Wimauma Academy

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 has an approved contract which collaborates with Erwin Technical College to enroll youth into their selected available career and technical courses which are aligned to the Master Credentials List (MCL); however, a review of five youth records found none of the reviewed youth received these services during the annual compliance review period. Each youth is required to begin and complete Florida Ready to Work (FLRTW) Soft Skills, cardiopulmonary resuscitation (CPR) ...

Limited compliance, DJJ review : Indicator 3.17 Baker and Marchman Acts (Critical)

Individuals who are believed to be an imminent danger to themselves or others because of mental illness or substance abuse impairment require emergency mental health or substance abuse services. The program has a policy and procedures to ensure any youth in imminent danger of harming themselves or others receive immediate services. A review of five individual mental health youth records was conducted, and none of the five were applicable for Baker or Marchman Act documentation. The program had two Baker Acts within the annual compliance review period for review. Both youth were Baker Acted from the same incident of criminal behavior; one displayed self-harm while under the supervision of program staff and one youth expressed self-harm ideations to law enforcement. The youth with self-harming behavior under program supervision was not placed on precautionary supervision at the time of the incident and mental health staff were not on-site during the incident; the other youth was not applicable for precautionary supervision by program staff. Both youth were taken into custody from the program by law enforcement and Baker Acted. Upon each youth’s return to the program, each was placed on precautionary supervision as required and a mental health referral for a mental health examination was completed by a licensed mental health clinical staff. Each youth was maintained on the appropriate supervision level until the assessment was conducted.

Limited compliance, DJJ review : Indicator 5.01 Youth Supervision (CRITICAL)

Program staff shall maintain active supervision of youth, including interacting positively with youth, engaging in a full schedule of constructive activities, closely observing behavior of youth and changes in behavior. Program staff can account for the whereabouts of youth under their supervision at all times. The center has a policy and procedures outlining the expectation of youth supervision. The program’s policy and procedures include what is considered active supervision. The daily schedule is posted and available to youth in each dormitory. The program’s staff-to-youth ratio is one staff to eight youth during daytime activities and one staff to twelve youth during nighttime (sleep). Three random staff were asked how many youth they were currently supervising, and each staff member was able to state how many youth they had under their supervision. The program did not have any escapes since the last annual compliance review. During the annual compliance review, observations of daily activities were observed. During the annual compliance review week, youth and staff interactions, youth movements, transport, education, group, and recreational activities were observed. Observation of youth movement resulted in observing youth searches. It was observed one staff member did not search youth according to Right Interactions (RI) on two separate occasions. The remaining staff members did search youth according to RI. On two occasions it was observed staff-to-youth ratio was not ...

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 ensuring staff observe youth at least every ten minutes during sleep time. The program had a deficiency assigned to this indicator and it was closed on November 10, 2025; therefore, a review of documentation was reviewed after this date. The program has fifty-eight cameras, and each was operational. Thirty days of video recording are maintained. The program has two open bay dormitories. A review of ten-minute check logs for each dormitory was conducted; a total of ten logs were reviewed. The checks were documented in real time, checks were conducted in ten-minute intervals, and the staff who completed the checks initialed each check conducted. Video observation found on March 18, 2026, on dormitory one, the check was completed at 12 a.m. and not again until 12:40 a.m.; however, staff documented the completion of checks every ten minutes. The program reported this incident to the Department’s Central Communications Center (CCC). On March 12, 2026, on dormitory two, a check was conducted at 5:20 a.m. and then not again until 5:41 a.m.; however, documentation reflected ...

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 has an approved contract which collaborates with Erwin Technical College to enroll youth into their selected available career and technical courses which are aligned to the Master Credentials List (MCL); however, a review of five youth records found none of the reviewed youth received these services during the annual compliance review period. Each youth is required to begin and complete Florida Ready to Work (FLRTW) Soft Skills, cardiopulmonary resuscitation (CPR) ...

Limited compliance, DJJ review : Indicator 3.17 Baker and Marchman Acts (Critical)

Individuals who are believed to be an imminent danger to themselves or others because of mental illness or substance abuse impairment require emergency mental health or substance abuse services. The program has a policy and procedures to ensure any youth in imminent danger of harming themselves or others receive immediate services. A review of five individual mental health youth records was conducted, and none of the five were applicable for Baker or Marchman Act documentation. The program had two Baker Acts within the annual compliance review period for review. Both youth were Baker Acted from the same incident of criminal behavior; one displayed self-harm while under the supervision of program staff and one youth expressed self-harm ideations to law enforcement. The youth with self-harming behavior under program supervision was not placed on precautionary supervision at the time of the incident and mental health staff were not on-site during the incident; the other youth was not applicable for precautionary supervision by program staff. Both youth were taken into custody from the program by law enforcement and Baker Acted. Upon each youth’s return to the program, each was placed on precautionary supervision as required and a mental health referral for a mental health examination was completed by a licensed mental health clinical staff. Each youth was maintained on the appropriate supervision level until the assessment was conducted.

Limited compliance, DJJ review : Indicator 5.01 Youth Supervision (CRITICAL)

Program staff shall maintain active supervision of youth, including interacting positively with youth, engaging in a full schedule of constructive activities, closely observing behavior of youth and changes in behavior. Program staff can account for the whereabouts of youth under their supervision at all times. The center has a policy and procedures outlining the expectation of youth supervision. The program’s policy and procedures include what is considered active supervision. The daily schedule is posted and available to youth in each dormitory. The program’s staff-to-youth ratio is one staff to eight youth during daytime activities and one staff to twelve youth during nighttime (sleep). Three random staff were asked how many youth they were currently supervising, and each staff member was able to state how many youth they had under their supervision. The program did not have any escapes since the last annual compliance review. During the annual compliance review, observations of daily activities were observed. During the annual compliance review week, youth and staff interactions, youth movements, transport, education, group, and recreational activities were observed. Observation of youth movement resulted in observing youth searches. It was observed one staff member did not search youth according to Right Interactions (RI) on two separate occasions. The remaining staff members did search youth according to RI. On two occasions it was observed staff-to-youth ratio was not ...

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 ensuring staff observe youth at least every ten minutes during sleep time. The program had a deficiency assigned to this indicator and it was closed on November 10, 2025; therefore, a review of documentation was reviewed after this date. The program has fifty-eight cameras, and each was operational. Thirty days of video recording are maintained. The program has two open bay dormitories. A review of ten-minute check logs for each dormitory was conducted; a total of ten logs were reviewed. The checks were documented in real time, checks were conducted in ten-minute intervals, and the staff who completed the checks initialed each check conducted. Video observation found on March 18, 2026, on dormitory one, the check was completed at 12 a.m. and not again until 12:40 a.m.; however, staff documented the completion of checks every ten minutes. The program reported this incident to the Department’s Central Communications Center (CCC). On March 12, 2026, on dormitory two, a check was conducted at 5:20 a.m. and then not again until 5:41 a.m.; however, documentation reflected ...

Limited compliance, DJJ review : Indicator 1.07 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), assistant FA, to be direct-care staff and can be counted in the staff-to-youth ratio. A review of documentation indicated the program’s instructors were qualified to deliver training in cardio-pulmonary resuscitation (CPR), first-aid, automated external defibrillator (AED) and Right Interactions (RI). 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 seven pre-service training staff records indicated all seven pre-service staff are missing Effective and Respectful Treatment of Youth training and not all training was documented in the Department’s Learning Management System (SkillPro) as required. Four of the seven staff were applicable to have completed 120 hours of training in the first 180 days. The three ...

Limited compliance, DJJ review : Indicator 1.08 In-Service Training

Residential contracted provider staff shall complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after pre-service/certification training is completed. Supervisory staff shall complete eight hours of training in addition to the twenty-four hours of annual in-service training) in the areas specified in Florida Administrative Code. The program has a policy and procedures outlining the in-service training requirements for staff. The program maintains an annual in-service training calendar and submitted an in-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. There were only four applicable in-service staff training records for the annual compliance review period. None of the four were applicable for supervisory training due to the supervisors still being in pre-service training phase. Two of the four in-service training staff records were missing Active Shooter Preparedness, Information Security Awareness, Mental Health and Substance Abuse, Emergency Response and Emergency Drills quarterly on each shift, Infection Control, Blood- borne Pathogens, and Exposure Control Plan. Three of the four staff were missing Trauma Responsive Practices. In addition to these ...

Limited compliance, DJJ review : Indicator 3.13 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. The program has a policy and procedures for youth placed on suicide precaution. At the time of the annual compliance review there was an open deficiency #53408-27380 for Suicide Prevention which was identified on February 20, 2025. The facility administrator (FA) confirmed there was only one applicable youth who was placed on suicide precautions since February 20, 2025. A review of one youth mental health and substance abuse record confirmed the Suicide Precaution Observation Logs, was maintained for the duration the youth was on suicide precaution. A review of the form confirmed the appropriate level of supervision and observations of the youth’s behavior documented in real time had exceeded the thirty-minute intervals. The supervision was documented at 12:57 p.m, and not again until 1:57 p.m. There was no warning signs observed; therefore, did not require notification to the FA or mental health clinical staff. The Suicide Precaution Observation Log was reviewed and signed by the supervisor and the mental health clinical staff. The Suicide Precaution Observation Log documented the safe housing requirements. Seven interviewed staff stated mental health staff and a supervisor are notified if a youth ...

Failed 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 maintains a policy and procedures to ensure ten-minute checks are conducted when the youth are asleep or in their rooms. The program has a total of fifty-eight cameras which were all operating at the time of the annual compliance review. The program’s video recording has a thirty-day storage capacity. 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. Checks are documented on the program’s ten-minute check logs with the time of each check noted in real time along with the initials of the staff conducting each check. A review of nine separate video footage samples which include two shifts and two dormitories of ten-minute checks and ten-minute check logs, documented by staff reflected several discrepancies. On April 9, 2025, dormitory one from 10:00 p.m. to 10:30 p.m., found staff conducted a check at 10:11 p.m. and the next check was conducted at 10:25 p.m. with staff walking halfway down the dormitory only checking the right side, no other checks were completed, yet the ten-minute check log showed ...

Limited compliance, DJJ review : Indicator 5.09 Searches and Full Body Visual Searches

The program shall perform searches to ensure no contraband is introduced into the facility. The program has a policy and procedures to ensure searches and full body visual searches are conducted according to Florida Administrative Code at the time of admission, after off-campus activities, and visitation. The parent/guardian is notified of searches during visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s admission. Youth are searched before all movement, during a new admission, during readmission, after returning from visitation, when returning from off-campus activities and/or appointments, when suspected of having contraband, or when a youth is determined to be a security risk. The program conducts searches as a method to prevent the introduction of contraband and unauthorized items into the program. The policy indicates searches of youth are conducted after off-site transports, after visitation, before moving youth from an outside area into the building, and prior to moving youth from the building to an outside area. There were observations of searches made during line movements, returning from an off-campus appointment, and before moving from the building to an outside area during the annual compliance review week. There were no off-campus activities or visitation to observe during the annual compliance review week. Youth Search and Full Body Visual Search Forms were reviewed and confirmed the program conducts full body ...

Limited compliance, DJJ review : Indicator 1.07 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), assistant FA, to be direct-care staff and can be counted in the staff-to-youth ratio. A review of documentation indicated the program’s instructors were qualified to deliver training in cardio-pulmonary resuscitation (CPR), first-aid, automated external defibrillator (AED) and Right Interactions (RI). 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 seven pre-service training staff records indicated all seven pre-service staff are missing Effective and Respectful Treatment of Youth training and not all training was documented in the Department’s Learning Management System (SkillPro) as required. Four of the seven staff were applicable to have completed 120 hours of training in the first 180 days. The three ...

Limited compliance, DJJ review : Indicator 1.08 In-Service Training

Residential contracted provider staff shall complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after pre-service/certification training is completed. Supervisory staff shall complete eight hours of training in addition to the twenty-four hours of annual in-service training) in the areas specified in Florida Administrative Code. The program has a policy and procedures outlining the in-service training requirements for staff. The program maintains an annual in-service training calendar and submitted an in-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. There were only four applicable in-service staff training records for the annual compliance review period. None of the four were applicable for supervisory training due to the supervisors still being in pre-service training phase. Two of the four in-service training staff records were missing Active Shooter Preparedness, Information Security Awareness, Mental Health and Substance Abuse, Emergency Response and Emergency Drills quarterly on each shift, Infection Control, Blood- borne Pathogens, and Exposure Control Plan. Three of the four staff were missing Trauma Responsive Practices. In addition to these ...

Limited compliance, DJJ review : Indicator 3.13 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. The program has a policy and procedures for youth placed on suicide precaution. At the time of the annual compliance review there was an open deficiency #53408-27380 for Suicide Prevention which was identified on February 20, 2025. The facility administrator (FA) confirmed there was only one applicable youth who was placed on suicide precautions since February 20, 2025. A review of one youth mental health and substance abuse record confirmed the Suicide Precaution Observation Logs, was maintained for the duration the youth was on suicide precaution. A review of the form confirmed the appropriate level of supervision and observations of the youth’s behavior documented in real time had exceeded the thirty-minute intervals. The supervision was documented at 12:57 p.m, and not again until 1:57 p.m. There was no warning signs observed; therefore, did not require notification to the FA or mental health clinical staff. The Suicide Precaution Observation Log was reviewed and signed by the supervisor and the mental health clinical staff. The Suicide Precaution Observation Log documented the safe housing requirements. Seven interviewed staff stated mental health staff and a supervisor are notified if a youth ...

Failed 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 maintains a policy and procedures to ensure ten-minute checks are conducted when the youth are asleep or in their rooms. The program has a total of fifty-eight cameras which were all operating at the time of the annual compliance review. The program’s video recording has a thirty-day storage capacity. 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. Checks are documented on the program’s ten-minute check logs with the time of each check noted in real time along with the initials of the staff conducting each check. A review of nine separate video footage samples which include two shifts and two dormitories of ten-minute checks and ten-minute check logs, documented by staff reflected several discrepancies. On April 9, 2025, dormitory one from 10:00 p.m. to 10:30 p.m., found staff conducted a check at 10:11 p.m. and the next check was conducted at 10:25 p.m. with staff walking halfway down the dormitory only checking the right side, no other checks were completed, yet the ten-minute check log showed ...

Limited compliance, DJJ review : Indicator 5.09 Searches and Full Body Visual Searches

The program shall perform searches to ensure no contraband is introduced into the facility. The program has a policy and procedures to ensure searches and full body visual searches are conducted according to Florida Administrative Code at the time of admission, after off-campus activities, and visitation. The parent/guardian is notified of searches during visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s admission. Youth are searched before all movement, during a new admission, during readmission, after returning from visitation, when returning from off-campus activities and/or appointments, when suspected of having contraband, or when a youth is determined to be a security risk. The program conducts searches as a method to prevent the introduction of contraband and unauthorized items into the program. The policy indicates searches of youth are conducted after off-site transports, after visitation, before moving youth from an outside area into the building, and prior to moving youth from the building to an outside area. There were observations of searches made during line movements, returning from an off-campus appointment, and before moving from the building to an outside area during the annual compliance review week. There were no off-campus activities or visitation to observe during the annual compliance review week. Youth Search and Full Body Visual Search Forms were reviewed and confirmed the program conducts full body ...

Limited compliance, DJJ review : Indicator 1.15 Advisory Board

The program has a community support group or advisory board meeting at least every ninety to 120 days. The program director solicits active involvement of interested community partners. The program has a policy and procedures regarding the community advisory board expectations. The facility administrator (FA) recited the policy and procedures for advisory boards. The program solicits members prior to scheduled meetings. The program has solicited all required community partners except for a LGBTQIA+ community member. Several community agencies have been contacted for membership and are pending. During the annual compliance review period, the program had one community advisory board meeting in their first quarter and has sent out invitations for the third quarterly meeting. The second quarterly meeting was missed. Attendees for the first quarter meeting either participated in person or virtually. An informal interview with one of the board members was conducted and they revealed they were a recent member who attended the first meeting. The board member indicated they provide mentoring services for the youth in the program. A deficiency was assigned prior to the annual compliance review due to the program not having an advisory board meeting in the second quarter or having identified advisory board members. During the annual compliance review week, the program was able to retrieve the advisory board member list, invitations for the first quarter advisory board meeting, and ...

Limited compliance, DJJ review : Indicator 2.20 Educational Access (Critical)

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 provide for educational access. The program integrates education into the daily schedule in such a way as to ensure the integrity of the required minimum instruction time distributed over a twelve-month period. The district approved calendar and daily school schedule were reviewed, which incorporated the required 250 days of instruction, with ten days used for teacher planning, and a minimum of twenty-five hours of instruction weekly. Youth are enrolled in academic courses through Wayne Halfway House and receive credit, as appropriate, when courses are completed. In a review of the youth interviews, one said there are interruptions throughout the school day and four said there are not. Youth comments include only for treatment team, and therapy, and treatment team meetings. A sample of three videos and six logbook reviews showed youth are being released on average of ten minutes early each day, which falls short of the required twenty-five hours of instruction a week.

Failed compliance, DJJ review : Indicator 3.02 Licensed Mental Health and Substance Abuse Clinical

Staff (Critical) Failed Compliance The program director is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure clinical staff working under their supervision are performing services the staff are qualified to provide based on education, training, and experience. The program is contractually required to have two full-time licensed therapists; one acting as the designated mental health clinician authority (DMHCA). The program had the DMHCA position filled but has not had a second licensed therapist since November 2023.

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. Due to Department-wide system outages, the Department’s Learning Management System could not be reviewed; therefore, staff training could not be verified. All five program staff did receive the internal mental health and substance abuse training as documented on the staff individual training plans. The program had two suicide response kits, one in master control and one in the clinic, co-located with first-aid kits. The program completed one of three drills during the annual compliance review period. The program operated on two shifts and two quarters were reviewed. The mock mental health drills conducted were in response to a simulated suicide attempt and/or incident of serious self-injury and none of the youth were utilized during the simulation. The program did provide semi-annual training on emergency response procedures and provided staff who were not present during a quarterly drill the opportunity to review each drill scenario and procedures. The facility administrator (FA) interview reiterated the program’s policy and indicated the program provides training or mock suicide drills for staff, including emergency response to suicide attempts or self-inflicted injury. All five staff interviews indicated the program has two suicide response kits, one each in master control and in the clinic. Three ...

Limited compliance, DJJ review : Indicator 4.12 Sick Call Process

All youth in the program shall be able to submit sick call requests and have complaints treated appropriately through the sick call system. The program shall respond appropriately, in a timely manner, and document all sick call encounters, as required by the Department. All youth in room restriction/controlled observation shall have timely access to medical care, as required by Rule. The program has a policy and procedures to ensure all youth can submit sick call requests and have their complaints treated appropriately through the program’s sick call system. A review of five Individual Healthcare Records (IHCRs) indicated none of the youth presented with similar sick call complaints three or more times within a two-week period. Two of the five IHCRs contained Sick Call Request forms completed by each youth and a registered nurse. A review of the Sick Call Referral Log indicated one of the three remaining IHCRs had one Sick Call Request form missing, and in the other two IHCRs two Sick Call Request forms were missing from each. The completed Sick Call Request forms were filed in each youth’s IHCR in reverse chronological order, were documented in accordance with the Florida Administrative Code, and none of the youth were in restricted housing. One of the five IHCRs documented all sick calls on the Sick Call Index. Three of the remaining four IHCRs had two sick calls missing from the Sick Call Index each, and one IHCR had one sick call missing from the Sick Call Index. All ...

Limited compliance, DJJ review : Indicator 1.15 Advisory Board

The program has a community support group or advisory board meeting at least every ninety to 120 days. The program director solicits active involvement of interested community partners. The program has a policy and procedures regarding the community advisory board expectations. The facility administrator (FA) recited the policy and procedures for advisory boards. The program solicits members prior to scheduled meetings. The program has solicited all required community partners except for a LGBTQIA+ community member. Several community agencies have been contacted for membership and are pending. During the annual compliance review period, the program had one community advisory board meeting in their first quarter and has sent out invitations for the third quarterly meeting. The second quarterly meeting was missed. Attendees for the first quarter meeting either participated in person or virtually. An informal interview with one of the board members was conducted and they revealed they were a recent member who attended the first meeting. The board member indicated they provide mentoring services for the youth in the program. A deficiency was assigned prior to the annual compliance review due to the program not having an advisory board meeting in the second quarter or having identified advisory board members. During the annual compliance review week, the program was able to retrieve the advisory board member list, invitations for the first quarter advisory board meeting, and ...

Limited compliance, DJJ review : Indicator 2.20 Educational Access (Critical)

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 provide for educational access. The program integrates education into the daily schedule in such a way as to ensure the integrity of the required minimum instruction time distributed over a twelve-month period. The district approved calendar and daily school schedule were reviewed, which incorporated the required 250 days of instruction, with ten days used for teacher planning, and a minimum of twenty-five hours of instruction weekly. Youth are enrolled in academic courses through Wayne Halfway House and receive credit, as appropriate, when courses are completed. In a review of the youth interviews, one said there are interruptions throughout the school day and four said there are not. Youth comments include only for treatment team, and therapy, and treatment team meetings. A sample of three videos and six logbook reviews showed youth are being released on average of ten minutes early each day, which falls short of the required twenty-five hours of instruction a week.

Failed compliance, DJJ review : Indicator 3.02 Licensed Mental Health and Substance Abuse Clinical

Staff (Critical) The program director is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure clinical staff working under their supervision are performing services the staff are qualified to provide based on education, training, and experience. The program is contractually required to have two full-time licensed therapists; one acting as the designated mental health clinician authority (DMHCA). The program had the DMHCA position filled but has not had a second licensed therapist since November 2023.

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. Due to Department-wide system outages, the Department’s Learning Management System could not be reviewed; therefore, staff training could not be verified. All five program staff did receive the internal mental health and substance abuse training as documented on the staff individual training plans. The program had two suicide response kits, one in master control and one in the clinic, co-located with first-aid kits. The program completed one of three drills during the annual compliance review period. The program operated on two shifts and two quarters were reviewed. The mock mental health drills conducted were in response to a simulated suicide attempt and/or incident of serious self-injury and none of the youth were utilized during the simulation. The program did provide semi-annual training on emergency response procedures and provided staff who were not present during a quarterly drill the opportunity to review each drill scenario and procedures. The facility administrator (FA) interview reiterated the program’s policy and indicated the program provides training or mock suicide drills for staff, including emergency response to suicide attempts or self-inflicted injury. All five staff interviews indicated the program has two suicide response kits, one each in master control and in the clinic. Three ...

Limited compliance, DJJ review : Indicator 4.12 Sick Call Process

All youth in the program shall be able to submit sick call requests and have complaints treated appropriately through the sick call system. The program shall respond appropriately, in a timely manner, and document all sick call encounters, as required by the Department. All youth in room restriction/controlled observation shall have timely access to medical care, as required by Rule. The program has a policy and procedures to ensure all youth can submit sick call requests and have their complaints treated appropriately through the program’s sick call system. A review of five Individual Healthcare Records (IHCRs) indicated none of the youth presented with similar sick call complaints three or more times within a two-week period. Two of the five IHCRs contained Sick Call Request forms completed by each youth and a registered nurse. A review of the Sick Call Referral Log indicated one of the three remaining IHCRs had one Sick Call Request form missing, and in the other two IHCRs two Sick Call Request forms were missing from each. The completed Sick Call Request forms were filed in each youth’s IHCR in reverse chronological order, were documented in accordance with the Florida Administrative Code, and none of the youth were in restricted housing. One of the five IHCRs documented all sick calls on the Sick Call Index. Three of the remaining four IHCRs had two sick calls missing from the Sick Call Index each, and one IHCR had one sick call missing from the Sick Call Index. All ...