health clinician authority (DMHCA) authorizing the youth’s placement in secure observation. The remaining record contained authorization from the FA and DMHCA prior to the youth’s placement in secure observation. Each record contained documentation of secure housing designation in writing. Two of three records contained a health status checklist completed prior to placement in secure observation, the remaining record did not contain a completed health status checklist. Two of three records reflected a visual check of each youth was completed to determine if each youth had any observable injuries which would make secure observation inappropriate; however, documentation did not confirm if the visual check was completed by a same gender staff for either of the two youth. The remaining record did not contain documentation a visual check was completed of youth. Two of three records confirmed the ...

Limited compliance, DJJ review : Indicator 5.04 Ten-Minute Checks (Critical)

A program shall ensure staff observe youth at least every ten minutes while the youth are in their sleeping quarters, either during sleep time or at other times, such as during an illness or room restriction. Staff shall conduct the observations in a manner to ensure the safety and security of each youth and shall document real time observations manually or electronically. The program has a policy and procedures in place to conduct ten-minute checks while the youth are in their sleeping rooms. The program had a major deficiency closed on October 17, 2025; therefore, this indicator will be rated a limited. The program’s policy states staff shall observe youth at least every ten minutes while the youth are in their sleeping rooms. the observations in a manner to ensure the safety and security of each youth and each observation shall be documented in real time. The program has a total of ninety-two operating cameras which store recordings for thirty-days. Staff are required to conduct room checks every ten minutes and document the time of the check on the ten-minute check log when youth are sleeping. A review of nine samples of video footage of the two dormitories confirmed staff conducted checks as required. A review of the ten-minute check logs revealed checks are conducted every eight minutes. Nine days were reviewed and confirmed checks were conducted in real time, and staff observed youth for safety. All reviews were on second-shift due to this being the only shift which ...

Limited compliance, DJJ review : Indicator 5.06 Logbook Entries and Shift Report Review

The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control, living unit logbooks, or both. The program ensures direct-care staff, including each supervisor, are briefed when coming on-duty. The program has a policy and procedures to ensure the program maintains a chronological record of events, incidents, and activities in a logbook located in master control. The program ensures the logbooks are bound with numbered pages. Some pages in the reviewed logbooks displayed pages stapled together and some ripped slightly. Pages were numbered consistently with no missing pages. A couple mistakes were scratched out and uninitialed, the remaining were crossed out with a single line and initialed by the staff making the entry. There were no erasures or white out areas. All entries included the dates and times of the events, with the names of the staff and youth involved, brief description of the events, and the names and signatures of staff making the entries. Eight incident reports to the Department’s Central Communication Center (CCC) were not documented in the logbook. The logbook indicated activities are held as scheduled. A review of the logbooks found the program documented incidents which included the use of mechanical restraints, special instructions for monitoring youth, population counts at the beginning, during, and end of shift, perimeter security checks, transports away from facility including the ...

Limited compliance, DJJ review : Indicator 5.16 Fire, Safety, and Evacuation Drills

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 policy and procedures to address fire, safety, and evacuation drills. It was confirmed through drill documentation, during the annual compliance review period, the program conducted fire drills monthly on every shift with the exceptions of missing fire drills on second shift for the months of September, July, June, May and April. First shift was missing a fire drill for the month of May. The drills included type of drill, date and time, participants, brief scenario, findings, and recommendations. The fire evacuation routes, and egress plans are posted throughout the facility. The program has twenty-one fire extinguishers which were inspected annually. The Continuity of Operations Planning (COOP) drills were conducted on first shift bi- annually as required by the COOP plan; however, there were no COOP drills completed on second shift for the annual compliance review period. Seven staff were interviewed, and all Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support reported participating in various types of drills during the past year, including fire, hostage, escape, medical, mental health, and suicide drills. Six of seven interviewed youth stated they have been instructed on what to do in the event of a ...

Limited compliance, DJJ review : Indicator 1.06 Pre-Service/Certification Requirements (Critical)

Residential contracted provider staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall have sixteen hours of supervisor training in addition to the required pre-service trainings. The program has a policy and procedures outlining the pre-service training and certification requirements for all new staff. The program considers youth care workers, shift supervisors, recreational therapist, facility administrator (FA), and assistant FA, to be direct-care staff and can be counted in the staff-to-youth ratio. A review of supporting documentation indicated the program’s instructors were qualified to deliver training in cardio-pulmonary resuscitation, first- aid, automated external defibrillator and Right Interactions. The program submitted a pre- service training plan on October 25, 2024, prior to implementation. The training plan was approved by the highest ranking official at the location, the assistant secretary for residential services, and the director of the Department’s Talent, Leadership, and Culture. A review of five staff pre-service training records indicated all five pre-service staff, who were past the first 180 days were missing multiple trainings. All five pre-service staff were applicable to have completed 120 hours of training in the first 180 days. The five staff were missing the following trainings. One staff was missing eleven pre-service trainings: DJJ ...

Limited compliance, DJJ review : Indicator 1.16 Special Contract Conditions

The program shall implement all items or services either negotiated or outlined in the contract which are considered Special Contract Conditions or listed within the Scope of Services Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary of Negotiated Points, Special Conditions, or older contract may not have them clearly identified as a special condition. These items typically exceed the minimum requirements outlined in Florida Statutes and Florida Administrative Code. The program has several additional services or items which were negotiated and outlined in the provider’s contract with the Department. These special contract conditions are: providing three snacks to the youth daily; have a sensory room; staff utilize a four-to-one positive reinforcement to redirection with the youth; applicable youth should participate in Supporting Partnerships to Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support Assure Ready Kids (SPARK) thirteen-week program or receive six months of mentoring; hold bi- annual career day events at the program; applicable youth in transition can earn home passes; all youth should receive a self-sufficiency and independent living skills assessment within thirty days of admission; each youth have a community-based safety plan and a relapse prevention plan developed prior to discharge; all transitioning youth should receive the Overcoming Obstacles curriculum ...

Limited compliance, DJJ review : Indicator 2.16 Exit Conference

An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review the status of goals developed at the transition conference and finalize release plans. The program has a policy and procedures to ensure each youth completing the program has an exit conference at least fourteen days prior to discharge. Three closed youth case management records were reviewed for exit conference documentation and two had documentation to confirm an exit conference was held fourteen days prior to release; the remaining record had an exit conference two days late. None of the reviewed records contained exit conference documentation to include signature of attendees, conference date, and conference content: transition activity status, education and /or employment status, review of the exit portfolio, and vocational plan. Each reviewed record contained dates of admission and discharge which matched the youth record in the Department’s Juvenile Justice Information System (JJIS) as required. All three reviewed records contained some documentation of exit conference attendees. All three conferences were attended by the youth, parent/guardian, juvenile probation officer (JPO), and other pertinent staff; one included educational staff, and the remaining two did not. The program was able to provide electronic calendar pages with meetings and the JPO’s case notes in JJIS confirmed the meetings took place for each record. Each exit conference was held separately from the ...

Limited compliance, DJJ review : Indicator 2.17 Youth Input

The program has a formal process to promote constructive input by youth. The program has a policy and procedures outlining a formal process to promote constructive input by youth through living unit meetings, annual Trauma Responsive and Caring Environment (TRACE) surveys, and allowing youth to complete grievances or “What’s Tea” forms. The program completed a TRACE assessment on May 16, 2025. Townhall meetings are held on each living unit every other Friday. The program has grievance forms and “What’s Tea” forms available for youth throughout the facility. The program’s “What’s Tea” form allows youth to request to speak with staff by indicating who they would like to speak with and why. The form has a section for staff to document the solution and sign after they meet with youth. A review of “What’s Tea” forms during the annual compliance review period found twenty-four of thirty-one completed forms were left blank by staff, with no documented solution or signature. The program held a meeting in June 2025 to establish criteria for youth eligible to participate in a youth advisory board. Youth were able to sign up for positions within the youth advisory board, and an election was held on June 23, 2025. A review of youth advisory board meeting minutes found a meeting was held in July 2025, and three youth attended. The program’s policy and procedures do not require the program to hold youth advisory board meetings at any specific time intervals. Five youth were interviewed ...

Limited compliance, DJJ review : Indicator 2.19 Contract Specific Career and Technical Education

Services (Residential Contract Provider) Limited Compliance The program shall implement all career and technical education services (formerly referred to as pre-vocational and vocational services) negotiated or outlined in the contract which are considered Contract Specific Conditions or listed within the Scope of Services Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary of Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as a special condition. Career and technical education service instruction shall be provided so the interests, aptitudes, and skills of the youth are developed, while building upon their existing strengths, in a manner supportive of their employability goals which provide an occupational advantage and workforce readiness in their community. These items may exceed the minimum requirements outlined in Florida Statutes and Florida Administrative Code. The program’s contract requires the implementation of all Career and Technical Education (CTE) services, formerly referred to as pre-vocational and vocational services. CTE instruction is designed to develop the interests, aptitudes, and skills of participating youth while building upon their existing strengths in a manner supportive of their individualized employability goals, promoting workforce readiness, and providing an occupational advantage within ...

Limited compliance, DJJ review : Indicator 3.13 Suicide Prevention Training (Critical)

All staff who work with youth shall be trained to recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and implementation of suicide precautions. The program has a policy and procedures which ensures 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. Five pre-service staff training records were reviewed for the completion of suicide prevention training. There were no in-service staff applicable during the annual compliance review period. All five pre-service staff completed the required training. The program has two suicide response kits which are co-located with first-aid kits in administration/master control and the medical station. The suicide response kits each contain a knife-for-life, a needle nose plier, and wire cutters. A review was conducted of the program’s mock suicide drills which confirmed the program completed the required quarterly drills on each shift. An observation of video camera review confirmed the two available drills recorded within the last thirty days were not being simulated. All mock mental health drills scenarios reviewed were in response to a suicide attempt and/or incident of serious self-injury; however, were not simulated in the drill. The program exceeded the required semi-annual training on emergency response procedures; however, it did not include life saving measures which includes mock ...

Failed compliance, DJJ review : Indicator 5.07 Key Control (CRITCAL)

The program has a system in place to govern the control and use of keys including the following: • Key assignment and usage including restrictions on usage; • Inventory and tracking of keys; • Secure storage of keys not in use; • Procedures addressing missing or lost keys; and • Reporting and replacement of damaged keys. The program maintains a policy and procedures addressing key control. The program’s policy and procedures include key assignment and usage, restrictions on usage, inventory and tracking, secure storage of keys when not in use, procedures for missing or lost keys, and reporting and replacement of keys. The program’s policy lists the position titles who can be issued permanent keys with written authorization of the facility administrator (FA). Each staff issued permanent keys must sign the Key Responsibilities form prior to being issued permanent keys. The policy details which staff can have access to restricted keys and which areas those keys can access. Restricted keys are locked in a separate black lock box inside the main key lock box and master control maintains control of the key to unlock the restricted key box. An informal interview with the assistant facility administrator (AFA) confirmed the access to restricted keys is only authorized for those on the approved list and are kept in a separate lock box in master control. Policy states any damaged keys should be reported to the shift supervisor to complete a maintenance request form and damaged keys ...

Failed compliance, DJJ review : Indicator 5.12 Weekly Safety and Security Audits

A program shall maintain a safe and secure physical plant, grounds, and perimeter. The program has a policy and procedures which designates the facility administrator (FA) or their designee as the person responsible for conducting weekly safety and security audits and the implementation of any corrective action warranted as a result of any deficiencies found Florida Department of Juvenile Justice Residential Annual Compliance Report Office of Accountability and Program Support during the weekly audits. The program’s policy meets the requirements outlined in Florida Administrative Code. The weekly safety audits are kept in a binder in the FA’s office. Findings are discussed and a corrective action plan is implemented to fix any deficiency noted. During the annual compliance review period, the program was missing weekly safety and security audits for the last week of January 2025, the entire month of February 2025, and all except for one week in March 2025. The completed audits documented safety repairs needed and the date and time the repairs were completed, or due to be completed. All forms were reviewed and signed by the FA. The forms include checks of radios, cameras, keys, telephones, mechanical restraints, the generator, flashlights, fire safety equipment, alarms, anchor points, youth rooms, recreation area, facility grounds, correction action needed, and corrective action completed. The program could not provide a Preventative Maintenance Checklist for any weeks during ...

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

The program shall have a tool management system ensuring youth do not use tools or equipment as weapons or security breaches. The program has a policy and procedures addressing tool inventory and management. The policy addresses the issuance, inventory, and control of equipment and tools. The policy prohibits machetes, bowie knives, or other long blades from the facility. The program does not keep any class A tools on-site; therefore, there is no inventory for sharp edged or pointed tools. All class A tools are kept in a locked shed at a different program on the same campus. The program does not have a kitchen on-site; therefore, the program does not have any kitchen tools. The program’s policy for missing/lost tools includes logging incidents in the logbook, stopping all youth movement, and conducting a search of facility and youth. The program has not had any dysfunctional tools which needed to be disposed of and/or replaced; however, policy states staff would report any dysfunctional tools to their immediate supervisor and the supervisor would notify the physical plant manager and facility administrator (FA). The physical plant manager is responsible for replacing and disposing of any dysfunctional tools. A review of the program’s tool inventory was conducted. The inventory listed six types of tools kept at the facility which are kept in a locked storage closet inaccessible to youth. Two tool quantities did not match the inventory, nor were the tools marked for easy ...

Failed compliance, DJJ review : Indicator 5.16 Fire, Safety, and Evacuation Drills

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 policy and procedures addressing fire, safety, and evacuation drills. A review of Continuity of Operations Plan (COOP) drills revealed the program was not conducting monthly drills on a rotational basis as required on each shift during the annual compliance review period. The program did not complete any drills for February, March, April, and May 2025, and only completed COOP drills on one shift for January and June 2025. The program completed seven drills to include fire, escape, and/or weather during the annual compliance review period; however, drill scenarios did not describe what happened during the drill and who participated. One drill did not include a sign-in sheet for the participants. The annual compliance review team observed fire evacuation routes and egress plans posted throughout the facility. The program has seven fire extinguishers which were inspected on November 14, 2024. Five staff were interviewed, and four stated they had participated in drills in the past twelve months to include fire, weather, emergency situations, and medical and mental health drills. One staff member stated they had not participated in any drills. Five youth were interviewed, and each confirmed they had been instructed on what to do in case of a fire and had participated in fire ...

Limited compliance, DJJ review : Indicator 5.18 Storage, Inventory, and Disposal of Flammable,

Poisonous, and Toxic Items and Materials Limited Compliance The program director or designee shall maintain strict control of flammable, poisonous, and toxic items and materials and a complete inventory of all such items. The maintenance personnel, or other trained staff who have the safety equipment for diluting, handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous items and toxic materials. The program has a policy and procedures for the storage, inventory, and disposal of flammable, poisonous, and toxic items and materials. The program’s policy does not include procedures for disposal of chemicals. The program only keeps cleaning supplies on-site which are stored in a locked storage closet inaccessible to youth. The physical plant manager, facility administrator (FA), shift supervisors, and dietary workers are the individuals authorized to handle flammable, poisonous, and toxic items and materials. A binder is stored with the chemicals containing the Safety Data Sheets (SDS) for the items located in the storage closet. The program has a binder with a chemical inventory and sign-in/sign-out sheet for any chemical usage. The program does not have any flammable materials stored on-site; however, policy states any flammable chemicals would be stored in a metal fireproof safety secured locker. The program did not have any chemicals which required disposal during the annual compliance review period. An informal interview with ...

Limited compliance, DJJ review : Indicator 5.21 Visitation and Communication

The program allows visitation and communication for youth while in the program. The program has a policy and procedures addressing visitation and communication. The program’s visitation schedule is posted in the lobby of the facility. The program’s policy and procedures are reviewed during orientation and are communicated to youth and parent/guardian within seventy-two hours of youth’s admission to the program. Visitation will occur for two hours unless prior authorization is approved by the facility administrator (FA). Policy states visitation requests must be submitted to the case manager at least three days prior to visitation; however, informal interviews with the case manager and FA, confirmed this is not required and will be removed from program’s policy. Policy states any visitors or communication with youth must be on the youth’s approved correspondence list which is maintained by the case manager. The program’s policy also states mail is opened in front of youth and outgoing mail is searched prior to leaving the facility. The program’s contract specifies the program is to provide visitation every Saturday and Sunday. A review of the visitation log confirmed the program is only providing visitation every other Saturday. A review of the program’s telephone log reflected telephone calls are provided on Mondays and Wednesday for all youth for fifteen minutes. As youth progress in the program, they can earn additional telephone calls. A review of the program’s mail log ...

Limited compliance, DJJ review : Indicator 1.02 Education Transition Plan (Education Contract Provider)

Upon admission, education staff and youth develop an education transition plan which includes provisions for continuation of education and/or employment. According to the contract, the contracted educational provider is required to develop an Education Transition Plan for each youth. Three closed youth records were reviewed, none of the closed records contained an Education Transition Plan. Many youth entered the program before December 12, 2024, when the new education provider, Florida Virtual School, started their initiation of the transition plans, so they would not have had an education transition plan developed by the provider. The youth, parent/guardian, instructional personnel in the program, department personnel for youth in the program, personnel from the post-release school district, and a certified school counselor were all involved with each youth through the education transition activities. Youth services and interventions based on assessed educational needs and post-release education plans were not on each youth’s Education Transition Plan, as none were completed; however, Electronic Education Exit Plans (EEEP) were completed for each youth and the required information was documented on the EEEP for each youth. The recommended educational placement for post-release was documented on the EEEP for each youth and was based on each youth’s individual needs and performance. Specific monitoring responsibilities by individuals who were responsible for the ...

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

The Educational Provider staff shall complete staff training as outlined within the contract. According to the contract, the contracted educational provider is required to provide its assigned staff with professional development/training as specified in their contract. Fourteen training records for educational staff, five facility-based teachers and nine virtual/flex teachers, were reviewed. Each of the facility-based teachers who had the required training with the exception of two staff missing mental health and substance abuse training, and one staff missing adolescence development training. None of the nine virtual/flex teachers had any of the required training which includes behavioral management and de-escalation, child abuse, suicide awareness and prevention, and professionalism, interpersonal communication, and ethics to include standards of conduct. The virtual/flex teachers had additional trainings; however, none were required. It was also noted not all trainings, for any of the fourteen teachers, were reflected in the Department’s Learning Management System (Skill Pro).

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

The Educational Provider shall develop and upload an Exit portfolio at least three school days prior to the youth’s exit from a residential commitment program. According to the contract, the contracted educational provider is required to develop and upload an exit portfolio for each youth. A review of three closed youth case management records found none of the records contained the individual Education Transition Plan. Two of the three youth records included results of district and statewide assessments, the remaining youth was non- applicable for the assessments. Two of the three youth records did not have a Progress Monitoring Plan, the remaining youth was non-applicable for the plan. None of the three youth were applicable for the Section 504 plan, English Language Learner, Behavior Intervention, or Individual Education plan. Two of the three youth had a cumulative transcript in their exit portfolio, the remaining youth was non-applicable. One youth record included a list of courses in progress with grades, the remaining two records did not. None of the youth earned industry certifications and only one youth was applicable for their high school equivalency diploma. All three youth had documents uploaded into the Department’s Juvenile Justice Information System within three school days, prior to the youth’s release.

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

Education staff shall develop and implement a career education competency development program. Florida Scholars Academy (FSA), the education contract provider, is currently in the process of developing the career education curriculum for the educational abilities and goals of youth in the program and appropriate for the length of stay and classification of the youth in the program. At the time of annual compliance review, no documentation of career education was available. Currently, youth at all facilities are working with Career Power Workplace Skills workbooks. A review of program activities confirmed no career exploration services are being provided beyond soft skills instruction. There has been no lead response from Florida Virtual School (FLVS) regarding additional career exploration or coursework options. According to the program schedule, eligible youth participate in Career Power Workplace Skills activities during designated instructional periods Monday through Friday. The instructional leader indicated career education activities are limited to the use of the workbooks, with no additional curriculum or industry-recognized credential instruction currently available. Interviews with youth confirmed the absence of career exploration opportunities beyond the soft skills content provided. To fully meet contractual requirements and promote workforce readiness, the program is encouraged to finalize and implement the career education curriculum and secure additional career ...

Limited compliance, DJJ review : Indicator 1.06 Pre-Service/Certification Requirements (Critical)

Residential contracted provider staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall have sixteen hours of supervisor training in addition to the required pre-service trainings. The program has a policy and procedures outlining the pre-service training and certification requirements for all new staff. The program considers youth care workers, shift supervisors, recreational therapist, facility administrator (FA), and assistant FA, to be direct-care staff and can be counted in the staff-to-youth ratio. A review of supporting documentation indicated the program’s instructors were qualified to deliver training in cardio-pulmonary resuscitation, first- aid, automated external defibrillator and Right Interactions. The program submitted a pre- service training plan on October 25, 2024, prior to implementation. The training plan was approved by the highest ranking official at the location, the assistant secretary for residential services, and the director of the Department’s Talent, Leadership, and Culture. A review of five staff pre-service training records indicated all five pre-service staff, who were past the first 180 days were missing multiple trainings. All five pre-service staff were applicable to have completed 120 hours of training in the first 180 days. The five staff were missing the following trainings. One staff was missing eleven pre-service trainings: DJJ ...

Limited compliance, DJJ review : Indicator 1.16 Special Contract Conditions

The program shall implement all items or services either negotiated or outlined in the contract which are considered Special Contract Conditions or listed within the Scope of Services Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary of Negotiated Points, Special Conditions, or older contract may not have them clearly identified as a special condition. These items typically exceed the minimum requirements outlined in Florida Statutes and Florida Administrative Code. The program has several additional services or items which were negotiated and outlined in the provider’s contract with the Department. These special contract conditions are: providing three snacks to the youth daily; have a sensory room; staff utilize a four-to-one positive reinforcement to redirection with the youth; applicable youth should participate in Supporting Partnerships to Assure Ready Kids (SPARK) thirteen-week program or receive six months of mentoring; hold bi- annual career day events at the program; applicable youth in transition can earn home passes; all youth should receive a self-sufficiency and independent living skills assessment within thirty days of admission; each youth have a community-based safety plan and a relapse prevention plan developed prior to discharge; all transitioning youth should receive the Overcoming Obstacles curriculum; and youth involved with the dependency system, the transition staff will assist with the transition to foster care or ...

Limited compliance, DJJ review : Indicator 2.16 Exit Conference

An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review the status of goals developed at the transition conference and finalize release plans. The program has a policy and procedures to ensure each youth completing the program has an exit conference at least fourteen days prior to discharge. Three closed youth case management records were reviewed for exit conference documentation and two had documentation to confirm an exit conference was held fourteen days prior to release; the remaining record had an exit conference two days late. None of the reviewed records contained exit conference documentation to include signature of attendees, conference date, and conference content: transition activity status, education and /or employment status, review of the exit portfolio, and vocational plan. Each reviewed record contained dates of admission and discharge which matched the youth record in the Department’s Juvenile Justice Information System (JJIS) as required. All three reviewed records contained some documentation of exit conference attendees. All three conferences were attended by the youth, parent/guardian, juvenile probation officer (JPO), and other pertinent staff; one included educational staff, and the remaining two did not. The program was able to provide electronic calendar pages with meetings and the JPO’s case notes in JJIS confirmed the meetings took place for each record. Each exit conference was held separately from the ...

Limited compliance, DJJ review : Indicator 2.17 Youth Input

The program has a formal process to promote constructive input by youth. The program has a policy and procedures outlining a formal process to promote constructive input by youth through living unit meetings, annual Trauma Responsive and Caring Environment (TRACE) surveys, and allowing youth to complete grievances or “What’s Tea” forms. The program completed a TRACE assessment on May 16, 2025. Townhall meetings are held on each living unit every other Friday. The program has grievance forms and “What’s Tea” forms available for youth throughout the facility. The program’s “What’s Tea” form allows youth to request to speak with staff by indicating who they would like to speak with and why. The form has a section for staff to document the solution and sign after they meet with youth. A review of “What’s Tea” forms during the annual compliance review period found twenty-four of thirty-one completed forms were left blank by staff, with no documented solution or signature. The program held a meeting in June 2025 to establish criteria for youth eligible to participate in a youth advisory board. Youth were able to sign up for positions within the youth advisory board, and an election was held on June 23, 2025. A review of youth advisory board meeting minutes found a meeting was held in July 2025, and three youth attended. The program’s policy and procedures do not require the program to hold youth advisory board meetings at any specific time intervals. Five youth were interviewed ...

Limited compliance, DJJ review : Indicator 2.19 Contract Specific Career and Technical Education

Services (Residential Contract Provider) The program shall implement all career and technical education services (formerly referred to as pre-vocational and vocational services) negotiated or outlined in the contract which are considered Contract Specific Conditions or listed within the Scope of Services Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary of Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as a special condition. Career and technical education service instruction shall be provided so the interests, aptitudes, and skills of the youth are developed, while building upon their existing strengths, in a manner supportive of their employability goals which provide an occupational advantage and workforce readiness in their community. These items may exceed the minimum requirements outlined in Florida Statutes and Florida Administrative Code. The program’s contract requires the implementation of all Career and Technical Education (CTE) services, formerly referred to as pre-vocational and vocational services. CTE instruction is designed to develop the interests, aptitudes, and skills of participating youth while building upon their existing strengths in a manner supportive of their individualized employability goals, promoting workforce readiness, and providing an occupational advantage within the youth’s ...

Limited compliance, DJJ review : Indicator 3.13 Suicide Prevention Training (Critical)

All staff who work with youth shall be trained to recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and implementation of suicide precautions. The program has a policy and procedures which ensures 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. Five pre-service staff training records were reviewed for the completion of suicide prevention training. There were no in-service staff applicable during the annual compliance review period. All five pre-service staff completed the required training. The program has two suicide response kits which are co-located with first-aid kits in administration/master control and the medical station. The suicide response kits each contain a knife-for-life, a needle nose plier, and wire cutters. A review was conducted of the program’s mock suicide drills which confirmed the program completed the required quarterly drills on each shift. An observation of video camera review confirmed the two available drills recorded within the last thirty days were not being simulated. All mock mental health drills scenarios reviewed were in response to a suicide attempt and/or incident of serious self-injury; however, were not simulated in the drill. The program exceeded the required semi-annual training on emergency response procedures; however, it did not include life saving measures which includes mock ...

Failed compliance, DJJ review : Indicator 5.07 Key Control (CRITCAL)

The program has a system in place to govern the control and use of keys including the following: • Key assignment and usage including restrictions on usage; • Inventory and tracking of keys; • Secure storage of keys not in use; • Procedures addressing missing or lost keys; and • Reporting and replacement of damaged keys. The program maintains a policy and procedures addressing key control. The program’s policy and procedures include key assignment and usage, restrictions on usage, inventory and tracking, secure storage of keys when not in use, procedures for missing or lost keys, and reporting and replacement of keys. The program’s policy lists the position titles who can be issued permanent keys with written authorization of the facility administrator (FA). Each staff issued permanent keys must sign the Key Responsibilities form prior to being issued permanent keys. The policy details which staff can have access to restricted keys and which areas those keys can access. Restricted keys are locked in a separate black lock box inside the main key lock box and master control maintains control of the key to unlock the restricted key box. An informal interview with the assistant facility administrator (AFA) confirmed the access to restricted keys is only authorized for those on the approved list and are kept in a separate lock box in master control. Policy states any damaged keys should be reported to the shift supervisor to complete a maintenance request form and damaged keys ...

Failed compliance, DJJ review : Indicator 5.12 Weekly Safety and Security Audits

A program shall maintain a safe and secure physical plant, grounds, and perimeter. The program has a policy and procedures which designates the facility administrator (FA) or their designee as the person responsible for conducting weekly safety and security audits and the implementation of any corrective action warranted as a result of any deficiencies found during the weekly audits. The program’s policy meets the requirements outlined in Florida Administrative Code. The weekly safety audits are kept in a binder in the FA’s office. Findings are discussed and a corrective action plan is implemented to fix any deficiency noted. During the annual compliance review period, the program was missing weekly safety and security audits for the last week of January 2025, the entire month of February 2025, and all except for one week in March 2025. The completed audits documented safety repairs needed and the date and time the repairs were completed, or due to be completed. All forms were reviewed and signed by the FA. The forms include checks of radios, cameras, keys, telephones, mechanical restraints, the generator, flashlights, fire safety equipment, alarms, anchor points, youth rooms, recreation area, facility grounds, correction action needed, and corrective action completed. The program could not provide a Preventative Maintenance Checklist for any weeks during the annual compliance review period. A review of program deficiencies related to safety and security during the annual ...

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

The program shall have a tool management system ensuring youth do not use tools or equipment as weapons or security breaches. The program has a policy and procedures addressing tool inventory and management. The policy addresses the issuance, inventory, and control of equipment and tools. The policy prohibits machetes, bowie knives, or other long blades from the facility. The program does not keep any class A tools on-site; therefore, there is no inventory for sharp edged or pointed tools. All class A tools are kept in a locked shed at a different program on the same campus. The program does not have a kitchen on-site; therefore, the program does not have any kitchen tools. The program’s policy for missing/lost tools includes logging incidents in the logbook, stopping all youth movement, and conducting a search of facility and youth. The program has not had any dysfunctional tools which needed to be disposed of and/or replaced; however, policy states staff would report any dysfunctional tools to their immediate supervisor and the supervisor would notify the physical plant manager and facility administrator (FA). The physical plant manager is responsible for replacing and disposing of any dysfunctional tools. A review of the program’s tool inventory was conducted. The inventory listed six types of tools kept at the facility which are kept in a locked storage closet inaccessible to youth. Two tool quantities did not match the inventory, nor were the tools marked for easy ...

Failed compliance, DJJ review : Indicator 5.16 Fire, Safety, and Evacuation Drills

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 policy and procedures addressing fire, safety, and evacuation drills. A review of Continuity of Operations Plan (COOP) drills revealed the program was not conducting monthly drills on a rotational basis as required on each shift during the annual compliance review period. The program did not complete any drills for February, March, April, and May 2025, and only completed COOP drills on one shift for January and June 2025. The program completed seven drills to include fire, escape, and/or weather during the annual compliance review period; however, drill scenarios did not describe what happened during the drill and who participated. One drill did not include a sign-in sheet for the participants. The annual compliance review team observed fire evacuation routes and egress plans posted throughout the facility. The program has seven fire extinguishers which were inspected on November 14, 2024. Five staff were interviewed, and four stated they had participated in drills in the past twelve months to include fire, weather, emergency situations, and medical and mental health drills. One staff member stated they had not participated in any drills. Five youth were interviewed, and each confirmed they had been instructed on what to do in case of a fire and had participated in fire ...

Limited compliance, DJJ review : Indicator 5.18 Storage, Inventory, and Disposal 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 maintenance personnel, or other trained staff who have the safety equipment for diluting, handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous items and toxic materials. The program has a policy and procedures for the storage, inventory, and disposal of flammable, poisonous, and toxic items and materials. The program’s policy does not include procedures for disposal of chemicals. The program only keeps cleaning supplies on-site which are stored in a locked storage closet inaccessible to youth. The physical plant manager, facility administrator (FA), shift supervisors, and dietary workers are the individuals authorized to handle flammable, poisonous, and toxic items and materials. A binder is stored with the chemicals containing the Safety Data Sheets (SDS) for the items located in the storage closet. The program has a binder with a chemical inventory and sign-in/sign-out sheet for any chemical usage. The program does not have any flammable materials stored on-site; however, policy states any flammable chemicals would be stored in a metal fireproof safety secured locker. The program did not have any chemicals which required disposal during the annual compliance review period. An informal interview with the physical plant ...

Limited compliance, DJJ review : Indicator 5.21 Visitation and Communication

The program allows visitation and communication for youth while in the program. The program has a policy and procedures addressing visitation and communication. The program’s visitation schedule is posted in the lobby of the facility. The program’s policy and procedures are reviewed during orientation and are communicated to youth and parent/guardian within seventy-two hours of youth’s admission to the program. Visitation will occur for two hours unless prior authorization is approved by the facility administrator (FA). Policy states visitation requests must be submitted to the case manager at least three days prior to visitation; however, informal interviews with the case manager and FA, confirmed this is not required and will be removed from program’s policy. Policy states any visitors or communication with youth must be on the youth’s approved correspondence list which is maintained by the case manager. The program’s policy also states mail is opened in front of youth and outgoing mail is searched prior to leaving the facility. The program’s contract specifies the program is to provide visitation every Saturday and Sunday. A review of the visitation log confirmed the program is only providing visitation every other Saturday. A review of the program’s telephone log reflected telephone calls are provided on Mondays and Wednesday for all youth for fifteen minutes. As youth progress in the program, they can earn additional telephone calls. A review of the program’s mail log ...