summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Miami-Dade Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3300 Northwest 27th Avenue
Miami, Florida 33142
Review Date(s): February 10-13, 2026
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:
Sharon Wong, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Dennis Brown, Detention Services, Operations Consultant, (Standard 5)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Interviews)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Interviews and
Video Observation)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Miami-Dade Regional Juvenile Detention Center MQI Program Code: 490
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Miami Dade County / Circuit 11 Number of Beds: 98
Review Date(s): February 10-13, 2026. Lead Reviewer Code: 181
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58
A ll in d ic a to rs h a v e b e e n ra te
D e te n tio n R a tin g P r o file
O v e ra ll R a tin g S u m m a ry
d S a tis fa c to ry a n d n o c o rre c tiv e a c tio n is n e e d e d a t th is tim e .
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting (CCC) * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 58
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p
b e lo w D e p
in a p ro g ra
aam
In d ic a to r R a tin g s
S ta n d a rd 2 - Y o u th M a n a g e m e n t
A d m is s io n
O rie n ta tio n
C la s s ific a tio n
N o tific a tio n o f J P O C irc u it G a n g R e p re s e n ta tiv e
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty
R e le a s e
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s
R e v ie w o f Y o u th in S e c u re D e te n tio n
D a ily A c tiv ity S c h e d u le
E d u c a tio n a l A c c e s s *
C a re e r E d u c a tio n
rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te
rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d
a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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ro g ra m o p e ra te s
to d o s o w ill re s u lt
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 58
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
* T h e D
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p ro g ra m
In d ic a to r R a tin g s
S ta n d a rd 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A E v a lu a tio n
T re a tm e n t a n d D is c h a rg e P la n n in g
M H /S A T re a tm e n t
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e
e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic
a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 58
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p
b e lo w D e p
in a p ro g ra
aam
In d ic a to r R a tin g s
S ta n d a rd 4 - H e a lth S e rv ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n
D H A /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g
S ic k C a ll P ro c e s s
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re
O ff-S ite C a re /R e fe rra ls
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s
M e d ic a tio n M a n a g e m e n t
P s y c h ia tric S e rv ic e s *
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n
P re n a ta l C a re /E d u c a tio n
rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te
rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d
a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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ro g ra m o p e ra te s
to d o s o w ill re s u lt
Standard 5: Safety and Security
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D e p
b e lo w D e p
in a p ro g ra
aam
In d ic a to r R a tin g s
S ta n d a rd 5 - S a fe ty a n d S e c u rity
A c tiv e S u p e rv is io n o f Y o u th *
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t*
T e n -M in u te C h e c k s *
C e n s u s C o u n ts a n d T ra c k in g
L o g b o o k M a in te n a n c e a n d R e v ie w s
K e y C o n tro l
V e h ic le s a n d M a in te n a n c e
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s *
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills
E s c a p e D rills
F ire D rills
S e a rc h a n d C o n tra b a n d P ro c e d u re s
rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te
rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d
a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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if a
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pre
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S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
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ro g ra m o p e ra te s
to d o s o w ill re s u lt
Program Overview
The Miami-Dade Regional Juvenile Detention Center is a state-owned detention center,
operated by the Department, located in Miami, Florida. The center serves youth in Miami-Dade
County in Circuit 11. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the ninety-eight-bed center.
Youth are provided with services which include youth orientation, behavior management, safety
and emergency procedures, transportation, mental health, and healthcare services. The
center’s educational services are provided by the Miami-Dade County School District. The
center’s management team includes the superintendent, two assistant superintendents, two
administrative assistants, twelve juvenile justice detention officer (JJDO) supervisors, and thirty
JJDOs. Mental health and healthcare services are provided through the contracted provider,
VitalCore Health Strategies, LLC. The center has seven full-time licensed mental health staff,
two traveling mental health staff, and one designated mental health clinician authority (DMHCA).
. Clinical services provided by the center include mental health and substance abuse
evaluations, mental health treatment planning, individual, group, and family therapy, mental
health crisis intervention services, on-site psychiatric services, and availability for substance
abuse services for youth with co-occurring disorders. Medical services are provided by one
DHA, six registered nurses (RN), one psychiatrist, one advanced practice registered nurse
(APRN), and one medical records clerk (MRC). The medical clinic maintains nursing coverage
Monday through Friday from 7:00 a.m.to 5:00 p.m., and on the weekends from 7:00 a.m.to 5:30
p.m. Food services are provided by Department staff and include menus, meal planning, meal
schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has five living modules which are divided by male and female.
There are 166 security cameras at the center, of which 158 were operational. During the annual
compliance review week, observations of the center’s grounds and landscaping, recreation
areas, kitchen area, administrative offices, and maintenance offices showed the areas were in
good condition; however, graffiti was present throughout the center. Metal arms of chairs were
peeled and rusting, and there was a foul odor throughout the center due to a piping issue. The
plexiglass on each of the living modules and in the classrooms had graffiti. All issues were
brought to the superintendent’s attention. Reviewed documentation confirmed all items needing
repairs were reported to the regional director of Detention services and work orders were
pending approval. During the week of the annual compliance review, the center had fifteen
vacancies, which included four JJDO Is, nine JJDO IIs, one maintenance mechanic, and one
assistant superintendent.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPs) requiring background screenings for all
Department staff, contracted providers, grant recipient staff, volunteers, mentors, and interns
with access to youth and confidential youth records. The center has a background screening
policy and procedures for volunteers, mentors, and interns who work with youth less than ten
hours a month requiring sight and sound supervision. The Annual Affidavit of Compliance with
Level 2 Screening Standards for school district teachers was submitted to the Department’s
Background Screening Unit (BSU) on January 8, 2026, meeting the annual requirement. A
review of twenty staff, five volunteers, and two contracted providers confirmed the center
received background screening results from the BSU/Clearinghouse for each prior to them
having contact with youth or confidential youth records. Reviewed documentation confirmed a
criminal history report was reviewed for each staff, volunteer, and contracted provider staff. Five
staff were applicable for having exemptions obtained prior to working with youth, and each was
obtained as required. The center utilizes an ergometric pre-employment assessment tool for all
direct care applicants. Reviewed documentation confirmed all applicable staff were
administered a pre-employment assessment, and a passing score was documented in each
applicant’s record. Reviewed documentation confirmed each volunteer and contracted staff was
added to the center’s Clearinghouse Employee Roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures (FOPs) requiring a five-year background
rescreening and renewal to be conducted for all Department staff, all contracted provider and
grant recipient staff, volunteers, mentors, and interns with access to youth and confidential
youth records. The center’s policy requires the staff and volunteers to have a five-year
rescreening completed through the Department’s Background Screening Unit
(BSU)/Clearinghouse. There were nine staff applicable for a five-year rescreening during the
annual compliance review period. Each staff’s rescreening was completed and submitted to the
BSU within the required time frames. There were no volunteers or contracted staff applicable for
a five-year rescreening since the last annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures (FOPs) requiring center staff to adhere to a code of
conduct prohibiting any form of abuse, profanity, threats, harassment, intimidation, horseplay, or
personal relationships with youth. The center’s policy and procedures require staff to
communicate and interact with youth in a manner which acts as a role model. A total of five staff
records were reviewed. Three of five reviewed staff records had disciplinary actions for a
violation of the code of conduct with management implementing an oral and written reprimand.
The center reported only two staff were applicable for receiving commendations since the last
annual compliance review. Both staff received commendations in the form of staff of the month.
A formal interview with seven staff confirmed staff’s behaviors shall be respectful of others and
reflect desired behaviors for youth. Violations may result in disciplinary actions up to dismissal.
A formal interview with seven youth confirmed they never had to report abuse to the Florida
Abuse Hotline. All seven youth agreed staff are respectful when talking to them or other youth
and they never heard staff using profanity or threatening language when speaking with other
youth. Each youth reported feeling safe in the center. All seven youth reported never
exchanging social media contact information, email, or telephone numbers with center staff.
Seven interviewed staff were able to explain the process for allowing youth to call the Florida
Abuse Hotline and/or the Department’s Central Communications Center (CCC). Three staff
reported they would notify the supervisor, and four reported they would notify the superintendent
to allow the youth to make a call to the Florida Abuse Hotline. Six staff reported they never
heard staff using profanity when speaking to youth; however, one staff reported once. Each staff
member reported they have never observed a coworker using threats, intimidation, or
humiliation when interacting with youth. Two of the seven staff reported the working conditions
at the center were very good, four reported good, and one reported conditions were fair. A
formal interview with the center’s superintendent confirmed the code of conduct policy is to
ensure staff communicate and interact with youth in a manner which provides a role model of
socially accepted behaviors.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures (FOPs) ensuring when a reportable incident occurs
the center notifies the Department’s Central Communications Center (CCC) within two hours of
becoming aware of the incident. The center had 196 reportable incidents since the last annual
compliance review. A review of nine incidents found all were reported to the CCC within two
hours of the incident. Each incident was documented in the center’s CCC logbook. A review of
the center’s internal incident/grievance reports confirmed there were no additional internal
incidents/grievances, which should have been reported to the CCC and were not. A formal
interview with the superintendent reported, whenever a reportable incident occurs, it shall be
reported to the CCC within two hours of gaining knowledge of the incident or event.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures (FOPs) regarding the use of physical intervention
techniques in accordance with Florida Administrative Code. The center’s policy requires Right
Interactions (RI) Reports to be completed on the same day and to be reviewed by an RI certified
instructor, and superintendent or designee. Documentation reviewed in the Department's
Juvenile Justice Information System (JJIS) confirmed a total of 362 RI incidents were reported
during the annual compliance review period. A total of nine incidents were reviewed. All nine
incidents had RI Reports completed for each use of countermoves, control techniques,
takedowns, or mechanical restraints. A review of nine RI Reports confirmed reports were
completed by the end of each staff’s workday. Each report included statements from all staff
involved and was reviewed by a supervisor or an RI instructor. None of the incidents reported
serious injury to youth or staff requiring immediate contact with the Florida Abuse Hotline or the
Department’s Central Communications Center (CCC). Each report documented a post-RI
interview was conducted with the youth by the administrator, or designee, as soon as possible,
and no longer than thirty minutes after the incident. None of the RI Reports indicated the need
for an RI medical review. Mechanical restraints were not used during any of the reviewed RI
incidents. Reviewed documentation confirmed the superintendent/designee reviewed each
report, after all other reviews, and made comments, if appropriate, within seventy-two hours.
The center had no additional RI incidents noted in internal incidents, grievances, or logbooks
which were not documented. The center’s RI rate during the previous quarter was 17.48 which
is above the statewide Detention RI rate of 13.67. Seven interviewed staff reported using verbal
interventions with youth prior to using RI or mechanical restraints. An interview with the
superintendent reported mechanical restraints are tracked on a separate log and in the logbook.
The superintendent reported the process for monitoring RI incidents and use of force is through
reports maintained in a shared network drive.
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1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures (FOPs) requiring detention staff to complete pre-
service/certification requirements specified by Florida Administrative Code within 180 days of
hire. A review of seven staff training records in the Department’s Learning Management System
(SkillPro) confirmed each staff completed the pre-service and certification requirements within
180 days of hire. Each staff completed a new staff orientation within thirty days of hire. All seven
staff completed the academy training consisting of 120 hours. The center had no returning direct
care and/or state support staff who returned less than one year from separation, applicable for
specific training requirements, since the last annual compliance review.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to 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.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures (FOPs) requiring all direct care staff to 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. The center’s policy requires both in-service and instructor-led training to be completed
annually and documented in the Department’s Learning Management System (SkillPro).
Supervisors are required to complete eight additional training hours. A review of three
supervisors and four direct care staff training records confirmed each staff completed the
required in-service trainings, which were documented in SkillPro. Trainings included active
shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking intervention, information security awareness, mental health
and substance abuse, Prison Rape Elimination Act (PREA), Right Interactions (RI) update,
professionalism, interpersonal communication, and ethics including standards of conduct,
sexual harassment, suicide awareness and prevention, and trauma responsive practices. All
staff completed trainings on the Emergency Care Plan, infection control, and Exposure Control
Plan to include blood-borne pathogens and infection control education, escape prevention, and
fire prevention plan/disaster procedure training. A review in SkillPro for the three supervisors
indicated the minimum of eight-hours of annual training in coaching, leadership, and personal
accountability were completed in addition to the twenty-four hours of required in-service training.
The center’s licensed nurse provided in-service education on girls’ healthcare annually to all
non-healthcare staff involved in the supervision or treatment of girls and this in-service training
included training on monitoring, observation, and emergency care of pregnant youth. Provided
documentation confirmed the center maintains an updated annual in-service training calendar
located in the training office, which was approved by the assistant secretary of Detention
services, the director of the Department’s Office of Talent Leadership, and Culture (TLC), and
the center’s superintendent. An interview with the superintendent confirmed the center’s training
requirements.
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1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submit a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures (FOPs) stating all youth have the right to grieve the
actions of center staff and conditions and circumstances in the center related to the violation or
denial of basic rights. The center’s procedures require a grievance form and a pencil to be
issued to any youth wishing to file a grievance. Grievance forms are available for youth to
access. Grievance forms and deposit boxes were observed on the living modules. A formal
interview with the superintendent reported the three phases of the grievance process. The first
phase, called the informal phase, is where a juvenile justice detention officer (JJDO) attempts to
resolve the complaint through verbal communication. The second phase, called the formal
phase, is where youth are given a grievance form and a pencil to complete the form. The
information is to be documented in the logbook, the form will be given to the JJDO supervisor
within two hours, and a response should be given to the youth by the end of the shift. If there
are findings, the supervisor will document them. The final phase, called the appeals phase, is
where the completed form is forwarded to the superintendent and reviewed. Then a response is
given within seventy-two hours, and the decision is final. Grievance forms are stored for one
year. Seven interviewed youth were aware of the process of filing a grievance; however, none
had ever filed a grievance. Seven staff were interviewed regarding the center’s grievance
process, and three stated forms are located on the living modules, youth fill out the form, and
the form is submitted to a supervisor. One staff stated forms were available on every living
module. Two staff stated they would talk to youth, allow youth to write the grievance, and then
pass it on to the supervisor. The final staff stated if a youth has a grievance, they would allow
the youth to write the grievance and put it in the box for the superintendent. A review of the
Department's Juvenile Justice Information System (JJIS) and the center’s grievance binder
confirmed two grievances were filed during the annual compliance review period. Both youth
grievances were documented in the Department’s Facility Management System (FMS), signed,
and resolved within the twenty-four hour time frame.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures (FOPs) outlining the process of entering and
sharing of alert information. The center’s policy requires alerts for youth to be appropriately
entered, downgraded, or discontinued in the Department’s Juvenile Justice Information System
(JJIS). Seven youth records were reviewed in JJIS for alerts. All alerts were updated, removed,
or entered by a registered nurse (RN), center admitting direct care staff, shift supervisors, or
licensed clinical social worker (LCSW). Each alert entered was documented in a shift report and
the center’s module logbooks. A review of the center’s module logbook indicated supervisors
and administrators were reviewing alerts as indicated with a signature by each highlighted note.
Additionally, the center has an alert board located in the kitchen. An informal interview with the
superintendent indicated staff are given updated alerts daily in shift briefings. Reviewed shift
reports indicated alerts were discussed during shift briefing. A shift briefing was not observed
during the annual compliance review week, due to the briefings not occurring while the review
team was on-site. The center’s process for updating alerts was discussed during an informal
interview with the shift supervisor, who stated alerts are updated by medical or mental health
staff, and/or during the admission process. Alerts are updated with new information as changes
occur. The center had no additional information found during the week of the annual compliance
review which should have resulted in an alert being entered. A formal interview with the center’s
superintendent indicated the center’s medical alerts are entered by nursing staff. Seven staff
were interviewed, and all seven reported alerts are discussed through shift briefings, alert forms,
and the logbook.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a structured method for analyzing data trends. The center's practice regarding
data trends is to gather information to identify patterns and areas of improvement. Information is
shared with staff and administration monthly through management meetings, briefings, and
posted in the briefing room. Reviewed documentation supported this practice. The center
participates in a community advisory board meeting, in which information is shared with
stakeholders on a quarterly basis. The information collected is used in decision making
practices. A review of meeting agendas, surveys, and data collection software confirmed the
center’s practices.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) to ensure proper screening, evaluation, and
documentation is provided for each youth admitted into secure detention in accordance with
Florida Administrative Code. Seven reviewed youth records each contained a completed
Admission Wizard which documented the review of an arrest affidavit/custody order, Detention
Screening Instrument (DSI), and a Suicide Risk Screening Instrument (SRSI). Each record
documented a full-body frisk search, which was completed by a juvenile justice detention officer
(JJDO) of the same gender, a telephone call to the youth’s parent/guardian, a snack/meal was
provided, and the completion of a medical, mental health, and substance abuse screening.
During the week of the annual compliance review, the center had no youth admissions while the
review team was on-site.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures (FOPs) requiring an orientation to occur within
twenty-four hours of a youth being admitted into the center and to be documented accordingly.
Each orientation includes the center’s rules and regulations, grievance procedures, visitation,
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telephone calls, availability of medical, mental health, and substance abuse services, access to
the Florida Abuse Hotline or the Department’s Central Communications Center (CCC) for youth
eighteen years of age or older, new law violations for destruction of property, youth rights,
expectations for behavior, and correlated consequences for failure to meet vital expectations.
Seven reviewed youth records confirmed the center provided an orientation within twenty-four
hours of admission and each contained a signed orientation acknowledgement documenting the
contents were discussed with each youth. During the week of the annual compliance review, the
center had no youth orientations while the review team was on-site. Seven interviewed youth
reported they were informed about the rules and regulations, daily schedule, education services,
visitation, abuse reporting, and behavior management system (BMS) during orientation.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) requiring all youth admitted to the center to
be classified during admission. Seven reviewed youth records confirmed the classification
process included a review of information concerning each youth’s history and status. Reviewed
documentation confirmed the classification for each youth included considerations such as
mental illness, intellectual disabilities, physical disabilities, history of violent behavior, gang
affiliation, criminal behavior, history of sexual offenses, vulnerability to victimization and sexually
aggressive behavior (VSAB) screening results, medical, suicide risk identified or suspected,
escape, security, and history of human trafficking. Each reviewed youth case record confirmed
the classification process included all the required topics to be considered prior to making each
room assignment including the youth’s gender, height, weight, age, and level of aggression.
Each youth was assigned a room based on their classification. Youth were reclassified if
changes in behavior or status were observed. All youth with a history of committing sexual
offenses or being a victim of a sexual offense were placed in a room alone. The superintendent
remains informed on how to identify and address local youth gangs through alerts, youth case
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management documentation, and the center's gang liaison. During an interview with the
superintendent, it was confirmed the center considers factors such as mental health status,
physical health status, cognitive performance, age, and prior victimization when assigning youth
to a room.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOPs) to guarantee pertinent gang information is
shared with the assigned juvenile probation officer (JPO) and the circuit’s gang representative
disseminates suspected gang activity information. One of the center’s juvenile justice detention
officer (JJDO) IIs serves as the active gang liaison and communicates with the JPO gang liaison
and law enforcement officer by email when a youth is identified as a suspected gang affiliate.
Seven youth case management records were reviewed, and none were applicable for
suspected gang activity; therefore, three additional youth case management records were
requested. Reviewed email correspondence between gang representatives and law
enforcement confirmed indications of suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang related drawings, or related activity were shared as required. An
informal interview with the center’s gang liaison confirmed the center’s practice is to forward all
necessary updates and/or information to the JPO, law enforcement officer, staff, supervisors,
and superintendent.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures (FOPs) requiring youth personal property to be
maintained securely. Seven youth case management records were reviewed, and each record
documented all property was inventoried by the admitting juvenile justice detention officer
(JJDO) and entered in the Department’s Juvenile Justice Information System (JJIS). A property
receipt was printed and signed by the youth and the JJDO in five records reviewed. Two of the
youth records reviewed were for youth who were transferred from another center and admitted
in the Department’s uniform, without personal property. All records contained a letter of
acknowledgment regarding unclaimed property. Personal items, such as clothing and shoes,
are placed in a black property bag and secured in the center’s property room. Currency and
other personal items of value are placed in a clear tamper proof bag and placed in a drop safe
which is under camera surveillance. Each tamper proof bag was labeled with the youth’s name,
Department identification number, and a list of the items in the bag with the Valuable Property
Receipt attached. A log was maintained to document all items placed in the drop safe and
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included the date, time, youth name, name of the officer who secured the property, and the
officer’s initials. The property storage room was only accessible by authorized staff. Four total
youth property bags were reviewed, and all were maintained and documented according to
policy. Three valuable property bags were reviewed from the drop safe, and all contained
documentation the property was dropped in the center’s safe. A review of the Department’s
Central Communications Center (CCC) reports since the last annual compliance review
indicated no incidents regarding youth property of value. Seven youth were interviewed, and
each youth reported when they arrived at the center, staff checked their property and they
signed a property sheet ensuring their property was accurate. The superintendent was
interviewed and advised admission staff is responsible for ensuring all youth personal and
valuable property is inventoried on the JJIS Property Receipt and signed by both the youth and
admission staff. Valuable property shall be placed in a clear tamper-proof bag and placed in a
drop safe under video surveillance. An admission was unable to be observed during the annual
compliance review week to confirm the center’s practice for admission of youth property, as no
admissions occurred while the annual compliance review team was on-site.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures (FOPs) to ensure all releases are verified by the
court’s authorization. Three closed youth records were reviewed for release. Each record
contained documentation of a detention order advising the youth to be released. The on-duty
supervisor reviewed all paperwork prior to each youth being released. All three youth were
identified prior to being released and the identification of the parent/guardian or responsible
adult was verified prior to the release with an identification card which was photocopied and
placed in each record. All required parties signed all applicable release forms. None of the youth
were identified as an endangered person. All three youth and their parents/guardians were
provided with future court dates and times upon release. All three closed records’ admission
and release dates correlated with the dates documented in the Department’s Juvenile Justice
Information System (JJIS). During the annual compliance review week, a release was observed,
and it was confirmed the releasing staff were following the center’s release procedures.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
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The center has facility operating procedures (FOPs) to ensure each youth's personal property is
maintained securely and returned to the youth in a timely manner upon their release. Three
closed youth records were reviewed for youth released with personal property, medication, and
aftercare instructions. Each record contained a Property Receipt form signed by the youth and
their parent/guardian upon release. Each record contained documentation verifying the youth
was released to an appropriate person to include a copy of their identification. One record was
applicable for a youth being released with medication. The medication receipt was signed by the
person taking custody of the youth and the person was informed of an upcoming appointment
for the youth. During the annual compliance review period there were examples of youth
property held for more than thirty days. Three examples were reviewed, and the center’s FOPS
were followed for the disposal of abandoned property for each. The process for disposal of
property after thirty days of a youth not retrieving their property includes sending out a letter to
the parent/guardian indicating they have thirty days to retrieve the property. If the
parent/guardian does not retrieve the property, the superintendent or designee must ensure all
money and property are counted and inventoried. One money order shall be sent to the regional
fiscal manager, then the money order is forwarded to headquarters. During the annual
compliance review week, a youth released with property was observed. The shift supervisor
retrieved the youth’s property from the safe and the youth and parent/guardian signed the
appropriate documentation for taking custody of the property. The parent’s/guardian’s
identification was confirmed by their issued driver’s license and a copy was made. The center’s
release procedures were followed during the observation of the youth release.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures (FOPs) ensuring Detention Reviews are conducted
weekly for proper management of youth and the appropriate sharing of information. An informal
interview was conducted with the center’s superintendent, who stated the weekly meetings are
held at 9:00 a.m. on Tuesdays and attended either in-person or virtually by circuit probation
staff, commitment managers, education, medical, mental health, and administrative staff within
the center. Weekly Detention Review meeting documentation, including sign-in sheets,
agendas, and youth specific information, since the last annual compliance review was reviewed,
which confirmed meetings were held weekly and all required participants attended. The purpose
of the Detention Review meeting is to discuss youth in the center, including court hearings,
placements, youth behavior, youth wellbeing, and youth status. A Detention Review meeting
was unable to be observed the week of the annual compliance review, as it took place at the
same time as the entrance meeting, and the review team was unaware prior to the entrance
meeting what time the Detention Review was taking place.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
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The center has facility operating procedures (FOPs) to ensure each youth participates in
constructive activities which benefit the youth and the center. During the annual compliance
review week, a center tour was conducted. The daily activity schedule was posted in each living
module and outlined the days and times for each youth activity. The schedule included times for
wake-up, personal hygiene, mealtimes, visitation, education, recreation and physical activities,
indoor activities, shift change, bedtimes, groups, and open program time. In addition, youth
were observed attending school and open programming in accordance with the schedule.
Logbook documentation confirmed activities such as wake-up, personal hygiene, mealtimes,
visitation, recreation, education, shift change, bedtime, and groups were conducted as
scheduled. Seven staff were interviewed, of which all reported the center’s daily schedule is
followed. Seven interviewed youth reported the center does have a daily activity schedule. Each
of the seven youth stated the daily activity schedule was followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center’s education services are directly supervised and administered by the Miami-Dade
County Public Schools. A review of the weekly/daily education schedule and the center’s
weekly/daily schedule confirmed both schedules were aligned with the start and end times for
educational classes and the center’s daily activities. Video observation review of three random
days of educational instruction confirmed youth arrived and exited from all classes at the
scheduled times. Seven youth were interviewed and reported the education program is
preparing them to pursue a high school diploma, high school equivalency diploma (GED),
vocational school, employment, and/or college. Each youth reported attending school Monday
through Friday. A review of the center’s logbooks for one random day for each month during the
annual compliance review period confirmed youth were being transitioned to and from education
classes at the correct times.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center provides youth with the opportunity to participate in a career themed curriculum. This
course of study is categorized as Type 1 Life Skills Curriculum and is based upon the age of
each youth as well as their individual intellectual and educational abilities and levels. This
course classification, which stresses soft skills, has activities which include learning
development and improvement of effective communication skills as well as focusing upon the
development of interpersonal and decision-making skills. Seven youth were interviewed, and all
seven reported receiving core academic subjects including math, science, history, reading, and
social studies. An interview with the education program’s transition counselor indicated a virtual
vocational platform is used for the career-based curriculum.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures (FOPs) ensuring a single licensed mental health
professional serves as the designated mental health clinician authority (DMHCA) to oversee
appropriate coordination and implementation of mental health and substance abuse services.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The DMHCA is a
licensed clinical social worker (LCSW) with a clear and active license in the State of Florida,
with an expiration date of March 31, 2027. The center has a back-up DMHCA in the event of
scheduled leave and/or absences, who is one of the contracted provider’s regional clinical staff,
who is a licensed mental health counselor (LMHC), with a clear and active license in the State
of Florida, with an expiration date of March 31, 2027. One of the full-time clinical staff can also
serve as the back-up in the DHA’s absence. The back-up DMHCA was not utilized during the
annual compliance review period. A review of the VitalCore Health Strategies, LLC. behavioral
health coordinator job description found the DMHCA oversees all clinical and administrative
operations. The DMHCA is on-site forty hours each week and ensures the appropriate
coordination and implementation of mental health and substance abuse services. The DMHCA
is a full-time staff and scheduled to be on-site forty hours each week, Tuesday through Friday,
between the hours of 7:00 a.m. to 5:00 p.m. and is on-call twenty-four hours a day, seven days
a week. A review of the mental health sign-in logbook confirmed the DMHCA was on-site, as
contractually required. An interview with the DMHCA confirmed they are responsible for
overseeing, coordinating, and implementing comprehensive mental health and substance abuse
services within the center. The DMHCA’s duties require integration of high-level program
oversight with direct involvement in daily service delivery to youth, ensuring all treatment
requirements are met for every youth in the center. The DMHCA coordinates the care for
various youth, full-time mental health staff, monitors caseloads, and reviews charts to ensure all
treatment requirements are satisfied. The DMHCA is responsible for scheduling to ensure hours
and coverage requirements are met/satisfied. The DMHCA holds weekly treatment team
meetings with clinical staff to review caseloads, treatment planning, youth progress, supervision
statuses, and any clinical concerns requiring collaborative attention. The DMHCA manages a
caseload and is responsible for completing all treatment requirements for each youth. Some of
these services include psychoeducation, emotional regulation, cognitive-behavioral techniques,
relapse prevention, and skill-building interventions. Additionally, the DMHCA provides individual
counseling, completes suicide risk assessments, Crisis Assessments, and completes follow-up
assessments for youth under elevated supervision statuses, such as precautionary observation
or close supervision. The DMHCA is responsible for maintaining consistent and ongoing
communication with all clinical staff at the center to ensure the delivery of high quality,
coordinated, and effective mental health and substance abuse services. Communication is
conducted on a daily basis, both formally and informally, and includes direct check-ins, clinical
consultations, and administrative coordination.
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3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. The center requires
mental health and substance abuse services to be provided by individuals with appropriate
qualifications. The clinical supervisor ensures the licensed clinical staff working under their
supervision perform services they are qualified to provide based on education, training, and
experience. The center has seven full-time licensed mental health staff and two traveling mental
health staff, in addition to the designated mental health clinician authority (DMHCA). A review of
the licenses of each mental health professional on the Department of Health (DOH) website
found all were clear and active in the State of Florida, with an expiration date of March 31, 2027.
Each licensed mental health professional is licensed under the appropriate Florida Statute
chapter and copies of the licenses were available on-site. The center did not have any non-
licensed staff at the time of the annual compliance review. The interviewed DMHCA confirmed
all mental health staff at the center are licensed and are on-site for a total of at least 150 hours
Monday through Friday and between sixteen and thirty-two hours on Saturday and Sunday.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. All mental health
services are being provided by licensed mental health professionals. There are no non-licensed
mental health staff providing services at the center. The center does not have a Chapter 397
license, and all substance abuse services are being provided by licensed mental health
professionals. Reviewed documentation and staff credentials confirmed all mental health
services are provided by licensed mental health professionals. Reviewed documentation
supported all substance abuse treatment and groups were facilitated by licensed mental health
professionals.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures (FOPs) to ensure the mental health and substance
abuse needs of youth are identified through a comprehensive screening process. The center’s
policy requires referrals to be made when youth are identified with mental health and/or
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substance abuse needs or are identified as a possible suicide risk in accordance with Florida
Administrative Code. Seven youth mental health records were reviewed. Each youth had a
Suicide Risk Screening Instrument (SRSI) and five of the youth had a new Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2) completed in the Department’s
Juvenile Justice Information System (JJIS). Two of the youth records reviewed were for youth
who were transferred from another center and the MAYSI-2 was completed during their initial
admission. Documentation supported a juvenile justice detention officer (JJDO) reviewed each
youth’s MAYSI-2 results, Face Sheet, and alerts during the admission process into the detention
center. The JJDO completed their assigned section of the SRSI for all seven youth. All seven
SRSIs were reviewed by a licensed mental health professional and included referral information
in the screening results sections. None of the reviewed MAYSI-2 screenings had all negative
responses invalidating the screening. Six of the seven reviewed youth were applicable for
further assessment according to the SRSI and/or MAYSI-2. Documentation supported each
youth was referred for an Assessment of Suicide Risk (ASR) by licensed mental health staff.
One of the seven youth had an elevated suicide risk subscale on the MAYSI-2. Each applicable
youth who required further assessment had a referral made and the superintendent/designee
was notified. Six of the seven applicable youth were placed on suicide precautions. Each of the
six records contained a completed mental health referral, which documented the youth’s need
for an ASR. Each youth applicable for suicide precautions placement had a suicide risk alert
opened in JJIS. Reviewed documentation confirmed the center’s JJDOs were trained to
complete the SRSI.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures (FOPs) regarding the process to identify the mental
health and substance abuse needs of youth through a comprehensive screening. When a
youth’s screening results require a referral for a comprehensive assessment, clinical staff will
either review the comprehensive assessment completed by a community provider, or clinical
staff will complete the comprehensive substance abuse mental health (SAMH) assessment. A
review of seven youth records indicated six youth were identified upon admission as in need of
a new or updated comprehensive evaluation. Three youth were applicable for a new SAMH
assessment completed by center staff. Each of the completed assessments included treatment
recommendations made which corresponded with diagnosed mental health or substance-
related disorders. Each youth received a new SAMH assessment by the thirty-first day of being
in the center. Each reviewed SAMH assessment included treatment recommendations for any
applicable diagnosed mental health or substance abuse disorder. Three youth had a
comprehensive assessment completed prior to their admission and updates were completed by
the detention center. Each of the assessments completed prior to admission were completed by
a community provider. Each of the reviewed community assessments and newly completed
assessments contained all required elements including the signature of the licensed mental
health professional who completed the assessment. Each of the applicable new and/or updated
community assessments/evaluations contained all required elements and the signature of the
licensed mental health clinician who completed them. All updated comprehensive assessments
and new assessments were maintained in the Department’s electronic medical record (EMR).
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An interview with the designated mental health clinician authority (DMHCA) confirmed as part of
the intake and assessment process for mental health and/or substance abuse, the DMHCA will
search the Department’s Juvenile Justice Information System (JJIS) to determine whether a
comprehensive evaluation has been uploaded for each youth. If a comprehensive evaluation is
not located in JJIS, the assigned juvenile probation officer (JPO) is contacted to inquire whether
one has been completed. If the JPO confirms a comprehensive evaluation has been completed,
mental health staff will update the youth’s records and upload the document to the youth’s
upload library in the EMR. If no comprehensive evaluation exists, or if the JPO does not
respond in a timely manner, a SAMH assessment will be completed by the youth’s thirty-first
day in secure detention and entered into the EMR to ensure timely and comprehensive
assessment documentation. This process ensures appropriate treatment plans can be
established, and each youth receives the necessary support promptly.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures (FOPs) for mental health and substance abuse
treatment and discharge planning. The provider’s contract requires the superintendent and
designated mental health clinician authority (DMHCA) or mental health/substance abuse clinical
staff to ensure the development and review of an initial and/or individualized treatment plan for
each youth receiving mental health/substance abuse treatment in the center. A review of seven
youth mental health and substance abuse records indicated all seven were applicable for
mental health and substance abuse treatment services. Each of the seven youth received a
mental health orientation which was held within fourteen days of admission. Each youth
required an initial treatment plan which was completed within seven days of the onset of
treatment. Each initial treatment plan was completed using the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Each of the seven initial treatment plans
addressed the reason for the treatment referral, the initial Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis, initial treatment methods, and goals. Four
youth were applicable for receiving psychiatric services and each plan included the required
medication information. All seven initial treatment plans were created and signed by a licensed
clinical professional and youth. Documentation supported each of the seven youth were
assigned to a mini-treatment team. Documentation confirmed the mini-treatment team members
were present and involved in the development of each initial treatment plan. All seven reviewed
youth required the completion of an individualized treatment plan. The individualized treatment
plans were developed for each youth receiving mental health and/or substance abuse treatment
in the center by the thirty-first day of the youth’s admission. Each individualized treatment plan
was completed on the Department’s form and included the DSM-5 diagnosis, symptoms which
were treatment-focused, treatment goals including mental health services if the youth had a
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mental illness, substance abuse services if the youth had a substance-related diagnosis, and
the youth’s strengths and needs. The individualized treatment plan for each youth addressed
the pharmacological interventions and matched the medication each youth was prescribed at
the time the treatment plan was developed. Each record included progress notes which
validated the youth was receiving treatment services as indicated on their treatment plan. The
individualized treatment plans were signed and dated by each youth, the mental
health/substance abuse professionals, treatment team members, and the parent/guardian.
Three of the seven youth were applicable for four, thirty-day periods requiring individual
treatment plan reviews, and one had five, thirty-day periods of treatment plan reviews. Three
youth were still within the treatment plan review periods and did not require a thirty-day review.
Each applicable individualized treatment plan was reviewed every thirty days by the treatment
team and modifications were documented on the review form and clearly identified as such.
Reviewed documentation indicated each individualized treatment plan review was signed and
dated by clinical staff, youth, licensed mental health professional, treatment team members, and
the parent/guardian. Each treatment plan included treatment and services provided by a
licensed psychiatrist. There were no youth identified as having a Prison Rape Elimination Act
incident. Three records were reviewed for discharge summaries. Each of the three reviewed
mental health and substance abuse treatment discharge summaries were documented on the
Department’s Mental Health and Substance Abuse Treatment Discharge Summary form upon
the youth’s discharge. A copy of the treatment discharge summary was provided to each youth,
parent/guardian, and juvenile probation officer (JPO). Each discharge summary included the
completion day of service, signature of a licensed mental health professional, and additional
documentation was completed and uploaded within fourteen days. The center conducts
treatment team reviews every Wednesday at 10:00 a.m. During the annual compliance review
week, a mini treatment team meeting was observed. Observations confirmed all detention staff,
mental health, medical, education, and other representatives were in attendance. The
parent/guardian was contacted by telephone. At the time of the mini treatment team meeting,
the youth’s education goals, general expectations, individual goals, behavior, and medication
were discussed. An interview with the DMHCA, indicated mental health staff ensure all youth
who remain in the center for thirty days or more, or sooner if behavioral indicators warrant
earlier intervention, are provided access to mental health treatment services. Additionally, youth
are invited to participate in treatment team meetings to engage in discussions on the services
and clinical interventions they would be receptive to receive. Once any youth is open and
receptive to engaging in services, mental health staff are responsible for tracking the youth by
using a caseload tool to ensure services prescribed in the individualized treatment plan are
delivered appropriately and consistently. By actively involving each youth with their treatment,
an environment which encourages the youth’s personal growth is achieved, which reinforces
their commitment to their recovery. The DMHCA reviews caseloads with mental health staff and
will meet with youth to review their individualized treatment plan. Once a treatment plan is
completed, mental health staff will ensure each youth is seen, to address, review, and conduct
any updates to their treatment plan. The DMHCA confirmed mental health staff meet with
administration informally daily, and formally twice a week during department head and treatment
team meetings.
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3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility operating procedures (FOPs) ensuring mental health and substance
abuse treatment planning focuses on treatment provisions to reduce or alleviate youth’s
symptoms of mental disorder or substance abuse impairment and enable youth to function
adequately in the juvenile justice setting. A review of seven youth mental health and substance
abuse records showed each youth required treatment. Each youth was assigned to a mini
treatment team consisting of a mental health staff, a staff from a different service area, youth,
and the youth’s parent/guardian if possible. Each of the applicable youth received individual,
group, or family counseling which was provided according to frequencies required by their
plans. Six of the seven youth had a current Authority for Evaluation and Treatment (AET), and
one youth had a signed court order. All documents were uploaded into each youth’s electronic
medical record (EMR). Each of the seven applicable youth signed consent for substance abuse
treatment using the Department’s form. Additionally, for the release of records, the proper
consent for substance abuse treatment records release was obtained for each youth using the
Department’s form. All treatment notes were documented on the Department’s
Counseling/Therapy Progress Notes form. At the time of the annual compliance review, a
review of three separate days of mental health groups confirmed licensed therapists conducted
group sessions with youth, as scheduled. Observations revealed mental health staff at the
center had adequate access to youth and confidential space to provide treatment services. The
observed groups were conducted as scheduled, and the groups were limited to ten or fewer
youth for the mental health groups. It was determined through reviewed documentation and
sign-in sheets, group therapy was limited to ten or fewer youth with mental health diagnoses.
Documentation review showed group therapy was limited to fifteen or fewer youth with
substance abuse diagnoses. Seven interviewed youth were asked to rate the mental
health/substance abuse services they were receiving at the center. One youth rated the
services as good. Six youth reported the mental health/substance abuse services were very
good. An interview with the designated mental health clinician authority (DMHCA) confirmed
youth who are at the center for at least thirty days or more, unless behavior warrants mental
health services prior to those thirty days, will receive mental health treatment. The DMHCA
described the process used for individualized mental health and/or substance abuse treatment
planning. Additionally, the DMHCA indicated youth are invited to participate in treatment team
meetings to engage in a collaborative discussion to help establish treatment goals and
objectives, which are used to develop an individualized treatment plan, which is tailored to their
specific needs. This process ensures treatment is youth-centered, goal-driven, and aligned with
the therapeutic services provided throughout their stay at the center and ensures personalized
treatment supports the continuity of care. The DMHCA indicated youth receive individual and
group counseling services to address both mental health and substance abuse diagnoses.
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3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures (FOPs) and a corresponding Suicide Prevention
Plan. The center has a written plan detailing their suicide prevention procedures, which was
reviewed and signed by the designated mental health clinician authority (DMHCA) and
superintendent annually. The plan was reviewed and signed by the superintendent and the
DMHCA on August 8, 2025. The plan included identification and assessment of youth at risk of
suicide, staff training for at least six hours annually on suicide prevention and implementation of
suicide precautions, which included quarterly mock suicide drills for all staff who encounter
youth on each shift, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and a review process. The center’s plan
includes an established review process for every serious suicide attempt or serious self-inflicted
injury. The review process included circumstances surrounding each event, center procedures
relevant to the incident, all relevant staff training, pertinent medical and mental health services
involving the victim, possible precipitating factors, and any recommendations as needed.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures (FOPs) ensuring suicide prevention services. The
policy and procedures address supervising, observing, monitoring, and housing youth identified
through screenings, documentation, and observation as being at risk for suicide, and protecting
youth with elevated risk of suicide in the least restrictive means possible. Any youth identified as
having suicide risk factors by screening, information obtained regarding the youth, or staff
observations must be placed on suicide precautions and receive an Assessment of Suicide Risk
(ASR). A review of seven youth mental health and substance abuse records showed there were
six youth applicable for placement on suicide precautions. Each of the six applicable youth were
placed on precautionary observation at the time of admission until an ASR was completed.
Each youth was placed on constant supervision based upon the Suicide Risk Screening
Instrument (SRSI) findings. The Department's Juvenile Justice Information System (JJIS)
showed youth alerts were entered in the system for all six youth. Reviewed documentation
confirmed ASR referral dates and times for each youth. A review of documentation revealed
each ASR was completed on the Department’s form. A review of documentation determined
each Suicide Precautions-Observation Log was completed in its entirety to include safe housing
areas, and all required signatures from supervisors and mental health staff. There were no
applicable youth released prior to receiving an ASR while on suicide precautions. Each record
showed mental health staff documented there was a consultation with the designated mental
health clinician authority (DMHCA) or licensed mental health professional on the Mental
Health/Substance Abuse Referral Summary form. The ASR was completed for each youth
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within twenty-four hours by a licensed therapist, utilizing the Department’s form. Each applicable
youth record revealed the superintendent, or designee was notified immediately of suicide risk.
A review of documentation indicated one youth required a Follow-Up ASR, which was
completed by a licensed therapist prior to the youth being removed from precautionary
observation. After the completion of the ASR, each youth was placed on standard supervision.
Reviewed documentation showed a conference was conducted by the superintendent and
licensed mental health professional to determine the reduction of each youth’s level of
supervision. Each of the six applicable ASRs were completed by a licensed mental health
professional and a review of assessment results included recommendations for supervision and
follow-up. Documentation in the center’s logbook and on each ASR confirmed administration or
supervisory staff provided specific instructions related to the ASR findings and suicide
precaution decisions. A review of JJIS determined alerts were appropriately entered and
removed following each youth being removed from precautionary observation. Additionally,
reviewed logbooks determined beginning and ending times were documented for youth placed
on precautions. The DMHCA was interviewed and stated the provider’s licensed mental health
staff conducts suicide risk screenings, using the suicide risk screening instrument (SRSI).
Mental health professionals are notified through various channels, which include formal
referrals, by email, telephone, and/or through direct in person communication. The DMHCA is
on-call twenty-four hours a day and responds to all mental health emergencies.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures (FOPs) regarding secure observation. The policy
requires youth placed on suicide precautions to remain under secure observation if less
restrictive methods are not effective. An interview with the superintendent confirmed the center
utilizes secure observation. A review of seven youth records indicated one youth’s record was
applicable. The center provided two additional applicable records for youth who were placed on
secure observation. Each of the three applicable youth placements were authorized by the
superintendent and the designated mental health clinician authority (DMHCA) and the secure
rooms were designated in writing. A review of the Department's Juvenile Justice Information
System (JJIS) showed each youth had a completed Health Status Checklist form completed
prior to each youth’s placement in secure observation. Staff completed the Suicide Precautions-
Observation Logs in their entirety and in real time for each youth. A review of documentation
showed within eight hours of placement, a new Assessment of Suicide Risk (ASR) was
completed for each of the applicable youth, and the youth’s parent/guardian was notified of the
youth’s potential suicide risk as indicated by the ASR. Additionally, a review of documentation
showed each youth’s juvenile probation officer (JPO) was notified of a youth’s potential suicide
risk as indicated on each ASR. One youth remained on secure observation beyond twenty-four
hours, and reviewed documentation confirmed mental health staff provided written support for
continuation of observation. Mental health staff provided supportive counseling services during
secure observation and observation logs documented supervision for each youth. Reviewed
documentation confirmed the level of supervision was reduced for each youth after a
conference with the superintendent and licensed mental health professional, which was
conducted to determine the discontinuation of secure observation and step-down to close
supervision. Supervision levels were documented in the center’s logbook and in each youth’s
mental health record by mental health clinical staff. Seven interviewed staff were asked what
staff were responsible for if a youth expressed suicidal thoughts. Each staff indicated staff are
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responsible for notifying mental health staff, submitting a referral, and documenting supervision.
One staff indicated staff will conduct a search of the youth and room for sharp objects. Seven
interviewed youth were asked if they have ever been placed on suicide watch while at the
center. Two of the seven youth indicated they had. The two applicable youth indicated while on
suicide watch/observations, staff were observing them at all times. An interview with the
superintendent confirmed the center’s practice of utilizing secure observation for potentially
suicidal youth.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures (FOPs) for the process to safely screen, refer,
assess, monitor, and protect youth with elevated suicide risk in the least restrictive means
possible. A review of seven youth mental health and substance abuse records revealed six
youth records were applicable for the youth having been placed on precautionary observation.
Each youth’s mental health and substance abuse record confirmed each youth had a
maintained Suicide Precautions-Observation Log. Each youth’s appropriate level of supervision
and observations of each youth’s behavior were documented in real time and did not exceed
thirty-minute intervals. None of the youth records were applicable for warning signs. Each log
was reviewed and signed by each shift supervisor and mental health clinical staff in each
record. All logs documented safe housing requirements. A review of video footage and
corresponding documentation of youth on precautionary observation or secure observation
confirmed supervision was always maintained by detention staff.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures (FOPs) to address suicide prevention training. The
policy requires all staff who work with youth to be trained to recognize verbal and behavioral
cues indicating suicide risk, suicide prevention, and implementation of suicide precautions. A
review of seven pre-service and seven in-service staff training records verified each staff
participated in suicide prevention training. Each of the seven reviewed staff records showed
training included suicide drills held at least quarterly on each shift. The center maintains twelve
suicide response kits located in master control, sub control on each living module, the center’s
training room, the center’s classroom/school office, and in the medical office. Each suicide kit
contained a rescue tool, wire cutters, and needle nose pliers. Each was co-located with the
center’s first-aid supplies which included a one-way cardiopulmonary resuscitation (CPR) mask,
face shield, and non-latex gloves. A review of mock suicide drills during the annual compliance
review period verified drills were held monthly on each shift. A review of documented drills for
the past twelve months showed suicide drills included the use of CPR, suicide response kits, the
automated external defibrillator (AED), and first-aid. All mock mental health drills were in
response to a suicide attempt and/or incident of serious self-injury. Drills were documented in
the logbook with a sign-in sheet to confirm staff participated in the drills. Center youth were not
used in drill simulations. Documentation supported all staff who come into contact with youth
participated in or were briefed on each suicide drill scenario. A review of video footage
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confirmed suicide drills were simulated. Staff who were not present during a drill could review
each drill scenario and procedures to understand the process and receive the necessary
training to respond to an incident of a suicide attempt or incident of serious self-inflicted injury in
the center. Seven staff were interviewed about the location of the center’s suicide response kits.
Staff indicated they were located throughout the center to include the center’s sub-controls,
classroom/school area, and in the medical office.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures (FOPs) to ensure the center responds to youth in
crisis in the least restrictive means possible to protect the safety of each youth and others while
maintaining control and safety of the center. The center maintains a Combined Emergency
Services Plan which includes procedures such as notification and alert system, means of
referral including youth self-referral, communication, supervision, documentation, and review.
The plan was last signed by the designated mental health clinician authority (DMHCA) and
superintendent on August 8, 2025.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has an Emergency Care and Crisis Intervention Service Plan outlining mental health
and substance abuse emergency procedures for youth who are believed to be an imminent
danger to themselves or others because of mental illness or substance abuse impairment. The
plan was reviewed and signed by the superintendent and the designated mental health clinician
authority (DMHCA) on August 8, 2025. The plan was last updated on March 15, 2025. The plan
is accessible to all staff and was located in each living module sub control, medical clinic,
mental health office, supervisor’s office, and master control. The plan included immediate staff
response, notifications, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for emergency mental health evaluation and treatment,
transport for emergency substance abuse assessment, and treatment under Chapters 394 and
397 of Florida Statute. The plan addressed documentation, training, and review.
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3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has a written Emergency Care Plan documenting the response procedures for youth
in crisis. None of the seven reviewed youth were applicable for Crisis Assessments. The center
reported having two youth who required a Crisis Assessment during the annual compliance
review period. Each of the two applicable assessments were completed within the required time
frame. Each of the Crisis Assessments documented the reason for assessment, a Mental Status
Examination and interview, determination of danger to self and others, initial clinical
impressions, supervision recommendations, treatment recommendations, recommendations for
follow-up or further evaluation, and notification to the parent/guardian of follow-up treatment. A
mental health alert was entered into the Department’s Juvenile Justice Information System
(JJIS) for each youth being placed on precautions after the completion of a Crisis Assessment.
The Crisis Assessments were completed within the required time frames by a licensed mental
health professional. One of the two youth received a Crisis Assessment as a result of a Prison
Rape Elimination Act incident. Documentation supported the youth was offered ongoing mental
health treatment services.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (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 center has facility operating procedures (FOPs) addressing Baker and Marchman Acts. A
review of seven youth mental health records revealed none were applicable for requiring Baker
Act procedures. Three additional records were requested and reviewed. Each youth was placed
on one-to-one supervision prior to the Baker Act. Documentation supported suicide risk alerts
were entered into the Department’s Juvenile Justice Information System (JJIS) for each youth
while pending off-site transportation. Each youth was placed on one-to-one supervision, and
supervision was documented on the Suicide Precautions-Observation Log until the time of the
youth’s authorized release. Documentation supported each youth was placed on suicide
precautions upon re-admission to the center. Each youth had a mental health referral completed
for a Mental Status Exam (MSE) completed after re-admission. Each youth had an MSE
completed as part of the Assessment of Suicide Risk (ASR). The MSE and ASRs were
completed by a licensed mental health staff for each youth. Each youth was maintained on
constant supervision until properly transitioned to a lower level of supervision. Each youth’s
supervision level was maintained until an appropriate assessment was conducted and licensed
mental health staff conferred with the superintendent or designee. A review of JJIS alerts
verified each suicide risk alert was discontinued based on the results of the ASR for each youth.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures (FOPs) for procurement of a contractual agreement
with a licensed physician to serve as the center’s designated health authority (DHA). The center
maintains a contract with VitalCore Health Strategies, LLC (VitalCore), which subcontracts with
a licensed physician to serve as the center’s DHA, and who is clinically responsible for the
medical care of all youth in the center. The DHA has specialty training and was Board certified
in pediatrics. The DHA held an unrestricted medical license which expires on January 31, 2028,
which met all requirements for independent and unsupervised practice in the State of Florida. A
review of the DHA’s license indicated there were no emergency actions, discipline, or public
complaints found. The DHA is responsible for reviewing and approving all medical/mental health
policies and protocols annually. All healthcare staff are annually required to complete training on
any new policies and review existing healthcare policies. The DHA is responsible for
communication with the center and healthcare staff regarding each youth’s medical needs. The
DHA is on-call twenty-four hours a day, seven days a week for consultation. The DHA is to be
on-site at least once a week, with a week defined as the seven-day period beginning on Sunday
and ending on Saturday with no more than nine days passing between on-site visits. A review of
the DHA’s sign-in logs since the last annual compliance review indicated the DHA was on-site at
least once a week as required. The DHA does not utilize tele-medicine. The center utilizes an
advanced practice registered nurse (APRN), who is on-site at least once a week and holds an
unrestricted license in the State of Florida, with an expiration date of April 30, 2027. The APRN
has Collaborative Practice Protocols in place with the DHA. The back-up medical doctor, who is
to provide coverage when the DHA is on scheduled absences or vacation, held an unrestricted
license in the State of Florida, which expires on March 31, 2026. The back-up DHA was not
utilized during the annual compliance review period. An interview with the DHA confirmed the
DHA is responsible for evaluating all healthcare policies and nursing protocols, provision of
weekly on-site clinical services including performing initial health screenings and comprehensive
medical evaluations for new admissions, physical examination of sick youth, follow-up
evaluation of all youth who received off-site healthcare services, and evaluation of all youth
presenting with a chronic medical condition including reevaluation every ninety days.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures (FOPs) for all healthcare procedures and protocols.
The designated health authority (DHA) is required to conduct an annual review of all medical
treatment FOPs. Reviewed documentation validated the DHA reviewed, signed, and dated all
healthcare related FOPs, all treatment protocols, and standing procedures on August 22, 2025.
The center superintendent signed and dated all updated FOPs on August 18, 2025. The
psychiatrist reviewed all FOPs related to psychiatric services and psychotropic medication on
August 22, 2025. Reviewed documentation validated the registered nurse (RN) manager and
the advanced practice registered nurse (APRN) signed the cover page in August 2025. All other
healthcare staff documented their review of the center’s healthcare FOPs and protocols on a
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cover page which was signed and dated in August 2025. The center’s non-healthcare staff
protocols were signed and dated by the DHA on August 22, 2025. Reviewed training records
supported all nursing staff completed and maintained current certifications in cardiopulmonary
resuscitation (CPR) and automated external defibrillator (AED). VitalCore Health Strategies,
LLC (VitalCore) has established a comprehensive clinical orientation for all newly employed
healthcare staff which includes the Department’s healthcare policies and procedures. A review
of each healthcare staff’s training record verified each newly employed healthcare staff received
a clinical orientation conducted by an RN.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures (FOPs) requiring the completion of an Authority for
Evaluation and Treatment (AET) or Limited Consent for Evaluation and Treatment (LCET) which
authorizes specific treatment for youth in the custody of the Department. A review of seven
youth Individual Healthcare Records (IHCRs) found all were applicable for requiring a signed
AET. There were no applicable youth who were over eighteen years of age. Six of seven
reviewed IHCRs contained a signed AET, and one was located by the center during the week of
the annual compliance review and uploaded to the IHCR. There was one applicable IHCR which
required a LCET due to involvement with the Department of Children and Families and an
inability to reach the parent/guardian. Each applicable AET was obtained prior to providing
medical services to the youth. Each of the applicable signed AETs were clearly marked as a
“copy” on the form. The interviewed nurse indicated the AET is signed by a parent/guardian
when a youth is under eighteen years of age and is valid while the youth is under the
supervision/custody of the Department. An interview with the registered nurse (RN) manager
confirmed the center’s practice of obtaining a new or current AET or documenting consent when
a youth is eighteen years of age.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures (FOPs) which require notification to be made to the
parent/guardian when there are significant changes in a youth’s condition and to obtain consent
when new medications and treatments are prescribed. A review of seven youth Individual
Healthcare Records (IHCRs) found six youth were applicable for new medication which required
applicable consent for newly prescribed medications and/or treatments. Four youth were
applicable for taking psychotropic medication at admission, all of whom were transferred from
another detention center; therefore, no additional notification or consent was required at the
time of admission. Three youth had a new psychotropic medication prescribed or discontinued,
or the drug dosage was significantly changed, and verbal consent was documented on page
three of the Clinical Psychotropic Progress Note (CPPN) or on an informed consent
chronological progress note for each of the three youth showing an attempt to obtain the signed
parent/guardian consent. Three of seven reviewed records contained immunization records
obtained through the Florida Department of Health Florida Shots website, which were verified
within seven days and reviewed within thirty days, while four of seven youth were transferred to
the center following an admission at another detention center where vaccinations were
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previously verified. None of the youth received vaccinations at the center. None of the reviewed
youth were eighteen years of age or older. An informal interview with the registered nurse (RN)
manager indicated youth over the age of eighteen are responsible for authorizing their
healthcare. For youth under eighteen, healthcare staff will send parental/guardian notifications
to obtain consent when new medications are ordered or stopped, if a youth is sent off-site for
care, has treatments prescribed, and/or to inform the parent/guardian of significant changes in
the youth's condition. These notifications are first completed verbally with a witness and
followed with a written letter, unless treatment or services are court ordered. When a new
psychotropic medication is prescribed, discontinued, or the drug dosage is significantly
changed, parent/guardian verbal consent is obtained. The RN manager indicated immunization
records are obtained through the Florida Shots website and vaccinations are not provided at the
center.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures (FOPs) requiring youth to be screened upon
admission for any emergency medical conditions requiring immediate medical attention or
concerns which may need a referral for further assessment by healthcare staff. In the event a
youth is admitted with a healthcare concern and licensed healthcare staff are available on-site,
a request is to be made for an urgent assessment of the youth, and the designated health
authority (DHA) is to be notified. Seven youth Individual Healthcare Records (IHCRs) were
reviewed. All seven IHCRs contained a Medical and Mental Health Admission Screening form
completed on the date of admission by a juvenile justice detention officer (JJDO), which was
reviewed and signed by a JJDO supervisor. Each screening form showed the screening was
reviewed by a registered nurse (RN) within twenty-four hours. Each screening form was
completed in the Department’s Juvenile Justice Information System (JJIS). One of seven
reviewed records was applicable for a change in physical custody since the youth’s admission.
Two additional applicable records were requested for review of healthcare admission
rescreening; however, none were available. The one applicable record contained a completed
rescreening which was completed by a JJDO and reviewed by a licensed healthcare staff within
twenty-four hours of the screening, as required. There were two youth applicable for a
qualitative urine pregnancy screening test, both of which included documentation of verbal
consent in the chronological progress notes, as required. An interview with the RN manager
confirmed the center’s practice for admission screening and rescreening.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures (FOPs) which require all admitted youth to receive
orientation to the general healthcare delivery services at the center. A review of seven youth
Individual Healthcare Records (IHCRs) supported each contained a completed Department
Health Education Form documenting the youth’s orientation to the center’s healthcare services.
Each youth received a general healthcare orientation on the day of admission to the center.
Reviewed documentation validated each youth’s orientation addressed access to medical care,
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sick call, what constitutes an emergency and when to notify staff, the center’s medication
process and side effect monitoring, the right to refuse care and how it is documented, and what
to do in the case of a sexual assault or attempted sexual assault. Additionally, youth are
oriented to the non-disciplinary role of healthcare providers, availability of healthcare staff,
dental hygiene, sexually transmitted infections, personal hygiene, immunizations, infection
control, nutrition, self-examinations, and a review of healthcare contacts. Each youth’s
healthcare education was documented on the Department’s required form. Three of the seven
reviewed youth records were for youth identified with chronic conditions, and all three applicable
healthcare education records included education on their medical condition.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures (FOPs) which require notification to the designated
health authority (DHA) of all youth admitted with chronic health conditions or youth in need of
emergency care. A review of seven Individual Healthcare Records (IHCRs) indicated there were
three youth admitted with a chronic medical condition. None of the admitted youth were
identified as needing emergency care upon admission. In each applicable instance, the DHA
was notified within twelve hours of the youth’s admission, and the notification was documented
in each IHCR on the admission progress note. All three youth with a chronic condition were
referred to the DHA and the notification was documented on the nursing admission
chronological notes in each IHCR. Each reviewed applicable record included referrals to the
DHA for the known or suspected condition. Four youth were applicable for being admitted while
taking psychotropic medication and documentation validated the psychiatrist was notified of
each youth’s admission. An interview with the registered nurse (RN) manager indicated the
DHA is notified by nursing staff when a youth is admitted with a chronic medical condition or is
taking prescribed medications. Notifications to the DHA are documented in the admission
chronological progress notes.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures (FOPs) requiring the completion or review and
updating of the Department’s standard Health-Related History (HRH) form. The center utilizes
and completes a HRH form for all youth admitted into physical custody, including those youth
transferred from other detention centers. A review of seven youth Individual Healthcare Records
(IHCRs) found each contained an HRH form completed electronically by a licensed nurse within
one day of each youth’s admission to the center. All seven HRH forms were reviewed by the
designated health authority (DHA) or advanced practice registered nurse (APRN) and were
maintained in each youth’s IHCR. Each of the applicable HRHs were completed prior to the
Comprehensive Physical Assessment (CPA). An interview with the registered nurse (RN)
manager indicated nursing staff are responsible for completing the HRH and confirmed they are
completed within or before the seven days of admission.
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4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures (FOPs) requiring a Comprehensive Physical
Assessment (CPA) form to be completed or updated for all applicable youth admitted
determining the health and wellbeing of each youth. A review of seven youth Individual
Healthcare Records (IHCRs) indicated five youth had a current CPA on record at admission and
two did not. The two youth records showed the designated health authority (DHA) completed a
CPA within seven days of each youth’s admission to the center. For the remaining five youth,
reviewed documentation showed each current CPA included a review of the Health-Related
History by the DHA. Each of the CPAs were completed in full to include the Medical Grade,
Tanner Stage, cardiovascular, body mass index, visual acuity field, and most recent
Tuberculosis (TB) Skin Test. All sections of each CPA for the applicable youth were marked
with an “O” or “X”. One of the seven reviewed youth records indicated a refusal for portions of
the examination and the record contained a signed refusal form reflecting the refused portion of
the CPA. Four youth were applicable for an update to the Department’s Problem List and
updates were made as required. An interview with the registered nurse (RN) manager explained
the CPA is reviewed with the completion of a focused note, up to six times, before a new CPA is
initiated to avoid confusion on each youth’s condition and to ensure clear documentation of any
current condition. The center’s policy and procedures for TB control and screening specify
required routine screening of all youth for latent and active TB, as well as environmental
controls in the case of a youth with active TB. All seven reviewed youth IHCRs confirmed each
youth had a TB screening completed. There were no applicable IHCRs reviewed which
contained a refusal for TB examination. The results of each TB test was documented on the
CPA and the Infectious and Communicable Diseases form. None of the reviewed youth were
applicable for a new TB screening or further evaluation. An interview with the RN manager
indicated if no record of a prior TST result within the past twelve months is located or identified
after a youth enters a detention center, and there is a valid consent for treatment on file, the test
will be administered within seven days of admission with a Practitioner Order. Gynecological
exams are not routinely completed for females.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures (FOPs) requiring all youth to be evaluated and
treated for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV), if
necessary. All sexually active youth are to be clinically screened and evaluated for STIs.
Screened youth are to be referred to the designated health authority (DHA) or advanced
practice registered nurse (APRN) to determine if further testing is necessary. A review of seven
youth Individual Healthcare Records (IHCRs) indicated two youth were applicable, therefore,
one additional applicable record was selected for review. A review of the three applicable
records showed each youth was screened for STIs. Each applicable youth required further
evaluation and three were referred; however, one youth declined consent for testing. Each of
the applicable youth’s screening results were documented on the Department’s STI form and
Infectious and Communicable Disease (ICD) form located in the IHCR. None of the youth
reviewed were applicable for a gynecological exam. A review of seven youth IHCRs found none
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of the youth were out of the Department’s physical custody for more than thirty days. The center
maintains a written policy and procedures providing each youth with the opportunity to receive
counseling, testing, and treatment for HIV. Seven youth records were reviewed and showed
each youth was offered HIV counseling and testing. One youth consented to have an HIV test,
as documented on the Department’s Human Immunodeficiency Virus Antibody Test Youth
Consent form. Reviewed documentation of the applicable IHCR verified written consent was
obtained by the center and confirmed the applicable youth was offered counseling, testing, and
treatment for HIV. Additionally, the HIV results were filed in the youth’s electronic IHCR. The
pre-test and post-test counseling was documented in the youth’s IHCR. An interview with the
registered nurse (RN) manager indicated all youth who are sexually active are screened for
STI’s within twenty-four hours of the youth’s admission to the center. Youth may consent to their
own screening and treatment, and youth are able to request an HIV test at any time while in
detention. Each youth’s STI results are noted on the ICD form and lab results are uploaded after
review by a practitioner. Youth are to be rescreened if a sexually active youth has been out of
Department custody, presents with symptoms, or reports recent sexual activity. HIV results are
maintained in a confidential manner and screening information for STIs is documented on each
youth’s ICD form. Each youth who receives HIV testing is offered pre- and post-testing
education by nursing staff, and counseling is provided by a certified HIV counselor or licensed
medical professional. Pre/post-test counseling is documented in each youth’s IHCR, and a copy
is provided to the youth upon release from the detention center. Seven youth were interviewed,
and each indicated they can request an HIV test at the center.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures (FOPs) which require youth in the center to be able
to submit sick call requests and have their complaints addressed appropriately through the sick
call system. Healthcare professionals conduct sick calls seven days a week in the center to
respond to youth medical illnesses or injuries of a non-emergent nature. Postings throughout
the center indicate sick calls take place daily from 9:00 a.m. to 11:00 a.m. and from 3:00 p.m. to
4:00 p.m. The center has approved treatment protocols for registered nurses (RN). The center’s
shift supervisors and authorized staff are trained by the RN manager on the center’s sick call
procedures and are to review all sick call requests in the absence of healthcare professionals.
The center utilizes an electronic Sick Call Request form and youth who request a sick call are to
inform staff of their complaint and staff will generate a sick call request in the Department’s
Juvenile Justice Information System (JJIS). A review of seven youth Individual Healthcare
Records (IHCRs) showed six of the youth had submitted sick call requests. Documentation in
each of the six IHCRs indicated the sick call was documented on the Sick Call Referral Log and
was conducted by a RN. There was one instance in which a youth presented with a similar sick
call complaint three or more times within a two-week period, and the youth was referred to the
designated health authority (DHA), as required. There were no applicable youth who were
treated where an immediate referral was needed to be made to the DHA to be notified
immediately of the youth’s medical condition. Each Sick Call Request form was maintained in
each IHCR in chronological order. Sick calls were documented on the Sick Call Index and
corresponded with the Sick Call Request forms. Sick call forms documented the nature of each
complaint, assessment, and notes were structured in the subjective, objective, assessment, and
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plan note format. None of the reviewed youth were in restricted housing/confinement. The
center’s sick call policy requires a shift supervisor to discuss each youth’s medical issues with
healthcare staff while the youth is in confinement. Nursing staff are required to make daily visits
when youth are in confinement and all youth in confinement are to receive all prescribed
medication. Nursing staff are to evaluate youth with active medical conditions every two hours
while the youth is in confinement. An interview with the RN manager confirmed the center’s
practice. Observation of a sick call for one youth was conducted during the annual compliance
review week. The youth was escorted to the medical clinic by a direct care staff. The youth
consented to observation of the sick call, and the RN discussed the nature of the sick call with
the youth. The center’s practice is to use the examination room when necessary for privacy;
however, in the observed instance the youth complained of flu-like symptoms; therefore, the
nurse conducted the sick call at the desk and examined the youth’s throat and took the youth’s
vital signs while the youth was sitting in a chair next to the desk. The youth was the only youth
in the medical clinic at the time. An interview with the RN manager confirmed the sick call
process and indicated when youth notify staff of a medical complaint, staff then input a sick call
through the electronic sick call system. Nursing staff conduct sick calls twice a day, and within
twenty-four hours, or sooner. The RN manager said youth are seen by either a RN or licensed
practical nurse (LPN), and if an LPN completes a sick call, the RN will conduct a review within
twenty-four hours. Youth are assessed, and vital signs, treatment, education, and follow-up
plans are completed. The RN manager confirmed sick calls are conducted daily from 9:00 a.m.
to 11:00 a.m. and from 3:00 p.m. to 4:00 p.m. in the medical clinic. The RN manager indicated
youth presenting with repeated similar sick call complaints are referred to the DHA and/or
advanced practice registered nurse (APRN). Seven staff were interviewed, and each stated a
nurse conducts and reviews sick calls. Seven youth were interviewed, and six youth indicated
they can see a nurse immediately after requesting a sick call, and one indicated they had never
submitted a sick call request. Six youth said nurses conduct sick calls, while one youth reported
never having submitted a sick call request. Additionally, one youth indicated staff, or the doctor,
can conduct sick calls.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures (FOPs) stipulating a comprehensive process for
episodic care, first-aid treatment, and emergency care. The center utilizes an Episodic Care Log
to document episodic care and first-aid treatment. The log is used to document the date, name
of youth, the youth’s Department identification number, nature of the illness or injury, the
treatment rendered, staff initials, nurse initials, verification of who provided the episodic care,
and whether the youth was recommended to receive off-site care. When licensed staff are not
on-site to assess youth, the designated health authority’s (DHA) approved non-healthcare
protocols are to be utilized to provide on-site care. If non-healthcare staff provide episodic or
first-aid care, the Department’s Report of On-Site Health Care by Non-Health Care Staff form is
to be used to document the care provided. If the level of need for a youth cannot be determined,
the on-call practitioner/DHA is to be contacted for guidance and referral to the emergency room
for off-site emergent care. Seven youth Individual Healthcare Records (IHCRs) were reviewed,
and all seven were applicable for episodic or first-aid care events. Each of the seven applicable
incidents showed the on-site care was provided by licensed healthcare staff and was
documented in problem-oriented charting, which included subjective, objective, assessment,
and plan (SOAP) elements. In each applicable instance, the nature of the complaint, findings,
treatment rendered, and education/instruction was documented. The review of the applicable
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youth IHCRs indicated none of the youth had any episodic care events conducted by non-
healthcare staff. Three youth required a referral for off-site care, which were completed as
required. Each applicable record contained parent/guardian notification, and documentation of
required follow-up/future care. One applicable youth was placed on the alert list because of the
medical encounter, as required. Each reviewed episodic care event was documented in the
Episodic Care Log. Each reviewed applicable record had a documented progress note
identifying first-aid or emergency care, the date and time of care, nature of the complaint,
findings regarding care, and the treatment rendered. The center has fourteen first-aid kits
located throughout the center and eight additional kits designated specifically for the center’s
transport vehicles. Observation of a randomly selected first-aid kit confirmed the kit was stocked
with the approved supplies and no contents were expired. Reviewed documentation confirmed
the kits were monitored monthly by nursing staff and were replenished as needed. The center
has eight automated external defibrillators (AEDs) located in the medical clinic, two living units,
and five for use in transport vehicles. Each AED is equipped with automated instructions.
Healthcare staff monitor the AEDs monthly to ensure the devices are operable. A review of the
AED check logs since the last annual compliance review validated this practice. The AED’s
batteries are monitored by a contracted provider annually, and documentation indicated the
batteries were last changed on August 21, 2025, and each had an expiration date of August
2029. The AED pads were last changed on August 21, 2025, and each had an expiration date
of December 28, 2027. During the annual compliance review week, observations were
conducted of each AED, all of which displayed a green battery indicator light to indicate the
device was operational. The center is to conduct emergency medical drills at least once
quarterly on each shift, and emergency drills are to include demonstration of cardiopulmonary
resuscitation (CPR)/AED at least once a year on each shift. A review of quarterly emergency
drills for the previous twelve months, verified the center conducted drills each month on each
shift to simulate an episodic care event which called for immediate first-aid, administration of
CPR techniques, and the initiation of the emergency procedures to follow when a life-
threatening emergency occurs. The use of CPR/AED was practiced during every drill
conducted. A list of emergency numbers, including the Poison Control Center, was posted in an
area accessible to non-licensed and licensed staff and inaccessible to youth. The center
provided documentation which confirmed supervisory and authorized direct care staff were
trained on the administration of the epinephrine auto-injector by a registered nurse (RN).
Reviewed documentation supported the DHA, the advanced practice registered nurse (APRN),
and all nursing staff maintained current certifications in CPR and AED. Seven staff training
records validated staff received CPR/AED/first-aid training, and the required training on the
center’s Emergency Care Plan. The center has a written policy which details the use, access,
and inventory of Narcan. The RN manager confirmed all nursing staff and authorized
supervisory staff are trained in the procedures for the use of Narcan. During the annual
compliance review week, observations confirmed the center maintained their stock of Narcan
within the locked medication cart and a backup supply stored in a locked medical clinic cabinet.
Documentation confirmed nursing staff conducted weekly and perpetual counts of Narcan
during the annual compliance review period. An interview with the RN manager confirmed
episodic care is conducted by licensed staff and documentation is to conform to professional
standards in SOAP note format. In the event episodic care is provided by non-licensed
Department staff, notes are to be documented on a Report of On-Site Care by Non-Healthcare
Staff form with review by nursing staff at the next available opportunity. The RN manager
indicated if any youth are sent off-site for medical care, the care is documented on the Off-Site
Care Log. The RN manager verified and confirmed all the information provided regarding the
center's AEDs. The RN manager confirmed the center conducts monthly medical drills on each
shift. Seven staff were interviewed, and each stated they can call 9-1-1 if they feel it is
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necessary. Seven youth were interviewed, and four stated the medical services at the center
are very good, and three rated the medical services as good.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures (FOPs) requiring timely referrals, documentation,
and coordination of medical services to an off-site healthcare provider, both emergent and non-
emergent, for youth, as required by the Department. A review of seven Individual Healthcare
Records (IHCRs) found five youth were applicable for off-site care. Each applicable youth was
taken off-site for medical care. Each of the five applicable IHCRs contained a completed
Summary of Off-Site Care Consultation Report form, as required. Each instance of off-site
emergency care was documented on the Episodic Care Log. The designated health authority
(DHA) was notified of each healthcare event. The completed Summary of Off-Site Care
Consultation Report form and discharge documentation was filed in each of the applicable
IHCRs. Each reviewed applicable IHCR contained discharge documentation and instructions.
The DHA documented a review of all off-site care findings, instructions, and information. Three
of the youth required follow-up appointments and each had the referral entered in the center’s
referral tracking log. An interview with the registered nurse (RN) manager indicated all youth
sent off-site for first-aid or emergency care are tracked on the off-site care log. The Summary of
Off-Site Care Consultation Report form is to be utilized if a youth is sent off-site and follow-up
testing, referrals, or additional appointments are requested by the provider. The RN manager
reported licensed nursing staff review all discharge paperwork and/or hospital orders with the
DHA. Additionally, nursing staff ensure the DHA reviews and initials all off-site care findings by
placing them in a folder for the DHA to review when the DHA is next on-site. The RN manager
confirmed nursing staff track follow-up referrals, testing, and appointments by documenting
them in each youth’s electronic medical record (EMR).
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures (FOPs) requiring youth identified with chronic
conditions to receive regularly scheduled evaluations and necessary follow-up care. The
frequency of each periodic evaluation is to be determined by the youth’s condition, clinical
needs, and clinically appropriate medical standards, but no less than once every ninety-days.
Youth are to be screened during the intake process for medical conditions, warranting periodic
evaluations and follow-up care. A review of seven youth Individual Healthcare Records (IHCRs)
indicated three youth were identified with a chronic condition. None of the reviewed youth were
diagnosed with a communicable disease. One of the three youth was applicable for taking
prescribed medication on an on-going basis. Each of the applicable youth received on-site care
for a physical health condition which was documented in the IHCR chronological progress notes
with clearly written treatment orders. Two youth received periodic evaluations, as required, and
one had been in the center less than ninety days at the time of the annual compliance review.
All three youth had a Medical Grade between two and four. None of the youth were pregnant,
and there were no youth applicable for taking Tuberculosis medication, which requires monthly
evaluations. Reviewed records reflected each youth’s Department Problem List was updated, as
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required. An interview with the registered nurse (RN) manager verified the center places youth
with chronic conditions on the chronic youth list and on the Department’s Office of Health
Services (OHS) weekly report. An interview with the designated health authority (DHA)
confirmed the center’s practice for chronic condition evaluations and periodic evaluations.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures (FOPs) requiring all medications and
pharmaceutical products to be procured, dispensed, administered, and stored safely,
accurately, and in accordance with state, federal, and industry standards. The center’s practice
is for nursing staff to verify all medications. Medications shall have a current, valid order, and
are to be given according to a current prescription or practitioner’s order. Nursing staff are to
verify medication with each parent/guardian when they deliver medication to the center. The
Medication Receipt, Transfer, and Disposition form is used to document medication received in
the original packaging from a licensed pharmacy with a current legible patient-specific label
affixed. Youth who are taking medication while in the care of the center are to have medication
administered by healthcare professionals. The center utilizes the Department’s Medication
Administration Record (MAR) for each youth receiving either prescription medications on a
routine basis or over-the-counter (OTC) medications. Seven youth Individual Healthcare
Records (IHCRs) were reviewed. Four youth were taking prescribed medication upon admission
and were applicable for medication management. All three applicable IHCRs were for youth who
transferred from another detention center where the medications had already been verified prior
to the youth’s transfer. The designated health authority (DHA) was contacted in each instance to
obtain an order to resume the medications, and the notification was documented in the
chronological progress notes for each youth. When current medications are continued,
discontinued, changed, or new ones are ordered, the DHA is to place an order on the
Practitioner Order form. Medications had a current, valid order, were administered pursuant to a
current prescription, and the DHA placed an order on the Practitioner Order form for each youth
with medication. The reviewed records for each youth applicable for having medication at the
time they were transferred from another detention center each included a completed Medication
Receipt Transfer Disposition form, as required. None of the reviewed youth required over-the-
counter medications not listed on the Authority for Evaluation and Treatment (AET) and none of
the reviewed youth required medication while in restricted housing. All seven reviewed records
included MARs for each youth’s over-the-counter, prescribed, and/or psychotropic medications
in the electronic medical record (EMR) which was utilized to document administration of all
medication and treatment including start and stop dates. None of the medications were
administered by non-healthcare staff. There were no lapses or errors noted for any medication
administration. Nursing staff documented side effect monitoring on each MAR at least weekly.
The reviewed policy and procedures indicated when a youth refuses the medication
administration, the refusal is to be clearly documented on the MAR and the Department’s
Refusal of Treatment form is to be completed. None of the reviewed applicable records
indicated the youth refused medication. An informal interview with the registered nurse (RN)
manager indicated refusals are to be documented on the MAR, and on the Department’s
Refusal of Treatment form. Observation of one medication administration confirmed this practice
when one youth refused medication during the week of the annual compliance review. Each
MAR contained all required elements, to include the youth’s name, Department of Juvenile
Justice identification number, date of birth, allergies, precautions, Medical Grade, medical alerts,
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medication start and stop dates, monitored side effects, and a current photograph of the youth.
Reviewed documentation reflected nursing staff and each youth initialed each medication
administration entry on the MARs. None of the youth were taking any parenteral medication. An
observation of a medication administration was conducted during the annual compliance review
week. The youth provided verbal consent prior to observation. The youth was escorted to the
medical clinic by a juvenile justice detention officer (JJDO). Observations supported the youth
approached the nurse administering medication individually and the nurse adhered to the Six
Rights of Medication Delivery/Administration by having the youth identify themself, identify the
medication prescribed, and applicable side effects. None of the medication was pre-poured from
the original packaging or placed in another container. Nursing staff administered the youth’s
medication. The youth and nursing staff electronically signed the MAR, and the medication
administration was documented, as required. An interview with the RN manager confirmed all
medications are to have a current, valid order, and are given as ordered on a current
prescription or the Practitioner Order form. Observations of medication storage indicated all
medications were separated by type, stored in a locked area designated for storage, and were
inaccessible to youth. The RN manager or a licensed medical staff trained approved non-
licensed healthcare staff to provide medication, and the center maintains a list of staff who have
access to the clinic and medications in the RN manager’s office. A review of supervisory training
records confirmed each authorized staff was trained in medication administration. The center
maintains a modified Class II permit and contracts with a licensed pharmacy, and a licensed
consultant pharmacist is on-site monthly. The center has a policy and procedures for medication
disposal which requires the pharmacy consultant to be responsible for the disposal of
medications in conjunction with an RN. Seven youth were interviewed, and four youth stated a
nurse administers medication and one said the doctor may administer their medication. Three
youth indicated they do not take any medication. Seven staff were interviewed, and one
supervisory staff stated they administer medication to youth and six staff indicated they did not
administer medication. The center did not have any standing orders, emergency treatment
orders, or pro re nata (PRN) orders for psychotropic medications.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center utilizes a licensed psychiatrist as the contracted designated mental health clinician
authority (DMHCA) to provide tele-psychiatry and medication management. The DMHCA holds
a license which expires on March 31, 2026. An interview with the DMHCA indicated the center
does not utilize a back-up psychiatrist. The psychiatrist provides services for two hours a week
utilizing tele-psychiatry, typically from 3:00 p.m. to 5:00 p.m. A review of seven Individual
Healthcare Records (IHCRs) records indicated four youth were prescribed psychotropic
medication prior to admission and the psychiatrist was notified at each youth’s admission. Each
applicable youth record documented an Initial Diagnostic Psychiatric Interview which was
completed within fourteen days of admission, as required, and included the reason for referral,
the youth’s medical, mental health and substance abuse history, a Mental Status Examination,
Diagnostic Statistical Manual of Mental Disorder-Fifth Edition (DSM-5) diagnosis, treatment
recommendations specific to the diagnoses, and prescribed medication. Each Initial Diagnostic
Psychiatric Interview documented the name of each medication, the explanation of the need for
the medication, and the required frequency of medication monitoring/management. Each youth
had a psychiatric evaluation conducted within thirty days of admission, as required. Each of the
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four applicable youth’s psychiatric interviews included the reasons and factors for the referral,
youth history, history of psychiatric illness to include medication management, substance abuse
and mental health treatment, a Mental Status Examination, identification of individual, family, or
environmental factors which may potentially account for or influence the youth’s difficulties,
diagnostic formulation, treatment recommendations for stabilization of the youth, prescribed
medication and frequency of medication, explanation of the need for the psychotropic
medication, most recent applicable therapeutic serum drug level, and signature of the
practitioner. All four youth had a Clinical Psychiatric Progress Note (CPPN) completed and each
form was clearly identified as a “Psychiatric Evaluation” in each youth’s IHCR. All four youth
were applicable for prescribed psychotropic medications and each evaluation included
identifying data, diagnosis, target symptoms of each medication, evaluation, and description of
effect of prescribed medication on target symptoms. Prescribed psychotropic medications in
each of the four applicable youth’s psychiatric evaluations included name, dosage, quantity,
frequency and route of administration, reasons for changes, side effects, youth’s adherence to
the medication regime, height, weight, blood pressure, most recent serum drug levels, and
documentation of telephone contact with the youth’s parent/guardian to discuss medications. All
four psychiatric evaluations were signed and dated by the psychiatrist and included monthly
monitoring directives for Tardive Dyskinesia. All four youth had an Authority for Evaluation and
Treatment (AET) completed at admission and three youth were applicable for a new
psychotropic medication having been prescribed, discontinued, or changed, and page three of
each youth’s CPPN showed documented verbal parent/guardian consent. Tele-psychiatry was
utilized to conduct the psychiatric evaluations of all four youth, and the proper consents were
documented in each of the four youth’s IHCRs.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center has facility operating procedures (FOPs) requiring any medical equipment classified
as sharps and stock medications to be secured and inventoried by using a routine perpetual
inventory with a descending count as each sharp is utilized and disposed of, or when any
medication is utilized. Documentation of each individual dosage of medication administered to
any youth is maintained on a Medication Administration Record (MAR) to demonstrate the
distribution of medications. Observation of the medical clinic demonstrated it was secured and
only accessible to healthcare professionals and approved supervisory staff. Juvenile justice
detention officer supervisors (JJDOS) are the non-healthcare, authorized staff who are trained
by a registered nurse (RN) to assist youth with self-administration of over-the-counter (OTC)
medication when licensed healthcare staff are not on-site and, in an emergency, the
epinephrine auto injector. The center maintains a secure refrigerator inside the locked medical
clinic. All medication requiring refrigeration is stored in a secured refrigerator used only for the
storage of medication. A locked medication cart is maintained in the medical clinic and stores
oral prescription and OTC medications prescribed for youth. The medication cart was clean and
organized with stock items stored separately from youth-specific medications. Narcotics and
controlled medications had individual perpetual descending inventories and were secured in a
separate locked area inside of the medication cart, behind two locks. Injectable, topical, and
liquid medications were stored separately and securely maintained. The center’s practice is for
two nursing staff to conduct shift-to-shift inventory counts of all controlled medications. Three
different controlled medications, three different sharps, and three different OTC medications
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were physically observed and counted. The observed counts corresponded accurately with the
counts listed on the individual inventory logs for each item. All physical inventories were
supported by the inventory logs for each item. The center maintains an inventory of all sharps
and medical equipment classified as sharps. A review was conducted of the medical binders for
sharps and OTC medications and confirmed perpetual inventories were maintained. Items
designated as sharps were stored in a designated locked cabinet in the medical clinic and were
inaccessible to youth. An informal interview with the RN manager validated the center’s practice
and procedures related to inventory discrepancies, which includes reconfirming the error, and if
confirmed, initiating coaching and training with staff. The center maintains a contract with a
licensed pharmacist, and a copy was maintained on-site. An informal interview with the RN
manager indicated the center’s disposal practice for expired and/or discontinued medications is
for the licensed consultant pharmacist and an on-site nurse to dispose of the expired
medication(s) utilizing a chemical medication disposal agent. All disposals are documented on
the Disposition and Destruction of Medications form. An interview with the RN manager
confirmed the center's process for securing all medications.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures (FOPs) requiring the implementation of infection
control procedures including prevention, containment, treatment, and reporting requirements
related to infectious diseases, according to the Occupational Safety and Health Administration
(OSHA) federal regulations and the Center for Disease Control and Prevention (CDC)
guidelines. The center maintains an Exposure Control Plan/Infection Control Plan which
includes a list of job classifications in which staff have the potential for occupational exposure,
and a list of tasks and procedures which may cause staff to experience occupational exposure.
Reviewed documentation supported the Exposure Control Plan/Infection Control Plan was
written in accordance with OSHA standards. The plan addressed common childhood infectious
diseases, self-limiting, episodic contagious illnesses, viral or bacterial infectious diseases,
Tuberculosis (TB), Hepatitis A, B and C, human immunodeficiency virus (HIV), bloodborne
pathogens, other outbreaks and epidemics, outbreaks of pediculosis, methicillin resistant
staphylococcus aureus and other antibiotic-resistant micro-organisms, food-borne illnesses,
bioterrorism agents, chemical exposure in the workplace, and protocols for needlestick post-
exposure intervention and treatment, as required. The community health department completes
all infectious disease and sexually transmitted infection testing, who then reports to the CDC.
The local county health department, CDC, and the Department’s Central Communications
Center (CCC) are notified of all incidents related to infectious/communicable diseases. The
center had no incidents of occupational exposure or quarantining of at least ten percent of the
population reported since the last annual compliance review. The center ensures Hepatitis B
immunizations are made available for staff and staff have access to protective equipment. A
review of seven youth Individual Healthcare Records (IHCRs) validated each youth received
infection control training within seven days of admission, which included training on hand-
washing techniques, universal/standard precautions, prevention/transmission of communicable
diseases, vaccinations, and the CDC guidelines for infection control. A review of seven pre-
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service and seven in-service staff training records supported each staff received training on the
center’s Exposure Control Plan/Infection Control Plan. An interview with the registered nurse
(RN) manager confirmed the center maintains an Exposure Control Plan, which is available to
the staff in the medical clinic. The RN manager conducts exposure control training for center
staff. Nursing staff are responsible for providing infection control training to youth. The RN
manager indicated the center utilizes the Miami-Dade County Health Department for provision
of additional medical services for the youth, including TB, sexually transmitted infections (STI)
and HIV testing, dental care, prenatal care, and routine gynecological care.
4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures (FOPs) for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. Nursing staff are required
to provide prenatal education to include alcohol and drug use, smoking, nutrition, sexually
transmitted infections, contraception, prenatal care, birthing process, postpartum care, basic
baby care, child/infant development, and parenting skills to all pregnant youth. While at the
center, nursing staff are to monitor each pregnant youth for weight and nutritional status. Seven
youth Individual Healthcare Records (IHCRs) were reviewed, and none were applicable for
prenatal care/education. The center was able to provide one IHCR for a pregnant youth who
was at the center since the last annual compliance review. A review of the applicable IHCR
revealed the applicable youth received prenatal care immediately upon determination of
pregnancy. The youth was placed on the Department’s Juvenile Justice Information System
(JJIS) alert system. The reviewed IHCR revealed the youth received education related to
pregnancy including alcohol and drug use, smoking, nutrition, sexually transmitted diseases,
contraception, prenatal care, birthing process, postpartum care, basic baby care, child
development, and parenting skills. All required topics were documented on the Health Education
Form. The youth received nutritious food in quantities appropriate for pregnant youth. The youth
did not receive routine, focused medical evaluations or routine monitoring of nutritional and
weight status as the youth was in secure detention for only two days. A review of seven staff
training records verified each staff received girls’ health training specific to working with
pregnant youth/girls. Staff training was provided by a registered nurse (RN) at the time of hire
and annually, thereafter. The center’s nursing protocols include treatment plans for pregnant
youth. Seven youth were interviewed, and two indicated they can receive prenatal, obstetrical,
or gynecological services when needed at the center and five were not applicable. An interview
with the RN manager confirmed female youth are given a pregnancy test upon admission with
youth consent. In the event a youth is pregnant upon admission, the youth is educated on
pregnancy issues by the RN manager, issued a special diet, started on pregnancy vitamins, and
scheduled for prenatal appointments and oversight by an obstetrician.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures (FOPs) to address active supervision of youth.
Daily observations were conducted during the annual compliance review week. Youth and staff
observations were made during school time, in the medical clinic during medication
administration and sick calls, during mealtimes and breaks, in the intake area, and during line
movements throughout the center. Detention staff maintained continuous supervision of youth
within their assigned areas. The interactions observed between staff and youth verified active
supervision. Staff were appropriately positioned in their designated areas and during line
movements which supported active supervision. Juvenile justice detention officers (JJDOs) and
master control operators communicated to receive authorization for all movement within the
center. A review of the center’s master control logbook confirmed headcounts were conducted
on a consistent basis during the beginning and ending of each shift, and prior to youth
movement. Seven staff were interviewed, and each stated there were enough staff to provide
for the safety and security of youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) requiring a behavior management system
(BMS) which offers a consistent set of rewards, privileges, and consequences for behavior. The
center’s rewards, privileges, and consequences are to motivate youth to meet the center’s
expectations. The BMS is a three-tiered level system. Once a youth is admitted into the center,
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the youth’s behavior level may increase or decrease depending on the youth’s behavior.
Observations during the annual compliance review week revealed postings of the BMS in all
living modules which clearly specified appropriate and inappropriate behaviors, rules, norms,
and expectations. The BMS indicated rewards for positive behavior and consequences for
inappropriate behavior. An interview with the superintendent confirmed this practice. The
center’s incentive calendar was posted on the living modules and throughout the center. All the
youth living modules had level boards, where youth could see their progress throughout the day.
Daily activities were observed and determined implementation of the BMS. A review of
documentation confirmed positive rewards were given to youth to match the BMS incentive
calendar, and rewards and consequences were given in accordance with the BMS. The
reviewed documentation did not indicate any instances of inappropriate use of restrictions or
group punishment. Seven interviewed staff were able to explain the center’s BMS process in its
entirety. Each interviewed staff reported receiving feedback daily, as needed, on their
implementation of the BMS. Seven interviewed staff reported supervisors provide feedback to
staff regarding the implementation of the BMS during shift briefings. Each interviewed staff
stated youth are given the opportunity to explain their behavior. Seven youth were interviewed
and two of the seven reported the BMS is fair, three stated the system is very good, and two
reported the system is good. Each youth was able to explain the different levels of the BMS.
Each youth reported peer punishment is not allowed. All seven youth stated they received
rewards based on their behavior. Four youth reported being sent to their room as a punishment
for fighting or acting out. Three youth reported never being sent to their room. Four youth
reported consequences were fair and three youth reported never receiving consequences. All
seven youth reported they never witnessed handcuffs or leg irons being used to control youth.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures (FOPs) addressing ten-minute checks. Staff utilize
a Visual Observation Report (VOR) on the outside of each youth’s door. The center had 166
cameras and 158 were operational. Video recordings are stored for thirty days. Documentation
was reviewed and verified work orders were submitted for the inoperable cameras. Camera
samples were reviewed for nine thirty-minute periods over the thirty days prior to the annual
compliance review week. Reviewed documentation and video confirmed all checks were
completed under the ten-minute designated time frame and with fidelity. Documents were
provided to confirm weekly reviews of management oversight. A review of ten-minute check
logs for thirty-minute increments from each shift on each living module, since the last annual
compliance review was completed. All checks were completed within the required time frame of
under ten minutes. Seven interviewed staff reported room checks are conducted every ten
minutes when a non-suicidal youth is placed in their room for sleeping or non-punishment
reasons. An interview with the superintendent confirmed the center’s practice.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures (FOPs) requiring staff to always be aware of the
exact number and location of all youth under their supervision. During the annual compliance
review week, master control officers were observed conducting scheduled and random census
counts. All movement within the center was stopped and juvenile justice detention officers
(JJDOs) called their findings into master control by radio. Once each count was verified,
movement within the center was allowed to continue. All findings were documented in the
master control and module logbooks. A review of the master control logbooks included one full
day from each month for twelve months prior to the annual compliance review confirmed
headcounts were conducted at the beginning and end of each shift, prior to and following
routine group movement, any time a population change occurred, randomly, at least once on
each shift, and before/after youth movements. Seven interviewed staff reported youth counts
were conducted at the beginning and ending of each shift, before and after school, and before
and after meals. Each staff stated emergency counts are conducted when visibility is hindered
such as an electrical outage, after a major disturbance, and when a youth is believed to be
missing.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
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The center has facility operating procedures (FOPs) in place regarding logbook maintenance
and reviews. The center maintains separate logbooks in master control, each living module, for
visitors, and for each vehicle. A review of logbooks for the past twelve months revealed each
logbook was bound with numbered pages, had the date documented at the top of the page, all
entries included the times of the events with the name of the staff and youth involved, contained
a brief description of the events, and the initials of the staff making the entries. All reviewed
entries revealed safety and security of the center, including medical, special needs, and mental
health alerts, were highlighted. Reviewed logbooks reflected all errors were struck through with
a single line and voided and initialed by the person correcting the error. Reviewed master
control logbooks included emergency situations, incidents, fire and escape drills, population
counts at the beginning and end of each shift, group movements, admissions and releases,
presence of law enforcement, names of youth placed in confinement including the time
confinement began and the time confinement ended, and the names of youth placed on
precautionary/secure observation, including the time precautionary and/or secure observation
began, and the time precautionary and/or secure observation was discontinued. Sample
logbooks from master control and each living module were reviewed for one day each month
during the annual compliance review period, not exceeding twelve months. Documentation
supported the center’s superintendent, or designee reviewed all logbooks on a weekly basis.
Each juvenile justice detention officer (JJDO) supervisor reviewed the logbooks maintained in
master control when accepting the responsibility of the center and each living module. Each
JJDO documented a review in the logbooks maintained in the living modules when accepting
responsibility of the area. Documentation indicated the superintendent, assistant
superintendent, or staff in charge of the center toured the youth living modules at least once
during each shift and documented their visit in each module’s logbook. An interview with the
superintendent confirmed the center’s practice.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) detailing the requirements of the center’s
key control, issuance of keys to staff, inventory of keys, and tracking. All staff are trained in key
control prior to key assignments. Key assignment and usage pertain to each staff’s role. The
storage area was observed and confirmed each key ring had a tamper proof color coordinated
key ring hub. All juvenile justice detention officer (JJDO) keys were blue, supervisor keys were
yellow, administration keys were black, medical/mental health keys were white, food service
keys were green, education keys were brown, and emergency keys were red. A review of the
key inventory sampling confirmed key rings on the inventory matched the actual key rings in
use. Keys which were not assigned were secured in the supervisor’s office in a tamper proof
lockbox. Staff are given a key by the supervisor at the beginning of the shift and return their
keys back to the supervisor at the end of the shift. Observations confirmed key distribution was
conducted during shift briefings by a supervisor. Emergency key rings were included as part of
the center’s key inventory. Observations confirmed the master key inventory included each ring
number, number of keys on each ring, capability of each key, and to whom each key ring was
issued. Reviewed documentation confirmed the issuance of keys and key ring numbers were
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documented on each shift report. Documentation included the date and time of issuance, name
of staff issuing the key ring, name of staff who received the key ring, and the time the key ring
was returned. Observations made during the week of the annual compliance review confirmed
all staff who were issued keys always carried the issued keys, did not allow youth to handle any
keys, did not remove the keys from the center or the center’s grounds, and the key box was not
easily accessible while locked. During the annual compliance review period, there was one
incident reported to the Department’s Central Communications Center (CCC) related to key
control concerns. It was reported staff received a retraining memorandum for key control as a
corrective action. A sample of five key rings were observed and compared to the inventory and
key log. It was confirmed keys were present on the key log, the key tags matched the number of
keys on the key rings, and the number of keys on the rings matched the inventory. Three staff
were informally interviewed about their keys, and all three staff knew the correct number of keys
on their key ring and the function of all the keys on their assigned key ring. An interview with the
master control operator confirmed staff are assigned a color coordinated key prior to entering a
secure area, and contractors are given a colored key to coordinate with their designated work
area. Keys are turned in prior to departure. The restricted key staff are to turn in or secure away
their personal items and receive the keys from a supervisor. Seven staff were interviewed and
were able to explain the key control process in its entirety. The interviewed superintendent
reported permanent keys are not assigned.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures (FOPs) to address transportation procedures and
the maintenance and operation of Department vehicles. The center has thirteen vehicles;
however, eleven total vehicles were used to transport youth. The additional two vehicles are not
used to transport youth and were down due to maintenance issues. Documentation supported
the maintenance mechanic completed monthly vehicle checks. A review of the vehicle
maintenance invoices revealed all vehicles received an annual inspection within the previous
year. Observations confirmed each of the center’s eleven utilized on-site vehicles had the
appropriate number of seatbelts, a seatbelt cutter, a window punch, a current fire extinguisher,
and a first-aid kit with items approved by the designated health authority (DHA). Reviewed
documentation confirmed the van logbooks documented acknowledgement of the vehicles
being checked, destination, number of youth and staff names, name of the juvenile justice
detention officer (JJDO) riding in the back of the van, the time transport began, and the time
transport ended. An observation of a youth transport was conducted during the annual
compliance review week. Prior to transporting youth, staff inspected the vehicles for contraband,
conducted a fuel check, maintained copies of transportation procedures in the vehicle, verified
the seat belts were operational, ensured the security screen was secure, and confirmed the
vehicle folder included the logs, vehicle and mechanical restraint keys, gas credit card, and
vehicle registration. Following transport, observations confirmed youth and staff were wearing
seatbelts, the van was searched for contraband, locked, and the youth was searched. A security
check was conducted of all vehicles, and all were locked when not in use. Seven interviewed
youth reported they felt staff were driving safely when transporting youth and they have never
seen anyone place contraband in a transport vehicle.
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5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOPs) to address tool inventory and tool
management requirements. The center's maintenance and kitchen tool policies require
inspections of tool control areas to be conducted monthly, and the results of inspections are
submitted to the superintendent or designee. Tools are stored in a locked area when not in use.
Observations made during the week of the annual compliance review confirmed this practice.
The center maintains a perpetual inventory of all tools and the superintendent or designee
reviews maintenance tool inventories monthly. The reviewed inventory was accurate at the time
of the annual compliance review and there were no missing tools noted. Ten randomly selected
tools were compared against the inventory, and the inventory log was accurate. The center also
maintains a perpetual inventory for signing in and out tools as they are utilized. The center has a
shadow board to easily identify any missing tools. Kitchen staff conduct an itemized inventory of
all equipment, including kitchen knives and other hazardous kitchen items, upon reporting for
duty. Observations of the kitchen confirmed there were no tools listed on the inventory missing
and there were no tools not listed on the inventory. An informal interview with maintenance staff
confirmed it is the center’s practice to always accompany service vendors when in a secure
area of the center. Reviewed documentation confirmed the center documented the issuance
and return of tools. The center allows youth to use cleaning items such as mops, brooms, and
other common household items, under direct staff supervision. Observations were unable to be
observed of youth using cleaning tools during the week of the annual compliance review as this
activity did not occur while the annual compliance review team was on-site. During an interview
with the superintendent, it was confirmed administration and maintenance staff have access to
center tools. Seven staff were interviewed regarding the process for broken tools and reported
the center’s practice is to complete a work order. Additionally, one staff stated they would report
any issue to the sergeant as well as completing a work order. Seven staff reported youth are
allowed to use mops and brooms. Seven youth were interviewed, and two youth stated the only
tools they use are mops and brooms, while five youth stated they don’t use any tools.
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5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has a safety plan to ensure proper use, storage, disposal, and inventory of
chemicals including poisonous, flammable, and toxic materials. Reviewed documentation
revealed the center maintained an inventory of all flammable, toxic, caustic, and poisonous
items during the annual compliance review period. Safety Data Sheets (SDS) were in the
location where the chemicals were stored, and available to staff. Only authorized staff are
permitted access to flammable, toxic, caustic, and poisonous items. All chemicals were stored
away from youth. During the annual compliance review week, the inventory was reviewed for
five selected chemicals and compared to the inventory sheets. All chemicals were accounted for
and the SDSs were present. Seven youth were interviewed and asked if they used chemicals to
clean. Two stated yes and five stated they do not clean with any type of cleaning agent such as
bleach, laundry soap, window, or toilet cleaners. The two youth stated staff spray, and they wipe
down the area where staff has sprayed. Seven interviewed staff confirmed youth are not
allowed to clean with substances which are toxic, flammable, or poisonous.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) regarding the disposal of flammable, toxic,
caustic, and poisonous items. The FOPs list the procedures to follow in the event of a chemical
spill. An interview with maintenance staff and reviewed documentation confirmed the center did
not have any instances of chemical spills or disposal of any flammable, toxic, caustic, or
poisonous items during the annual compliance review period. Maintenance staff reported the
center uses a local waste management company for chemical disposal and does not fry food;
therefore, there is no disposal of kitchen grease.
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5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures (FOPs) addressing the process for youth placed in
temporary confinement under twenty-four hours. The center had 480 confinements lasting less
than twenty-four hours during the annual compliance review period. Fifteen confinement reports
were reviewed. Each confinement report contained documentation which supported each youth
had the required meals, access to medical care as required, daily access to mental health care
as needed, daily shower, clean clothing, access to hygiene items, mattress/bedding, and the
right to grieve a confinement placement. None of the youth were applicable for needing
education materials due to school not being in session, or because youth were not in
confinement for long periods of time. Fifteen reviewed reports confirmed prior to placing each
youth in confinement, a supervisor approved all confinements, staff placed only one youth in
each confinement room, each room was searched, and documentation of each search was
entered into the Department’s Facility Management System (FMS). All fifteen reports confirmed
once each youth was placed in confinement, the youth was supervised and supervision was
documented on the confinement Visual Observation Report (VOR) log, at a minimum of every
five minutes for the first hour of confinement. Reviewed reports confirmed the reason each
confinement was necessary, which was explained to each youth, a supervisor conducted an
initial confinement review with each youth within one hour of the incident, and each full report
was completed before the end of the shift. Reviewed reports confirmed a supervisor conducted
additional applicable reviews with each youth at a minimum of every three hours and
documented the reviews in FMS. Additionally, a supervisor/staff continually counseled each
youth and considered removing each youth from confinement as soon as the youth was able to
safely rejoin the population and there was no threat to safety. None of the reports confirmed a
physical injury was observed. Each report confirmed the superintendent, or designee reviewed
all confinement reports within forty-eight hours, excluding weekends and holidays, unless it is
their regularly scheduled workday, and determined whether each confinement was appropriate
or inappropriate. Observations confirmed windows and cameras were free of
obstructions/scratches, so youth could be visually observed. An interview with the
superintendent confirmed confinement is used as a short-term strategy used for managing a
youth's behavior, and it is tracked through analytics software and the Department’s Juvenile
Justice Information System (JJIS) daily. The superintendent reported management reviews the
use of confinement, lockdown, and restraints daily. Seven staff were interviewed, and all seven
stated the center’s step-by-step process for placing youth in confinement is to complete a
confinement report, conduct and document ten-minute checks, search the confinement room,
contact the supervisor, and document it in the logbook. Seven interviewed staff reported youth
who are placed in temporary confinement are provided with education materials.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
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The center did not have any confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures (FOPs) to address the Continuity of Operations
Plan (COOP). Reviewed drill documentation confirmed the center conducted three COOP drills
during the annual compliance review period, as required, including at least one drill completed
prior to hurricane season. Reviewed documentation for all drills contained the type of drill, date
and time, participants, a brief scenario, and any resulting critique or corrective action. During an
interview with the superintendent, it was reported the COOP is the center’s comprehensive
safety/emergency plan.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) to address an Escape Prevention Plan. The
center’s policy and plan require the center to conduct escape drills on a quarterly basis.
Reviewed documentation confirmed escape drills were completed quarterly during the center’s
two shifts since the last annual compliance review. A review of seven training records confirmed
staff were trained in escape prevention annually. A review of the center’s logbooks confirmed
documentation of each drill. Seven interviewed staff reported they participated in escape drills.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has facility operating procedures (FOPs) for addressing fire prevention and safety.
Reviewed documentation supported the center conducted fire drills every month, on each shift
since the last annual compliance review. A review of the center’s logbooks confirmed each of
the drills were documented. Reviewed documentation confirmed fire extinguishers were
inspected annually. Seven interviewed youth reported they were instructed on what to do in
case of a fire. Seven interviewed staff reported fire drills take place at least monthly.
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5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) to address searches and contraband.
During the annual compliance review week, a search was observed, and staff thoroughly frisk
searched the youth, while wearing gloves, prior to admission. The search consisted of two staff,
both the same gender as the youth, and searches of the youth were conducted individually and
not in a group setting. The center conducts electronic/wand searches on all persons entering
the center, with all items entering the secure area being examined, prohibiting personal keys,
personal cellular telephones, and any additional contraband items. Observations confirmed
rooms were searched upon each youth’s release, rooms were searched prior to placing a new
youth in a room, and all rooms were searched for contraband on each awake shift. The center
documents searches in a shared network drive. A review of random shift reports for one day for
each month during each awake shift for the annual compliance review period confirmed youth
room searches were documented and completed as required. The center did not report any
instances which may have compromised the safety or security of the center throughout the
annual compliance review period. Observations during the annual compliance review week
confirmed searches of staff, visitors, and contractors/vendors were completed electronically and
a frisk search was completed prior to allowing entry to the secure area. Reviewed
documentation confirmed the center’s visitor log did contain a contraband attestation statement.
Twenty-seven reviewed staff records confirmed each staff had a contraband attestation form
included in their record. Four reviewed newly hired staff records each contained a contraband
attestation form. Reviewed policies indicated the center is to document confiscation of
contraband in the master control logbook, complete incident reports, identify findings and
disposition of contraband, contact law enforcement if any found item was considered illegal or if
there was evidence of any type of unlawful activity, secure confiscated items and hand-deliver
the items to the supervisor, document the chain of custody of confiscated items, notify the
Department’s Central Communications Center (CCC) of discovery and confiscation of illegal
contraband, and notify the regional director or designee of any confiscation of contraband.
During an interview the superintendent reported youth searches occur as often as needed. The
superintendent further stated if a youth or staff is found with contraband, administration and
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local law enforcement shall be contacted. There were two instances where contraband was
found since the last annual compliance review and all the Department’s policies and procedures
were followed.
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report_type: QI Detention