state: FL

facility_name: Orange Youth Academy

summary: QI Detention - FY25-26 - 6 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Orange Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
2800 S. Bumby Avenue
Orlando, Florida 32806
Review Date(s): August 5 - 8, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Bonita Williams, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Education Coordinator (Standard 2)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Tra’Shana Harley, Brevard Regional Juvenile Detention Center, Field Trainer Coordinator
(Standard 2)
Melissa Johnson, Office of Accountability and Program Support, Regional Supervisor (Standard
3)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 1 and Interviews)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Orange Regional Juvenile Detention Center MQI Program Code: 247
Provider Name: State Operated Contract Number: NA
Location: Orange County / Circuit 9 Number of Beds: 95
Review Date(s): August 5 – 8, 2025 Lead Reviewer Code: 184
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 57
Lim ited R atings
3.12 S uicide P revention Training *
4.12 E pisodic/First A id C are/E m ergency C
5.04 C ensus C ounts and Tracking
are
Failed R atings
1.08 G rievances
2.10 E ducational A ccess *
5.07 V ehicles and M aintenance
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 57
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a
S ta ff C o d e o f C o n d u c t S a
In c id e n t R e p o rtin g C C C * S a
R ig h t In te ra c tio n s (R I) S a
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a
In -S e rv ic e T ra in in g S a
G rie v a n c e s
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a
D a ta T re n d A n a ly s is S a
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 a tte n tio n if a p ro g
D e p a 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 ic a to rs . F
a p ro g ra m 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 ).
tis fa c to ry
tis fa c to ry
tis fa c to ry
tis fa c to ry
tis fa c to ry
tis fa c to ry
tis fa c to ry
F a ile d
tis fa c to ry
tis fa c to ry
ra m
a ilu re to d o
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access * Failed
2.11 Career Education 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 5 of 57
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 57
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 e p
b e lo w D e p
in a p ro g ra
aam rtm
rtm
a
eele n t h
n t s
rt fo
a s id e n
ta n d a rd
rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
S ta n d a r d 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 r v 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 A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
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 *
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
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
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 ).
te a tte n tio n if a p ro
d ic a to rs . F a ilu re to
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
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
L im ite d
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
g ra m o p e ra te s
d o s o w ill re s u lt
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 57
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 a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 4 - H e a lth S e r v 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 * S a tis fa c
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa c
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c
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 S a tis fa c
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 S a tis fa c
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa c
H e a lth -R e la te d H is to ry S a tis fa c
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 a tis fa c
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g S a tis fa c
S ic k C a ll P ro c e s s S a tis fa c
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 L im ite
O ff-S ite C a re /R e fe rra ls S a tis fa c
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 S a tis fa c
M e d ic a tio n M a n a g e m e n t S a tis fa c
P s y c h ia tric S e rv ic e s * S a tis fa c
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 S a tis fa c
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 S a tis fa c
P re n a ta l C a re /E d u c a tio n S a tis fa c
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 a tte n tio n if a p ro g ra m
D e p a 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 ic a to rs . F a ilu re
a p ro g ra m 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 ).
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
dto
ry
to ry
to ry
to ry
to ry
to ry
to ry
to d o
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 57
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 a
o p e ra te s b e
d o s o w ill re
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th * S a tis fa c to ry
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* S a tis fa c to ry
T e n -M in u te C h e c k s * S a tis fa c to ry
C e n s u s C o u n ts a n d T ra c k in g L im ite d
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 S a tis fa c to ry
K e y C o n tro l S a tis fa c to ry
V e h ic le s a n d M a in te n a n c e F a ile d
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 * S a tis fa c to ry
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 S a tis fa c to ry
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 S a tis fa c to ry
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 S a tis fa c to ry
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 N o n -A p p lic a b le
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 S a tis fa c to ry
E s c a p e D rills S a tis fa c to ry
F ire D rills S a tis fa c to ry
S e a rc h a n d C o n tra b a n d P ro c e d u re s S a tis fa c to ry
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 a tte n tio n if a p ro g ra m
lo w D e p a 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 ic a to rs . F a ilu re to
s u lt in a p ro g ra m 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 ).
Program Overview
The Orange Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Orlando, Florida. The center serves youth in Orange and Osceola
counties in Circuit 9. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the ninety-five bed center.
Youth are provided 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 Orange County School Board. The center’s
management team includes the superintendent, three assistant superintendents, two
administrative assistants, eleven juvenile justice detention officer supervisors (JJDOS), and
seventy-one juvenile justice detention officers (JJDOs). Mental health and healthcare services
are provided through the contracted provider, VitalCore Health Strategies, LLC. Mental health
services are provided by one designated mental health clinician authority, one psychiatrist, three
licensed mental health counselors, and two licensed clinical social workers. 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 designated health authority
(DHA), two advanced practice registered nurses (APRNs), four registered nurses (RNs), and
one licensed practical nurse. The medical clinic maintains nursing coverage twelve hours a day,
seven days a week. 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 six living modules which are divided by male and
female. There are 162 security cameras at the center, of which 154 were operational at the time
of the annual compliance review. The non-working cameras were located at the west unit, which
is being turned over to a new provider. Video recordings are stored for thirty days. The living
module youth room windows all have scratches; however, do not impede view inside of the
rooms. At the time of the annual compliance review, the center had sixteen vacancies, which
included one food service worker, five JJDO I positions, eight JJDO II positions, and one
JJDOS.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57
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) for volunteers, mentors, and interns who
work with youth less than ten hours a month requiring sight and sound supervision. An Annual
Affidavit of Compliance with Level 2 Screening Standards was submitted to the Background
Screening Unit (BSU) on January 31, 2025, meeting the annual requirement. The center utilizes
local school board teachers and background screenings were completed by the Clearinghouse
on January 31, 2025, meeting the annual requirement. Since the last annual compliance review,
the center hired twenty-seven staff. Each staff had a completed background screening, which
included a criminal history, prior to contact with youth or confidential youth records. None of the
hires required an exemption prior to hire. Twenty of the twenty-seven completed the pre-
employment assessment tool and had a passing score. The remaining seven hires are
contracted staff and not required to take the pre-employment tool. Each of the seven contracted
hires were added to the Clearinghouse employee roster, as required.
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) for five-year rescreening’s. The center had
four applicable staff for a five-year rescreening. Each of the applicable staff had a five-year
rescreening/renewal calculated from the agency date of hire.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 57
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) for staff code of conduct. A review of three
staff for disciplinary actions and three staff for commendations were reviewed. The three staff
receiving disciplinary actions received a written reprimand and/or training. Three staff received
commendations for either employee of the month or employee excellence. Nine staff reported
during interviews, in order to report allegations of abuse they are to notify the supervisor, call
the youth to make the call, and the supervisor or staff are allowed to call the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC). None of the interviewed
staff reported ever observing a co-worker using profanity when speaking to youth or using
threats, intimidation, or humiliation when interacting with youth. One staff reported the
conditions were poor, two staff reported fair and six staff reported good. Nine youth reported
during interviews, they feel safe at the center. Six reported staff are respectful when speaking to
youth and three reported staff are not respectful. Eight youth reported never hearing staff use
curse words when speaking with youth and one reported hearing staff use curse words
occasionally. None of the youth reported hearing staff threaten youth. The superintendent was
able to confirm knowledge of the code of conduct and examples of disciplinary actions if
violated. One of the nine interviewed youth reported staff have stopped them from calling the
Florida Abuse Hotline. One of the nine interviewed youth reported staff have not stopped them
from calling the Florida Abuse Hotline. Seven of the nine interviewed youth reported never had
to report an abuse. Eight of the nine interviewed youth reported never filling a grievance and
one youth reported the grievance process is good.
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) for incident reporting to the Department’s
Central Communications Center (CCC). Since the last annual compliance review, the center
had 181 CCCs. Eighteen CCCs were reviewed for compliance. Each of the eighteen CCCs
were reported within ttwo hours. Seventeen of the CCCs were documented in the logbook, one
was not. There were no other internal incidents/grievances which should have been reported to
the CCC and were not. The interview with the superintendent confirmed knowledge of the
incident reporting process.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 57
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) for Right Interactions (RI). The center’s RI
rate during the previous quarter was 12.17, which is below the statewide Detention RI rate of
13.49. Since a previous assigned deficiency was closed on April 10, 2025, the center had 119
RI incidents; therefore, eleven RI incidents were reviewed. None of the RI incidents resulted in
serious injury, youth alleging abuse, mechanical restraints being used, or required a medical
review. Each RI was reviewed by the supervisor or the RI instructor. The post RI interview was
conducted within the required time frame for each RI incident. The superintendent/designee
reviewed each RI within the required time frame. One of the eleven RI reports were not
completed by the end of the staff workday and another RI report did not include statements from
all staff involved. During the interviews with seven staff, each reported using verbal redirection
prior to using physical restraints or mechanical restraints. The superintendent reported restraint
usage is documented on a tracking log and RI incidents were reviewed by video and incidents.
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.
Eight staff pre-service training records were reviewed. No other staff records were applicable for
the timeframe for staff selection. Two of the eight staff were still in their first 180-days of hire.
Five of the remaining six completed the pre-service training and certification requirements within
the 180-days of hire. The one remaining staff completed the training thirty-seven days late. The
detention center administration had requested an extension from the regional office prior to the
expiration of the 180 days due to the staff falling ill. The regional office had not forwarded the
extension to the Department’s Office of Talent, Leadership, and Culture office until the week of
the annual compliance review. All eight staff completed staff orientation within thirty days of hire.
Seven of the seven staff, completed the academy training, which consists of 120 hours. The
remaining two staff have not completed the academy training at the time of the annual
compliance review. None of the eight staff were a rehire.
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.
Nine staff in-service training records were reviewed. Seven of the nine staff completed all
required in-service training. The remaining two staff were missing five and four trainings
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 57
respectively. Three of the nine staff were supervisory staff and all three had completed the
required minimum eight hours of supervisory training in coaching, leadership, and personal
accountability. Twenty-two of the forty-eight applicable non-healthcare staff did not receive in-
service education on girls’ healthcare, including training on monitoring, observation, and
emergency care of the pregnant youth. The center uses the annual in-service training plan as a
training calendar. The annual in-service training plan was approved by the highest ranking
official at the center, the assistant secretary of detention, and the director of the Department’s
Talent, Leadership, and Culture.
The superintendent stated he received training in certified public manager (CPM) and
completed required training in the Department’s Learning and Management System (SkillPro)
and tier training. The superintendent also stated the center staff are required to complete annual
in-service training.
1.08 Grievances Failed 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 submits 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) for grievances. Youth are able to request
grievance forms from staff. The forms are located in the control room on each module. Five
grievances were reviewed, and each were entered in the Department’s Facility Management
System (FMS). The center did not have the original grievance for any of the five grievances.
Since the original grievances were not available, it could not be determined if the grievances
were resolved in real time. None of the nine interviewed staff were able to explain the grievance
process. Nine youth were interviewed and had a limited understanding of the grievance
process. Two youth knew to fill out the form and the supervisor reviews it. One of the nine
interviewed youh reported the grievance process is good, the remaining eight interviewed youth
reported never filling out a grievance form. The superintendent interview confirmed knowledge
of the grievance process.
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.
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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) for entering alerts and sharing of alert
information. Medical and mental health staff review alerts and ensure the alerts are correctly
tracked and managed. Alerts are shared during shift briefings with supervisors and direct care
staff. T Logbooks were reviewed and confirmed alerts were documented in logbooks. Shift
briefing was not able to be observed during the annual compliance review week due to the
briefing was held either before or after the team was on-site.. Alerts for nine youth were
reviewed and each youth required either an alert being entered or updated. Each alert included
all required documentation in logbooks and the Department’s Juvenile Justice Information
System (JJIS). There were no additional alerts found which should have been entered into the
alert system. The superintendent reported knowledge of the alert process. All nine interviewed
staff reported management inform them of issues within the center by documenting in the
logbook, and/or staff meetings. One staff reported the process for communicating information is
poor, two reported fair, five reported good and one reported very good.
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 facility operating procedures (FOPs) for data trend analysis. The center’s
practice regarding data trend analysis is to provide information during meetings, advisory board
meetings, and as needed to the department leadership through emails and/or telephone calls.
Meeting are held monthly or as needed as documented through agendas and meeting minutes.
Administration will discuss information gathered with supervisors and this in turn is used in
identifying areas of concern.
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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) outlining the admission process for youth
entering the center. Nine youth records were reviewed for the admission process. The staff
reviewed all required documentation upon each youth’s admission. The Admission Wizard
included all required documentation. An observation of a youth admission was conducted during
the week of the annual compliance review, and the staff followed the requirements for
admission of the youth.
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) outlining the orientation process for youth
entering the facility. Nine youth records were reviewed for the orientation process. The staff
reviewed all required documents upon the youth’s admission. Orientation was provided to each
youth both verbally and in writing. The brochure included all required information to include
signatures from both staff and youth at the time of admission. Nine youth interviews indicated
staff told youth about the rules and regulations, daily schedule, education services, visitation,
abuse reporting, and the behavior management system (BMS). During the week of the annual
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compliance review, one youth orientation was observed and the staff provided all required
information to the youth during the orientation process.
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) outlining the classification process for youth
entering the center. Nine youth records were reviewed for the classification process. The staff
classified each youth according to the center’s screening. Although there was no classification
form indicated in any of the nine folders, the classification information required was found in
other forms such as the Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB),
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2), face sheet and
admission wizard. Nine records confirmed the following considerations were part of the
classification process, mental illness, intellectual disabilities, physical disabilities, history of
violent behavior, criminal behavior, gang affiliation, medical, suicide risk or identified suspected,
escape, security, and history of human trafficking. The following required topics were also
considered before making a room assignment for each youth such as the youth’s sex, youth’s
height, youth’s weight, youth’s age and level of aggressiveness, changes in behavior observed,
and history of committing sexual offenses or is a victim of a sexual offense. The center
designated a juvenile justice supervisor (JDOS) as the gang liaison. According to the gang
liaison interview, the superintendent remains informed of identified local youth gangs in the
Department’s Juvenile Justice Information System (JJIS) alerts and email. The superintendent’s
interview indicated classifications are used when assigning youth rooms.
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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) regarding newly admitted youth to
determine gang affiliation. During the annual compliance review week, an informal interview was
conducted with the gang representative twice. The gang representative stated detention staff
and the appropriate juvenile probation officer (JPO) are informed of youth involved in gangs
through the Juvenile Justice Information System (JJIS) alerts. Nine youth records were
reviewed for gang affiliation and none of them were applicable. The center provided three
applicable youth records and each indicated a referral for the youth was emailed to the JPO
when suspicious activity such as youth flashing gang signs, gang tattoos, gang related drawings
or any other observed related activity.
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) outlining the policy for admission and
storage of youth’s personal property. All youth’s personal property and valuable property is
logged into the Department’s Juvenile Justice Information System (JJIS), maintained securely
and returned to the youth or the parent/guardian in a timely manner upon the youth’s release.
Nine youth records were reviewed, and each record included a letter of acknowledgment form,
signed by each youth. Each letter of acknowledgment included all required elements. Eight of
nine youth records included the youth’s signature on the property and valuable receipt form, and
remaining one youth did not sign the property and valuable receipt form. seven of the nine youth
records contained the staff signature on the property and valuable receipt form. The remaining
two did not have staff signature on the Property receipt Forms. Two of nine youth had both
property and valuables, and seven of nine youth records documented the youth did not have
valuables but had personal property upon arrival. Two of nine youth records did not include the
personal property of value being secured in a clear tamper proof property bag, the date, youth’s
name, the youth’s Departments identification number (DJJID), a listing of items in the bag, and
the bag was not in a tamper proof bag, nor placed in a drop safe. Two of applicable youth
records were not logged correctly in the drop safe bound logbook including date, time, youth’s
name, youth’s DJJID, printed name of the officer who secured the property, and the officer’s
initials. Seven of nine youth records were not applicable due to not having valuable property.
One of nine youth records did not have a property receipt form placed in the youth’s active
record. The remaining eight youth had a receipt form placed in their record. Each of the nine
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youth had other personal property, including clothing placed in an assigned locker/bag and
documented on the Property Receipt form. The personal and valuable Property Receipt Form
was placed in eight of the nine youth records. The remaining youth did not have a
personal/valuable Property Receipt in the record.
During the annual compliance review, there was no observation of the center receiving youth
personal property because the youth observed during intake returned from the hospital and did
not have any property to document. There were no Department Central Communications Center
(CCC) reports for the annual compliance review period regarding youth property valued over
fifty dollars. Nine youth were interviewed, and each youth reported when they arrived at the
center, they gave staff their property and signed a property sheet ensuring their property was
accurate. The superintendent also indicated the personal property is stored in the storage room
and property safe, supervisors and administration staff have access to the storage room, and
after thirty days of unclaimed property, property is disposed of, and a receipt is obtained.
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) outlining the policy for releases. None of
the nine youth records were applicable for release; therefore, an additional three closed youth
records were provided for review. Each record had a copy of a release form, which documented
the supervisor had reviewed all paperwork related to the youth’s court documents and release.
Each youth had their identification verified prior to release. The parent/guardian identification
was verified prior to release for each youth, and a photocopy of the parent/guardian
identification was placed in each youth’s youth record. None of the reviewed youth records
identified the youth as an endangered person. Each youth and the person to whom the youth
was released, were reminded of future court dates and signed the release forms. The date of
admission and the date of release documented in each youth’s record correlated with the dates
documented in the Department’s Juvenile Justice Information System (JJIS). All three youth
records indicated all required parties signed all applicable release forms. During the annual
compliance review, a release was observed, and it was confirmed the releasing staff followed
the center’s procedures for a youth release from the center.
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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.
The center has facility operating procedures (FOPs) outlining the policy for the release of
youth’s personal property, medication, and aftercare instructions. None of the nine youth were
applicable; therefore, three applicable youth records were requested and reviewed. Each record
contained a Property Receipt form signed by the youth and parent/guardian upon release. Each
record contained documentation verifying the youth was released to an appropriate person to
include a copy of their identification. None of the selected records were applicable for a youth
being released with medication. During the annual compliance review there were three
examples of property being held for more than thirty days (abandoned property). The FOPs
were followed for the disposal of abandoned property. During the annual compliance review, a
youth released with property was observed. The 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/guardian’s identification was confirmed by the issued
driver’s license and a copy was made. The youth and parent/guardian were notified of any
health or welfare issues, including, medical, mental health, and/or substance abuse needs and
any pending appointments. All release procedures for the center 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) outlining the policy for the review of youth
in secure detention. The center has an officer delegated as the detention review specialist
(DRS). During the annual compliance review week, an observation of the weekly review
meeting was able to be conducted in the briefing room. During the observation, it was confirmed
the meeting was attended by required attendees and a discussion of each youth was
conducted. There was documentation of all required participants for each of the reviewed
meetings since the last annual compliance review. The review of the weekly review was
documented in the Department’s Facility Management System (FMS). Each week on Thursday,
all youth in the center are discussed during the weekly review meeting with mental health,
medical, residential staff, education, and the juvenile probation officers (JPOs). The
superintendent stated reviews are conducted on a weekly basis by the DRS. The
superintendent stated residential staff, mental health, clinic management, education, state
attorney’s office and the DRS attends the meeting. The purpose of the review is to discuss the
youth in the center and any questionable court orders, as well as capacity/overcrowding issues
which may arise.
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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.
The center has facility operating procedures (FOPs) outlining the policy for the daily activity
schedule. During the annual compliance review, a center tour was conducted, and the daily
activity schedule was posted on all the living modules. Youth were also observed attending
school and participating in activities as indicated on the daily schedule. After reviewing logbook
documentation, activities such as wake-up/personal hygiene, mealtimes, visitation, recreation,
education, shift change, bedtime, and groups were conducted as scheduled. Eight of the nine
youth reported the daily schedule is followed and the remaining one youth stated the daily
schedule is not being followed. Nine staff were interviewed and two of nine reported the center
does not follow the daily activity schedule due to staff shortage, while seven of nine reported the
center does follow the daily activity schedule.
2.10 Educational Access (Critical) Failed 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 has facility operating procedures (FOPs) to provide for educational access. The
center integrates education into the daily schedule in such a way as to ensure the integrity of
the required minimum instruction time distributed over twelve months. The district-approved
calendar and daily school schedule were reviewed, which incorporated the required 250 days of
instruction, with ten days used for teacher planning, and a minimum of twenty-five hours of
weekly instruction. A discrepancy was noticed between the approved school district bell
schedule and the daily activity schedule. The daily activity schedule reflects the start of the
school day at 8:15 a.m. and ending at 2:30 p.m. every day. The school-approved bell schedule
has a start time of 8:00 a.m. and ends at 2:20 pm on Monday, Tuesday, Thursday, and Friday.
On Wednesday, there is a start time of 8:00 am and an end time of 1:35 p.m. A random sample
of three videos and three logbook reviews showed on two of the three days, the youth were not
moved for their educational classes. On day one, there was no movement observed by the
video reviewer, and no educational movement was noted in the logbooks. On day two, first and
second periods were delayed due to teachers moving furniture, but no further entries were
made to reflect youth moving to or from school. On the third day, it showed movement starting
at 8:15 a.m. and ending at 1:30 p.m., which is not the approved school district bell schedule for
this day. In addition, randomly selected logbook entries over the past five months (since a
deficiency was closed on April 24, 2025) were reviewed. School started fifteen minutes late daily
according to the approved school district schedule, and on two of the days, the school was
released on average of twenty-three minutes early. Six of the nine interviewed youth indicated
they attend school Monday through Friday, while three youth stated they do not. Two of the nine
interviewed youth reported the center doing very well with preparing them for the high school
equivalency diploma (GED), high school, vocational school, employment, and/or college. Four
of the nine interviewed youth reported the center is doing well and three youth reported the
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center is not well in preparing them for GED high school, vocational school, employment, and/or
college. Seven of the nine interviewed staff stated there is minimal interference of educational
instruction, while two staff stated there interference with educational instruction. During an
interview with the Superintendent, it was confirmed there is minimal interference in educational
instruction.
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 has facility operating procedures (FOPs) to provide for career education. Career
educational services are provided through the Orange County School District. The center
provides requirements for Type 1 Programming. The center provides education programming to
include communication, interpersonal, and decision-making. All nine interviewed youth reported
taking life skills, math, science, history, reading, social studies, and/or physical education. The
center provides vocational competency development programs for all youth. Youth are enrolled
in academic courses through Orange County Public Schools. Nine youth were interviewed, and
the youth results confirmed one student is taking life skills, five are enrolled in math, four are
taking science, three students are taking history, four are taking reading, two are taking social
studies, and one responded with none of the above.
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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 a contract with Vital Core Health Strategies, LLC to provide mental health
services at the center. The center has a designated mental health clinician authority (DMHCA)
who coordinates services and provides coverage at the center for forty hours each week. The
DMHCA is a licensed mental health counselor (LMHC) and has an active license through the
State of Florida, which expires on March 31, 2027. The center has a back-up DMHCA whose
license expires on March 31, 2027. The DMHCA provides oversight and coordination of mental
health services, including the completion of Assessments of Suicide Risk (ASR), supportive
services, and individual therapy. The DMHCA also provides supervision of non-licensed staff. A
review of the mental health logbook sign-in confirmed the DMHCA at a minimum, was on-site
weekly as required by contract. During an interview, the DMHCA confirmed overseeing the
coordination and implementation of mental health and substance abuse services, and to make
sure the services are consistent and effective. The DMHCA provides the following clinical
services at the center; assessments, comprehensive evaluations, individual counseling, crisis
management, and substance abuse treatment. The DMHCA is always available for
communication either face-to-face or by telephone, unless she is out on leave. Furthermore, the
DMHCA confirmed communication with the clinical staff occurs weekly through email.
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 center has a contract with Vital Core Health Strategies, LLC to provide licensed mental
health staff who deliver mental health and substance abuse services at the center. The center
had six licensed mental health counselors (LMHC) and four licensed clinical social workers
(LCSW), and one medical doctor, who is the psychiatrist, since the last annual compliance
review. All were working under the direction of the designated mental health clinician authority
(DMHCA), who is also a LMHC. Five LMHC’s and four LCSW’s have clear and active licenses
in the State of Florida with expiration dates of March 31, 2027. One LMHC had a license which
expired on March 31, 2025, but has not been providing services since December 4, 2024. The
psychiatrist also has a clear and active license in the State of Florida with an expiration date of
January 31, 2026. All licenses were posted in the mental health office and copies were provided
while on-site. Each licensed mental health staff was licensed under the appropriate Florida
Statutes chapter. The clinical supervisor ensures the licensed clinical staff under their
supervision are providing services they are qualified to provide based on education, training,
and experience. The center currently has two vacancies, both are behavioral health
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professionals. The first position has been vacant since July 25, 2025, and the second since July
1, 2025, due to a recent authorization for an additional full-time position.
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 center has facility operating procedures (FOPs) regarding non-licensed mental health and
substance abuse clinical staff. The FOPs included requirements for direct supervision,
education, and training. The center reported not having non-licensed mental health and
substance abuse clinical staff since the last annual compliance review.
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) regarding the assessment of youth for
mental health and substance abuse needs upon admission. Nine youth mental health records
were reviewed, and each youth was screened using the Suicide Risk Screening Instrument
(SRSI) and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). Each
youth was entered into the Department’s Juvenile Justice Information System (JJIS). All
screening documents were reviewed by detention staff, and the SRSI was completed at intake
for all nine youth. The nurse or mental health staff completed the required sections of the SRSI,
and the completed entries included an accurate referral section in the “Screening Results”
sections for all nine youth records. Six youth had a positive, “YES” response on the SRSI, and
three youth did not. Six youth records indicated each youth was placed on suicide precautions
and a mental health referral was completed, which documented each youth’s need for an
Assessment of Suicide Risk (ASR). Three youth records did not because the screenings were
marked as “Invalid.” Six youth records documented the SRSI screening included a “Yes”
response when the youth have any open or closed suicide risk alerts in JJIS, as prompted within
the JJIS SRSI navigation screen. Three youth records were not applicable. Three youth records
were applicable for all negative responses, and the screening was marked as “invalid” and
referred for a comprehensive assessment on the MAYSI-2 referral section. Six youth records
did not have an invalid screening. All nine youth records confirmed the results of the SRSI and
MAYSI-2 indicated a need for a further assessment, a referral was made, and the
superintendent/designee was notified. Six youth records indicated an elevated suicide risk
subscale, and the youth were placed on suicide precautions and referred for an ASR. Three
youth were not applicable. All nine youth records documented the results of the MAYSI-2 which
indicated the need for a comprehensive assessment, and the screener referred the youth to a
mental health clinical staff for a comprehensive assessment within the detention center.
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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 mental health and substance
abuse evaluations. Four of the nine selected youth were applicable and were identified after
admission as in need of and referred for a Substance Abuse Mental Health evaluation. Two
youth were applicable for a new Substance Abuse Mental Health evaluation which was
completed by the center provider, Vital Core Health Strategies, LLC. Two youth were applicable
for an updated Substance Abuse Mental Health evaluation which was completed by the center
provider, Vital Core Health Strategies, LLC. The center’s provider completed the Substance
Abuse Mental Health evaluation for hthe two applicable youth within fourteen days of admission.
The center was unable to provide the original updated Substance Abuse Mental Health
evaluation for one youth; however, the center completed a new updated Substance Abuse
Mental Health evaluation after being made aware of the exception during the annual compliance
review. Treatment recommendations were made which corresponded to all diagnosed mental
health or substance related disorders for all four youth records. The Comprehensive Mental
Health/Substance Abuse evaluation consisting of the Substance Abuse Mental Health
evaluation was in the Department’s Office of Health Services (OHS) Electronic Medical Records
None of the youth were applicable for a Comprehensive Assessment by the Community
Provider. During the interview, the designated mental health clinician authority (DMHCA) stated
any youth whose Massachusetts Youth Screening Instrument-2 (MAYSI) screening, staff
observations, or behavior after admission indicate a need for further assessment are referred for
a mental health and substance abuse evaluation. The juvenile probation officer (JPO) is
responsible for ensuring the comprehensive assessment is conducted within fourteen calendar
days of the referral for detained youth. Mental health may send a request for the comprehensive
evaluation by email to the JPO.
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 provides mental health and substance abuse treatment to any youth determined to
need services and any youth who are in the center for more than thirty days. Three of the
reviewed nine youth were applicable for initial treatment plans. Each of the nine youth received
a mental health orientation within fourteen days of their admission. Each youth’s initial treatment
plan included all required elements which was in place within seven days of the onset of
treatment and was signed by all required parties. The plans were developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form or a form which
contains all required information for all three youth. Each of the three initial treatment plans
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documented the reason for the referral, initial Diagnostic and Statistical Manual of Mental
Disorders-5 diagnosis/symptoms, initial treatment methods including counseling and frequency,
initial treatment goals, psychiatric services including psychotropic medication and frequency,
medication the youth was admitted with in order to compare with the initial treatment plan, and
the mental health substance abuse professional signature signed by a licensed clinical
supervisor. Furthermore, each of the three initial treatment plans contained the youth signature,
mini treatment team assignment, and all members of the mental health clinical staff, youth and
mini treatment team members who participated in development of the plan were involved in the
development of the plan. Five youth were applicable for an individualized treatment plan;
however, one youth was transferred out prior to having an individualized treatment plan. The
four youth records documented the individualized treatment plan was developed for youth
receiving mental health and/or substance abuse treatment in the center by the thirty-first day of
the youth’s admission. The four youth individualized treatment plans included DSM-5 diagnosis,
symptoms which are treatment focused, treatment goals including mental health services if the
youth have a mental illness, substance abuse services if the youth have a substance related
diagnosis, and the youth’s strengths and needs. Two youth treatment plans had psychotropic
medications listed in the initial treatment plan which matched the psychotropic medications the
youth was prescribed at the time the individualized treatment plan was developed. Two youth
were not applicable for psychotropic medication, and one youth did have psychotropic
medication listed in the initial treatment plan; however, the youth was transferred out of the
center before the individualized treatment plan could be completed. Four youth records
documented in the progress notes the youth were receiving treatment services as stipulated on
the treatment plan. A review of the four youth records confirmed the individualized treatment
plan was signed by the youth, mental health substance abuse professionals, treatment team
members, and parent/guardian. Two of the four youth were applicable for Individualized
Treatment Plan Reviews, while the other two youth have not had a thirty-day review during the
annual compliance review due to not being in the center for thirty days. One youth had two
thirty-day periods requiring individual treatment plan reviews, and the other youth had one thirty-
day period requiring an individual treatment plan review. Each review was completed within the
required time frame for each applicable youth. Each review was completed and documented on
the Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form
and revisions were documented on the forms. There were no modifications documented on the
review form for the applicable youth. A review of the two youth Individualized treatment plan
reviews indicated they were signed and dated by the clinical staff, youth, licensed mental health
professional, treatment team members, and parent/guardian. Furthermore, each treatment team
plan included the treatment and services provided by a licensed psychiatrist or a
licensed/certified psychiatric advanced practice registered nurse (APRN) working under the
clinical supervision of licensed psychiatrist. None of the youth were an alleged victim of a Prison
Rape Elimination Act (PREA) event; therefore, it was not required to be included in the plan.
None of the nine youth records selected were eligible for Mental Health/Substance Abuse
Treatment Discharge Summaries. The center provided three closed youth mental health records
for review. Each of the three youth records included the Department’s Mental Health/Substance
Abuse Treatment Discharge Summary form. A copy of each discharge summary was provided
by mail to the juvenile probation officer (JPO), parent/guardian, and youth. Each youth was
released prior to clinical staff having each youth sign the discharge summary. The Discharge
Summary was completed on the day of service, signed by the licensed mental health
professional, and the upload of additional documentation was completed within fourteen days
for the applicable youth records reviewed. A mini-treatment team meeting was unable to be
observed during the annual compliance review week, as the center held the meeting the day
before the annual compliance review started.
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During the interview, the designated mental health clinician authority (DMHCA) explained to
ensure services are provided at the center the DMHCA and mental health team keep track of all
comprehensive assessments requested and received by the JPO. Furthermore, the DMHCA
and mental health team keep track of all services provided to the youth. To review and update
an individual treatment plan, the mental health team creates a treatment plan within seven days
of initial treatment when taking psychotropic medication and the initiation of the initial psychiatric
diagnosis interview. The initial treatment plan is discussed in treatment team and signed. If a
youth needs mental health treatment and is in the center for more than thirty days, an
individualized treatment plan is created. The plan is based on information from the
comprehensive evaluation. The DMHCA or designee participates in administrative meetings
weekly with the superintendent and/or assistant superintendents, as well as other department
heads. There are numerous informal meetings daily to discuss services, youth, and any issues
which may arise.
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) to provide mental health and substance
abuse treatment planning to provide interventions which will reduce the youth’s symptoms of
mental disorder or substance abuse. Nine youth mental health records were reviewed for
mental health and substance abuse treatment, and five were applicable. Each applicable youth
was assigned to a mini-treatment team which consisted of mental health clinical staff, staff from
a different service area, youth, and parent/guardian, if available. Each youth’s plan included
individual, group, or family therapy prescribed at least weekly. A review of progress notes
revealed each youth received counseling according to the frequency required by the plan. Two
applicable youth required substance abuse treatment and did receive individual, group or family
counseling according to the frequency of their plan. Four youth had a consent for treatment
Authority for Evaluation Treatment (AET) form signed, and one youth who remained in the
Department of Juvenile Justice (DJJ) custody had a limited consent in the Department’s
Juvenile Justice Information System (JJIS) since June 23, 2022. Two youth applicable for
substance abuse treatment had the proper consent for substance abuse treatment obtained
through the signed Mental Health Substance Abuse form. All treatment notes were documented
on the Department’s Counseling/Therapy Progress Notes form.
A review of group sign-in sheets confirmed group therapy was limited to ten or fewer youth for
mental health and limited to fifteen or fewer youth for substance abuse treatment groups. A
review of group sign-in sheets confirmed groups did not have more than the required number of
youth and were held on the modules for the required time. Mental health staff have adequate
access to youth and confidential space to provide treatment services. A video review of one
group conducted within the last thirty days, Decision Making, confirmed the group was
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conducted as scheduled, with two youth involved in the group. During the interview, the
designated mental health clinician authority (DMHCA) stated the process used for individualized
mental health and substance abuse treatment planning considers if a youth needs mental health
treatment and is in the facility more than thirty days and an individualized treatment plan is
created. The treatment plan is based on information from the comprehensive evaluation. It is
created with the youth and discussed and reviewed in treatment team. The substance abuse
treatment plan can be in combination with the mental health treatment plan. The center provides
the following substance abuse and mental health treatment services; assessments,
comprehensive evaluations, individual counseling, crisis management, group counseling, and
psychiatric services as needed.
Nine youth were interviewed and asked to rate the mental health and substance abuse services
at the center. Four youth stated good, two youth stated very good, and three youth stated they
are not receiving services.
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 a Suicide Prevention Plan detailing suicide prevention procedures which is
reviewed and signed by the designated mental health clinician authority (DMHCA) and
superintendent annually. The plan included identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and review process. The center has an
established review process for every serious suicide attempt or serious self-inflicted injury and a
mortality review for a completed suicide, including all required elements. The multidisciplinary
review includes circumstances surrounding the event, center procedures, all relevant training
received by involved staff, medical and mental health services involving the victim, precipitating
factors, and recommendations.
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 a Suicide Prevention Plan in place which outlines the procedures for youth
identified as at-risk, which includes a review process for any instances of a serious suicide
attempt, self-inflicted injury, or completed suicide. A minor deficiency was assigned on October
31, 2024, by the Office of Health Services (OHS) for suicide risk screenings not being
completed when youth are released from the juvenile detention center on precautionary
observation (PO). The minor deficiency was closed on January 2, 2025.
Nine youth mental health records were reviewed, and one youth was applicable. The center
provided two more youth mental health records which were applicable. One youth was identified
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as a suicide risk during admission screening, and two youth were identified through staff
observation. The three youth had alerts entered in the Department’s Juvenile Justice
Information System (JJIS) upon identifying each youth with suicide risk and documenting each
youth’s PO status. The three youth had a suicide risk assessment referral date within the time
frame. Each Assessment of Suicide Risk (ASR) document had an assessment on the day of
service for each youth. The three youth were placed on standard supervision prior to the ASR
completion. Each PO log was completed in its entirety for each youth, and all alerts were closed
appropriately following each youth’s removal from PO. The clinical staff were involved in the
process for each youth. None of the three youth were released prior to receiving an ASR or
while on PO. An ASR was completed for all three youth. Each youth had documentation staff
consulted with the designated mental health clinician authority (DMHCA) or licensed mental
health professional on the mental health substance abuse referral summary. The
superintendent and clinical staff were notified immediately of suicide risk for each youth. Each
youth ASR documented the date and time a referral was made to the mental health
professional, the date and time the youth was placed on PO, and each ASR was completed
within twenty-four hours. A follow up ASR was completed prior to removal of two youth from PO.
One youth did not have a completed ASR due to a referral. The youth was placed on close
supervision following the ASR, and there was no need for a follow up. The DMHCA and the
superintendent consulted regarding each youth being placed on and stepped down from PO.
Staff entered the date and time each youth was placed on and discontinued from PO in JJIS.
The discontinuation of close supervision was documented in accordance with the center’s
suicide prevention plan for each youth. Each ASR was administered by licensed mental health
staff. Each youth suicide risk assessment included the results of the assessment including
recommendations for supervision and follow up. A review of logbooks and ASRs confirmed
each youth had an entry about being placed on and stepped down from PO, which included
instructions on what staff were to do while the youth was on PO. Each of the applicable ASRs
were documented on the Department’s form which included all required elements. A review of
JJIS confirmed alerts were appropriately entered and determined if JJIS alerts were removed
following youth removed from PO for each youth. A review of logbooks confirmed beginning and
ending times were documented for youth placed on precautions.
During the interview, the DMHCA explained screeners from the Juvenile Assessment Center
(JAC) complete the initial sections of the Suicide Risk Screening Instrument (SRSI). The
juvenile justice detention officer (JJDO) will complete a portion of the SRSI when the youth
arrive at the Juvenile Detention Center (JDC). Youth in JDC at intake are seen by mental health
who complete the mental health/nursing portion of the SRSI. The process for a referral following
a screening consists of if a youth is found to be a suicide risk or to have any history of being
placed on suicide risk during the JAC screening, an alert is opened in JJIS and the detention
center is notified. If the youth is determined to be a suicide risk because of the JJDO screening
portion, a suicide risk alert is opened in JJIS, and a referral is generated in OHS. The DMHCA
further explained mental health professionals are notified by email and telephone. The DMHCA
is on call twenty-four hours a day, seven days a week unless on leave. When the DMHCA is on
leave there is a backup licensed professional on call twenty-four hours a day, seven days a
week. Measures taken for a referral assessment by a mental health professional for a youth
who appears to be acutely suicidal involve the mental health team conducting a suicide risk
assessment immediately and initiating a Baker Act, if needed. When a youth is potentially
suicidal and mental health is on-site staff are told immediately by word of mouth what steps to
take. Notifications are also documented in master control logbook and in the youth's module
logbook. Email notifications are also sent. Prior to revising a youth's mental health supervision
level, the licensed mental health staff meet with a supervisor face-to-face. Documentation is
made in the master control logbook, in the module logbook, in the ASR, in electronic Medical
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Record (EMR) (or handwritten when the computer is down), and alerts are updated. If the center
has a potential suicidal youth or has a youth who has attempted suicide, the superintendent will
be notified by JJDO supervisor/JJDO as soon as possible after the emergency, medical will be
notified by JJDO supervisor or designee if injury or substance related symptoms (911 will be
called if necessary). Mental Health will be notified by JJDO supervisor or designee, youth 's
parent/guardian and JPO will be notified by superintendent or designee.
During interviews with nine staff, they explained their responsibilities if a youth expresses
suicidal thoughts. Seven staff stated they notify the mental health authority, four staff stated
document supervision, and four staff stated youth are to be on constant sight and sound. Nine
youth were interviewed seven youth stated they have never been placed on suicide watch, and
two youth stated they have. Two youth stated the staff watched them the entire time.
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.
A minor deficiency was assigned on October 31, 2024, by the Office of Health Services (OHS)
for documentation related to secure observations to include the referral, Assessment of Suicide
Risk (ASR) not completed, and no health status checklist. The minor deficiency was closed on
January 2, 2025. Nine youth mental health records were reviewed, and one youth was placed in
secure observation. The center provided two additional youth mental health records which were
applicable. The designated mental health clinician authority (DMHCA) and superintendent
authorized each placement. Each placement was documented in writing and the secure room
was designated. Each youth had a complete Health Status Checklist completed prior to
placement in secure observation. Each youth had a Suicide Precautions Observation log
completed in its entirety. Each youth had an ASR completed within eight hours of placement.
For each youth placement, the parent/guardian was notified of the youth’s potential suicide risk
as indicated by the ASR. The juvenile probation officer (JPO) was notified of placement for each
youth. Each youth remained on secure observation beyond twenty-four hours, and reviewed
documentation confirmed a mental health professional provided written support for continuation.
Mental health staff provided supportive counseling while each youth was in secure observation.
The observation logs documented supervision of each youth during placement. The level was
reduced for each youth only after a conference with the superintendent or licensed mental
health professional. For each youth the discontinuation of secure observation and step down to
close supervision was documented in the center’s logbook and documented in each youth’s
mental health record by the mental health clinical staff.
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 youth placed on suicide precautions. A
minor deficiency was assigned on October 31, 2024, by the Office of Health Services (OHS) for
missing observation logs. The minor deficiency was closed on January 2, 2025. A major
deficiency was assigned on February 19, 2025, by OHS for missing precautionary observation
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(PO) logs and incorrect completion of the log. The major deficiency is currently open. Nine youth
mental health records were reviewed for the completion of Suicide Precaution Observation
Logs, and one youth was applicable. The center provided two more youth mental health records
which were applicable. All three youth had been placed on PO and were applicable for the
completion of Suicide Precaution Observation Logs. The center used the Department’s Suicide
Precaution Observation Logs for each youth. Each youth had Suicide Precaution Observation
Logs for the duration of their placement. The appropriate level of supervision and observations
of each youth’s behavior was documented in real time and did not exceed thirty-minute
intervals.
One youth displayed warning signs while on PO and a notification to the superintendent or
designees and mental health clinical staff was documented on the Suicide Precautions-
Observation Log. Two youth did not display any warning signs. Each log was reviewed and
signed by the shift supervisor and mental health staff. Each observation log documented safe
housing requirements. Video review of three youth on PO was conducted and confirmed the log
was completed in the increments as required.
During an interview, the superintendent explained the center uses secure observation if a youth
is currently on close observation or PO and goes into behavioral confinement, then the youth is
stepped up to secure observation.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Failed 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.
Nine in-service and nine pre-service staff training records were reviewed and confirmed suicide
prevention training was completed as required. A minor deficiency was assigned on October 31,
2024, by the Office of Health Services (OHS) for mental health drills not being completed. The
minor deficiency was closed on December 20, 2024. Mock suicide training drills were held no
less than quarterly on both shifts, for all staff who encounter youth, and were in response to a
suicide attempt and/or incident of serious self-injury. The center has a total of six suicide
response kits located on each of the four modules and one in each control room. Each suicide
kit is co-located with a first-aid kit. Each suicide response kit includes a one-way
Cardiopulmonary Resuscitation (CPR) mask, micro shield or face shield, non-latex gloves, first
aid supplies, a flashlight and a gown. A review of corresponding documentation of suicide drills
confirmed the drills were simulated, and no youth were used in drill simulations. The center
completed twenty-one drills since the last annual compliance review. The center did not conduct
suicide drills quarterly on each shift. A video review of mock suicide drills could not be
conducted because the last drill was conducted on July 3, 2025, which is over thirty days.
Documentation indicated a mock drill was completed on July 10, 2025, during second shift;
however, upon completing video review it was verified a drill was not completed on this date
during second shift. After reviewing the documentation, the superintendent confirmed the drill
never took place. This information was reported to the Department’s Central Communications
Center. The center did provide semi-annual training on emergency response procedures which
included mock training in emergency response to a suicide attempt or incident of serious self-
inflicted injury which included the use of Cardiopulmonary Resuscitation (CPR). Staff who were
not present during a quarterly drill did have the opportunity to review each drill scenario and
procedures in an effort to understand the process and receive the necessary training to respond
to an incident of a suicide attempt or incident of serious self-inflected injury in the facility.
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Nine staff were interviewed and asked where the knife for life, wire cutters, and needle nose
pliers which make up the suicide response kit are kept. Four staff stated master control, nine
staff stated sub control, four stated medical, and one staff stated all sub control rooms.
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 a combined Emergency Services Plan, detailing crisis intervention procedures.
The plan included notification and alert system, means of referral, communication, supervision,
documentation, and review.
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 facility operating procedures (FOPs) regarding the process for emergency
mental health and substance abuse services. The center’s Emergency Care Plan was signed
April 11, 2025, by the superintendent and is in master control. The plan included immediate staff
response, notifications, communication, 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,
documentation, training, and review. The plan is accessible to all staff.
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 facility operating procedures (FOPs) to ensure any youth demonstrating acute
psychological distress receive a detailed evaluation or Crisis Assessment, by a licensed mental
health professional. Nine youth mental health records were reviewed, and none of the youth
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were applicable for a crisis assessment. The center provided five youth mental health records
which were applicable for having a Crisis Assessment completed. The Crisis Assessments
included the reason for the assessment, mental status examination and interview, determination
of danger to self/others, initial clinical impressions, supervision recommendations, treatment
recommendations, and recommendations for a follow up or further evaluation for all five youth.
Four of the five Crisis Assessments did not have a parent/guardian notification of follow up
treatment, and one did. None of the five reviewed youth records documented the youth were
placed on precautions after completion of the Crisis Assessment; therefore, a mental health
alert was not entered into the Department’s Juvenile Justice Information System (JJIS). All five
youth records indicated after the Crisis Assessment, the youth remained on standard
supervision. None of the five reviewed youth were identified by direct care staff or clinical staff
as having acute emotional or behavioral problems, or acute psychological distress. All five youth
records documented the Crisis Assessment was conducted by a licensed mental health
professional, or by a non-licensed mental health clinical staff working under the direct
supervision of a licensed mental health professional. All five youth records documented the
Crisis Assessment was conducted immediately or within two hours for emergencies, or within
twenty-four hours based on the needs of the youth; none of the Crisis Assessments were
completed late. Three of the five youth records indicated each youth was an alleged victim in a
Prison Rape Elimination Act (PREA) event, and each 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) to ensure any youth believed to be an
imminent danger to themselves or others because of mental illness or substance abuse
impairment is provided emergency services. Nine youth individual mental health records were
reviewed; one was applicable. The center provided two more youth records applicable for a
Baker Act. Each of the three incidents indicated while pending an off-site transport for a Baker
Act, a suicide risk alert was opened, each youth was placed on one-on-one supervision, with
documentation on a precautionary observation (PO) log of staff maintaining PO until the youth’s
release, as required. Two youth records indicated each youth was taken into protective custody
under a Baker Act, one on August 4, 2025, and one on August 1, 2025. As of the week of the
annual compliance review, neither youth had returned to the center. Upon re-admission to the
center after the Baker Act, documentation confirmed the remaining applicable youth was placed
on suicide precautions and a referral was made to mental health. A mental Status Examination
(MSE) was completed by or under the direct supervision of a licensed mental health
professional for one of the three Baker Act incidents. The only applicable incident documented
the youth was maintained on a minimum of constant supervision until properly transitioned to a
lower level of supervision, determined by an assessment completed by a mental health
professional and mental health staff conferring with a licensed supervisor and superintendent or
designee. One youth record documented the suicide risk alert in the Departments Juvenile
Justice Information System (JJIS) was discontinued based upon an Assessment of Suicide Risk
(ASR) and Crisis Assessment. Two youth were not applicable, because at the time of the
annual compliance review, they had not returned to the center.
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During the interview, the designated mental health clinician authority (DMHCA) stated eight
youth were required to be transferred to the Crisis Stabilization Unit during the past year for
Baker Act Services. No youth were required to be transferred to the Crisis Stabilization Unit
during the past year for Marchman Act services.
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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 maintains a contract with VitalCore Health Strategies, LLC (VitalCore), who
maintains an agreement with a medical doctor (MD). The center has a MD holding an
unrestricted license and meeting all requirements for independent and unsupervised practice in
the State of Florida to serve as the designated health authority (DHA). The DHA’s specialty
training is in family practice, and their license expires on January 31, 2027. The center utilized
three advanced practice registered nurse (APRN) during the annual compliance review period,
each of which hold an unrestricted license in the State of Florida, with an expiration date of April
30, 2026, for one license and two licenses expire on July 31, 2026. Each APRN has a
Collaborative Practice Protocol in place with the DHA and copies are maintained on-site. One of
the three APRNs is acknowledged by the State Board of Nursing as having qualifications in
autonomous practice. The APRN provides the clinical services on-site, and the DHA performs
the administrative duties. The center does not utilize a physician’s assistant. The DHA’s contract
condition requires the DHA to be on-site once a week with no hourly requirement specified. A
review of the center’s DHA sign-in and sign-out logs for the annual compliance review period
found the DHA was on-site once a week, as contractually required, with the exception of one
week in October during which there was a hurricane. The center has two back-up DHAs through
their contract with VitalCore; however, the back-up DHA was only used for one week during the
annual compliance review period. One back-up DHA is a MD who holds an unrestricted license,
with a specialty in internal medicine, which expires on January 31, 2027, and meets all
requirements for independent and unsupervised practice in the State of Florida. The other back-
up DHA is a MD who holds an unrestricted license, with a specialty in pediatrics, which expires
on January 31, 2027, and meets all requirements for independent and unsupervised practice in
the State of Florida. The center has facility operating procedures (FOPs) detailing the tele-
medicine process, including the sign-in and sign-out process for the practitioner. Tele-medicine
was utilized for youth during the annual compliance review period, with Department approval
and the tele-medicine log was utilized.
An interview with the DHA confirmed the DHA completes Comprehensive Physical
Assessments, conducts periodic evaluations, and sick calls if requested during the weekly site
visits. The DHA reports being on-site one day each week, communicating with medical and
center staff through telephone, in person, and email communication, and being available on-call
twenty-four hours, seven days a week. The DHA stated they provide on-site clinical services,
along with the designated APRN. The DHA also reported all off-site care medical findings,
instructions, and information are communicated telephonically by nursing staff, placed in a
folder for review and both results and emergency room follow ups are signed by the DHA during
the next on-site visit. The DHA interview stated all communication with nursing staff is
documented in the Electronic Medical Record. Additionally, the DHA indicated in the event of a
scheduled leave of absence, the regional registered nurse is contacted and arranges back-up
DHA coverage.
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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 health-related procedures and
treatment protocols utilized at the center. The designated health authority (DHA) and
superintendent signed and dated all respective treatment protocols, policies, and procedures,
and conducted an annual review of all treatment protocols as required. This was demonstrated
by the signature and date of the DHA, superintendent and psychiatrist on March 12, 2025. The
nursing staff signed and dated a review of all nursing protocols between the dates of March
2025 and July 2025. Any new policies or changes in policies made during the year were
reviewed, signed, and dated by each nurse on a signature page. An annual review of medical
policies, procedures, and protocols was conducted on July 2, 2025, by all required individuals.
The psychiatrist reviewed and developed the FOPs, or other protocols related to psychiatric
services and psychotropic medication management. The healthcare personnel hired since the
last annual compliance review received a comprehensive clinical orientation to the Department’s
healthcare policies and procedures, given by a registered nurse (RN). The treatment protocols
or standing procedures were approved, written, and authorized by the DHA.
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.
All nine reviewed Individual Healthcare Records (IHCRs) had a valid Department Authority for
Evaluation and Treatment (AET) form with the word “COPY” stamped on the form. Eight of nine
AET forms were signed by a parent/guardian and a Department representative. The electronic
medical record (EMR) for the remaining youth, who was in the care of the Department of
Children and Families (DCF), contained a Limited Consent for Evaluation and Treatment,
signed by the superintendent and the court authorized all treatment procedures or delegated an
authorized person through a court order. All AETs were obtained prior to each youth receiving
medical services, and none of the youth were eighteen years old. The nursing interview
indicated parents are contacted during the admission process to obtain a new or current AET. If
the parent is unable to be reached after several attempts the juvenile probation officer (JPO) is
contacted for assistance in obtaining a signed AET. An eighteen year old youth can provide
verbal consent to receive medical services and can sign/initial for treatment or medications
rendered.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed. Eight of nine reviewed IHCR
were applicable for parental/guardian notification/consent and the remaining youth was not
applicable. In all eight IHCRs, written notifications were sent utilizing the Department’s Parental
Notification of Health-Related Care: General, Parental Notification of Health-Related Care:
Medications forms, or the Department’s Acknowledgment of Receipt of the Clinical Psychotropic
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Progress Note (CPPN). One of eight youth IHCRs was applicable for parent/guardian
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET) and consent was provided by the parent/guardian; the
remaining seven did not require OTC medications. Two of the youth were taking psychotropic
medications at the time of admission. In the two IHCRs, the staff witnessed all telephone call
attempts and conversations for psychotropic medications. Two youth had a new psychotropic
medication prescribed and the parent/guardian verbal consent for psychotropic medication was
documented on page three of the Department’s CPPN and the IHCR showed an attempt to
obtain the written parent/guardian consent. Seven youth had a new medication ordered and
there was documentation of attempted contact to the parent/guardian in the progress notes, as
well as written parental/guardian notices sent regardless of telephone notifications. The IHCR
for one youth in the care of the Department of Children and Families documented the center is
awaiting a court order for one medication. The center obtained consent prior to administering
newly prescribed psychotropic medications or changes to psychotropic medications for the DCF
youth. Nine reviewed IHCRs confirmed vaccinations were verified within thirty days of each
youth’s admission. The nursing interview indicated parent/guardian notification should be made
either verbally or in writing at the time of the qualifying event occurring or within a twenty-four
hour period. The nursing interview indicated the designated health authority (DHA) is contacted
in order to obtain a physician order to transport a youth offsite for emergency care. In case of
psychotropic medications, the parent/guardian is contacted by the psychiatrist and verbal
consent it obtained to initiate any changes. If the parent/guardian is unable to be contacted, the
CPPN and the Acknowledgement of Receipt of CPPN are utilized or a Practitioner Form is
mailed to the parent/guardian. The nurse further stated the center does not provide vaccinations
on-site; however, if appropriate consent has been obtained, youth are sent offsite to the Health
Department to receive vaccinations, and medical staff will obtain immunization records from the
Florida Shots Immunization portal upon a youth’s admission.
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.
All nine reviewed Individual Healthcare Records (IHCRs) had a Department Medical and Mental
Health Admission Screening Form completed by a juvenile justice detention officer (JJDO) or
juvenile justice detention officer supervisor (JJDOS) on the date of admission. In all nine records
a licensed medical staff reviewed the screening form within twenty-four hours. All nine records
documented the designated health authority (DHA) notification, as required. Two of nine IHCRs
were applicable for a rescreening; therefore, one more example was requested. In all three
applicable IHCRs, there was a change in physical custody and the center completed a
healthcare admission rescreening each time a change in custody occurred. All three
rescreenings were completed by a JJDO or JJDOS on the date of admission and a licensed
medical staff reviewed the rescreening form within twenty-four hours. Three of the youth
received a qualitative urine pregnancy screening test and the chronological progress notes for
all three youth included documentation of verbal and/or written consent. The nursing interview
indicated all newly admitted youth are seen by nursing staff within the first twenty-four hours.
Intake packages are provided to the nursing staff as notification of new intakes, in addition to
the intake being documented in the Department’s Juvenile Justice Information System (JJIS).
The admission screening is conducted by direct care staff and a nurse will conduct a review and
document it by signing and dating the intake package. When a change in physical custody
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occurs, a new intake packet is provided to medical to be reviewed, signed and dated, prior to
completing the new intake.
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) including access to medical care, sick call,
what constitutes an emergency and when to notify staff, the medication process to include side
effect monitoring, the right to refuse care and how it is documented, what to do in the case of a
sexual assault or attempted sexual assault, the non-disciplinary role of the healthcare providers,
and general infection control/hygiene. In all nine reviewed Individual Healthcare Records
(IHCRs), each youth received a general healthcare orientation, and all topics were documented
on the Department’s Health Education Record form and each of the seven youth identified with
a chronic condition was educated 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.
Seven of nine reviewed Individual Healthcare Records (IHCRs) documented a referral to the
designated health authority (DHA) for youth with known or suspected chronic conditions and
mental health issues and the remaining two youth did not have any chronic conditions. None of
the youth were identified as requiring emergency care upon admission. The DHA was notified
within twelve hours or no later than noon the day following each youth’s admission, which was
documented in each youth’s chronological progress notes/IHCR. Two of the nine youth were
taking psychotropic medication upon admission, and the psychiatrist was notified. The nursing
interview indicated a nurse contacts the DHA telephonically as soon as or within twenty-four
hours a youth with a chronic condition is seen in the clinic, and this is documented on the
admission chronological progress note.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed, and each included a Health-
Related History (HRH) form completed within seven days of admission by a licensed healthcare
staff on the Department’s form. Each HRHs was completed prior to the Comprehensive Physical
Assessment (CPA), as evidenced by signature and date. The designated health authority
reviewed each HRH as indicated by a check mark on each CPA. A review of the HRH forms
confirmed signatures and dates for the most current admission. The nursing interview indicated
the HRH is completed by the nurse within 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) addressing when any part of the
Comprehensive Physical Assessment (CPA) is not conducted or refused by the youth, as well
documentation of the center’s Tuberculosis (TB) screening process. In all nine Individual
Healthcare Records (IHCRs), the CPA was documented on the Department’s CPA form noting
each youth’s Medical Grade. Six of nine IHCRs included a current CPA on file at admission
because they were transferred from another detention center. The current CPA for the six youth
were each reviewed and signed off by the designated health authority (DHA) or advanced
practice registered nurse (APRN) during the focused evaluation and all sections of the CPA
were marked with an “O” or an “X”. The remaining three youth included a new CPA, and each
was completed within seven days of admission. The three applicable youth received a new CPA
completed by the DHA or APRN and there were no missing/incomplete elements. None of the
youth refused any part of the exam; however, the DHA/APRN deferred a portion of the exam
due to each youth not showing any indicators needing the deferred portion. In all nine IHCRs
the Department’s Problem List was updated, as required. The Tier I Tuberculosis (TB)
screening was completed for all nine youth within seventy-two hours. Six of nine IHCRs
contained a Tuberculosis Skin Test (TST) completed within the last year and the remaining
three youth IHCR confirmed a TB test was completed within seven days of admission with no
further evaluation required. The results for all nine TST documented on the Infectious
Communicable Disease (ICD) and the CPA forms matched. The nursing interview indicated the
CPA must be completed within seven days of admission and yearly, as applicable. TB
screenings are completed by nursing staff within twenty-four hours of admission. The center
does not conduct routine gynecological exams.
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.
Nine youth were clinically screened and evaluated for sexually transmitted infections (STIs).
Four of nine youth required further evaluation, and the designated health authority/advanced
practice registered nurse reviewed the STI screening tool and noted a referral on the form. The
four IHCR documented testing and screening results on the Department’s Infectious
Communicable Diseases (ICD) form and the testing was filed in the lab section of each IHCR.
None of the three female youth consented to a gynecological exam. One of the sexually active
youth were out of the Department’s physical custody and the IHCR indicated a rescreen was
completed. One of the IHCR reflected the youth was tested for Sexually Transmitted Infection
(STI), not HIV and one youth was in behavioral confinement at the time of HIV testing, this youth
was placed on the HIV testing log and the pre-test counseling was documented in the IHCR.
The two remaining youth received the testing and the pre and post-test counseling was
documented in each IHCR, and the test results were placed in a sealed envelope marked
confidential with a practitioner having reviewed the results. Both youth’s confidentiality was
protected by not including the HIV status or any other STI diagnosis on the center’s internal alert
system. All four applicable IHCRs included documented consent from the youth. All nine youth
interviews confirmed they can ask for a HIV test. The nursing interview indicated the nurse
completes the STI screening form with each youth within twenty-four hours of admission. The
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designated health authority reviews the STI screening tool during the completion of the
Comprehensive Physical Assessment (CPA) and determines if additional testing/treatment are
required for the youth. The STI screenings, evaluations, referrals, and testing are documented
in the IHCR on the Infectious and Communicable Disease (ICD) form, as well as in a progress
note. If a youth has been out of the Department's physical custody for more than thirty days
and/or symptoms present, a nurse will conduct a STI screening, and the same process as
mentioned before is utilized. A youth’s HIV testing results are given verbally to the youth, as well
as documented on the ICD form in the IHCR. Youth can consent to testing using the HIV Youth
Consent form completed during the admission process. If a youth consents, they are added to
the HIV testing log and the pre/post-test counseling is documented on the Individual Health
Education Record. The community center/health department completes HIV pre-counseling,
testing and post-counseling on-site.
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) including a process for youth to receive
regular medical care while in room restriction/confinement. In four of nine reviewed Individual
Healthcare Records (IHCRs), each youth had a sick call event and all sick call events were
documented on the Sick Call Referral Log. None of the youth presented with similar sick call
complaints three or more times within a two-week period. In all four IHCRs, each youth and a
registered nurse (RN) completed the Department’s Sick Call Request form, and they were filed
in each IHCR in reverse chronological order. One of the four applicable youth was in restricted
housing and the IHCR confirmed the youth was questioned daily for sick call/health complaints.
All Department Sick Call Request forms were documented in accordance with Florida
Administrative Code and all Sick Call Requests were documented on the Department Sick Call
Index. Observations confirmed the dates listed on the Sick Call Index corresponded to the
completed Sick Call forms located in each reviewed IHCR. A review of the daily schedule,
observations of the posted schedule, and nurse interview indicated sick call is conducted daily,
pursuant to contract requirements. Sick call hours were posted next to the clinic door, as well as
on each module. The center has approved treatment protocols for both RN and licensed
practical nurse (LPN) level staff. Only licensed nurses conduct sick call; however, the center
does have procedures in place whereby a supervisor will review all sick call requests as soon as
possible and within four hours after a request is submitted if there are no licensed nurses on-
site. Approval was given by management and the Department’s Office of Health Services for the
review annual compliance review team to not observe a sick call event while the annual
compliance review team was on-site because of the number of youth with a COVID diagnosis.
The nursing interview indicated youth requesting to see the nurse and/or physician will notify the
floor staff of a medical complaint and the staff will place the sick call in the electronic system.
The nurses respond to the sick call within twenty-four hours to address the medical needs of the
youth. Sick call is routinely completed by the RN and licensed practical nurse (LPN). The clinic
manager reviews sick call documentation daily utilizing the Electronic Medical Record (EMR) for
any sick call completed by an LPN. If the DHA is on-site they will also conduct sick call. Sick
calls are conducted in the clinic. Any youth who have submitted similar sick call complaints
three or more times within a two-week period are referred to the DHA/advanced practice
registered nurse and added to the list to be seen. The nursing interview stated the center has
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DHA approved treatment protocols. Youth in restricted housing/confinement are assessed and
evaluated for medical complaints or distress daily by nursing staff when nursing staff are on-site
and detention staff monitor youth during room checks at regular intervals. Five of nine youth
interviews indicated a nurse conducts sick call, four youth stated they had not needed sick call.
Four of the five applicable youth indicated they can be seen within one day when they request a
sick call, and one youth indicated they can be seen within two days of requesting a sick call. Six
of nine staff interviews stated the nurse reviews sick call, three also stated supervisors do and
one staff was not sure. All nine staff indicated the nurse conducts sick call, and one also said
the doctor.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Limited 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) addressing a process to ensure first-aid kit
contents are maintained and stored to prevent expiration or deterioration, as well as the use,
access, and inventory of Narcan. In six of the nine reviewed Individual Healthcare Records
(IHCR) each youth required on-site first-aid or episodic care. The remaining three were not
applicable. In the six applicable IHCRs each youth received episodic care or first-aid by a
licensed healthcare staff, and it was documented in problem-oriented subjective, objective,
assessment, and plan (SOAP) charting. None of the first-aid events were conducted by non-
healthcare staff. In all six applicable IHCRs the first-aid/episodic care event was documented
including the nature of the complaint, the findings of the person rendering care, the treatment
rendered, the education/instruction provided to each youth, an entry was made in the Episodic
Care Log, and if required a referral to off-site care, the plans for follow-up/future care, youth
placement on the alert list, and parental/guardian notification were conducted.
The center has twenty first-aid kits, one each in the three sub control rooms, three modules, the
kitchen, intake area, training area, East and West Annex clinic, East and West Annex master
control, and seven are used for transportation. Three first-aid kits were checked and all of them
contained designated health authority (DHA) approved contents which were not expired. A
review of the first-aid kit checks since the last annual compliance review indicated all were
completed as required monthly.
The center has three automated external defibrillators (AED) one each in master control, East
and West Annex clinic, which was verified through the nurse interview. The AED procedures
were maintained in each AED box. All three AEDs had green lights and were in working order
during the annual compliance review week. All AED batteries expire on May 20, 2027, and the
three AED pads on February 28, 2027. The AED pads were exchanged last on October 29,
2024, and the batteries July 1, 2022. The nurses conduct the monthly AED checks, which were
completed as required for the annual compliance review period.
A review of medical drills for the last year was conducted. The center maintained all of the
medical drills. A total of twenty-five drills were conducted at a minimum of once a quarter on
each shift. The nurse interview indicated drills are conducted at least monthly on each shift. The
center had only two shifts during the review period. Four of the twenty-five drills simulated an
episodic care event which called for immediate first-aid, and the initiation of the emergency
procedures to follow when a life-threatening emergency occurred. The remaining twenty-one
drills were missing the notation. None of the drills demonstrated the use of cardio-pulmonary
resuscitation (CPR) or the use of an AED; therefore, none of the staff were able to participate in
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a man-down drill demonstrating the use of CPR or an AED in the last year. Ten of the twenty-
five drills documented the emergency medical bag or first-aid kit were brought to the drill.
A list of emergency numbers, including the poison information control center, were posted in
master control and the East Annex clinic, which the nurse interview confirmed. The numbers
were accessible for non-licensed and licensed staff, and inaccessible to all youth. A review of
training conducted by a registered nurse indicated six authorized direct care staff were
appropriately trained on the administration of the epinephrine auto-injector. A review of nine pre-
service and nine in-service training records indicated all staff received training in episodic, first-
aid, and CPR. The center maintains four doses of Narcan in the locked medical cart and the
nurses, as well as trained supervisors have access. A review of the training roster for Narcan
indicated three of the seven supervisors did not receive the training. Narcan is inventoried
weekly and perpetually.
The nursing interview indicated the center has eighteen first-aid kits; however, it should be
noted the first-aid kit checks documented twenty. The nurse stated in the interview when non-
healthcare staff provide first-aid/emergency care to youth it is documented on the Report of On-
site Healthcare by Non-Health Care Staff form. Events when youth are sent off-site for
emergency medical care are documented on the Episodic Care Log. The nurse said CPR
techniques must be practiced on a regular basis, which is defined as once a quarter. The nine
interviewed staff conveyed they can call 9-1-1 if needed. One of nine interviewed youth rated
the medical care as very poor, four as good, one as very good and the remaining one never
received any medical care. The youth rating the medical care as very poor stated the nurses did
not believe the parent/guardian when information was provided regarding the youth’s medical
condition and they were rude, as well as the nurses sharing medical information with the other
youth; however, not revealing the name of the youth. The center staff were made aware of the
complaint against the nurses. Five youth stated the nurse provides them medication and the
remaining four said they never received any medication while at the center. One also mentioned
he was taken care of really well by the nurses.
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.
Three of nine Individual Healthcare Records (IHCRs) were applicable for youth who required
off-site care. The three applicable youth required off-site care and for all three events there was
a Summary of Off-Site Care Consultation Report form filed in each IHCR. All three events were
documented on the Episodic Care Log. In all three IHCRs the parental/guardian notification
efforts were documented, the designated health authority (DHA) reviewed and signed all off-site
care findings, instructions, and information and each had the discharge and other applicable
documents filed in the IHCR, as well as the DHA being notified of an emergency event. Each of
the three youth required follow-up appointments. Two of the three had a follow-up appointment
and the remaining youth has a pending appointment at the time of the annual compliance
review. The nursing interview indicated youth who are sent off-site for first-aid or emergency
care are tracked on the Episodic Care Log. When a youth returns to the center the off-site care
findings are reviewed by the receiving nurse and then are placed in a folder for the DHA to
review and initial. The DHA will then provide orders to follow on-site. The nurses track follow-up
appointments in a calendar and send email communication to the center staff to arrange
transportation.
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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.
Seven of the nine reviewed Individual Healthcare Records (IHCRs) were applicable for chronic
conditions. In all seven applicable IHCRs, each youth had a chronic condition, which was
documented on the Department’s Medical/Mental Health Screening form. None of the youth
took antituberculosis medication, nor had any communicable diseases. One youth was
pregnant. Six of the seven chronic youth were identified as taking prescribed medication on an
on-going basis and were undergoing treatment for physical health conditions. Each youth was
entered on the Chronic Conditions Roster and had a Medical Grade of two to five. One of seven
youth were applicable for receiving periodic evaluations. Six of the seven youth had not been at
the center long enough to receive periodic evaluations every ninety days and the center
provided two additional applicable youth. Periodic evaluations were tracked on the Chronic
Conditions Roster and each youth IHCR included documentation of completed periodic
evaluations conducted prior to renewing a prescription medication which expired. The
Department’s Problem List was updated in all three youth IHCRs. The designated health
authority (DHA) interview indicated periodic evaluations are completed a minimum of every
ninety days for youth with chronic conditions. The nursing manager runs reports and schedules
periodic evaluations as appropriate. The nurse interview indicated youth with chronic conditions
are seen by the DHA every ninety days and the DHA follow-ups are managed using the medical
tracker.
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) including medication disposal, which
indicates unused medications are either returned to the pharmacy for credit or destroyed using
the medication destroyer solution. Also, destroyed medications are logged on the medication
disposal log, are signed, dated, and witnessed by another medical staff. Eight of nine Individual
Healthcare Records (IHCRs) were applicable for receiving medication while at the center. Three
of the eight youth were taking medication at admission and the medication was verified prior to
being admitted into the center and documented in each youth’s chronological progress notes
and the Department’s Medication Receipt Transfer Disposition form. In the three applicable
IHCRs, the designated health authority (DHA) and, when applicable, the psychiatrist was
contacted to obtain the order to resume the specified medications. In all eight records, all
medications had a current, valid order and were administered pursuant to a current prescription.
In those eight records the DHA placed an order on a Practitioner Order form for any current
medications which were continued, discontinued, changed, or new ones ordered. Three youth
were in restricted housing and the nursing staff completed daily visits, other required services,
completed documentation, and the youth received all prescribed medications, as ordered and
on time. Five of the eight youth received over-the-counter (OTC) medications not listed on the
Authority for Evaluation and Treatment (AET) form which were administered according to
approved protocols or practitioner’s order. In all eight IHCR the Department Medication
Administration Record (MAR) was used to document all medication and treatment, including
start and stop dates. None of the medication administration was conducted by non-healthcare
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staff and there were no lapses or errors in medication administration. Two of the youth had
refusals which were clearly documented on the MAR and each youth signed the Refusal of
Treatment Form. Two of the youth received parenteral medication, which was administered by
licensed healthcare staff. In all eight IHCRs, the MARs included youth name, Department
identification number, date of birth, youth allergies, precautions, Medical Grade, and medical
alerts. The MAR book and the electronic MARs include a current picture of each youth. All
MARs documented weekly side effect monitoring by the nursing staff. A nurse and the youth
initialed each medication administration entry. During the annual compliance review week, an
observation of medication administration for youth was not conducted. Approval was given by
management and the Department’s Office of Health Services for the annual compliance review
team to not observe medication administration because of the number of youth with a COVID
diagnosis. A review of documentation indicated the center had designated staff trained by a
registered nurse in medication administration, which was confirmed by the nursing interview.
The nursing interview indicated when a youth arrives with medication, the medication is verified
using the Medication Receipt Transfer Disposition Discharge Form to ensure the right
medication, dosage and amount are correct. The center utilizes Department MARs and
medication administration is scheduled daily at 7:00 a.m., 12:00 p.m., 5:00 p.m., and 7:00 p.m.
The center has a modified Class II permit, confirmed by the nursing interview. Six of nine staff
interviews indicated they do not provide medication to youth, three stated they do. Five of nine
youth interviews indicated the nurse provides medication and four stated they do not take
medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
Observations during the annual compliance review week included the storage of sharps and
over-the-counter (OTC) stock medications. The center had them located in locked cabinets in
the clinic utilizing weekly and perpetual inventories, keeping sharps and OTC medications
separated. The medication cart was observed to be clean and organized, keeping youth-specific
medications separated from all other medications, as well as keeping injectables, topicals, and
liquids divided. All controlled substances were maintained in a separate lock box within the
locked medication cart utilizing a perpetual inventory with a shift-to-shift count documented on
the Department’s Individualized Controlled Medication Inventory Record. The clinic had a
medication specific refrigerator which contained tuberculosis testing serum and insulin. All
medication and sharp storage areas are inaccessible to youth and only accessible to staff with a
key. Observation, during the annual compliance review week, of a nurse counting three
controlled medications, three OTC medications and three sharps indicated all counts matched
the ending inventory numbers. A review of documentation indicated non-healthcare staff
received training in the delivery and oversight of medication self-administration by a registered
nurse. The nursing interview indicated controlled medications are secured with a double locking
system, in a lock box within the locked medication cart. The pharmacist is on-site monthly,
reviews the medication cart for organization, monitors the controlled medication, reviews the
destruction log, reviews Medication Administration Records, and checks the temperature of the
refrigerator used to house medications. A copy of the pharmacy consultant license was
observed during the annual compliance review.
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4.17 Psychiatric Services [Contract Provider] (Critical) 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 maintains a contract with VitalCore Health Strategies, LLC (VitalCore), to provide
mental health services, including the provision of a psychiatrist to provide psychiatric services to
youth at the center. The VitalCore contract includes telepsychiatry services; however, this
service was not utilized since the last annual compliance review. The center has a psychiatrist
holding an unrestricted license and is board certified in Psychiatry by the American Board of
Psychiatry and Neurology, with experience and training with Child and Adolescent Psychiatry.
The psychiatrist’s license expires on January 31, 2026. The center has a back-up psychiatrist
through their contract with VitalCore. The back-up psychiatrist holds an unrestricted license,
with a specialty in osteopathic physician, which expires on March 31, 2026, and meets all
requirements for independent and unsupervised practice in the State of Florida. The center
does not have a psychiatric advanced practice registered nurse.
The interview with the designated mental health clinician authority (DMHCA) indicated they
meet with the psychiatrist once a week. The nurse interview confirmed the medication disposal
process for the center and how controlled substances are stored. Two of the nine reviewed
youth mental health records were applicable for psychiatric services; therefore, the center
provided one additional youth record. Each of the applicable youth entered the center on
psychotropic medication or were referred for a psychiatric interview, and each received an initial
diagnostic interview within fourteen days of the youth’s admission to the center. Each youth’s
Initial Diagnostic Psychiatric Interview included all the required elements. Each of the applicable
youth had an in depth psychiatric evaluation completed within thirty days of their
admission/referral which included all required elements. The form was clearly identified as a
psychiatric evaluation. The psychiatric evaluation was signed by the psychiatrist. Each
applicable youth record had a signed Authority for Evaluation and Treatment (AET). The Clinical
Psychotropic Progress Note (CPPN) was filled out in entirety for each applicable youth.
The psychiatrist ordered monitoring for Tardive Dyskinesia on a monthly basis as indicated on
the CPPN for one youth. No other youth were applicable for monitoring Tardive Dyskinesia.
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.
A review of nine Individual Healthcare Records (IHCR) found all youth received infection control
training within seven days of admission. The nine youth also had training in hand-washing
techniques, universal/standard precautions, prevention/transmission of communicable diseases,
vaccinations, and Center for Disease Control and Prevention (CDC) guidelines for infection
control. The center’s exposure control plan was written in accordance with Occupational Safety
and Health Administration (OSHA) conditions including all requirement for risk assessment and
methods of compliance. The center had infection control procedures in place including
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prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to OSHA and the CDC guidelines. The procedures included common, infectious
diseases of childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious
diseases, tuberculosis, Hepatitis A, B, C and human immunodeficiency virus (HIV) infectious
diseases caused by bloodborne pathogens, other outbreaks or epidemics caused by any other
infectious agent, whether spread directly or indirectly, outbreaks of pediculosis and/or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other antibiotic-resistant micro-
organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures in the workplace.
The center has a process for needle stick post-exposure evaluation, and makes Hepatitis B
immunization available for staff, as well as providing access to protective equipment. The center
did not have any instances in which infectious diseases and sexually transmitted infections
(STIs) had to be reported to the local health department, CDC, the Department’s Central
Communications Center (CCC) or involved the quarantining or hospitalization of at least ten
percent of the total population of youth or staff. The superintendent maintains a separate file
containing documents for youth and staff who have experienced a facility/occupational
exposure. All records are maintained as confidential for a ten-year period, as required. A review
of nine pre and nine in-service staff training records found all were trained on the center’s
specific Exposure Control Plan. The nursing interview indicated a copy of the Exposure Control
Plan is located in medical and is available to the nurses. A registered nurse (RN) conducts
infection control training for staff, and youth receive the training during admission. A RN also
provides training to staff on the center’s Exposure Control Plan. The nurse stated HIV testing
and immunization services are routinely used through the county health department.
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.
A review of nine Individual Healthcare Records (IHCR) found one of the youth were applicable
for prenatal care. The center provided two additional youth applicable for prenatal care. The
three applicable youth received prenatal care immediately upon determination each was
pregnant and continued until discharge/transfer. None of the youth were at the center long
enough to receive routine, focused medical evaluations every thirty days. All three youth were
placed on the internal alert system for vital nutrition and health awareness for staff, and an alert
was entered into the center’s internal alert system regarding one of the three youth’s sleeping
arrangements. The sleeping arrangements for the remaining two youth were not updated in the
center’s internal alert system; however, this type of alert is not completed by the contracted
provider. None of the youth complained of issues related to pregnancy and there were no post-
birth psychological and physical care plan developed; the youth were at the center for only
fourteen, eighteen and twenty-one days respectively. In each IHCR, daily monitoring for danger
signs of pregnancy complications were documented. All three IHCRs contained education
provided to each youth, including alcohol and drug use, smoking, nutrition, sexually transmitted
diseases, contraception, prenatal care, birthing process, postpartum care, and basic baby care,
child/infant development, and parenting skills. The education was documented in each IHCR
within the Health Education Record. The three applicable youth were provided with nutritious
food in quantities appropriate for a pregnant youth, and each received routine monitoring by a
nurse, including nutritional and weight status. A review of staff training indicated a licensed
nurse provided in-service education on youth’s prenatal healthcare annually to all non-
healthcare staff involved in the supervision or treatment of youth, which included observation
and monitoring of emergency care needs/symptoms of possible miscarriage. The center has
nursing protocols and treatment plans for pregnant youth. A review of nine in-service training
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records found all had training in detention services women health. The nursing interview
indicated the center provides prenatal care to youth once they know a youth is pregnant, an off-
site obstetrician appointment is scheduled, the youth is started on a pregnancy diet receiving
additional fruit/vegetables and snacks and is educated regarding prenatal care. The designated
health authority (DHA) assesses the youth every thirty days and pregnant youth receive weekly
vital sign and weight checks. Every female youth is routinely tested upon admission only if
verbal consent is received. Each pregnant female youth is given a handout, and the nurses
review shaken baby syndrome, difference of breastfeeding and bottle feeding, what to expect
with body changes, dietary needs, sudden infant death syndrome, post-partum, and more. Girl’s
healthcare training is conducted with the non-licensed healthcare staff by the clinic manager.
Two of nine interviewed youth stated they have received prenatal, obstetrical, or gynecological
services while at the center and the remaining seven youth are not applicable.
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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) governing the supervision of youth. The
FOPs require staff to be constantly aware of the location of youth assigned to their supervision.
Observations of staff supervising youth were conducted each day of the annual compliance
review. Staff were observed supervising youth in the housing modules while engaged in indoor
activities, on the recreation field while youth were involved in outdoor activities, in the dining hall
during feeding of the lunch meal, and while being escorted to and from each location. Staff were
randomly questioned regarding the number of youth they were supervising, and all staff were
aware of the total number of youth under their supervision, the breakdown of how many youth
were currently being supervised, and the location of the remaining youth. Positive interactions
between staff and youth were observed each day, and supervision was appropriate each day with
staff stationed strategically to properly supervise all youth. During the annual compliance review,
all movements were heard announced and authorized by master control. These announcements
included the housing module, number of youth being moved, the location of transition, and a
conclusion of the movement. Nine staff were interviewed, and six said they believed there was
enough staff to provide for the safety and security of youth and staff, while three said they did not
feel there was enough 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.
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The center has facility operating procedures (FOPs) which requires the center to establish a
behavior management system (BMS). The BMS offers rewards and privileges for good
behaviors, and consequences for negative behavior. These are designed to motivate youth to
meet and exceed the center’s expectations. Postings of the BMS were observed in all living
areas, the dining hall, and in all common areas where youth are. The postings specified
appropriate and inappropriate behaviors, rules, and expectations. A review was conducted of
youth point cards which confirmed youth are receiving their rewards for good behavior and are
also held accountable for any negative behavior. All rewards and consequences observed were
in accordance with the BMS postings. A review of documentation also verified the center
prohibits the use of group punishment and there were no instances of inappropriate use of
restrictions or group punishment displayed during the annual compliance review period. Nine
staff were interviewed, and all were able to define the BMS and give examples of the rewards
youth can be given for achieving and advancing through their levels. Six staff said they believed
the BMS was effective, while three said they did not feel it was working. Some of the reasons
given by staff for the BMS not working was the youth sometimes do not care, and not all kids
can work with the BMS system. All staff said they speak with youth about consequences being
imposed, they all allow youth an opportunity to explain their behavior and speak with youth
about alternative acceptable behaviors. One staff said they regularly receive feedback on the
implementation of the BMS from their supervisors, one staff said they receive feedback daily, six
said they only receive it as needed, and one said they never receive feedback. All staff knew
what could and could not be taken away from youth because of bad behavior. All staff said they
have never seen a co-worker take meals, snacks, clothing, education, or medical care from a
youth because they were acting out, and they have never observed any other staff encourage
youth to beat up another youth. Nine youth were interviewed and asked what they thought of the
BMS. Five said the BMS was either good or very good, two said it was fair, and two said it was
very poor. Six youth were able to explain the different levels and how to move from one level to
another, while three were unaware of the different levels. Eight youth were able to describe how
youth receive rewards at the center, and one said they do not receive rewards. Seven youth
said all staff use the rewards the same way, one youth said they had not been at the center long
enough to understand how rewards are used, and one youth said they do not receive rewards.
All youth said youth are not allowed to punish other youth. Six youth said they had been sent to
their room for punishment and three said they have not been sent to their room for punishment.
The six youth who said they had been sent to their room for punishment said the punishment
was because of a fight, and they received their necessities during the time they were in their
room. The six youth also said the room door was locked and they were allowed out of their room
within twenty-four hours. Six youth said the consequences they received were fair, and the
remaining three said they have not received consequences. None of the youth interviewed said
they have ever seen handcuffs or leg irons used on out-of-control youth to prevent them from
hurting themselves or others. The superintendent was interviewed and explained the BMS is a
system used to track youth behavior on a three-level system.
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
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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) requiring staff to visually check on youth at
least every ten minutes while they are in their rooms for any reason. The center has a total of
162 cameras, and at the time of the annual compliance review, 154 were operational. The non-
working cameras were located at the West unit, which is being turned over to a new provider.
Video recordings are stored for thirty days. The center had a deficiency which was closed on
April 3, 2025; therefore, a review of ten-minute check logs for thirty-minute increments from
each shift and each housing module from May 2025 through July 2025 was conducted and
compared with the ten-minute check wand reports. Out of a total forty-three checks reviewed, all
but eleven were completed within ten minutes, with ten of the eleven being between one and
three minutes late and one being five minutes late. Three days of video, July 17, 2025, July 28,
2025, and August 3, 2025, were reviewed and compared with the wand report. All checks were
conducted on time except for two; one was eight minutes late and one was twelve minutes late.
Nine staff were interviewed, and all said checks are to be conducted every ten minutes when
youth are in their room for non-punishment reasons. The superintendent was interviewed and
asked about the ten-minute check process, and said staff are required to visibly observe any
youth in a room for sleeping purposes or any other time they are in the room, at a minimum of
every ten minutes.
5.04 Census, Counts, and Tracking Limited 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) which require staff always know the exact
number and location of all youth under their supervision. A count was observed during the
annual compliance review week at the recreation field. An informal count was called by master
control. When the count was conducted, all three staff assigned to supervise the youth on the
recreation field counted the youth and verified the total count with each other before calling in
the count to master control. Staff were aware of the total number of youth assigned to them, and
the actual number of youth present. Master control verified the location of all youth with the staff
supervising the youth. Nine staff were interviewed, and all were able to articulate the different
times when a count is conducted at the center, as well as the steps to take in the event a count
is not correct. All staff were also aware of when emergency counts are conducted. A review of
logbooks for one full day from each month during the annual compliance review period was
conducted. Counts were consistently conducted at the beginning and end of each shift, prior to
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and following group movement, anytime a population change occurred, and randomly at least
once on each shift. A total of eleven code blue (fights) were noted on the reviewed logbook
entries, with a count being conducted after one of the eleven.
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.
The center has facility operating procedures (FOPs) governing logbooks. The center maintains
logbooks in master control, each module, and for each transport vehicle. A review of logbooks
for one day each month since the last annual compliance review revealed logbooks were bound
with numbered pages and displayed the date at the top of each page. All entries had the
times of the events displayed in a.m./p.m., the name of the staff and youth involved, a
brief description of the event, and the initials of the staff who made the entry. Any entry
impacting the safety and security of the center was highlighted. Any errors were struck through
with a single line, had void written after the error, and included the staff’s initials. Logbook
reviews included the superintendent’s weekly review, the juvenile justice detention officer
supervisor’s (JJDOS) reviews when assuming center responsibility, the daily JJDOS review of
logbooks maintained in the living area, the juvenile justice detention officer (JJDO) review of the
living area logbook when beginning their shift, and the superintendent, assistant superintendent,
or JJDOS during their daily tour of each living area. The superintendent was interviewed and
advised management reviews logbooks at least weekly. A review of the master control logbooks
for one full day each month during the annual compliance review period was conducted which
confirmed all emergency situations, incidents, drills, receipt of medication and mental health
care, population counts at the beginning and end of each shift, counts, group movements,
admissions and releases, presence of law enforcement, searches, and youth on precautionary
or suicide observation with the beginning and ending times were consistently documented.
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
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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) requiring the center to be responsible for
maintaining inventory and control of all center keys. The FOP includes key assignment and
usage, restrictions on usage, inventory and daily tracking of keys, secure storage of keys,
procedures to follow when keys are missing or lost, and the reporting and replacement of lost or
damaged keys. A review of the key storage area revealed master control has a locked key box
where keys are maintained. An inspection of the area was conducted during the annual
compliance review, and the key box was found to be secured. An observation was also
conducted of staff arriving and departing the center and staff were observed to turn in personal
keys and receive a tag so they can retrieve their personal keys at the end of their workday. This
was also the case with the annual compliance review team for each day of the review.
Restricted keys are only issued to approved staff from each department. The key box contains a
list of the staff authorized to check out a particular key ring. The staff must turn in their personal
keys to retrieve the facility key ring. Emergency key rings are in the superintendent's office and
only the superintendent and assistant superintendents are authorized to access them. The
master key inventory was reviewed and included the key ring number, number of keys on each
ring, identification of which lock each key accessed, and who the key ring was issued to. All
facility key rings contained a color-coded marker which coincided to each department.
Documentation of key issuance included the date and time of issue, name of staff issuing the
key ring, name of staff who the key ring was issued to, and the time the key ring was returned.
The issuance of keys and key rings was documented on each shift report. Staff carrying keys
were observed to always carry the keys on their person and in their pockets. Staff did not allow
youth to handle facility keys. Keys are not allowed to be removed from the facility without prior
authorization from the superintendent. During the annual compliance review week, the key box
was found to be secured and, in an area not easily accessible. During the annual compliance
review period, there were no incidents reported to the Department’s Central Communications
Center (CCC) or Program Monitoring and Management (PMM) deficiencies related to key
control concerns.. A sampling of five key rings was observed and compared to the inventory and
key log. All key rings except for one matched the key ring inventory. The egress keys were not
on the control room key inventory log. This was immediately corrected by center staff. Three
staff were informally interviewed about the number of keys on their key rings and the function of
each key, and all were aware of how many keys were on their key rings and which doors each
key accessed. An informal interview was conducted with the master control operator, who
advised keys are only issued to authorized staff. Nine staff were interviewed, and all were able
to explain the center’s key control policy and knew which keys were restricted. The
superintendent was interviewed and advised no staff are issued permanent keys.
5.07 Vehicles and Maintenance Failed 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) designed to ensure any vehicle used by the
center to transport youth is properly maintained, and the center is required to maintain
documentation on the use and maintenance of each vehicle. During the annual compliance
review, center staff advised they had nine transport vehicles. Of the nine transport vehicles,
three were assigned to the center within the past two months, and the center has not yet put
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those vehicles online. The remaining six transport vehicles did not undergo an annual vehicle
inspection by a certified mechanic as required from the time of the last annual compliance
review. When this information was shared with center leadership staff, they put the six transport
vehicles without annual inspections offline, and began using the newly acquired transport
vehicles, which were less than a year old; therefore, did not yet require an annual vehicle
inspection. The center has made arrangements to have the six transport vehicles without an
annual inspection, get inspected by a certified mechanic before being placed back online. A
review of documentation revealed maintenance staff conducts monthly visual checks of all
transport vehicles. These monthly checks include tires, battery, and windshield wipers. All of the
transport vehicles were found to have the appropriate number of functioning seatbelts, a
seatbelt cutter/window punch tool, and a current fire extinguisher. The center has first-aid kits
for each transport vehicle, which are stored in the intake office, and are checked out whenever
staff go on a transport. Each transport vehicle has a corresponding logbook. Each logbook was
reviewed and contained an acknowledgement the vehicle was checked for contraband and
required equipment, prior to and after a transport, the destination of the transport, number of
youth and staff names, name of the officer riding in the back of the van, and the time the
transport began and ended.
A transport was observed during the annual compliance review. Transport staff were observed
to inspect the vehicle for contraband, ensure the vehicle had sufficient fuel, verified the
equipment to include the seatbelts were present and functioning, ensured they had the proper
documentation and logs for the transport, ensured they had a cellular telephone for the
transport, and documented the vehicle inspection in the logbook. Transportation staff conducted
searches of youth prior to the youth being placed in the vehicle, and ensured the youth were
secured with a seatbelt prior to departing. All nine center vehicles were inspected, and
confirmed all were locked when not in use. Nine youth were interviewed, and all said they have
never seen staff place contraband in a transport vehicle. Seven youth said staff drive safely
when driving in transport vehicles, and two said staff did not drive safely.
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) which require they ensure all tools and
equipment used for maintenance and in the kitchen are properly maintained and accounted for.
The center’s tool policy requires for all tools to be stored on a shadow board, in a secured area,
accurately identified, numbered, and inventoried. All tools must be checked out/in as they are
used, and this shall be noted on a tool checkout form. Knives are to be secured in a separate
locked box. An inspection was conducted of the tool room and kitchen area where tools are
stored. All tools were properly stored and there were no tools missing. Documentation
confirmed the kitchen staff conduct an itemized inventory of all equipment, including knives,
upon reporting for duty. During an informal interview, maintenance staff confirmed all service
vendors were accompanied by center staff when they are in a secure area of the center.
Maintenance staff also advised if a tool is lost or missing, the facility is locked down and a
search is conducted to find the tool, and if a tool is lost or damaged, a report is submitted, and a
replacement tool is ordered. Once the replacement tool arrives, it is marked and added back to
the active inventory. The superintendent was interviewed, and advised the only staff with access
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to class A tools are the maintenance mechanic and administration. Nine staff were interviewed,
and seven were unsure of the center’s practice for damaged or missing tools, while two said
they had to notify maintenance and a supervisor. All staff were aware of youth being limited to
using scrub brushes, mops, and brooms but only under direct supervision. Nine youth were
interviewed, and seven said they could use mops and brooms, while two said they do not use
any tools. A sample of ten tools from the kitchen and maintenance tool area were inspected. All
ten tools had proper markings for easy identification, had an accurate inventory, and the
inventory was signed by the superintendent/designee. Nine of the ten tools were secured at the
time of the inspection. During the inspection, the bread knife was not in the locked knife box and
not checked out. The food service staff advised they had just checked out the knife and did not
sign it out. It was signed out before the reviewer left the area.
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 facility operating procedures (FOPs), which name the superintendent as the
person responsible for the implementation of a safety plan addressing proper use, storage, and
disposal of chemicals, including flammable, toxic, caustic, and poisonous items. A review was
conducted of the center’s Safety Plan which requires flammable, toxic, caustic, and poisonous
items to be maintained in a shed with limited staff access and no youth access. Safety Data
Sheet (SDS) must also be located where the chemicals are stored. During an inspection of the
flammable, toxic, caustic, and poisonous storage area, five random flammable, toxic, caustic,
and poisonous items were inspected. All items were properly inventoried and stored with the
appropriate SDS sheet for each item. This area is restricted to authorized personnel, and in an
area inaccessible to youth. Nine youth were interviewed, and five said they are allowed to clean
with items if staff spray the solution, while four said they do not handle any cleaning agents. All
nine-youth said they do not have access to any flammable, toxic, caustic, and poisonous items.
Nine staff were interviewed, and seven said youth are not allowed to handle flammable, toxic,
caustic, and poisonous items, and two said they were. Nine staff also said they can spray items
with cleaning solution and youth can wipe them down.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 57
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) which designate the maintenance staff as
the person responsible for diluting, handling, and disposing of hazardous items and toxic
materials in accordance with Occupational Safety and Health Administration (OSHA) standards.
From the time of the last annual compliance review, there have been no instances of a
chemical spill or the need to dispose of any flammable, toxic, caustic, or poisonous items.
During an informal interview with the center's maintenance staff, it was explained a vendor is
used monthly to remove kitchen grease from the appropriate storage area. The maintenance
staff also advised any flammable, toxic, caustic, and poisonous items are either used or taken to
an approved facility for disposal, should the need arise to dispose of such items.
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 maintains facility operating procedures (FOPs) which govern the requirements for
behavioral confinement for less than twenty-four hours. The center had 912 instances of youth
placed in confinement for less than twenty-four hours since the time of the last annual
compliance review. All confinements are documented in the Department’s Facility Management
System (FMS). A sample size of fifteen confinements under twenty-four hours were reviewed.
Documentation confirmed all fifteen youth had access to mental healthcare as
requested/needed, and all received notice of their right to grieve a confinement placement. All
were provided three meals a day, plus snacks, as required based on the amount of time they
were in confinement. Eleven youth were applicable for being afforded a daily shower, based on
the time they were placed and released from confinement. Ten of the eleven youth received a
shower prior to placement in confinement. One did not receive a shower. Nine youth were
applicable for needing education materials based on the time they were placed and released
from confinement, and eight received educational materials. One did not. All confinements were
approved by a supervisor prior to the youth being placed in confinement, and only one youth at
a time was placed in a confinement room at any given time. Documentation also confirmed each
room was searched prior to placing a youth in confinement. Each of the fifteen reviewed youth
for confinement under twenty-four hours contained a Visual Observation Report (VOR) which
documented visual supervision at a minimum of every five minutes. None of the youth were
applicable for having a physical injury; therefore, assessments and treatment were not needed.
All fifteen youth were explained the reason for confinement, as documented on the VOR. The
supervisor conducted an initial confinement review for all youth within one hour of the incident
occurring, and each report was completed in full before the end of the shift. FMS contained
documentation which verified the supervisor conducted additional reviews at a minimum of
every three hours for any youth remaining in confinement longer than three hours. None of the
confinements interfered with visitation; therefore, notifications for potential visitors were not
needed. All confinement reports were reviewed by the superintendent within forty-eight hours.
The superintendent was interviewed, and advised confinement is a short-term strategy used for
managing youth behavior, which is tracked on the FMS monthly and on quarterly reports. The
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 57
superintendent also said regional detention management reviews the use of confinement
monthly. Nine staff were interviewed, and all were able to articulate the step-by-step process for
placing a youth in confinement, and they also said youth placed in confinement are provided
education materials. During a tour of the facility, windows and doors to youth rooms and
cameras were free of obstructions, so the youth may be visually observed. It was also noted
several windows had been scratched and need to be replaced, but visual observation of youth is
not impeded as a result of the scratches.
5.12 Confinement Over Twenty-Four Hours and
Satisfactory Compliance
Confinement 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.
The center has facility operating procedures (FOPs) governing the use of confinement in the
event it is needed for a period over twenty-four hours. Since the time of the last annual
compliance review, there was only one youth placed in confinement over twenty-four hours. The
supervisor conducted additional reviews with the youth at a minimum of every three hours, as
required, and continuously counseled the youth for consideration of removing the youth from
confinement as soon as the youth was able to safely rejoin the other youth in population. A
confinement review was conducted over the phone a minimum of two hours before the end of
the twenty-four-hour period by the regional director/designee. The superintendent provided the
regional director/designee with a copy of the youth Confinement Report and all documented
reviews and interviews with the youth. The superintendent and a member of the center’s mental
health team met with the youth prior to the confinement review to discuss continued
confinement, and the superintendent documented the decision to extend the use of confinement
beyond twenty-four-hours. Mental health staff saw the youth as soon as reasonably possible,
and thereafter, regular reviews were conducted. After the youth was released from confinement,
a copy of the confinement review documentation was distributed to the regional director and the
assistant secretary for detention services.
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) in place requiring the establishment of a
Continuity of Operations Plan (COOP), and for COOP drills to be conducted at a minimum of
twice a year. The center conducted two drills from the time of the last annual compliance review;
however, both drills were conducted during hurricane season. One was conducted August 2024,
and one was conducted June 2025. A review of documentation determined both drills contained
the type of drill, date and time, participants, brief scenario, findings, and recommendations, as
required. The superintendent was interviewed, and confirmed the center’s comprehensive
safety/emergency program is the COOP.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 57
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedures regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) which require the center to develop and
implement an escape prevention plan. In addition, the center is required to conduct escape drills
at least quarterly on each shift. The escape drills were reviewed since the time of the last annual
compliance review. The center conducted monthly escape drills on each shift, which exceeds
the requirement. A review of nine staff training records was conducted and revealed all staff
were trained in escape prevention annually. A review of logbooks confirmed the documentation
of each drill. Nine staff were interviewed, and six said they have participated in at least one
escape drill since the time of the last annual compliance review.
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) requiring the implementation of a disaster
preparedness fire prevention plan. In addition, the center is required to conduct monthly fire
drills on each shift. The plan was reviewed and approved by the local fire official who also
conducted the annual inspection of all fire extinguishers. A review of fire drill documentation
since the time of the last annual compliance review revealed fire drills were conducted monthly
on each shift, except for four drills from September 2024 through December 2024 which could
not be located for the A-shift. Logbooks were reviewed and each of the fire drills was properly
documented. Nine staff were interviewed, and eight said the center conducts fire drills every
month on each shift, and one said they do not. Nine youth were interviewed, and seven said
they have been instructed on what to do in the case of a fire, and two said they have not.
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
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 57
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) designed to stop illegal contraband and
prohibited items from entering the facility. This includes the delineation of certain items to be
considered contraband and providing youth and staff with this list. The center must also have a
policy on contraband and searches and establish a system to prevent the introduction of
contraband, identify contraband items and materials through searches of the physical plant,
facility grounds, staff, youth, and visitors. Any contraband found must be documented, to include
the documentation and confiscation of any illegal contraband and the manner of disposition. The
center must complete an incident report identifying findings for all recovered illegal contraband,
notify the regional director, and report these to the Department’s Central Communications
Center (CCC) within two hours. In all instances involving confiscation of illegal or prohibited
contraband, the center must turn the item over to local law enforcement and a criminal report
must be filed. A review of the Department’s Facility Management System (FMS) revealed
searches are being documented electronically. During the annual compliance review week, a
transport of four youth was observed, and staff conducted thorough pat searches of each youth.
Staff wore gloves during each search and verbalized the search with each youth. Since the time
of the last annual compliance review, there were no reported strip searches, other than during
admission. During the annual compliance review week, members of the review team were
subjected to electronic searches. These were conducted anytime a staff, visitor, or volunteer
entered the secure part of the facility. During the annual compliance review, a person later
identified as a volunteer was observed on the secure floor with a non-clear rolling bag. This was
brought to the attention of the administration, and the superintendent advised once the bags are
checked, they can be allowed on the secure floor. All personal keys and cellular telephones are
prohibited from entering the secure area of the facility. A review of logbooks for one day each
month from the time of the last annual compliance review confirmed room searches are
conducted on each awake shift, prior to placing a youth in a room, and whenever a youth is
released. Since the time of the last annual compliance review, there have been no instances
which may have compromised the safety or security of the center. All visitors entering the facility
are required to complete a contraband attestation statement. A review of twenty-two newly hired
staff training records was conducted, and all contained a signed contraband attestation;
however, two were signed during the annual compliance review week. Seven instances of
contraband entering the center were reported since the last annual compliance review. The
confiscation of contraband and notification to the CCC was documented in the logbook for each.
A review of FMS confirmed all incident reports regarding contraband were entered into the
system. Confiscated items were handed to the on-duty supervisor. One of the contraband
incidents required law enforcement to be contacted for the illegal contraband entering the
center, and appropriate notifications were made. The superintendent was interviewed and
advised all contraband must be documented in the master control logbook. An incident report
identifying findings and the disposition of the contraband must be completed. The
superintendent also said lockers are provided outside the secure area for staff to safely secure
any items they cannot bring inside the secure area of the facility.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 57

source: DJJ

rule: Indicator 1.08

excerpt: Grievances

rule: Indicator 3.12

rule: Indicator 4.12

rule: Indicator 5.04

excerpt: Census, Counts, and Tracking

rule: Indicator 5.07

excerpt: Vehicles and Maintenance