summary: QI Residential - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Duval Academy Re-Review
Wayne Halfway House
(Contract Provider)
7500 Ricker Road
Jacksonville, Florida 32244
Review Date(s): November 4, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Bradley Taylor, Office of Accountability and Program Support, Lead Reviewer (Standard 2)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 2)
BUREAU OF MONITORING AND QUALITY IMPROVEMENT
RE-REVIEW ADDENDUM
Program Name: Duval Academy MQI Program Code: 1280
Provider Name: Wayne Halfway House Contract Number: 10796
Location: Duval County / Circuit 4 Number of Beds: 28
Review Date(s): November 4, 2025 Lead Reviewer Code: 229
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the area (2)
Assessment and Performance Plan.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 3 of 19 (Revised July 2022)
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 19 (Revised July 2022)
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2 .0 5
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Summary
The Duval Academy is a twenty-eight-bed program, for fourteen to eighteen year old males,
located in Jacksonville, Florida. The program is operated by Wayne Halfway House, through a
contract with the Department. The program provides Mental Health Overlay Services (MHOS)
and Substance Abuse Treatment Overlay Services (SAOS). In addition, the program fosters
each youth by providing Cannabis Youth Treatment (CYT), Living In Balance (LIB), Aggression
Replacement Training (ART), Impact of Crime (IOC), and Dialectical Behavior Therapy (DBT).
Additional treatment services provided include individual, group, family, and recreational
therapy. Program administration is comprised of a facility administrator (FA), an assistant facility
administrator (AFA), a human resources/administrative assistant, a food service manager, and a
physical plant manager. Case management services are provided by two case managers
supervised by the program’s designated mental health clinical authority (DMHCA). Mental
health staff at the program include the DMHCA, two non-licensed therapists, a recreational
therapist, and a transition services manager. Medical services are offered daily from 7:00 a.m.
to 5:00 p.m. and are provided by a designated health authority (DHA) a health services
administrator (HSA), one full time registered nurse (RN), and two part time RNs. Educational
services are provided by the Florida Scholars Academy. The layout of the program includes: a
main building, which includes administration, staff offices, youth living areas, a dining room,
kitchen, a classroom, and large meeting area/pavilion, and two classroom portables. The
program has thirty-six operating security cameras providing coverage. At the time of the re-
review, the program had no vacant positions. A re-review was conducted for standard two.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 19 (Revised July 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contracts to Parent/Guardian and Court Notifications
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a written policy and procedures in place to address initial contact to the
youth’s parent/guardian as well as the committing court. The policy stipulates guidelines for
initial contacts to parent/guardians for youth upon admission. The youth’s parent/guardian is
contacted by phone and followed up with an admission packet which includes program
information and a questionnaire to assist in treatment planning. Parents/guardians are asked to
complete and send back in the provided self-addressed envelope provided by the program. The
assigned case manager staff notifies the youth’s committing court, assigned juvenile probation
officer (JPO), and post-residential services case manager, as applicable, in writing upon
admission. Five youth case management records were reviewed, and all records contained
documentation the parents/guardians were contacted by telephone on the day of admission. All
records indicated parents/guardians were mailed a parent admission letter on the day of
admission. All reviewed records contained a copy of the Judge Notification of Admission Letter
sent to the committing court informing them of the youth’s placement which was mailed on the
day of admission. The documentation further indicated the youth’s assigned JPO was copied on
the notification and if known at the time of admission, the youth’s post release counselor.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures in place to address initial contact with the youth’s
parent/guardian as well as the committing court. The program’s policy states case management
staff will contact the parent/guardian by telephone, within twenty-four hours of admission, to
notify them of the youth’s placement in the program. The case management staff is to send
written notification to the parent/guardian within forty-eight hours of admission to the program.
The assigned case manager will notify the committing court, assigned juvenile probation officer
(JPO), and post residential services case manager, as applicable, within five working days. Five
youth case management records were reviewed. Each record contained documentation
showing the program notified the parent/guardian by telephone with twenty-four hours of
admission and were notified in writing within forty-eight hours. Each record also contained
documentation showing the court and JPO were notified within five working days of the youth’s
admission.
2.02 Youth Orientation
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a written policy and procedures in place to address youth orientation. Five
youth case management records were reviewed, and all contained documentation showing the
youth participated in an orientation on the day of admission. The youth’s assigned case
manager completed the Orientation Checklist which addresses the program’s rules,
expectations and goals, as well as services applicable to the youth. This orientation includes a
review of all requisite information and the following information: assignment to a treatment team,
introduction to key staff and their roles, assignment of a living unit, group leader, and primary
counselor, review of the program goals, services, responsibilities, and expectations, review of
the behavior management system and disciplinary actions, review of disaster preparedness
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 19 (Revised July 2022)
procedures and emergency building evacuation procedures and routes to include advising youth
of areas which are off-limits, student area search procedures, contraband policy and
consequences for possession, review of the daily facility schedule guidelines, dress code and
hygiene expectations, review of resident rights, grievance and abuse reporting, access to
emergency medical, dental, and mental health/substance abuse services including hours of sick
call, performance planning and eligibility for release criteria, visitation schedule, telephone and
correspondence policies and procedures, release criteria and anticipated length of stay, review
of personal property/valuables guidelines, criteria for off-campus activities,; rules and
regulations regarding youth conduct, review of the program’s gang pamphlet, and a review of
the student handbook. Information contained on the orientation checklist is discussed with the
youth by the case manager on the day of admission. Once all information is reviewed,
completed forms are signed and dated by both youth and the case manager. All records
contained a signed acknowledgement attesting each youth had received a copy of the
program’s handbook for youth. Additional information reviewed with the youth at admission
included a review of rewards and consequences, Prison Rape Elimination Act (PREA)
information, information on how to access outside victim advocates for emotional support
services related to sexual abuse, and items deemed unauthorized when in possession of youth.
During the annual compliance review the program did not have any admissions to observe. Five
youth were interviewed and all five indicated they participated in the orientation process on the
day of their admission, were provided with the aforementioned materials, and were encouraged
to ask questions if they had any.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures to provide youth orientation to the program’s rules,
expectations, goals, and services applicable to the youth on the day of youth’s admission or
prior to admission into the program. The program utilizes an orientation checklist during the
process to ensure all required elements are addressed. Youth are also provided a handbook
detailing all required elements and are required to sign a form indicating they received and
reviewed the handbook. During the re-review, the program did not have any admissions;
therefore, an observation of orientation could not be completed. Five youth case management
records were reviewed. A review of records verified each youth received an orientation to the
program on the day of admission.
2.03 Written Consent of Youth Eighteen Years or Older
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a written policy and procedures which addresses written consent of any youth
eighteen years of age or older and outlines steps for the assigned case manager. Language
which addresses the program’s expectations for written consent are contained within their
orientation policy. Five youth case management records were reviewed to determine if the
program obtained written consent for providing youth information with the parent/guardian,
Department of Children and Families, or other applicable agencies. None of the five records
reviewed were applicable. The program provided three additional case management records for
youth over the age of eighteen. All three records contained an Authorization to Release
Information form which was signed by the youth on their eighteenth birthday or upon admission
to the program for those youth who were already eighteen years of age at the time of
placement. All Authorization to Release Information forms were signed and dated by the youth
as well as a witness. There were no incidents observed where information was sent to a
parent/legal guardian without consent.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 19 (Revised July 2022)
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures to obtain written consent of any youth eighteen years
of age or older for release of their confidential information to their parent/guardian. Five youth
case management records were reviewed. Three youth were applicable for requiring written
consent. Each of the three applicable youth case management records contained written
consent forms signed by the youth.
2.04 Classifications Factors, Procedures, and Reassessment for Activities
The program originally received a Limited Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a written policy and procedures in place which addresses a classification
system, is implemented in accordance with Florida Administrative Code, and promotes safety
and security as well as the effective delivery of treatment services. The system is designed to
ensure the safest room and dorm assignment for the arriving youth. Upon being admitted to the
program the youth is assessed for youth demographic information, physical characteristics, level
of maturity, background information, key indicators or abnormal behaviors, such as medical
needs and mental health/substance abuse needs, youth’s skill level, current committing
offense(s), demonstrated behavior at intake, the youth’s prior history, security risk, gang
affiliation/involvement, internal alert classification, and vulnerability and or level of aggression.
Missing from the program’s classification form and screening process was the youth’s
perception of vulnerability as well as a review of the youth’s history of potential or verified
human trafficking. The form classifies youth based on their risk. Five case management records
were reviewed. All five reviewed records demonstrated the classification meeting was
completed at the time of the youth’s admission. Two youth were admitted with verified medical
alerts in the Department’s Juvenile Justice Information system (JJIS) which were not identified
on their classification forms. Another youth was admitted as a designated gang member on the
classification information; however, JJIS and other screening documents did not support this.
None of the aforementioned designations were transferred to the program’s internal alert
system. According to the program, each youth is placed on an internal security level known as
“orientation” level; however, two of the records demonstrated contradictory information relating
to this. Three youth were placed on orientation level, while two other youth were placed on
security alert for reasons not supported in JJIS or internal screening documents. The program
maintains a separate binder of risk assessments which the program’s policy states are
completed at “regular intervals”. The risk assessments reviewed demonstrated an ongoing
review of each youth’s review of potential increase in movement and/or privileges, participation
in possible work projects or off campus activities. None of the youth reviewed were eligible for
work projects; however, the youth were granted the ability to utilize class B tools such as mops
and brooms. An interview with the program director revealed ”all rooms are double youth
occupancy. Youth prior victimization is assessed using the Vulnerability and Sexually
Aggressive Behavior screening (VSAB) and youth identified as having prior victimization are
placed strategically away from peers identified as aggressive on the VSAB. Housing
assignments are a collaboration between the operational and clinical teams.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures to utilize a classification system, in accordance with
Florida Administrative Code, promoting safety and security, as well as effective delivery of
treatment services. The program utilizes a classification system for which a youth’s classification
is determined by their individual needs and identified risk factors. A review of the program’s
classification form revealed the form includes all required elements. For the youth’s perception
to vulnerability and the youth’s history of potential or verified human trafficking, the program
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 19 (Revised July 2022)
utilizes the Screening for Vulnerability to Victimization and Sexually Aggressive Behavior
(VSAB), located in the Department’s Juvenile Justice Information System (JJIS). A review of five
youth case management records revealed each youth record contained an admission
classification form including all required elements. Each youth was classified for the purpose of
assignment to a living area, sleeping room, and group. A review of the JJIS alert list for any
issues affecting classification was completed for each youth and any identified risks were
entered into JJIS. The program’s policy and procedures also address reassessment prior to
consideration for increase in the youth’s privileges or freedom of movement or participation in
any work projects or off-campus activities. Each youth record contained a reassessment prior to
consideration for participation in work projects or off-campus activities. The treatment team, as
necessary throughout the youth's commitment, will reassess and reclassify, 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.
2.05 Gang Identification: Notification of Law Enforcement
The program originally received a Failed Compliance rating for this indicator during the 2024-
2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a written policy and procedures in place which outlines notification of law
enforcement regarding youth entering the program with suspected gang affiliation, or
documented gang membership, as well as for youth who are observed engaging in gang
activities during their commitment to the program. Five case management records were
reviewed; however, only one was applicable for gang affiliation or membership. The program
was able to provide two additional records for review of gang identification and notification. Each
of the youth were admitted with previous gang alerts from their home counties confirmed in the
Department’s Juvenile Justice Information System (JJIS), as well as completed gang
questionnaires. None of the identified youth had any documentation to support local law
enforcement or law enforcement in the youth’s home county were contacted. Two of the three
applicable youth records contained notifications to the school system and all three applicable
youth had notifications to the juvenile probation officer (JPO).
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures for gathering information on gangs or youth involved
in gang and sharing this information with law enforcement. Five youth case management
records were reviewed. One youth case management record was applicable for gang
involvement. No other youth were applicable for gang involvement during the re-review
compliance period. Documentation revealed local law enforcement and law enforcement from
the youth’s home county were notified of the youth’s suspected gang activity. This notification
was completed prior to the seven-day notification from the Department. A review of the
Department’s Juvenile Justice Information System (JJIS) showed an alert was placed in the
internal alert system for the youth being identified as a gang member while in the program.
Documentation also revealed notification was sent to the youth’s juvenile probation officer (JPO)
and the educational provider. No notification to the youth’s post-residential counselor was
needed as the youth was not applicable.
2.06 Gang Identification: Prevention and Intervention Activities
The program originally received a Failed Compliance rating for this indicator during the 2024-
2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 19 (Revised July 2022)
The program has a written policy and procedures in place which addresses the implementation
of gang prevention and intervention strategies. During the admission process, youth are
screened for gang involvement with the gang questionnaire and cross referencing the youth’s
face sheet and alerts page in the Department’s Juvenile Justice Information System (JJIS). The
policy stated the use of Impact of Crime curriculum (IOC) will be a component of the intervention
strategies used. The policy further stated the program will also seek out “education and guest
speakers”. The program provided a “gang binder” which offered “Gang 50 Stories” as an
additional intervention activity, not mentioned in their policy; however, the program could not
provide any completed assignments for any of the youth identified as gang members. Five
records were reviewed and one youth was applicable. A review of the JJIS alerts and closed
record samples revealed two additional samples. The one youth identified in JJIS was not
identified as such in the program’s “gang binder”. Each of the identified youth had delinquency
intervention goals related to completing IOC; however, none of the youth had any specific
identified goals or objectives related to gang prevention/intervention. A review of sign-in sheets
revealed each youth was participating in or had completed the IOC curriculum. The program’s
internal alert system failed to identify all three youth as gang involved, but did identify one youth
who was not affiliated with a gang according to JJIS as gang affiliated on their alert board. The
program’s policy as well the program director’s interview indicated a youth will be provided the
opportunity to “dis-affiliate” from their identified criminal street gang should they choose.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures requiring the implementation of gang prevention and
intervention strategies. One youth record was applicable for youth identified as a member or
affiliated with a gang. Documentation reflects the youth participates in gang prevention and
intervention strategies at the program. The youth’s performance plan includes relevant goals
and objectives related to gang intervention strategies for the youth to complete prior to release
from the program. The program utilizes Arise: Fifty Gang Stories curriculum for youth with gang
affiliations. The program provides youth an opportunity, if they desire, to develop a plan to
disaffiliate with a criminal street gang.
2.07 Residential Assessment for Youth (RAY) Assessments and Re-Assessments
The program originally received a Limited Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place to ensure a Residential Assessment for
Youth (RAY) is completed within thirty days of the youth’s admission to the program and the
RAY re-assessments are completed within ninety days after completion of the initial RAY . Five
youth case management records were reviewed, and all five records contained an initial RAY
completed within the required timeframe. All initial RAYs were completed with the Department’s
Juvenile Justice Information System (JJIS). Five records were also reviewed for eligibility of
RAY re-assessments. Four youth were eligible. All four records demonstrated the youth’s RAY
re-assessments were completed beyond the ninety-day requirement. One record only had a
modified initial RAY within the required timeframe. The remaining three records were twenty-
three, nine, and one day late. None of the printed RAY re-assessments had corresponding
comparative reports.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures requiring an initial assessment of each youth is
conducted within thirty days of admission, utilizing the Residential Assessment for Youth (RAY)
tool. Documentation of the initial assessment process is maintained in the Department’s
Juvenile Justice Information System (JJIS). The program completes reassessments on each
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 19 (Revised July 2022)
youth at least every ninety days from the date of the initial assessment. Other updates or
reassessments are to be completed when deemed necessary by the intervention and treatment
team to effectively manage each youth. Five youth case management records were reviewed.
Three of the five contained a RAY which was completed within thirty days of admission. Two
youth RAYs were one day late. All five assessments were maintained in JJIS, as required. None
of the reviewed records required a re-assessment. The program maintained all assessment
documentation in each youth’s case management records.
2.08 Youth Needs Assessment Summary (YNAS)
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place to ensure the Youth Needs Assessment
Summary (YNAS) is conducted within thirty days of the youth’s admission to the program. The
youth’s assigned case manager is responsible for gathering information from all members of the
treatment team as well as collateral documents and incorporating this information into the YNAS
report. Five youth case management records were reviewed, and all contained a YNAS report
which was completed with the required timeframe. All YNAS reports were completed prior to the
youth’s Individualized Performance Plan (IPP) in the Department’s Juvenile Justice Information
System (JJIS).
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures which require they ensure a Youth Needs
Assessment Summary (YNAS) is completed within thirty days of each youth’s admission. A
review of five youth case management records confirmed a YNAS was completed within thirty
days of admission for three of the five youth. Two of the YNAS were completed one day late.
Each YNAS was documented in the Department's Juvenile Justice Information System (JJIS)
and included the top three criminogenic needs for each youth.
2.09 Performance Plan Development, Goals, and Transmittal (Critical)
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a written policy and procedures which addresses the intervention and
treatment team, including the youth and the need to meet and develop the performance plan
within thirty days of admission. The program’s policy outlines the required members of the
treatment team, which include, youth, juvenile probation officer (JPO), and parents/guardians to
be involved in the development of the youth’s Individualized Performance Plan (IPP) within thirty
days of admission to the program. Parents/guardians are provided a questionnaire at admission
and encouraged to provide feedback in the development of the plan accordingly. Other
disciplines provide input in order to create the youth’s IPP. Five youth case management
records were reviewed. All five contained documentation of the IPPs were developed within the
required timeframe and developed following the youth’s Youth Needs Assessment Summary
(YNAS) and initial Residential Assessment for Youth (RAY), as required. The youth’s
intervention and treatment team were present during the development of the IPPs and included
participation from the following parties: treatment team leader (youth’s case manager), youth,
program administration, direct care/living unit representative, mental health treatment staff,
education/vocation staff, and medical staff. All IPPs contained individualized goals based on the
prioritized needs of the youth. The top three criminogenic needs were identified in each
performance plan reviewed. One of the plans did not address delinquency interventions and two
did not address court ordered sanctions. The remaining plans met all required elements. All five
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 19 (Revised July 2022)
IPPs had corresponding transmittals within ten working days to the juvenile probation officer,
courts and parents/guardians requesting their review and signature. None of the five reviewed
records contained returned signature pages. Each IPP listed the responsibility of staff in
completing the goal, responsibility of youth in completing the goal, start date, and projected
completion/end date. All five interviewed youth indicated they participated in the development of
their performance plan.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures requiring the intervention and treatment team,
including the youth, to meet and develop a performance plan within thirty days of admission.
These plans are developed after the Residential Assessment for Youth (RAY) and the Youth
Needs Assessment Summary (YNAS) are completed. The performance plan specifies the target
date for completion of each goal, including the youth’s responsibilities to accomplish the goal,
and the program’s responsibilities to enable the youth to complete the goal. Upon completion,
the program must 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. Three of the five had a performance plan developed within thirty days of
admission. Two plans were developed one day late. All five performance plans were developed
after the RAY and YNAS, and all were signed by the intervention and treatment team leader, the
youth, the facility administrator (FA), a living unit representative, treatment staff, education staff,
and all other parties who had significant responsibility in goal completion. All five youth had their
parent/guardian participate in the development of the performance plan by telephone, and
signature sheets were mailed for the parent/guardian to sign and return to the program. None of
the parent/guardians returned the signature sheet. All performance plans included goals which
were based upon the prioritized needs identified during the initial assessment, and the top three
criminogenic needs for each youth. Delinquency interventions, target court-ordered sanctions,
transition activities, youth and program staff responsibilities for goal accomplishment, as well as
target dates for goal completion were listed on the performance plans. All five youth records
contained documentation verifying a copy of the plan was sent to the committing court, JPO,
parent/guardian, and DCF counselor, where applicable.
2.10 Performance Plan Revisions and Incorporation of Other Plans
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place which addresses performance plan revisions.
The program meets formally as a multidisciplinary team to review the youth’s performance plan
goals every thirty days 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 re-assessment and should the results warrant, will revise the youth’s
performance plan goals. Five youth case management records were reviewed and four were
applicable. The youth reviewed each had at least one RAY re-assessment completed. Two of
the four reviewed records reflected changes when warranted due to progress, while the
remaining two had behavioral issues noted and a lack of progress. Each of the four applicable
records reflected the incorporation of both academic and treatment plans within the youth’s
performance plan. One youth warranted inclusion of their Department of Children and Families
(DCF) case plan and demonstrated the plan was incorporated into their respective performance
plans. Three closed records were reviewed and one open record contained documentation
showing the youth’s performance plan was updated to facilitate transition activities during the
last ninety days of the youth’s commitment.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 19 (Revised July 2022)
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures to address revisions to individualized performance
plans, when determined necessary, by the intervention and treatment team. The policy requires
revisions when new criminogenic needs are identified during the Residential Assessment for
Youth (RAY) reassessments, when the youth demonstrate progress or lack of progress toward
completing a goal, or when new information is acquired or revealed. Five youth case
management records were reviewed and four were applicable for a performance plan revision.
All revisions had at least one monthly review of each youth due to RAY reassessments, newly
acquired information, progress towards completing goals, and/or lack of progress toward goal
completion. Two applicable youth’s individualized performance plan revisions were completed to
facilitate activities during the last sixty days in the program. None of the youth’s performance
plans were applicable for referencing additional treatment and academic plans as they did not
have any such plans. None of the youth reviewed were applicable for a behavior support or
case plan.
2.11 Performance Summaries and Transmittals
The program originally received a Limited Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place to ensure performance summaries and
transmittals are completed within required timeframes. At each ninety-day interval, beginning
ninety days from the signing of the youth’s Individualized Performance Plan (IPP), the
intervention and treatment team meets to create a performance summary. In addition, prior to
the youth’s release, discharge, or transfer from the program, the intervention and treatment
team will meet in order to create the performance summary. Five open and three closed youth
records were reviewed for the completion of performance summaries. Three of the open youth
and all three closed youth records were applicable for performance summaries. A total of eight
summaries were reviewed. Seven of eight performance summaries reviewed were completed
within timeframe requirements and the remaining one was twenty-three days late. Three of the
five open youth performance summaries did not capture any youth comments, instead noting
the section was “not applicable”. Each of the open youth summaries had corresponding
transmittals to required individuals; however, the closed records did not have any corresponding
transmittals. All performance summaries included the youth’s status on each performance and
treatment plan goal, the youth’s overall adjustment and progression in the residential
commitment program, the youth’s overall progress during the rating period, youth’s interaction
with peers, interaction with staff, overall behavior adjustment to the program, and any significant
positive and negative events. Two performance summaries did not note the youth’s readiness to
change and two summaries did not document the youth’s grades or academic status. The
completed performance summary was signed and dated by the staff member preparing the
performance summary (case manager), who was also the treatment team leader; program
director or designee, and the youth. A review of the three open records found the three
applicable youth did not receive a copy of their performance summary. Three closed records
were reviewed for discharge and release summaries. All three records contained the original
release summary which included the justification for the youth’s release from the program. All
records contained a Pre-Release Notification (PRN), completed at least forty-five days prior to
the youth’s release. All summaries and PRNs were signed by the appropriate parties and
maintained in the youth’s closed case management record. None of the closed records
contained notification to the parents/guardians confirming the youth’s release date once the
program received the approved PRN from the committing court. All three closed records
contained documentation supporting the exit Residential Assessment for Youth (RAY) was
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 19 (Revised July 2022)
completed for each youth following approval of their release. No youth were applicable for the
Sexually Violent Predator Program (SVPP).
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures to address the requirements for completion of
performance summaries every ninety days. The performance summaries are due within ninety
days of the signing of the youth’s individual performance plan (IPP), or at shorter intervals, if
requested by the committing court. The policy further requires the treatment team to prepare a
performance summary prior to the youth’s release, discharge, or transfer from the program. The
performance summary provides information to the youth, parent/guardian, juvenile probation
officer (JPO), and other parties related to the status of each performance goal and describes the
youth’s overall adjustment to and performance in the program. Five youth case management
records were reviewed and four were applicable for performance summaries. Three of four
youth records had the performance summaries completed within ninety days of the individual
performance plan. The remaining record had one summary which was completed forty-nine
days late. Reviewed documentation reflected each youth was allowed to read and add
comments prior to signing in each summary, each youth was provided a copy, and the original
summaries were filed in each youth case management record. All summaries were signed by
the applicable treatment team members and the youth. In two youth records, all summaries
were sent to the committing court, juvenile probation officer (JPO), and parent/guardian within
ten working days of completion. In one of the remaining records, two applicable summaries
were reviewed and one of the summaries was not sent to the committing court, JPO, or
parent/guardian; however, the other was sent within the required timeframe. In the last
remaining record, one applicable summary was reviewed and the summary was not sent to the
committing court, JPO, or parent/guardian. The program provided three closed records for
review of release summaries. In all three records, there was a signed copy of the original
summary sent to the JPO along with the Pre-Release Notification (PRN) at least forty-five days
prior to the youth’s anticipated release date. Each summary contained the justification for
release. All reviewed records were applicable for direct discharge and all discharge summaries
were sent to the appropriate parties. None of the records were applicable for the Sexually
Violent Predator Program (SVPP). In all three records, the program provided written notification
to the youth’s parent/guardian of the approval for release. An exit Residential Assessment for
Youth (RAY) was completed in all three records. None of the records were applicable for victim
notifications being mailed.
2.12 Parent/Guardian Invovement in Case Management Services
The program originally received a Limited Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures to encourage and facilitate the involvement of the
youth’s parents/guardians in the case management process. The policy outlines how parent
participation is facilitated throughout the entire youth’s length of stay in the program. If the
parent/guardian is unable to attend any of the meetings in person, they are given the
opportunity to participate by telephone and can provide verbal or written input as well. Five
youth records were reviewed and reflected the youth’s parent/guardian are contacted at the time
of admission and mailed an admission letter which is inclusive of a handbook and a
questionnaire asking for input into treatment planning. There were no formal treatment teams
scheduled or observed during the annual compliance review week. None of the five youth
records indicated the parents/guardians were provided any advance notice of the youth’s formal
treatment teams. Additionally, there was no correspondence inviting the parents/guardians to
participate in the youth’s transition. The formal treatment teams reviewed indicated many
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 19 (Revised July 2022)
parents/guardians participated by phone; however, there were no comments noted to confirm.
The program reported they provide weekly visitation; however, documentation of visitation was
sporadic. The facility administrator was interviewed and advised family sessions are offered
monthly. Five interviewed youth stated their parents/guardians are involved in their case
management through weekly telephone calls, case management communicating with them,
family therapy, visitation and/or video calls, and treatment team meetings.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures to encourage and facilitate involvement of the youth’s
parent/guardian in the case management process. The program invites the youth’s
parent/guardian to participate in the assessment process, development of the youth’s
performance plan, progress reviews, provides advanced notice of formal treatment team
meeting dates and times, and transition planning. If unable to attend, the program gives the
parent/guardian the opportunity to participate by telephone. A treatment team was observed,
and found the parent was participating by telephone during the meeting. They were able to
provide input on the youth’s progress or lack of progress. The program reaches out to the
parent/guardian through regular mail and e-mail to facilitate involvement. The program also has
family days where the parent/guardian can come and spend time with the youth.
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews)
The program originally received a Limited Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place to ensure each youth and their intervention
and treatment team meet on a bi-weekly basis to review the youth’s performance, to include
Residential Assessment for Youth (RAY) re-assessment results, progress on individualized
performance plan (IPP) goals, positive and negative behaviors, including behavior resulting in
physical interventions, and treatment plan progress. Five youth case management records were
reviewed and a twenty-three formal treatment team reviews were reviewed. Each meeting was
held at thirty day intervals and contained components which addressed a review of the
Performance Plan Progress Report, performance plan goal focus for the month, stages of
change, physical and medical progress report, education progress report, review of progress
reports, mental health/substance abuse progress report, issues/concerns with peers or staff,
overall program adjustment, and program behavior and performance progress report. The
documentation contained evidence participants who actively participated could sign. This
included the youth’s parents/guardians and juvenile probation officer (JPO). The reviews
documented if the parent/guardian and JPO participated, it was by phone and there were no
comments or signatures confirming their participation. Each record also contained informal
treatment team meetings held every thirty days. None of the informal reviews had any evidence
the youth participated in the meeting. Only the case manager’s signature was present. The five
youth records reviewed did not contain any evidence the youth’s parent/guardian and JPO
received advance notice of the meetings. The program was able to provide two chronological
notes which contained phone notifications to parents and one email to a JPO. There were no
scheduled treatment teams to observe during the program’s annual compliance review week.
Five interviewed youth stated staff talk about their performance to include their progress on
performance plan goals, positive and negative behavior, and treatment progress during
treatment teams. All five-youth indicated they are able to show the skills they have learned by
self-reporting during their treatment teams about what they are working on, what they need to
work on, and what they want to work on.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 19 (Revised July 2022)
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program has a policy and procedures to address the members of the treatment team and
meetings. The policy identifies the case manager to be the treatment team leader. The
program’s treatment team members consist of the case manager/treatment team leader, youth,
and representatives from program administration, education, the youth’s living unit, mental
health treatment, education, and medical. The juvenile probation officer (JPO) is also part of the
treatment team, and, when applicable, the transition case manager, and the youth’s
parent/guardian or the Department of Children and Families (DCF) case worker are included.
Five reviewed case management records documented eleven formal treatment teams were held
as required. Ten of the eleven reviewed treatment teams included documentation of all required
elements. The remaining reviewed treatment team was missing documentation of two required
attendees, comments from treatment team members, a brief synopsis of the youth’s progress in
the program, positive and negative behaviors, behaviors resulting in physical interventions, and
treatment progress. Four of the five reviewed case management records held ten informal
treatment teams as required and included all required documentation. The remaining case
management record did not have any documentation of two informal treatment team meetings
being held.. All required parties were invited and encouraged to participate through advanced
notification, and when participation could not be arranged, opportunity to provide verbal or
written input was given. A treatment team meeting was observed, and all required staff were
present.
2.14 Transition Planning, Conference, and Community Re-Entry Team Meeting (CRT)
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place addressing the program’s transitional
planning process, to include participation of the program and the youth in the Community Re-
Entry Team (CRT) meeting. A review of three closed youth case management records revealed
two out the three records contained evidence a transition conference summary being completed
at least sixty days prior to the youth’s targeted release date. One transition conference summary
was one day late. Each record also contained evidence of documentation each transition plan
was developed by the youth, case manager (treatment team leader), administrative
representative, clinical services representative, education representative, medical
representative, juvenile probation officer (JPO), and the youth’s parent/guardian. Documentation
in all three closed records verified all attendees signed and dated the transition plan. Two of the
three records did not show evidence of the plan being sent with a request for return with
signature to the parent/guardian and JPO. None of the plans had a signed and returned
signature page from their JPO or parent/ guardian. Additionally, none of the closed records
contained evidence any plans sent electronically had a return email acknowledgment from the
youth’s assigned JPO. All three youth records contained evidence of the youth and assigned
case manager participating in the CRT held prior to the youth’s release. The program was able
to provide email notification from the assigned JPOs inviting participation to the CRT. Records
further contained evidence the treatment team members reviewed transition activities listed on
the youth’s Individualized Performance Plan, identified additional transition activities, identified
target completion dates, and the person responsible for completion.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
Three closed youth case management records were reviewed for transition planning,
conference, and Community Re-Entry Team (CRT) meeting. The transition conference was held
at least sixty days prior to the youth’s targeted release date in two of the three records. The third
transition conference was held seven days late. The youth, treatment team leader, program
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 19 (Revised July 2022)
director, and other team members attended the transition conference for all three youth. The
treatment team leader invited the youth’s juvenile probation officer, parent/guardian, education
staff, and other pertinent parties, for all three records. During the transition conference, the
participants reviewed transition activities in the youth’s performance plan, revised the
performance plan, identified additional transition activities, identified target completion dates,
and persons responsible for completion in all three records. The treatment team leader obtained
attendees dated signatures and a copy of the plan was sent with a request for return with
signature to anyone not in attendance, who had a responsibility for completion of transition
goals, in each of the three records. When the plan was transmitted electronically the return
email acknowledgement receipt was printed and filed with the plan. For all three applicable
youth, a Community Re-Entry Team (CRT) meeting was conducted prior to the youth’s release.
The youth and case manager participated in the CRT meeting in all three records, and there
was evidence of an invitation to participate in the meeting.
2.15 Exit Portfolio
The program originally received a Limited Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place addressing the program’s exit process to
include assembling an exit portfolio for each youth to assist them once they are released back
into their home community. A review of three closed youth case management records found all
contained elements of an exit portfolio. None of the records verified the exit portfolio was
initiated during the youth’s transition conference. None of the portfolios contained state issued
identification cards, social security cards, or birth certificates; however, there was evidence
these documents were solicited from the parents/guardians at admission. None of the exit
portfolios contained a calendar with all dates, times, and locations of upcoming community
appointments. All three exit portfolios contained a copy of the youth’s transition conference. Two
of the three portfolios contained the following: vocational certificates, educational records,
school transcripts, and resumes. Only one youth portfolio contained a sample of employment
application. None of the youth’s portfolios contained evidence they were verified at the youth’s
exit conference, provided to the youth upon their release, or forwarded to the youth’s juvenile
probation officer. A review of the program’s contract did not reveal any additional requirements
for the youth’s portfolios.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
Three closed youth case management records were reviewed for the Exit Portfolio. The Exit
Portfolio was discussed and initiated for the youth during the transition conference in all three
records. All three Exit Portfolios included a copy of the youth’s transition plan, calendar with
dates, times and locations of upcoming community appointments, education and/or vocational
certificates, education records, school transcripts, resume, and sample employment
applications. One of the three Exit Portfolios included the youth’s social security card, birth
certificate, and state identification card and the second Exit Portfolio contained a state
identification card. The third record did not include any identification documentation; however,
there was documentation showing the program made attempts to obtain the documents from
the youths’ parent/guardians. All three Exit Portfolios were verified during the Exit Conference,
and documentation indicated the portfolio was completed and given to the youth upon release.
All three records reflected program staff forwarded the Exit Portfolio information to the youth’s
juvenile probation officer. The program’s contract does not have any additional requirements for
the Exit Portfolio.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 19 (Revised July 2022)
2.16 Exit Conference
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has a policy and procedures in place which addresses participation of the youth
and treatment team in the exit conference. Three closed youth case management records were
reviewed for the completion of an exit conference. All three records contained documentation an
exit conference was conducted after the juvenile probation officer (JPO) was notified of each
youth’s release. Each of the records reflected the meetings were conducted at least fourteen
days prior to the youth’s release in which the status of goals developed at the transition
conference were reviewed and release plans were finalized. A summary of the conference was
found in all of the records and included the date, signatures, names of participants by phone,
and a summary of pending transition goals. As required, each exit conference noted the
required treatment team members participated in person or by telephone. Exit conferences were
held separately from the transition meeting and Community Re-Entry Team (CRT) meeting.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
Three closed youth records were reviewed for an Exit Conference. The conference was
conducted after the program notified the youth’s juvenile probation officer (JPO) of the release
and at least fourteen days prior to release in all three records. Reviewed documentation
indicated the date of the conference, signatures, and a summary of pending transition goals
were included in the Exit Conference in all three records. The youth’s date of admission and
date of termination were documented in each record and correlated with the Department’s
Juvenile Justice Information System (JJIS). The status of transition activities established at the
Transition Conference and plans were finalized for the youth’s release were reviewed. Also
included were provisions for continuation of education and/or employment in all three records.
Documentation showed the youth’s parent/guardian and JPO were aware of the vocational plan
for the youth, and the youth’s case manager and parent/guardian were aware of the plan,
documents, and post-release discharge plans in all three records. The intervention and
treatment team leader, parent/guardian, education representative, JPO, youth, and other
pertinent parties participated in all three youth Exit Conferences, as required. All three Exit
Conferences were held separately from the Transition and Community Re-Entry Team
meetings, as required.
2.17 Youth Input
The program originally received a Satisfactory Compliance rating for this indicator during the
2024-2025 annual compliance review, conducted March 11, 2025, through March 14, 2025.
The program has written policy and procedures which promotes constructive input by youth.
The program uses informal “Speak Out” forms, grievance procedures, community meetings, and
the student council meetings (youth advisory board). The student council meeting process
outlines participation which is contingent upon the youth’s consistent display of leadership,
civility, and positivity skills as well as demonstrate community service. Members of the board
meet with the administration and treatment team monthly for cohesion. Meeting minutes for the
annual compliance review period reflected youth input. The program’s policy did not specify
frequency of meetings, but there were minutes demonstrating they were held at least monthly.
Speak Out forms were reviewed for the annual compliance review period and reflected
communications between youth and treatment team members for a variety of reasons. Most
communication related to programmatic requests such as the need for more hygiene, level-ups,
or informal conflict resolution. All five interviewed youth stated the program holds town hall
meetings monthly and youth are also able to speak to staff about what happens at the program
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 19 (Revised July 2022)
as well as utilize speak out forms. The facility administrator was interviewed and confirmed
youth advisory board, speak out forms, grievance forms, youth surveys, youth meetings with
facility administrator, and assistant facility administrator, and Monthly Town Hal meetings” are
utilized for youth input.
During the re-review the program received a Satisfactory Compliance rating for this indicator.
The program hosts weekly youth advisory board and town hall-style meetings to promote
constructive input by youth. Youth also have access to the grievance process and speak-out
forms to provide individual input to program administration. During the annual compliance
review, the program was found to promote constructive input by youth using informal “speak
out” forms, grievance procedures, community meetings, and the student council meetings
(youth advisory board).Meeting minutes for the annual compliance review period relected youth
input.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 19 (Revised July 2022)

program_name_raw: Duval Academy Re-Review Standard 2


state: FL

facility_name: Escambia Boys Base

summary: PREA

raw_content:
Program: Escambia Boy Base Year2Cylce4
Report Type: PREA
Fiscal Year:
Status:
PDF URL: https://www.djj.state.fl.us/content/download/1074647/file/Florida_Escambia Boy Base_Year2Cylce4.pdf?version=1

source: DJJ

report_type: PREA

program_name_raw: Escambia Boy Base Year2Cylce4