Walton Academy for Growth and Change

Limited compliance, DJJ review : Indicator 2.08 Youth Needs Assessment Summary (YNAS)

The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the initial assessment process in the Department’s Juvenile Justice Information System (JJIS) on the YNAS. Five youth case management records were reviewed for Youth Needs Assessment Summary (YNAS) reports. Three of five youth records contained a YNAS report which was completed beyond the thirtieth day of youth admission. One was completed one day late, one completed twenty days late, and the remaining was completed twenty-six days late. The remaining two records contained YNAS reports which were completed as required. A review of the Department’s Juvenile Justice Information System (JJIS) confirmed each YNAS was documented and contained youth’s top three criminogenic needs. The program conducted an internal audit and discovered deficient areas on June 30, 2025. An internal corrective action plan was initiated upon discovery. All exceptions discovered during the annual compliance review were identified subsequent to corrective action plan.

Failed compliance, DJJ review : Indicator 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 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. Five youth case management records were reviewed for performance plan development, goals, and transmittals. Each of the five records contained a completed Individualized Performance Plan (IPP). One of five records contained an IPP which was developed within thirty days of youth admission. The remaining four records contained IPPs which were developed beyond the thirtieth day of youth admission. The late IPPs were respectively one, forty-one, forty-nine, and sixty-seven days late. Each of the five IPPs were developed after the initial Residential Assessment of Youth (RAY) assessment and Youth Needs Assessment Summary (YNAS) were completed. Documentation review confirmed all required attendees were present physically or participated by telephone. All members ...

Limited compliance, DJJ review : Indicator 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 the staff are qualified to provide based on education, training, and experience. As of February 2026, the therapeutic manager position vacancy which had been open since September 2025, has been filled. At the time of this annual compliance review, the program was under a corrective action plan for an open minor deficiency for Non-Licensed Mental Health and Substance Abuse Clinical Staff. The deficiency was identified by the Department’s Office of Health Services (OHS). The designated mental health clinician authority (DMHCA) assures the non-licensed clinical staff working under their supervision are performing services they are qualified to provide based on education, training, and experience through weekly supervision. A review of documentation revealed the DMHCA conducted weekly, face-to-face direct supervision with the non-licensed clinical staff throughout the duration of the annual compliance review period. The supervision was documented on the Department’s Licensed Mental Health Professionals and Licensed Substance Abuse Professionals Direct Supervision Log form. The program holds a valid and current Chapter 397 license which is displayed in the front lobby. The non-licensed mental health and substance abuse ...

Limited compliance, DJJ review : Indicator 4.03 Facility Operating Procedures

The program shall have facility operating procedures (FOP) for all health-related procedures and protocols utilized at the program. The program has facility operating procedures (FOPs) for all health-related procedures and protocols utilized at the program. The designated health authority (DHA), program director, and psychiatrist revised and signed the program’s health-related FOPs as required. All four nurses reviewed, signed, and dated a cover page for all health-related FOPs. A previous RN was missing from the sign-in sheet. The comprehensive clinical orientation to the Department’s healthcare orientation curriculum was provided, but neither of the two nurses hired during the review period signed it. The RN providing the orientation signed off on one of the nurse’s orientations, but the nurse did not sign as receiving the training. The DHA is the only person who authorizes and approves treatment protocols or standing procedures at the program.

Limited compliance, DJJ review : Indicator 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 BMS utilized at the program. The program has implemented a revised behavior management system (BMS) as of January 2026. The new BMS was developed by program administration. At the time of this annual compliance review, the program was under a corrective action plan for an open major deficiency for BMS. The deficiency was identified by the Department’s Residential Operations. The program’s BMS was observed in the youth handbook. The handbook included rules of governing conduct and positive and negative consequences. The BMS includes recognition of accomplishments and positive behaviors at a four to one ratio of positive to negative consequences, according to the provider’s contractual agreement. The program’s BMS includes all required elements. The system incorporates a point card in which youth have the ability to earn points based on their daily behavior and participation in activities. There are a total of four levels, which include Orientation, Rookie, Intern and Ram. The program’s BMS notates staff members are responsible for providing consistent ...

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 total of eighty-four cameras. All but one camera was reported to be working at the time of the annual compliance review week. The program director stated the malfunctioning camera has been reported to the repair company and they are awaiting its reparation. The program’s video recording system is stored up to thirty days. Documentation of room checks for youth in their rooms during period of sleep times were observed for the scope of the annual compliance review period. One thirty-minute period for a day each month was observed. All checks were documented by staff signatures and indicating the time of the checks. All were done at ten-minute increments. Video review was observed. A total of nine time periods, covering all three youth living units, were observed. Staff were observed performing checks and looking into youth room observation windows. In three of nine samples observed, three of nine samples observed, staff did not pause long enough to observe youth in the room. Exceptions were identified in two of the nine time periods. In one of the two one ten-minute check was not conducted. ...

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 maintains one central logbook, which is located in the master control room and primarily completed by the master control operator. Logbooks were reviewed for logbook entries. One day each month for the scope of the annual compliance review period was observed, for a total of eight days reviewed. All logbooks were neat and bound with numbered pages. Entries were made in ink with no erasures or whiteout areas. No entries or pages appeared to be destroyed or removed. One of the eight days of logbook entries was observed errors were struck through with a single line and initialed by staff correcting the error. For the remaining seven days observed, errors found were written over with no initials or were lined through with no staff initials. One of eight days reviewed found entries included a signature of the staff making the entries. The remaining seven of the eight days did not include staff signatures at the end of the entry. These exceptions consisted of the initials of the staff making the entry, or did not include any initial or signature of the staff at all. Internal incidents reported to the Department’s Central Communications Center (CCC) were documented for all applicable days. The program also ...

Limited compliance, DJJ review : Indicator 5.08 Contraband Procedures

The program’s policy must address illegal contraband and prohibited items. A program shall delineate items and materials considered contraband when found in the possession of youth, the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or clothing, any intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any controlled substance, any prescription or non-prescription drug which has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any explosive substance, non-facility issued electronic equipment or devices to include smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and non-facility issued keys. The program shall provide youth with the list of contraband items and materials and inform the youth of the consequences if found with contraband. The program shall establish a system to prevent the introduction of contraband and identify contraband items and materials through searches of the physical plant, facility grounds, and both staff and youth. The program shall document the confiscation of any illegal contraband and the manner of disposition. The program shall keep a copy of the documentation in the youth’s case record. If a confiscated item is not illegal or prohibited, the program director or designee has the discretion to discard of the item, return ...

Limited compliance, DJJ review : Indicator 2.08 Youth Needs Assessment Summary (YNAS)

The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the initial assessment process in the Department’s Juvenile Justice Information System (JJIS) on the YNAS. Five youth case management records were reviewed for Youth Needs Assessment Summary (YNAS) reports. Three of five youth records contained a YNAS report which was completed beyond the thirtieth day of youth admission. One was completed one day late, one completed twenty days late, and the remaining was completed twenty-six days late. The remaining two records contained YNAS reports which were completed as required. A review of the Department’s Juvenile Justice Information System (JJIS) confirmed each YNAS was documented and contained youth’s top three criminogenic needs. The program conducted an internal audit and discovered deficient areas on June 30, 2025. An internal corrective action plan was initiated upon discovery. All exceptions discovered during the annual compliance review were identified subsequent to corrective action plan.

Failed compliance, DJJ review : Indicator 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 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. Five youth case management records were reviewed for performance plan development, goals, and transmittals. Each of the five records contained a completed Individualized Performance Plan (IPP). One of five records contained an IPP which was developed within thirty days of youth admission. The remaining four records contained IPPs which were developed beyond the thirtieth day of youth admission. The late IPPs were respectively one, forty-one, forty-nine, and sixty-seven days late. Each of the five IPPs were developed after the initial Residential Assessment of Youth (RAY) assessment and Youth Needs Assessment Summary (YNAS) were completed. Documentation review confirmed all required attendees were present physically or participated by telephone. All members ...

Limited compliance, DJJ review : Indicator 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 the staff are qualified to provide based on education, training, and experience. As of February 2026, the therapeutic manager position vacancy which had been open since September 2025, has been filled. At the time of this annual compliance review, the program was under a corrective action plan for an open minor deficiency for Non-Licensed Mental Health and Substance Abuse Clinical Staff. The deficiency was identified by the Department’s Office of Health Services (OHS). The designated mental health clinician authority (DMHCA) assures the non-licensed clinical staff working under their supervision are performing services they are qualified to provide based on education, training, and experience through weekly supervision. A review of documentation revealed the DMHCA conducted weekly, face-to-face direct supervision with the non-licensed clinical staff throughout the duration of the annual compliance review period. The supervision was documented on the Department’s Licensed Mental Health Professionals and Licensed Substance Abuse Professionals Direct Supervision Log form. The program holds a valid and current Chapter 397 license which is displayed in the front lobby. The non-licensed mental health and substance abuse ...

Limited compliance, DJJ review : Indicator 4.03 Facility Operating Procedures

The program shall have facility operating procedures (FOP) for all health-related procedures and protocols utilized at the program. The program has facility operating procedures (FOPs) for all health-related procedures and protocols utilized at the program. The designated health authority (DHA), program director, and psychiatrist revised and signed the program’s health-related FOPs as required. All four nurses reviewed, signed, and dated a cover page for all health-related FOPs. A previous RN was missing from the sign-in sheet. The comprehensive clinical orientation to the Department’s healthcare orientation curriculum was provided, but neither of the two nurses hired during the review period signed it. The RN providing the orientation signed off on one of the nurse’s orientations, but the nurse did not sign as receiving the training. The DHA is the only person who authorizes and approves treatment protocols or standing procedures at the program.

Limited compliance, DJJ review : Indicator 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 BMS utilized at the program. The program has implemented a revised behavior management system (BMS) as of January 2026. The new BMS was developed by program administration. At the time of this annual compliance review, the program was under a corrective action plan for an open major deficiency for BMS. The deficiency was identified by the Department’s Residential Operations. The program’s BMS was observed in the youth handbook. The handbook included rules of governing conduct and positive and negative consequences. The BMS includes recognition of accomplishments and positive behaviors at a four to one ratio of positive to negative consequences, according to the provider’s contractual agreement. The program’s BMS includes all required elements. The system incorporates a point card in which youth have the ability to earn points based on their daily behavior and participation in activities. There are a total of four levels, which include Orientation, Rookie, Intern and Ram. The program’s BMS notates staff members are responsible for providing consistent ...

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 total of eighty-four cameras. All but one camera was reported to be working at the time of the annual compliance review week. The program director stated the malfunctioning camera has been reported to the repair company and they are awaiting its reparation. The program’s video recording system is stored up to thirty days. Documentation of room checks for youth in their rooms during period of sleep times were observed for the scope of the annual compliance review period. One thirty-minute period for a day each month was observed. All checks were documented by staff signatures and indicating the time of the checks. All were done at ten-minute increments. Video review was observed. A total of nine time periods, covering all three youth living units, were observed. Staff were observed performing checks and looking into youth room observation windows. In three of nine samples observed, three of nine samples observed, staff did not pause long enough to observe youth in the room. Exceptions were identified in two of the nine time periods. In one of the two one ten-minute check was not conducted. ...

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 maintains one central logbook, which is located in the master control room and primarily completed by the master control operator. Logbooks were reviewed for logbook entries. One day each month for the scope of the annual compliance review period was observed, for a total of eight days reviewed. All logbooks were neat and bound with numbered pages. Entries were made in ink with no erasures or whiteout areas. No entries or pages appeared to be destroyed or removed. One of the eight days of logbook entries was observed errors were struck through with a single line and initialed by staff correcting the error. For the remaining seven days observed, errors found were written over with no initials or were lined through with no staff initials. One of eight days reviewed found entries included a signature of the staff making the entries. The remaining seven of the eight days did not include staff signatures at the end of the entry. These exceptions consisted of the initials of the staff making the entry, or did not include any initial or signature of the staff at all. Internal incidents reported to the Department’s Central Communications Center (CCC) were documented for all applicable days. The program also ...

Limited compliance, DJJ review : Indicator 5.08 Contraband Procedures

The program’s policy must address illegal contraband and prohibited items. A program shall delineate items and materials considered contraband when found in the possession of youth, the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or clothing, any intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any controlled substance, any prescription or non-prescription drug which has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any explosive substance, non-facility issued electronic equipment or devices to include smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and non-facility issued keys. The program shall provide youth with the list of contraband items and materials and inform the youth of the consequences if found with contraband. The program shall establish a system to prevent the introduction of contraband and identify contraband items and materials through searches of the physical plant, facility grounds, and both staff and youth. The program shall document the confiscation of any illegal contraband and the manner of disposition. The program shall keep a copy of the documentation in the youth’s case record. If a confiscated item is not illegal or prohibited, the program director or designee has the discretion to discard of the item, return ...

Limited compliance, DJJ review : Indicator 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. 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 written policy and procedures to ensure a Residential Assessment for Youth (RAY) is completed within thirty days of the youth’s admission to the program, and the RAY Reassessments are completed every ninety days after the completion of the initial RAY. Seven youth case management records were reviewed, and six out of seven contained an initial RAY completed within the required time frame. One youth’s RAY was seventeen days late. All seven youth records had the initial assessment maintained in the Department’s Juvenile Justice Information System (JJIS). Each youth also had a copy of their RAY overview report filed within their individual record. Seven youth case management records were reviewed to determine whether a RAY Reassessment was completed within ninety days. Five records were applicable for RAY Reassessments. One record contained the required RAY Reassessment ...

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 maintains a written policy and procedures addressing logbook entries and shift reports. A review of one full day each month during the annual compliance review period revealed master control logbooks were bound with pages numbered. All entries were made in ink with no erasures or white-out areas. There was no indication of logbook entries being destroyed or removed. Three noted errors were struck through with one line and initialed by staff as required; however four errors were not struck through with one line and/or initialed by the staff correcting the error, with three errors being written over. All master logbooks included dates, times, events, names of staff and youth, if applicable, brief description of events, and names and signatures of staff making entries. The logbook was reviewed for incidents reported to the Department’s Central Communications Center, and all were found to be documented in the master control logbook. According to the program director, the program does not maintain living unit logbooks. A review of shift reports maintained during the annual compliance review period indicated incidents, events, and activities were documented in eleven out of twelve shift reports. For one month ...

Failed compliance, DJJ review : Indicator 6.01 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 career and technical education (CTE) services required to be provided by the program per contract are Florida Ready to Work (FRTW) Soft Skills, Occupational Safety and Health Administration (OSHA-10), Cardiopulmonary Resuscitation and First Aid (CPR/FA), Certified Nursing Assistant (CNA), Entrepreneurial Program/Club, and Junior Achievement program. During the annual compliance review period, the program delivered two of the six required services. Forty-eight youth participated in ...

Limited compliance, DJJ review : Indicator 6.08 Florida Youth College (Post-Secondary Contract Provider)

The post-secondary provider, upon receiving the referral for services, shall assign a Florida Youth College Career Navigator to each youth. Each youth shall attend an orientation session to develop a career pathway plan. The career pathway plan shall include postsecondary education options at a state or technical college or pre-apprenticeship/apprenticeship programming that leads to an industry credential or academic credit. For youth transitioning from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after their release. Three youth records were reviewed to assess the post-secondary services provided following referral to Florida Youth College (FYC). Each of the records contained documentation verifying the day, date, and time of the youth’s FYC orientation. Additionally, all records included a career plan tailored to the youth’s individual interests and aptitudes. No follow-up services were documented, as one youth relocated out of state and the remaining two youth chose not to continue participating in the program. The program currently has an open Outcome-Based Corrective Action Plan (OBCAP).

Limited compliance, DJJ review : Indicator 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. 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 written policy and procedures to ensure a Residential Assessment for Youth (RAY) is completed within thirty days of the youth’s admission to the program, and the RAY Reassessments are completed every ninety days after the completion of the initial RAY. Seven youth case management records were reviewed, and six out of seven contained an initial RAY completed within the required time frame. One youth’s RAY was seventeen days late. All seven youth records had the initial assessment maintained in the Department’s Juvenile Justice Information System (JJIS). Each youth also had a copy of their RAY overview report filed within their individual record. Seven youth case management records were reviewed to determine whether a RAY Reassessment was completed within ninety days. Five records were applicable for RAY Reassessments. One record contained the required RAY Reassessment ...

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 maintains a written policy and procedures addressing logbook entries and shift reports. A review of one full day each month during the annual compliance review period revealed master control logbooks were bound with pages numbered. All entries were made in ink with no erasures or white-out areas. There was no indication of logbook entries being destroyed or removed. Three noted errors were struck through with one line and initialed by staff as required; however four errors were not struck through with one line and/or initialed by the staff correcting the error, with three errors being written over. All master logbooks included dates, times, events, names of staff and youth, if applicable, brief description of events, and names and signatures of staff making entries. The logbook was reviewed for incidents reported to the Department’s Central Communications Center, and all were found to be documented in the master control logbook. According to the program director, the program does not maintain living unit logbooks. A review of shift reports maintained during the annual compliance review period indicated incidents, events, and activities were documented in eleven out of twelve shift reports. For one month ...

Failed compliance, DJJ review : Indicator 6.01 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 career and technical education (CTE) services required to be provided by the program per contract are Florida Ready to Work (FRTW) Soft Skills, Occupational Safety and Health Administration (OSHA-10), Cardiopulmonary Resuscitation and First Aid (CPR/FA), Certified Nursing Assistant (CNA), Entrepreneurial Program/Club, and Junior Achievement program. During the annual compliance review period, the program delivered two of the six required services. Forty-eight youth participated in ...

Limited compliance, DJJ review : Indicator 6.08 Florida Youth College (Post-Secondary Contract Provider)

The post-secondary provider, upon receiving the referral for services, shall assign a Florida Youth College Career Navigator to each youth. Each youth shall attend an orientation session to develop a career pathway plan. The career pathway plan shall include postsecondary education options at a state or technical college or pre-apprenticeship/apprenticeship programming that leads to an industry credential or academic credit. For youth transitioning from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after their release. Three youth records were reviewed to assess the post-secondary services provided following referral to Florida Youth College (FYC). Each of the records contained documentation verifying the day, date, and time of the youth’s FYC orientation. Additionally, all records included a career plan tailored to the youth’s individual interests and aptitudes. No follow-up services were documented, as one youth relocated out of state and the remaining two youth chose not to continue participating in the program. The program currently has an open Outcome-Based Corrective Action Plan (OBCAP).

Limited compliance, DJJ review : Indicator 2.10 Performance Plan Revisions

Performance reviews shall result in revisions to the youth’s performance plan when determined necessary by the intervention and treatment team. The program has a written policy and procedures in place which address performance plan revisions. After the creation of the Individualized Performance Plan (IPP), at thirty-day intervals, the assigned treatment team meets to formally review the youth’s performance plan goals and determine whether revisions are necessary. In addition, every ninety days after completion of the initial Residential Assessment for Youth (RAY), case management staff complete a RAY Reassessment and, should the results warrant, will revise the youth’s performance plan goals. Five youth case management records were reviewed and two were applicable for IPP revisions. An additional record was requested and provided. Each of the three reviewed records had at least one RAY Reassessment completed; however, none of the findings were reflected on the youth’s formal treatment team forms, with several forms indicating the youth didn’t even have a reassessment during the annual compliance review period. Only one treatment team form mentioned a RAY Reassessment was completed; however, did not go into details. In all three reviewed records, there were clear indications the IPP interventions and goals should have been reviewed for potential revision based on the RAY Reassessment findings. Two of the youth also demonstrated regression in their goals without IPP revisions. ...

Limited compliance, DJJ review : Indicator 3.12 Suicide Precaution Observation Logs (Critical)

Youth placed on suicide precautions shall be maintained on one-to-one or constant supervision. The staff assigned to observe the youth shall provide the appropriate level of supervision and record observations of the youth's behavior at intervals of thirty minutes, at a minimum. Five youth mental health records were reviewed for Suicide Precaution Observation Logs. None of the five youth selected were applicable. Three additional youth mental health records were provided for review. Two of the three youth records included documentation the Suicide Precaution Observation Logs were maintained for the duration the youth was on suicide precaution. Two of the three youth records included documentation the appropriate level of supervision and observations of the youth’s behavior were documented in real time, every thirty- minutes. One youth did not have Suicide Precaution Observation Logs completed for five hours and thirty-seven minutes out of the twenty-six hours the youth was on precautionary observation. The logs for this youth were completed incorrectly for seven of those hours. These observations were documented at one-hour intervals instead of the required thirty-minute intervals. Two of the three youth did have warning signs observed and notification to the program director and mental health clinical staff were documented on the logs. All three youth records included documentation the logs were reviewed and signed by each shift supervisor and by the mental health clinical ...

Limited compliance, DJJ review : Indicator 5.08 Contraband Procedures

The program’s policy must address illegal contraband and prohibited items. A program shall delineate items and materials considered contraband when found in the possession of youth, the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or clothing, any intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any controlled substance, any prescription or non-prescription drug which has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any explosive substance, non-facility issued electronic equipment or devices to include smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and non-facility issued keys. The program shall provide youth with the list of contraband items and materials and inform the youth of the consequences if found with contraband. The program shall establish a system to prevent the introduction of contraband and identify contraband items and materials through searches of the physical plant, facility grounds, and both staff and youth. The program shall document the confiscation of any illegal contraband and the manner of disposition. The program shall keep a copy of the documentation in the youth’s case record. If a confiscated item is not illegal or prohibited, the program director or designee has the discretion to discard of the item, return ...

Failed 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 maintains a written policy and procedures for tool inventory and management. The program’s policy addresses issuance, inventory, control of equipment and tools, in addition to prohibited items such as machete, bowie knives, and long blade knives. A review of issuance and return of tool logs maintained during the annual compliance review period revealed no issues. An informal interview with maintenance revealed procedures for missing tools is to conduct an investigation and search, notify the program director (PD), complete the missing tools form, and complete the Department’s Central Communications Center (CCC) report. Tools which need to be replaced require staff to gain approval from the PD, complete the replacement tool form, and update the inventory sheet. Daily inventories of Class A tools and monthly inventories of Class B tools were not completed during the annual compliance review period. Through observations and informal interviews with maintenance, not all tools were on the Class A master list and Class B master list. Maintenance is aware of the issue and is in the process of organizing the shed and inventorying all tools. A sample of seven Class A tools revealed five were not on the Class A master list; however, each tool was secured. The Class B master list was handwritten, and according to policy should be typed and readily ...

Limited compliance, DJJ review : Indicator 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 maintains a written policy and procedures for the storage, inventory, and disposal of flammable, poisonous, and toxic items and materials. All flammable, poisonous, and toxic chemicals are maintained in secure locations which are inaccessible to youth. Areas used to store these items include the front bathroom, kitchen, master control, and maintenance shed. An inventory of five items in the front bathroom revealed nine bottles of cleaner in the closet, but the inventory documented eight. In addition, two of the cleaners were documented on the inventory sheet but were not located in the front bathroom closet. Maintenance stated the chemicals were in the maintenance shed. There were no Safety Data Sheets (SDSs) for any chemicals in the front bathroom closet. An inventory of five chemical items in the kitchen revealed all items were accounted for as required; however, two were missing SDSs. The kitchen staff stated chemicals were new and they were in the process of obtaining the SDS for both chemicals. Kitchen staff added SDSs to the chemicals during the annual compliance review week. An inventory of four chemical items in master control revealed all items were accounted for and each had the appropriate SDS as required. An attempt to inventory items in the maintenance shed revealed ...