state: FL

facility_name: Hillsborough Juvenile Detention Center West

summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Hillsborough West Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3948 W. Martin Luther King Jr. Blvd.
Tampa, Florida 33614
Review Date(s): February 3-6, 2026
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Jennifer Tummino, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Education Coordinator (Standard 2)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standards
1 & 4)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Qualia Turner, Manatee Regional Juvenile Detention Center, Superintendent (Standard 5)
Program Name: Hillsborough West Juvenile Detention Center MQI Program Code: 294
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Hillsborough County / Circuit 13 Number of Beds: 80
Review Date(s): February 3-6, 2026 Lead Reviewer Code: 201
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 51
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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 51
1 .0 1
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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 S a
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D a ta T re n d A n a ly s is S a
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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 ).
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Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 51
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p 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 2 - Y o u th M a n a g e m e n t
A d m is s io n S a tis fa
O rie n ta tio n S a tis fa
C la s s ific a tio n S a tis fa
N o tific a tio n o f J P O C irc u it G a n g R e p re s e n ta tiv e S a tis fa
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty S a tis fa
R e le a s e S a tis fa
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa
R e v ie w o f Y o u th in S e c u re D e te n tio n S a tis fa
D a ily A c tiv ity S c h e d u le S a tis fa
E d u c a tio n a l A c c e s s * S a tis fa
C a re e r E d u c a tio n S a tis fa
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
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 ).
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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 51
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
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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 E v a lu a tio n
T re a tm e n t a n d D is c h a rg e P la n n in g
M H /S A T re a tm e n t
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
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 ).
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Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Psychiatric Services* Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control/Education Satisfactory
4.19 Prenatal Care/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 7 of 51
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 51
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 S a tis fa c to ry
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 S a tis fa c to ry
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 Hillsborough West Regional Juvenile Detention Center is a state-owned detention facility,
operated by the Department, located in Tampa, Florida. The center serves youth in Hillsborough
County in Circuit 13. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the eighty-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 Hillsborough School Board. The center’s management
team includes the superintendent, three assistant superintendents, two administrative
assistants, nine juvenile justice detention officer (JJDO) supervisors, and fifty-nine JJDOs.
Mental health and healthcare services are provided through the contracted provider, VitalCore
Health Strategies, LLC. Mental health services are provided by one psychiatrist, one designated
mental health clinician authority, who is a licensed clinical social worker (LCSW), one additional
LCSW, one licensed mental health counselor (LMHC), three pro re nata (PRN) LMHCs, and one
unpaid intern. 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 six registered nurses (RNs), one medical doctor, one part-time advanced practice registered
nurse (APRN), one PRN RN, and a medical records clerk. The medical clinic maintains nursing
coverage Monday through Friday, from 7:00 a.m. through 7:00 p.m., and on weekends, from
7:00 a.m. through 5:00 p.m. Food services are provided by one food service director and four
food service workers, 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 four living modules which are divided by male and female. There are eighty security
cameras at the center, of which seventy were operational. At the time of the annual compliance
review, the center had nine vacancies, which included six juvenile justice detention officer Is and
three juvenile justice detention officer IIs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 51
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 addressing initial background screenings for all
staff and volunteers and to ensure all volunteers, mentors, and interns working with youth less
than ten hours a month have the required sight and sound supervision while on-site. The center
has teachers who are paid by the local school board, and they received an Annual Affidavit of
Compliance with Level 2 Screening Standards on January 21, 2026. The center had twenty-
three new staff and four newly contracted staff during the annual compliance review period. All
twenty-seven background screenings received an eligible rating prior to the date of hire, and
each background screening included a criminal history review. Twenty-two of the twenty-three
newly hired staff received a passing score on the pre-employment assessment, the remaining
staff was not applicable, and contracted staff are not applicable for the assessment. All four
contracted staff were added to the Clearinghouse 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 addressing the five-year background rescreening
process. A review of the center’s staff rosters revealed the center had four staff applicable for a
five-year rescreening during the annual compliance review period. All four staff received a five-
year rescreening within the required time frame, each rescreening was submitted to the
Department’s Background Screening Unit (BSU) at least ten business days prior to the staff’s
five-year anniversary date, and each was returned with an eligible rating.
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 51
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 which require all staff to adhere to a code of
conduct. The center provided three staff personnel records with commendations and three staff
personnel records with violations of the code of conduct during the annual compliance review
period. A review confirmed each of the six staff records included a code of conduct form signed
upon hire. Documentation confirmed management responded to each code of conduct violation.
One staff was immediately placed on no youth contact after a code of conduct violation for
excessive force and subsequently resigned. The two remaining staff received an oral and
written reprimand, respectively, after violations of the code of conduct. Three staff received
certificates of appreciation during the annual compliance review period, which were presented
to them during an all-staff meeting. Nine staff were interviewed regarding staff conduct. All nine
staff confirmed youth are allowed to call the Florida Abuse Hotline or the Department’s Central
Communications Center (CCC) if needed to report abuse. Six of the nine staff indicated
supervisory staff is notified when a youth makes a request to call and seven staff confirmed staff
are allowed to call if needed. Eight of nine staff indicated they have never heard staff use any
profanity while speaking with youth, and the remaining staff stated they have heard it
occasionally, in conversation. All nine staff confirmed they have never observed another staff
using threats, intimidation, or humiliation when interacting with youth. Six of the nine staff stated
working conditions at the center were very good and the remaining three staff said working
conditions were good. Nine youth were interviewed. Seven of the nine youth confirmed they
have never been stopped from reporting abuse to the Florida Abuse Hotline since they have
been at this center and the remaining two youth indicated they have never had to report abuse.
All nine youth confirmed staff are respectful when dealing with youth and have never heard staff
curse, or threaten other youth or themselves. All nine youth stated they feel safe at the center
and have never exchanged personal information with staff. The superintendent was interviewed
and advised the center’s code of conduct ensures staff communicate and interact with youth in
a manner which provides a role model of socially acceptable behaviors for youth. If there is an
allegation of abuse from a youth, the staff is immediately removed from contact with the youth,
the youth will be afforded the opportunity to call the Florida Abuse Hotline, the center notifies
law enforcement, if necessary, and calls the CCC.
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 which require the Department’s Central
Communications Center (CCC) to be notified within two hours of an incident, or within two hours
of becoming aware of an incident. The center had seventy-two CCC incidents during the annual
compliance review period. Seven incidents were reviewed and all incidents were reported within
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 51
two hours of the center becoming aware of the incident. A review confirmed all seven incidents
were documented in the center’s logbook. A review of internal incidents and grievances found
no other incidents which should have been reported to the CCC. The superintendent was
interviewed and advised any reportable incident must be reported within two hours to the CCC.
The superintendent also advised any allegations of physical, sexual, or emotional abuse will be
called in to the Florida Abuse Hotline.
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 governing right interactions (RI), which is the
Department’s approved protective action response (PAR) curriculum. The center is required to
utilize physical intervention techniques and anytime RI is used, staff must complete and file an
RI Report in accordance with Florida Administrative Code. The center had a total of 292 RI
incidents reported during the annual compliance review period. Nine RI incidents were
reviewed, and each RI Report was completed by the end of the staff’s workday. All nine RI
Reports included statements from all staff involved and none resulted in serious injury to the
youth or staff involved. None of the RI incidents resulted in a youth alleging abuse; therefore,
did not require a call to the Florida Abuse Hotline. Each RI Report was reviewed by a supervisor
and a RI instructor or RI certified supervisor. A post-RI interview was conducted with the youth
within thirty minutes of the incident for all nine incidents reviewed. None of the youth required a
medical review. All nine RI Reports were reviewed by the superintendent or designee within
seventy-two hours. There were no other RI incidents noted in internal incidents, grievances, or
logbooks which were not documented by a RI Report. The center’s RI rate during the previous
quarter was 15.98, which was above the statewide detention RI rate of 13.67. Nine staff were
interviewed, and all stated they try to talk with youth before using physical or mechanical
restraints. The superintendent was interviewed and indicated mechanical restraints may only be
used in exigent circumstances, where they are necessary to prevent harm to youth or staff. The
use of mechanical restraints requires the regional director or designee to be notified. Staff will
complete the mechanical restraint log and ensure ten-minute circulation checks are completed
whenever mechanical restraints are utilized. The staff supervising the youth should have a
handcuff key readily available. The mechanical restraints should be removed as soon as it is
safe to do so. A RI Report shall be completed and submitted for review. Mechanical restraints
shall never be used as a means of discipline. Staff will not carry mechanical restraints on their
person.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures which require detention staff to be trained in
accordance with Florida Administrative Code. Detention staff must complete pre-service
certification requirements within 180 days of hire. A sample of nine staff were reviewed for pre-
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 51
service training. All nine staff completed all pre-service and certification requirements within 180
days of hire, to include academy training which consisted of 120 hours of training. Additionally,
all nine staff completed a new staff orientation within thirty days of hire.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures which require all direct care staff to complete
twenty-four hours of in-service training, including mandatory topics, each calendar year,
effective the year after pre-service/certification training. Additionally, supervisory staff must
complete eight hours of training in the areas specified in Florida Administrative Code. Nine staff
training records were reviewed for in-service training, and all staff completed the required
twenty-four hours of annual training, with totals ranging from sixty-one to 125 hours. All staff
completed each of the required courses. Three supervisory staff training records were among
the nine reviewed training records. Each of the three supervisory staff completed a minimum of
eight hours of supervisory training in the areas of coaching, leadership, and personal
accountability, with totals ranging from thirteen to forty-eight hours. A licensed nurse provided
in-service education on girls’ healthcare to all non-healthcare staff involved in the supervision or
treatment of girls. This training included monitoring, observation, and emergency care for
pregnant youth. The center maintains an annual in-service training calendar, which is updated
as changes occur. The training calendar was approved by the highest ranking official at the
center, the assistant secretary of detention, and the director of the Department’s Office of
Talent, Leadership, and Culture. The superintendent was interviewed and advised he has
completed numerous management training classes and also confirmed staff are required to
attend juvenile detention certification training which consists of two phases.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth 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 which give youth the right to grieve, to ensure all
youth are treated fairly, respectfully, and without discrimination, and their rights are protected.
During a tour of the center the week of the annual compliance review, grievance forms were
observed in each housing unit, available for youth to access as needed. The superintendent
was interviewed and outlined the different phases of the grievance process, including timelines.
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The superintendent also advised all completed forms are signed by the youth and maintained in
a grievance file uploaded in the Department’s Facility Management System (FMS). The
superintendent indicated there were no grievances during the annual compliance review period,
which was confirmed by a review of FMS. Nine youth were interviewed and five said they have
never filled out a grievance form, two said the process is very good, and two stated good. Eight
of nine youth were familiar with the grievance process and the remaining youth indicated they
have not had to use the form. Nine staff were interviewed, and all were able to articulate an
understanding 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.
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 maintains facility operating procedures which require critical and special alerts to be
documented in the Department’s Juvenile Justice Information System (JJIS). Nine youth records
were reviewed for alerts. There was a total of twenty-four alerts among the nine reviewed youth.
A review of the center’s logbooks confirmed all applicable alerts were documented. All alerts
entered by center staff included the name and title of the staff entering and/or updating the alert
for each youth. A review of shift briefing reports confirmed alerts are reviewed with staff prior to
them going on duty. No additional alerts were found during the annual compliance review which
should have been entered into the JJIS alert system. The superintendent was interviewed and
advised the JJIS alert report is reviewed daily by supervisors and administrators to ensure the
report correctly reflects the status of each youth. Supervisors also ensure the detailed alert list is
read aloud during shift briefing. The superintendent also stated medical alerts are entered by
the contracted provider. Five of nine interviewed staff confirmed they are informed of alerts
during shift briefing. Two staff knew there were alert forms which can be reviewed, four staff
indicated alerts are documented in the logbook, and six said they could also check JJIS to find
youth alerts. Eight of nine staff stated management informs staff about issues within the center
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mainly through shift briefings. Some also said information is shared by documenting in the
logbook, during staff meetings, through email, and verbally. All nine staff indicated this process
is very good or good for communicating information to staff from management.
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.
An informal interview with the superintendent revealed information is gathered through tableau
which is entered by staff at the Department’s headquarters. The center has monthly supervisor
meetings and also all staff meetings during which trends are discussed, and staff brainstorm
better practices. Copies of meeting agendas were provided to the annual compliance review
team, which confirmed this information is being discussed with all staff. The center shares
relevant information with the juvenile justice circuit 13 community advisory board and the
juvenile assessment center (JAC) advisory committee during their quarterly meetings. Copies of
advisory board and JAC board meeting agendas were also provided which supported
information is being shared. The center completes monthly comparisons of incidents to
determine if any identified trends are moving in a positive direction.
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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 outlining the admission process for youth entering
the center. Nine youth records were reviewed for admission requirements. Each youth record
contained a completed Admission Wizard which notated a review was completed of each
youth’s arrest affidavit or custody order, Detention Risk Assessment Instrument (DRAI), and
Suicide Risk Screening Instrument (SRSI). Documentation was also notated in each record of a
completed full body search, youth telephone call or attempted call made to the parent/guardian,
a meal provided to each youth, and a medical, mental health, and substance abuse screening
were completed. An observation of a youth admission was conducted during the week of the
annual compliance review, and the staff followed all 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 outlining the orientation process for youth entering
the facility. Nine youth records were reviewed for orientation requirements. There was evidence
in each record the youth signed the orientation acknowledgement form to document all required
topics, which were discussed at orientation. Copies of the forms were maintained in each youth
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record. Orientation was completed on the day of admission for each youth. During the week of
the annual compliance review, one youth orientation was observed, and the staff provided all
required information to the youth during the orientation process. Observations found the center
played the required orientation video, which in included the Prison Rape Elimination Act video.
All nine interviewed youth confirmed center staff discussed facility rules and expectations with
them at the time of their admission.
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.
Nine youth records were reviewed for classification requirements. All nine contained evidence
the classification process for each youth included consideration for mental illness, intellectual
and physical disabilities, history of violent behavior, criminal behavior, sexual history,
vulnerability to victimization, medical, suicide risk, escape, security, and history of human
trafficking. One record documented the youth’s gang affiliation as required, the remaining eight
were not applicable. Each youth was assigned to a room based on their completed
classification, which included all required topics. Staff review alerts and the Department’s
Juvenile Justice Information System (JJIS) face sheet for each youth for things such as history
of human trafficking, gang information security issues, and past criminal history. All required
topics are considered prior to youth room assignments being made. The superintendent is
informed on the procedure to identify and address local youth gangs by the admission/intake
supervisor. An interview with the superintendent confirmed the initial intake process consists of
reviewing the Detention Risk Assessment Instrument (DRAI), Suicide Risk Screening
Instrument (SRSI), Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB),
Community Assessment Tool (CAT), and both past and current charges of each youth to assist
with classification and housing unit and room assignments.
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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 a facility operating procedures which outline the process for notification of any
suspected gang activity. Nine youth records were reviewed for gang notification requirements.
None of the nine reviewed youth were applicable for requiring notification. An informal interview
with the admission/intake supervisor indicated, at the time of the annual compliance review, no
youth had been identified by the center as being a possible gang member. According to the
superintendent, the center’s admission/intake supervisor is currently serving as the gang
representative for the detention center. The center’s admission/intake supervisor stated in an
informal interview, in the event a youth were to enter the facility, and the detention staff
determined they suspected the youth of being a gang member, they would take photographs of
the youth and any evidence and the documentation would be provided through email to the
youth’s assigned juvenile probation officer.
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. Personal property for each youth is maintained in the
intake area of the detention center. Personal property for youth, which is not considered
valuable, is placed in a mesh bag along with the youth’s Property Receipt Form. Each bag is
secured in a personal property room in the intake area. Valuables are maintained in a drop safe
with key access, which is limited to assigned staff. The drop safe is under video surveillance.
The safe has a valuables logbook sitting on top of it containing documentation of the property
stored, the youth’s name, the name of the staff securing the valuable items, and the time in and
out of the safe for each property secured. A sample of nine youth records were reviewed for the
admission and storage of personal property. Three of the reviewed youth records were also
applicable for valuable property. . A completed Property Receipt Form was maintained for each
youth outlining the items collected. Each record included a signed letter of acknowledgement
regarding unclaimed property. All valuable property items reviewed were documented in the
valuables logbook and were placed in a tamper proof property bag in the safe, as required. All
nine youth had personal property located in the property closet, placed in a mesh bag with a
copy of their Property Receipt Form. An observation of a youth intake/admission indicated staff
followed the center’s personal property FOP. A review of the Department’s Central
Communications Center (CCC) reports for the scope of the annual compliance review found
none were applicable for incidents involving youth property valued over fifty dollars. Nine youth
were interviewed. Eight of nine youth confirmed when they arrived at the detention center, staff
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checked their personal property and had them sign a form stating the personal property was
correct. One youth transferred to the center and the property bag was transferred from staff to
staff, reviewed by the receiving staff, signed by the intake/admission staff, then secured in the
closet. The superintendent was interviewed and stated a juvenile justice detention officer
ensures each youth signs their property paperwork and documentation is saved in the
Department’s Juvenile Justice Information System (JJIS). Valuable property is stored in safe
which is located in the intake office under video surveillance. Only supervisors and
administration have access to valuable property. Clothes and non-valuable property are stored
in a locker under video surveillance. After thirty days of a youth not retrieving their property, the
center sends out a certified letter to their parent/guardian saying they have thirty days to retrieve
the property. If they have not retrieved the property, an inventory is done with the unclaimed
property, and then it is donated. Any money is added up and a money order is made which is
sent to the regional office.
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 outlining the policy for releases. Three closed youth
records were reviewed for release requirements. For each of the three reviewed records, there
was evidence the on-duty supervisor reviewed all paperwork prior to releasing the youth, which
included a review of any court requirements and verification of the youth’s identification and
identification of the parent/guardian responsible for picking-up the youth. None of the youth
reviewed were applicable for having an Endangered Person alert. Documentation indicated
each youth was reminded of any future court dates, as required. All three records had evidence
all required parties signed all applicable release forms. The date of admission and date of
release for each youth correlated with the dates indicated in the Department’s Juvenile Justice
Information System (JJIS), as required. A release was observed during the annual compliance
review. Detention release forms were observed being completed on a computer by the releasing
officer on the Detention Release Wizard. The youth was also verified as not being on any
special precautions or special observation status. A copy of the receiving party’s photograph
identification was made by detention staff.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
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Three closed youth records were selected and reviewed for release requirements related to the
release of youth personal property, medications, and aftercare instructions. All three reviewed
records had evidence the youth and parent/guardian signed the receipt of property form upon
release. All three youth records had documentation verifying the youth was released to an
approved person, with a copy of their identification attached to the closed records. One of the
three youth was applicable for being on medications and the parent/guardian receiving the
youth signed the receipt of medications form, as required. There was evidence in each record
the releasing officer reminded the person to whom the youth was being released to of any
health or welfare issues, including medical, mental health, and/or substance abuse needs, and
pending appointments. A review of three samples of property held for more than thirty days
found the center followed the disposal process, as required. There was no personal property
valued over fifty dollars held for more than thirty days. A release was observed during the
annual compliance review week. The youth had no prescribed medications, which was verified
by the detention officer releasing the youth to the custody of a receiving commitment program
and their staff. The youth was also verified as not being on any special precautions or special
observation status. A copy of the receiving party’s photograph identification was made by
detention staff.
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 conducts weekly Detention Reviews for youth on Thursdays. Observation of a
Detention Review being held was made during the annual compliance review week. Participants
included detention administration, and a representative from education, medical, and mental
health. In addition, a residential commitment manager and probation representative were
present through virtual conferencing. Signature forms were passed around for staff, along with
the Department’s Juvenile Justice Information System (JJIS) active alerts for each youth. Each
youth’s status in the detention center was discussed, along with their number of total days in
detention, future court dates, alert information, and any changes in their status. Participants
were given opportunities to provide input regarding each youth. Documentation of previous
Detention Reviews is maintained electronically. A review of the documentation found reviews
are conducted weekly as required. One day each month was reviewed for the scope of the
annual compliance review. There was documentation all participants attended, as required.
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 a daily activity schedule which is posted in all living areas as well as the
cafeteria. Observations during the annual compliance review week revealed staff and youth are
adhering to the daily schedule. Youth were seen participating in mealtimes and educational
classes. The posted daily schedule includes the scheduled times for youth visitation, recreation
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and physical activities, indoor and outdoor activities, groups, bedtimes, and mealtimes, as well
as wake up and personal hygiene. Nine interviewed staff all confirmed the center’s daily activity
schedule is followed, as required. Nine interviewed youth confirmed the center has an activity
schedule and eight of nine youth stated the schedule is followed daily. One of nine youth stated
bedtimes are different than the posted schedule, adding everyone goes to bed at 6:00 p.m., not
by levels.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to ensure educational access. The center
integrates education into the daily schedule in such a way to ensure the integrity of the required
minimum instruction time distributed over a twelve-month period. A review of three random days
of video, the corresponding logbook entries, and a random review of logbooks for one day each
month for twelve months showed youth are starting and ending school at the appropriate times.
In a review of youth interviews, all nine interviewed youth indicated they attend school Monday
through Friday. Three of nine youth stated the center is preparing them very well for high
school, vocational school, employment, and/or college, while five youth said well, and the
remaining youth commented not well citing he would like more science and social studies
classes. Nine staff were interviewed and all nine stated there is minimal interference in
education instruction. The superintendent’s interview 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 for career education. Career educational services
are provided through the Hillsborough County School district. The center provides vocational
competency development Type One programming for all youth, which includes communication,
interpersonal, and decision-making skills. In a review of nine youth interviews, all nine youth
were able to articulate education classes they are taking while at the center.
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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 designated mental health clinician authority (DMHCA) who is a licensed
clinical social worker (LCSW). The DMHCA is responsible for coordination and implementation
of mental health and substance abuse services and is on-site for forty hours a week.
The DMHCA has a clear and active license in the State of Florida, with a license expiration date
of March 31, 2027. The provider has a backup DMHCA, as required by contract; however, there
was no other DMHCA used during the annual compliance review period. The backup DMHCA is
LCSW, who has a clear and active license with an expiration date of March 31, 2027. A copy of
the DMHCA position description was reviewed, and a review of the sign-in logs confirmed the
DMHCA was on-site a minimum of forty hours a week. The DMHCA was interviewed and
advised they oversee the mental health services provided to youth and families. In addition, the
DMHCA also conducts Assessments for Suicide Risk (ASR), follow up ASRs, initial and
individualized treatment plans, discharge summaries, mental health referrals, provides
supportive counseling, and crisis interventions. The DMHCA communicates with juvenile
probation officers (JPO) weekly to provide psychiatrist and treatment team information, as well
as discharge diagnosis information. The DMHCA participates in weekly Detention Review
meetings with the JPO and provides services and resources to youth and parents/guardians
upon release as needed. The DMHCA conducts mental health groups, which focus on anger
management, decision making, and life skills. The DMHCA also advised the center is given
hours for two full-time licensed clinicians, and they communicate daily with each of these
individuals.
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.
A review of the provider’s contract revealed each detention facility will have, at minimum, a
designated mental health clinician authority (DMHCA) and one licensed mental health
professional on-site forty hours each week. Other than the DMHCA, the center has one full-time
licensed mental health counselor (LMHC), one full-time licensed clinical social worker, and three
LMHC who are used pro re nata. The DMHCA ensures all licensed clinical staff working under
their supervision are performing services they are qualified to provide based on their education,
training, and experience. The center has copies of all licenses on-site. All licenses were
reviewed with no issues noted.
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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 which require mental health and substance abuse
staff to have the appropriate qualifications to provide services. The designated mental health
clinician authority (DMHCA) is required to ensure clinical staff working under their supervision
are performing services they are qualified to provide based on education, training, and
experience. The center does not have any non-licensed clinical staff working under the
supervision of the DMHCA; however, the center has one unpaid intern who does not provide
services. During an informal interview, the DMHCA confirmed the center does not have any
vacancies in mental health.
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 which require they identify the mental health and
substance abuse or possible suicide risk needs of youth by conducting a comprehensive
screening process during admission. Nine youth records were reviewed for mental health and
substance abuse admission screening, and all contained screening documents which were
completed during each youth’s detention intake. The suicide risk screening instrument (SRSI)
was completed during intake, and both the SRSI and the Massachusetts Youth Screening
Instrument (MAYSI-2) were initiated in the Department’s Juvenile Justice Information System
(JJIS). For all reviewed records, documentation confirmed mental health staff completed the
required sections of the SRSI. The completed entries included accurate referral selections in the
screening results section. Six records indicated the youth had positive responses on the SRSI,
and each youth was placed on suicide precaution. A mental health referral was completed
which documented the youth’s need for an Assessment of Suicide Risk (ASR). The SRSI
screening in each record included a yes response when youth had any open or closed suicide
risk alerts within JJIS. In eight of the nine records reviewed, the results of the MAYSI-2 and
SRSI indicated a need for further assessment. The SRSI of the remaining youth did not indicate
a need for further assessment. Based on the results of the MAYSI-2 assessment in two records,
the need for further assessment was required and the appropriate referrals were made with
notification to the superintendent. The remaining seven records did not require a referral based
on the MAYSI-2. None of the records were applicable for all negative responses requiring an
invalid marking. None of the MAYSI-2 assessment results indicated an elevated suicide risk
subscale; therefore, none of the youth had to be placed on suicide precautions or referred for an
ASR based on the elevated suicide risk subscale.
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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.
Nine youth records were reviewed for mental health and/or substance abuse comprehensive
evaluations, and none were applicable. The center provided three applicable youth records to
meet the sample size. All three youth were identified at admission and referred to the
center provider for a mental health and/or substance abuse evaluation. One of the three
comprehensive mental health and/or substance abuse evaluations completed by the center
was classified as new and the remaining two were classified as updated. All three evaluations
were completed within thirty-one days of admission. All evaluations contained treatment
recommendations made which corresponded to all diagnosed mental health or substance
related disorders. Each of the comprehensive evaluations consisted of the Substance Abuse
and Mental Health form, which were documented within the Department’s Office of Health
Services Electronic Medical Record. The designated mental health clinician authority (DMHCA)
was interviewed and said the juvenile probation officer (JPO) is responsible for ensuring youth
identified in need of further mental health and/or substance abuse assessments are referred for
a comprehensive assessment by the JPO, contracted provider, or juvenile assessment center.
The JPO is responsible for ensuring when the comprehensive assessment of a detained youth
is received, the information is forwarded to the detention center. If an assessment is not
received, the DMHCA contacts the JPO to obtain it. The DMHCA is responsible for ensuring a
thorough review of comprehensive assessments received and completion of a comprehensive
assessment by the thirty-first day after admission, if one has not been received. If a youth is in a
detention center and exhibits behavior, or information is obtained, which indicates the youth is in
need of in-depth mental health or substance abuse assessment, the DMHCA will ensure the
youth receives an in-depth comprehensive assessment.
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.
Nine youth records were reviewed for treatment and discharge planning, and all contained
documentation showing they received a mental health orientation within fourteen days of
admission. Two youth required a treatment plan; therefore, the center provided an additional
applicable youth to meet the sample size. Each initial treatment plan was in place within seven
days of the onset of treatment, and all were developed on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. All included the reason for referral of treatment
and the initial diagnosis. Each initial treatment plan included initial treatment methods including
counseling and frequency of counseling, initial treatment goals, psychiatric services including
psychotropic medication, and frequency of monitoring, the medication each youth was admitted
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with in order to compare with the initial treatment plan, the mental health and substance abuse
professional’s signature, the youth signature, if the youth was assigned a mini-treatment team,
and the members involved in the development of the initial treatment plan. None of the selected
youth were applicable for individualized treatment plans; therefore, the center provided three
applicable youth to meet the sample size. All of the individual treatment plans were developed
for each youth receiving mental health and/or substance abuse treatment in the center by the
thirty-first day of the youth’s admission. All contained a diagnosis, symptoms which are
treatment focused, treatment goals, strengths, and needs. Two of the three youth were taking
psychotropic medications, and the medications listed in the initial treatment plan matched the
medications the youth was prescribed at the time the treatment plan was developed. All
progress noted confirmed each youth was receiving treatment services as stipulated on the
treatment plans. Each individualized treatment plan was signed by the youth, mental health and
substance abuse professionals, and treatment team members. Parents/guardians participated
by telephone, and the treatment plans properly noted this participation. One of the treatment
plans was applicable for a thirty-day review, and this review was conducted timely. Modifications
were clearly identified on the plan review, and the plan review was signed by the clinical staff,
youth, licensed mental health professional, treatment team members, and parent/guardian
participation by telephone was also noted. None of the nine youth records selected for this
annual compliance review were applicable for discharge summaries; therefore, the center
provided three additional records to meet sample size. Each discharge plan was documented
on the Department’s Mental Health/Substance Treatment Discharge Summary form, which was
completed upon each youth’s discharge. Documentation confirmed each was completed on the
last day of service, signed by the licensed mental health professional, and all uploads were
completed within fourteen days. During the annual compliance review, a mini-treatment team
was observed, which was attended by the youth, mental health staff, parent/guardian attempted
by telephone, and the psychiatrist. The team discussed group availability, mental health and/or
substance abuse issues, needs, and goals with the youth. During an interview, the designated
mental health clinician authority (DMHCA) said detention is a transient stage for most youth,
typically lasting less than twenty-one days. If a mental health professional determines it is in the
best interest of a youth, treatment services are initiated prior to discharge from detention. In this
case, an initial treatment plan is developed within seven days of initiation of services. The
DMHCA provides information to parent/guardians of all youth in need of such services upon
release. The center provides an array of services for youth identified at risk of mental health and
substance abuse problems. The DMHCA also said a review of the individualized treatment plan
is conducted every thirty days by mental health staff.
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.
Nine youth records were reviewed for mental health and substance abuse treatment and two
were applicable; therefore, the center provided an additional youth record to meet sample size.
The three applicable records indicated each youth was assigned to a mini-treatment team which
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consisted of a mental health clinical staff, one staff from a different service area, youth, and
parent/guardian if possible. Each record noted the youth required mental health treatment and
received individual, group, or family therapy counseling according to frequency required by the
plan. Each plan included individual, group, and/or family therapy prescribed at least weekly.
Two of the youth records indicated the youth required substance abuse treatment. All youth
records contained a signed Authorization for Evaluation and Treatment (AET). The proper
consent for treatment and release of records was obtained through the signed Department
forms for each youth who required substance abuse treatment. The treatment notes containing
all the required elements were documented in the Department’s Counseling/Therapy Progress
notes for each youth. The center holds mental health and/or substance abuse groups daily from
4:00 p.m. through 6:00 p.m. A review of video, logbooks, and sign-in sheets confirmed groups
are being held in accordance with the daily activity schedule. Mental health staff have adequate
access to youth and confidential space to provide services. A review of sign-in sheets confirmed
group therapy is limited to ten or fewer youth with mental health diagnoses for mental health
treatment groups and fifteen or fewer youth with substance abuse diagnoses for substance
abuse treatment groups. Nine youth were interviewed and asked how they would rate mental
health and substance abuse services at the center. Five said they were very good, one said
they were fair, and three said they were not participating in mental health or substance abuse
services at the center. The designated mental health clinician authority (DMHCA) was
interviewed and asked about the process used for individualized mental health treatment
planning. The DMHCA said an Individualized Mental Health/Substance Abuse Treatment Plan is
required when a youth enters ongoing mental health/substance abuse treatment. A
comprehensive mental health and/or substance abuse evaluation must be completed by or
reviewed by the DMHCA or other licensed mental health professionals. The treatment plan is
developed by the mini-treatment team for youth receiving treatment and must be completed
before the thirty-first day of the youth being in detention. If a youth has a substance dependence
goal, the individualized treatment plan will include substance abuse goals and treatment.
3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures which require they maintain a written plan
addressing suicide prevention. The suicide prevention plan includes the identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
referral, communication, notification, documentation, immediate staff response, and the review
process. The center has an established review process for every serious suicide attempt or
serious self-inflicted injury which requires hospitalization or medical treatment. The review
process includes the circumstances surrounding the event, center procedures relevant to the
incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations for policy
change, training, physical plant, medical or mental health services, and operational procedures.
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
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observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures in place to ensure they supervise and monitor
youth identified as having suicide risk factors. Nine youth records were reviewed for suicide
prevention services, and six were applicable for suicide prevention services. All six were
determined to be at risk during the admission screening and were placed on precautionary
observation (PO), under constant supervision. Documentation showed the start date and time,
and all appropriate alerts were entered in the Department’s Juvenile Justice Information System
(JJIS). Each Assessment of Suicide Risk (ASR) had the referral date and time and clearly
documented the assessment of each youth on the day of service. All six youth had suicide PO
logs, which were completed in their entirety. A qualified mental health professional was involved
in each of the applicable cases. None of the youth were released prior to receiving an ASR;
therefore, there was no need to notify the parent/guardian of each youth about suicide
precautions. Staff documented a consultation with the designated mental health clinician
authority (DMHCA), as well as notifying the superintendent of the suicide risk for each youth.
Documentation included the date and time each referral was made, as well as the time each
youth was placed on PO. All six ASRs were completed within twenty-four hours. A follow-up
ASR was required and conducted for all six youth. In each record, the date and time the youth
was discontinued from observation was documented. Each youth was stepped down to
standard supervision and documentation was in accordance with the center’s suicide prevention
plan. All ASRs were completed by a licensed mental health counselor (LMHC). All ASRs
included the results of the assessment including recommendations for supervision and follow-
up. The center’s logbooks and each ASR indicated staff were provided specific instructions for
each youth related to the ASR findings and suicide precaution decisions. A review of JJIS
confirmed all alerts were entered and removed following each youth’s removal from PO.
Logbook reviews also contained the beginning and ending time of PO for each youth. The
DMHCA was interviewed and said the initial screening process begins at the juvenile
assessment center (JAC) with the administration of the Massachusetts Youth Screening
Instrument (MAYSI-2) to assess mental health and substance abuse issues, and the Suicide
Risk Screening Instrument (SRSI) to assist in identifying youth at risk of suicide. If the intake
screener at the JAC determines a youth is a suicide risk, the youth is placed on suicide
precautions and maintained on constant supervision when entering the detention center. Intake
screening continues at the detention center with detention staff, who immediately review all
screening instruments and forms. If the information obtained at intake suggests a youth is a
potential suicide risk, the youth is placed on PO and maintained on PO until an ASR is
completed by a mental health professional. The information is also entered into JJIS as a
suicide risk alert. If mental health staff are on duty, mental health staff notify the parent/guardian
by telephone, and the juvenile probation officer (JPO) through email. If mental health staff are
not on duty, the on duty supervisor will notify the parent/guardian by telephone and a mental
health referral will be submitted to the Department’s Office of Health Services. If necessary, the
Department’s Central Communications Center (CCC) report will be completed, and the
supervisor will email and call the DMHCA to notify them of the youth placement. Nine staff were
interviewed, and all were able to articulate the steps to be taken if a youth expresses suicidal
thoughts, to include notifying mental health staff and a supervisor, searching the youth, and
keeping the youth under constant observation until mental health staff arrive to conduct an
evaluation. Nine youth were interviewed, and one said they were placed on suicide observation
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while at the center. The youth reported staff watched them at all times while on suicide
observation.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures which require they place youth on secure
observation when less restrictive means are not effective. Nine youth records were reviewed for
secure observation, and none of the records were applicable for secure observation. The center
provided three additional records which were applicable. Each of the placements were
authorized by the superintendent and designated mental health clinician authority (DMHCA).
The secure room was designated in writing, and the health status checklist was completed prior
to placement in secure observation for each youth. All three suicide precaution observation logs
were completed entirely, and an Assessment of Suicide Risk (ASR) was completed within eight
hours for each. Documentation verified parent/guardian and juvenile probation officer (JPO)
notification was completed for each as well. None of the youth remained on secure observation
beyond twenty-four hours. Mental health staff provided supportive counseling services during
each secure observation status. A review of the observation logs documented supervision and
each youth’s level was reduced only after a conference with the superintendent and licensed
mental health professional. The discontinuation of secure observation and step-down to close
supervision was documented in the center’s logbook and each youth’s mental health record by
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.
Nine youth records were reviewed for suicide precaution observation (PO) logs and six were
applicable for being placed on PO. All six records included PO logs which were maintained for
the duration the youth was on PO, included the appropriate level of supervision, and the
observation of behavior documented in real time. None of the checks exceeded thirty minutes.
Warning signs, when observed, were documented on each PO log, along with the notification of
the superintendent or designee and mental health clinical staff. Each PO log was reviewed and
signed by the shift supervisor and mental health clinical staff. Each PO log documented safe
housing requirements. Video footage was reviewed for the three youth and corresponding
documentation confirmed proper supervision was maintained for the duration each youth was
on PO.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Nine pre-service and nine in-service training records were reviewed for suicide prevention
training. All staff completed suicide prevention training as required. Training records were
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reviewed and indicated suicide drills are held no less than quarterly on each shift. The center
has sixteen first-aid kits, located in the kitchen, master control, medical, the sub-control of the
four youth modular housing units, and nine for transport vehicles. The center has six suicide
response kits, which contain a knife-for-life, wire cutters, and needle nose pliers. These are co-
located with first-aid kits in master control, medical, and in the sub-control of the four youth
modular housing units, and were all observed during the annual compliance review week. The
center’s suicide training included mock drills for all staff who encounter youth. A review of the
center’s mock suicide drill book confirmed they conduct monthly suicide drills on each shift. All
suicide drills were in response to a suicide attempt and/or incident of serious self-injury, and no
youth were used in drill simulations. Staff who were not present during any quarterly drills had
the opportunity to review the drill scenario and procedures to understand the process and
receive the necessary training to respond. A review of video recordings revealed staff were
properly simulating and participating in drills. Nine staff were interviewed, and all knew where
the suicide response kits are stored.
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 which allows the center to respond
to a youth in crisis in order to protect the safety of the youth and others, while maintaining
control and safety. The center’s combined emergency services plan includes a notification and
alert system, means of referral, including self-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 an emergency care plan which includes 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 was approved and last updated on July 24, 2025. A copy of the plan is in
the superintendent’s office, mental health office, and medical. The emergency care plan is
available to all staff.
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3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
Nine youth records were reviewed for Crisis Assessments and none of the nine youth were
applicable for a Crisis Assessment; therefore, the center provided three applicable records for
review. All three records included the reason for the Crisis Assessment, a mental status
examination and interview, initial clinical impressions, supervision and treatment
recommendations, parent/guardian notifications, and recommendations for follow-up or further
evaluation. Mental health alerts were entered into the Department’s Juvenile Justice Information
System (JJIS) for each youth. All of the Crisis Assessments were conducted by licensed mental
health professionals and conducted within twenty-four hours. Two youth were alleged victims in
a prison rape elimination act (PREA) event, and both were 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.
Nine youth records were reviewed for Baker and Marchman Acts and none were applicable for
Baker or Marchman Acts. A request for additional records was made. The designated mental
health clinician authority (DMHCA) advised there were two youth for whom the center had to
utilize a Baker Act during the annual compliance review period and provided copies of those
records for review. Documentation confirmed both youth had suicide risk alerts opened, and
both were placed on one-to-one supervision, while pending transport. Youth supervision was
documented on a suicide precaution observation (PO) log until each youth’s authorized release.
Documentation also confirmed both youth were placed on suicide precautions upon re-
admission from their Baker Act. Both records contained a completed referral for a mental status
examination (MSE) which were completed by a licensed mental health professional. Both youth
were maintained on constant supervision until they were transitioned to a lower level of
supervision. Both youth had a suicide alert and a mental health alert entered into the
Department’s Juvenile Justice Information System (JJIS) and the discontinuation of the alerts
and precautions were based upon an Assessment of Suicide Risk (ASR).
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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 facility operating procedures requiring a designated health authority (DHA)
who is clinically responsible for the medical care of all youth at the center. The center maintains
a contract with VitalCore Health Strategies, LLC which subcontracts with a licensed physician to
serve as the center’s DHA. The DHA holds an unrestricted, clear, and active license which
expires January 31, 2027, with a specialization in pediatrics. The center utilizes a part-time
advanced practice registered nurse (APRN) whose license expires July 31, 2026. The APRN
and the DHA have a valid Collaborative Practice Protocol agreement in place. The center did
not utilize a physician’s assistant during the annual compliance review period. The DHA is
contracted to be on-site weekly, and a review of sign-in logs confirmed the DHA was on-site
weekly during the annual compliance review period. The DHA is on-call twenty-four hours a day.
The center has a back-up DHA who is a licensed physician. The back-up DHA holds an
unrestricted, clear, and active license which expires January 31, 2027. The back-up physician
was not utilized during the annual compliance review period. The DHA provides clinical and
administrative services for the center. The center was approved by the Department’s Office of
Health Services to provide tele-medicine services for youth which can be considered for three
out of every four weeks. The center has a tele-health binder which the DHA utilizes to sign-in
and sign out and document each youth seen if they provide tele-medicine service. The DHA did
not utilize tele-medicine services during the annual compliance review period. An interview with
the DHA confirmed the center’s practice.
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 maintains facility operating procedures for all health related procedures and
protocols utilized at the center. Documentation confirmed the designated health authority
approved and signed all healthcare policies, protocols, and procedures on June 3, 2025, and
the superintendent signed on May 30, 2025. A review of documentation also confirmed all
nursing staff reviewed all nursing protocols, as evidenced by a date and signature from each.
There were no new protocols or policies or changes to existing protocols or policies during the
annual compliance review period. An annual review of all medical policies, procedures, and
protocols was conducted on May 27, 2025, and the review was confirmed with a signature and
date on the cover page. The psychiatrist reviewed and developed the facility operating
procedures and protocols related to psychiatrist services and psychotropic medication
management on June 3, 2025. A review of documentation for one newly employed healthcare
staff during the annual compliance review period confirmed a registered nurse provided the staff
with a comprehensive orientation to the Department’s health care policies and procedures.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center maintains facility operating procedures ensuring the completion of an Authority for
Evaluation and Treatment (AET) form or Limited Consent for Evaluation and Treatment form
authorizing specific treatment for youth in the custody of the Department. Nine youth Individual
Healthcare Records were reviewed. Eight of nine youth records contained a valid AET signed
by the youth’s parent/guardian and a Department representative prior to providing medical
services. The remaining youth was in the custody of the Department of Children and Families
(DCF) services and did not have a court order; however, the youth had a valid Limited Consent
for Evaluation and Treatment. None of the reviewed youth were eighteen years of age or older,
which would request a release of information. An interview with nursing staff confirmed the
center will reach out to the juvenile probation officer or DCF case worker if they are unable to
obtain a valid AET or Limited Consent for Evaluation and Treatment. All youth ages eighteen
and older will provide verbal consent and initial for any treatment or medications provided.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains facility operating procedures ensuring parents/guardians are informed of
significant changes in each youth’s condition and to obtain consent when new treatments or
medications are prescribed. Nine youth Individual Healthcare Records (IHCR) were reviewed.
One youth was applicable for being prescribed over-the-counter (OTC) medications beyond
those covered under their Authority for Evaluation and Treatment (AET) form, and their record
contained documentation the parent/guardian was notified and provided consent for the OTC
medication. The remaining eight youth were not prescribed OTC medications beyond those
approved on the AET. Four of the nine reviewed youth were applicable for receiving medication
at the center which required written notification sent to their parent/guardian and each record
contained written documentation on the Department’s form. All attempted contacts to each
parent/guardian were documented in the progress notes. The remaining youth did not require
written parent/guardian notification of medication as they received medications covered under
their AET. Two of nine youth were applicable for being admitted to the center on psychotropic
medication and both records reflected staff witnessing attempts to notify the parent/guardian
and notification on the Acknowledgement of Receipt of Clinical Psychological Progress Note
(CPPN) form. Documentation also confirmed both youth’s parent/guardian gave verbal consent
for any new, discontinued, or significantly changed psychotropic medication which was
documented on page three of the CPPN. None of the reviewed youth were applicable for being
in the custody of the Department of Children and Families where parental rights were
terminated and requiring court authorization for treatment/medication. All nine youth IHCRs
reflected vaccinations were verified by healthcare staff through Florida Shots within thirty days
of admission. None of the youth were applicable for receiving vaccinations/immunizations at the
center. An interview with nursing staff confirmed the center’s practice.
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4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures to ensure youth are screened upon admission for
healthcare concerns which may require a referral for further assessment by healthcare staff.
Nine youth Individual Healthcare Records (IHCR) were reviewed, and each record contained a
Healthcare Admission Screening Form completed on the day of admission by a juvenile justice
detention officer (JJDO), and reviewed by licensed healthcare staff within twenty-four hours.
Each record included documentation of notification to the DHA. Two of the nine reviewed
records were applicable for receiving a qualitive urine pregnancy test and both applicable
records contained verbal and/or written consent. None of the reviewed youth were applicable for
being out of the center’s custody and requiring a healthcare admission rescreening. Three
additional youth IHCRs were requested for a minimal sample of three. Each youth had a change
of physical custody and received a healthcare admission rescreening upon return to the center
by a JJDO which was reviewed by a registered nurse within twenty-four hours. An interview with
nursing staff confirmed the center’s practice.
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 maintains facility operating procedures (FOP) ensuring all youth receive an
orientation to healthcare processes and services at the center. The center’s FOPs contain all
required elements. Nine youth Individual Healthcare Records were reviewed, and
documentation confirmed each youth received a general healthcare orientation upon admission,
which included all required heath education topics documented on the Department’s form. Two
of nine youth were applicable for having a chronic condition which required prescription
medications and both youth were educated on their medication.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures ensuring the designated health authority (DHA) or
designee is notified when youth are admitted to the center requiring emergency care or routine
notification in accordance with Department requirements. Nine youth Individual Healthcare
Records were reviewed. Five of nine youth were applicable for having known or suspected
chronic conditions and documentation confirmed a referral was made to the DHA for each.
None of the reviewed youth were identified as in need of emergency care upon admission. Each
record reflected the DHA/designee was notified within twelve hours of the youth’s admission to
the center, which was documented in the youth’s progress notes. Two of nine reviewed youth
were admitted on psychotropic medication and documentation confirmed the psychiatrist was
notified of the admission of both youth. An interview with nursing staff confirmed healthcare staff
notify the DHA by telephone upon admission, and this is also documented on the medical intake
log.
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4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures which require the Department’s Health Related
History (HRH) form to be completed for all youth admitted to the center. Nine youth Individual
Healthcare Records were reviewed, and each contained a HRH completed within seven days of
admission. Each HRH was completed by licensed healthcare staff prior to the completion of the
Comprehensive Physical Assessment (CPA) as evidenced by the signature/date on the form.
Documentation on the CPA confirmed the designated health authority reviewed each youth’s
HRH. A review of the HRH confirmed each youth’s HRH contained signatures and dates for the
most current admission. An interview with nursing staff confirmed the center’s practice.
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 maintains facility operating procedures (FOPs) ensuring a Comprehensive Physical
Assessment (CPA) form is completed for all youth upon admission to the center. Nine youth
Individual Healthcare Records (IHCR) were reviewed, and each record contained a CPA
completed or updated within seven days of admission by the advanced practice registered
nurse (APRN). Six of nine reviewed youth had a new CPA completed, the remaining three youth
had a current and valid CPA in their IHCR. Each youth’s CPA had the youth’s Medical Grade on
the form. The three youth who had current CPAs in their IHCR each received a focused
evaluation which was reviewed and signed by the APRN. All nine youth had all sections of the
CPA marked with an “O” or an “X”. None of the reviewed youth were applicable for refusing any
part of the exam. Five of nine reviewed youth were applicable for having a chronic condition and
documentation confirmed each youth’s Problem List was updated. Three of the nine reviewed
youth had a current Tuberculosis (TB) test completed within the past year documented in their
IHCR. The remaining six youth had TB tests completed within seven days of admission. All nine
youth had a Tier I TB screening completed within seventy-two hours of admission. None of the
reviewed youth were applicable for needing further evaluation prior to entering the general
population or requiring transportation to the nearest hospital or local health department. None of
the reviewed youth were suspected of having active TB which would require isolation. A review
of the center’s FOPs confirmed the center’s process for TB screening and rescreening as well
as the center’s process for documentation when any part of the CPA exam is not conducted or a
youth refuses a portion of the exam. An interview with nursing staff confirmed the center’s
practice. Nursing staff also stated gynecological exams are routinely completed upon admission
to the center.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center maintains facility operating procedures to ensure all youth are evaluated and treated,
if necessary, for sexually transmitted infections (STI) and human immunodeficiency virus (HIV)
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risk factors. Nine youth Individual Healthcare Records (IHCR) were reviewed. Five of nine youth
were applicable for being sexually active and were clinically screened and evaluated for STIs.
The remaining four youth were not sexually active. Three of the five youth who were sexually
active were applicable for requiring further evaluation and the advanced practice registered
nurse reviewed each STI screening tool and referred each youth for further testing which was
documented on the Department’s form. All three applicable youth had testing ordered and
results and diagnosis were documented on each youth’s Infectious Communicable Diseases
form and filed in the lab section of their IHCR. Two of nine reviewed youth were applicable for
having a gynecological exam completed and both youth’s consent was documented in their
IHCR. None of the nine reviewed youth were applicable for being out of the Department’s
custody, which would require a STI rescreen. Documentation confirmed all nine youth were
offered counseling, testing, and if warranted, treatment for HIV. Two of nine reviewed youth
received HIV testing within thirty days of request, and each record contained documentation of
the youth’s consent for testing. Both youth records reflected HIV test results were filed in the
youth’s hard copy IHCR, were reviewed by the designated health authority, and were not
included in the center’s internal alert system to ensure youth’s confidentiality. Documentation
confirmed both youth received pre and post-test counseling which was documented in both
youth’s progress notes. One additional youth requested HIV testing and signed their consent;
however, testing had not yet occurred as next available testing date was after the annual
compliance review week. Nine youth were interviewed and each confirmed they can request an
HIV test. An interview with nursing staff confirmed the center’s practice.
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) to ensure youth have access to medical
care through the sick call system. The nine youth Individual Healthcare Records (IHCR)
reviewed were not applicable for sick call review; therefore, three additional youth IHCRs were
reviewed. All three reviewed records contained a completed Sick Call Request form. Each sick
call was also located on the center’s Sick Call Referral Log. None of the three reviewed records
contained a youth who presented with similar sick call complaints three or more times within a
two-week period. Each reviewed sick call request form was completed by a registered nurse
(RN) and was filed in the youth’s electronic healthcare record, in reverse chronological order,
and was completed in accordance with Florida Administrative Code. None of the youth required
restricted housing. Each youth’s sick call appeared on the youth’s Sick Call Index, and the dates
corresponded to the sick call request form. None of the reviewed youth were applicable for room
restriction or confinement; however, the center has FOPs to ensure youth receive medical
services and sick call while in confinement/room restriction.
A review of the center’s daily activity schedule, posted schedule, and nurse interview confirmed
sick call is conducted daily and youth are seen within twenty-four hours of submitting a sick call
request. The center has approved treatment protocols for medical staff, RNs, and licensed
practical nurses. Sick calls are conducted daily from 08:00 a.m. until 10:00 a.m., and the hours
are posted on the medical clinic door. Sick calls are only conducted by nursing staff; however,
the center does have a process for supervisors to review sick call requests when there are no
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nursing staff on-site. A sick call was unable to be observed during the annual compliance review
week due to no sick calls occurring while the annual compliance review team was on-site.
Nine youth were interviewed, three stated they are seen within one day of making a sick call
request, the remaining six stated they have never requested a sick call. Three youth stated
nursing staff conduct sick call; the remaining six youth have never requested a sick call. One
youth also stated the doctor completes sick calls in addition to nursing staff. Nine staff were
interviewed, and each staff confirmed nursing staff review sick call requests. Two staff stated if
nursing staff are not on-site, supervisors will review sick calls. All staff stated nursing staff
conduct sick calls. An interview with nursing staff confirmed the center’s practice.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center maintains facility operating procedures which encompass a comprehensive process
for the provision of episodic and first-aid care. Nine youth Individual Healthcare Records were
reviewed, and two youth were applicable for receiving on-site first-aid or episodic care. One
additional record was requested for a minimum sample of three records. Each record reflected
youth received episodic or first-aid care from licensed healthcare staff which was documented in
the problem-oriented (subjective, objective, assessment, and plan) or standard narrative
charting. Each record contained the nature of the compliant, and the findings of the person
providing care. Each record contained documentation of treatment rendered and
education/instructions to youth. None of the youth were applicable for needing a referral for off-
site care, requiring follow-up care, or needing to be added to the center’s alert list. One of the
three reviewed youth was applicable for requiring parent/guardian notification and
documentation confirmed the parent/guardian was notified. All three youth had an entry of their
care documented on the center’s Episodic Care Log. None of the reviewed youth required a
follow-up evaluation with licensed healthcare staff.
The center has sixteen first-aid kits which are located as follows: one in master control, one in
intake, one in the kitchen, one in each of the four living modules, and one for each of the nine
transport vans. An observation of three first-aid kits during the annual compliance review week
confirmed each kit contained all designated health authority approved contents. Nursing staff
check all first-aid kits monthly and document these checks on the first-aid monitoring log. The
center has two automated external defibrillators (AED), one in the medical office and one in sub-
control on the B-1 module. The AED procedures are co-located with each AED. Nursing staff
check the AED batteries and pads each month to ensure each AED is operational and the
checks are documented. A review of the center’s AED tracking sheets since the last annual
compliance review period confirmed the center’s practice. The AEDs were self-tested in front of
the annual compliance review team during the annual compliance review week to ensure they
were operational. The batteries in both AEDs have an expiration date of August 19, 2026, and
each AED has a light-emitting diode (LED) indicator which is lit green when the unit is fully
functional. Both observed AEDs displayed green LED indicator lights during the week of the
annual compliance review. Both AED’s pads expire January 28, 2028. Nursing staff check the
AED batteries and pads each month to ensure each AED is operational and the checks are
documented. The center also has an outside agency who services the AEDs and this was last
completed on September 23, 2025.
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A review of medical drills contained in the medical drill binder for the annual compliance review
period confirmed drills are conducted monthly on all shifts and simulate episodic care events
which require immediate first-aid, AED, and/or administration of cardiopulmonary resuscitation
(CPR) techniques, and the initiation of emergency procedures when a life-threatening
emergency occurs. Documentation confirmed all staff with direct contact with youth had the
opportunity to participate in at least one emergency “man down” drill annually. Observations
during the annual compliance review week confirmed emergency numbers are posted out of
view of youth in the medical clinic. Nine pre-service and nine in-service staff training records
were reviewed, and each staff was trained in CPR, first-aid, episodic care, the administration of
the epinephrine auto-injector, and the administration of Narcan. Narcan is kept in the first-aid kit
in the medical office and in the medication cart and is inventoried by healthcare staff monthly.
Nine youth were interviewed. Two youth stated they are not receiving health services. The
remaining youth rated health services as very good to fair. Nine staff were interviewed, and
each stated they can call 9-1-1, if necessary. An interview with nursing staff confirmed the
center’s practice.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center maintains facility operating procedures which provide for timely referrals and
coordination of medical services to an off-site healthcare provider. Nine youth Individual
Healthcare Records (IHCR) were reviewed, and no youth were applicable for receiving off-site
medical services. Three additional records were requested for a minimum sample of three
records. Each record reflected off-site care was required and contained a Summary of Off-Site
Care Consultation Report form. Each instance of off-site care appeared on the center’s Episodic
Care Log. Parent/guardian notification efforts were documented in two of three IHCRs, the
remaining youth did not require a parent/guardian notification. All three IHCRs contained
discharge and other applicable documents, documentation the designated health authority
(DHA) was notified of the emergency event, and the DHA reviewed and signed all off-site care
findings, instructions, and information. None of the reviewed youth required any follow-up
appointments. An interview with nursing staff confirmed the center’s practice.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures to ensure youth who have a chronic condition
receive regularly scheduled evaluations and follow-up. Nine youth Individual Healthcare
Records (IHCR) were reviewed, and five youth were applicable for having a chronic condition.
None of the applicable youth had a communicable disease or were pregnant. One of the five
youth was taking prescribed medication on an on-going basis; however, two of five did have
medications prescribed for their chronic condition which was prescribed pro re nata. All five
youth were undergoing treatment for a physical health condition, were classified as a Medical
Grade two through four, and were placed on the chronic conditions list. None of the youth were
applicable for a periodic evaluation due to not being in the facility ninety days. Three additional
IHCRs were requested for youth who were applicable for periodic evaluations for a minimum
sample of three. Each youth had a periodic evaluation at least every ninety days which was
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documented in the youth’s progress notes. None of the youth were applicable for taking anti-
Tuberculosis medications, being pregnant, or receiving an off-site care evaluation which would
require follow-up by the designated health authority (DHA). One of the three reviewed youth
was applicable for needing a renewal of a prescription medication and the periodic evaluation
was conducted prior to the renewal of the prescription medication. None of the youth had a
lapse in care or a missed periodic evaluation. All reviewed youth were added to the
Department’s Problem List. Periodic evaluations are tracked by utilizing a spreadsheet which
documents the dates of all required periodic evaluations. An interview with the DHA confirmed
periodic evaluations are conducted at minimum every ninety days and are tracked by nursing
staff; however, for more complex conditions, periodic evaluations may be conducted every thirty
or sixty days. An interview with nursing staff confirmed the center’s practice.
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 maintains facility operating procedures for medication management. Nine youth
Individual Healthcare Records (IHCR) were reviewed, and six of nine youth were applicable for
having received medications at the center. Each youth record reflected all medications had a
current, valid order and were administered according to a current prescription. Two of the six
applicable youth were taking medication prior to being admitted to the center and both youth
medications were verified by healthcare staff which was documented in the progress notes in
the IHCRs. Both youth were taking psychotropic medications and the psychiatrist was contacted
to obtain an order to resume the medications, and new medications were reflected on the third
page of the Chronological Psychological Progress Notes. None of the youth were applicable for
medications being continued, changed, discontinued, or ordered which would require the order
be placed on the Practitioner’s Order Form. None of the reviewed youth were applicable for
being in restrictive housing. One of the six applicable youth received over-the-counter (OTC)
medications which were not listed on the Authority for Evaluation and Treatment form. The OTC
medication was administered according to the Practitioner’s Order. All six reviewed youth had
the Department’s Medication Administration Record (MAR)/Electronic Medical Record which
documented all medication and treatment. Each MAR is pre-printed and clearly delineates
medication start and stop dates. None of the reviewed youth were applicable for receiving
medication from non-healthcare staff. No youth had any lapses or errors in medication
administration. Each youth record clearly documented the completion of weekly side effect
monitoring by nursing staff on the youth’s MAR. None of the reviewed youth were applicable for
refusing medication. Each MAR contained all required elements, except for one youth’s
prescribed medication is pro re nata (PRN) and has not needed to be administered yet. One
youth was applicable for requiring parenteral medication and documentation confirmed the
medication was administered by licensed nursing staff. Documentation confirmed the center had
no standing orders, emergency treatment orders, or PRN orders for psychotropic medications.
One youth was observed for medication administration during the annual compliance review
week. The youth provided verbal consent prior to observation. The youth was escorted to the
door of the medical office by a juvenile justice detention officer (JJDO) and youth approached
nursing staff who administered the medication. No other youth received medication while
youth’s medication was administered. The nursing staff identified themself and stated the youth
was there to receive their specified prescription medication. The medication was prepared and
administered by the same healthcare staff and was not pre-poured from the original packaging
and placed in another container for subsequent administration. The nurse verified each youth’s
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allergy and alert status by looking at the MAR and the youth’s IHCR. Once youth’s medication
was administered, youth and nursing staff electronically initialed the MAR. The JJDO and
nursing staff ensured medication was swallowed. Nine youth were interviewed and two of nine
stated they have taken medications at the center, which are administered by nursing staff. The
remaining seven youth stated they have not taken medications. Nine staff were interviewed, two
staff stated they administer medication, and the remaining staff stated they do not administer
medications. The two staff who administer medications are supervisors who have been trained
by nursing staff to administer medications when nursing staff are not on-site. An interview with
nursing staff confirmed the center’s practice.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains facility operating procedures (FOPs) which address psychiatric services at
the center. The center has a contract with VitalCore Health Strategies, LLC to provide
psychiatric services to include psychiatric evaluations, psychiatric consultations, medication
management, and medical supportive counseling to youth with a diagnosed mental disorder
and/or substance related disorder. The psychiatrist holds a clear and active license with the
State of Florida with a specialty in child and adolescent psychiatry, which expires January 31,
2028. The center does not utilize an advanced practice registered nurse (APRN) for psychiatric
services. The center utilizes a back-up psychiatrist who holds a clear and active license under
Florida Status 459, which expires March 31, 2026. The center has a facility operating procedure
(FOP) for tele-psychiatry for medication management. A review of nine youth Individual
Healthcare Records was conducted, and two youth entered the center on psychotropic
medications; however, one youth was just admitted to the center and did not receive a
psychiatric interview until the annual compliance review week; therefore, two additional records
were requested for a minimum sample of three. Each youth entered the center on psychotropic
medication and were referred for a psychiatric interview. Each applicable youth received an
initial or updated diagnostic psychiatric interview within fourteen days of admission. Each initial
psychiatric interview included all required elements. All three youth were applicable for an in
depth psychiatric evaluation within thirty days, and each evaluation was completed within thirty
days and included all required elements. There were no changes to medication for any of the
applicable youth. None of the applicable youth were under the supervision of the Department of
Children and Families. None of the reviewed youth received telepsychiatry services. Each of the
three youth had documentation of consent for psychotropic medication as reflected by a signed
Authority for Evaluation and Treatment form. The designated mental health clinician authority
(DMHCA) indicated in an interview they meet with the psychiatrist weekly and the psychiatrist is
on call as needed for any emergency needs.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center has facility operating procedures for medication and sharps inventory. Medical
equipment classified as sharps were secure and inventoried using a descending count utilizing
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a routine perpetual inventory as each sharp is used and disposed of. All medications in the clinic
were identified in a secure locked area and were inaccessible to youth. The medication cart has
a lock, was organized and clean, and contained stock items separate from youth specific
medications. Narcotics and other controlled medications were stored separately from other
medications in a secondary locked box with a perpetual inventory. Oral medications were not
stored with injectable or topical medications and, although there were no medications requiring
refrigeration, the refrigerator was empty and had a lock. Medical has a log in which they
document all sharps and over-the-counter (OTC) medications weekly and a shift-to shift
inventory count of all controlled substances was documented on each youth’s individualized
Control Medication Inventory Record, as required. All medical training was conducted by a
registered nurse (RN) or higher. Two controlled medications (only two youth at the center were
taking controlled medication), three OTC medications, and three sharps were observed, and the
counts were all correct compared to the logs. Discrepancies after recounts are documented as a
medication error with notifications to the designated health authority (DHA), superintendent, and
a call the Department’s Central Communications Center (CCC). Medications must be disposed
of by using the pharmacy consultant and nursing staff. The documentation of disposed
medication is maintained and kept in medical. The designated area to store youth’s medication
was observed. Nursing interviews confirmed controlled medications are disposed of between
nursing staff and the pharmacy consultant; other medications are disposed by nursing staff with
a prescription destroyer solution. Controlled substances are kept in a locked compartment in the
medication cart which is also locked. The center has a current agreement with a consulting
pharmacist who is on-site monthly to review the medication cart, medication cabinets,
medication refrigerator, dispose of medications, and ensure everything is labeled as required.
The pharmacy consultant’s license is maintained in medical.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures for infection and exposure control. A review of nine
youth Individual Healthcare Records (IHCR) was conducted, and each youth’s Health Education
Form verified they received all required training at admission. The center’s Exposure Control
Plan was written in accordance with the Office of Safety and Health Administration guidelines to
include all elements of risk assessment and methods of compliance. The infection control
procedures include all required elements. The center’s process for needle stick post-exposure
includes intervention and referring for off-site treatment, if necessary. Hepatitis B vaccines are
available to all staff. Staff have access to protective equipment. Each positive test result is
forwarded to the local health department, if applicable. The center had one instance of a youth
with a sexually transmitted infection and documentation confirmed the local health department
was notified by nursing staff. The superintendent confirmed the center has not had any incidents
of youth or staff exposure; however, the center indicated they would maintain a separate file
containing all information of any exposure incidents, if any were to occur, which would remain
confidential for a ten-year period as required. Nine pre-service and nine in-service training
records were reviewed, and each staff received training on the center’s specific Exposure
Control Plan. The nursing staff interview confirmed all staff have access to the center’s
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Exposure Control Plan, and the registered nurse manager provides exposure control and
infection control training to staff. Each youth admitted to the center receives infection control
training by a nurse. The local health department routinely offers immunizations.
4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures for prenatal care and education. None of the nine
reviewed youth were identified as pregnant at the center during the time of the annual
compliance review. Three additional youth records were provided to review prenatal care and
education. All three youth received prenatal care immediately upon determination the youth was
pregnant. The designated health authority (DHA) provided each youth with a routine, focused
medical evaluation every thirty days or sooner, if ordered. Prenatal care was provided at
recommended intervals for all three youth. Each youth was placed on an internal alert system
for vital nutrition and health awareness for staff with an alert in the Department’s Juvenile
Justice Information System (JJIS). An alert was entered into the center’s internal alert system
for sleeping arrangements for two mattresses and pillows for support for the three applicable
youth. All three youth were at the center less than a month, so none were applicable for focused
medical evaluations by the DHA every thirty days. One of the three youth had complaints or
issues, and the DHA was notified as required. All three youth were monitored for danger signs
of pregnancy complications as required. All three youth had a documented plan for post-birth
psychological and physical care. Education for all three youth was found in the youth’s
Individual Healthcare Record (IHCR) under the education tab to include alcohol and drug use,
smoking, nutrition, sexually transmitted infections, contraception, prenatal care, birthing
process, postpartum care, basic baby care, child/infant development, and parenting skills which
were conducted by a licensed staff. Each youth received nutritious food and appropriate
servings as ordered by the DHA and evidence of routine monitoring of nutritional and weight
status of the pregnant youth was found in each of the youth’s IHCR. A review of in-service
training was found to include observation and monitoring of emergency care needs/symptoms
for possible miscarriage, and the center has nursing protocols and treatment in place for
pregnant youth. Eighteen staff training records were reviewed to ensure compliance and all
reviewed records were in compliance. The nurse was interviewed regarding services provided
to pregnant youth and stated a pregnant female will be started on a pregnancy diet and is
provided education, prenatal vitamins, and any orders required by the DHA. Female youth are
tested at admission. Prenatal care is set up for each youth once it has been determined they are
pregnant. Obstetrical care is scheduled, and the youth is started on a pregnancy diet as ordered
by the DHA. The registered nurse (RN) manager provides non-licensed healthcare staff
education on girl’s healthcare with the topics of women’s health and adolescence health. Nine
youth were interviewed; none of youth were applicable for prenatal, obstetrical, or gynecological
services relating to pregnancy.
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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 to ensure youth are actively supervised by staff.
Observations were made daily during the week of the annual compliance review, including
observations of youth attending school and mealtimes. Observations confirmed all youth
movements were called into master control and documented in both housing area and master
control logbooks, staff were following the daily activity schedule, and all youth were actively
supervised by the appropriate number of staff. Positive interactions between staff and youth
were observed during the week of the annual compliance review. Staff maintained constant
supervision of all youth in their assigned area, all line movements were controlled by staff, and
staff were well positioned inside the classrooms as well as the dining hall; staff ratio and
interaction were in accordance with policy. Video review was completed of three full days of
group which confirmed the center provided group sessions as scheduled, and supervision was
within the contracted ratio. Nine staff were interviewed, and all nine indicated the center has
enough staff to provide for the safety and security of youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) detailing the behavior management system
(BMS) to ensure the safety and security of youth and staff. During the annual compliance review
week, BMS posters were observed throughout the center which were accessible to youth. The
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posters provide clear, specified rules and expectations. The center provides a BMS which
includes incentives for positive behavior and consequences for inappropriate behavior. The
center’s BMS includes the use of a three-tiered level system where all newly admitted youth are
placed in level two and are given the opportunity to level up by following the rules and meeting
required expectations. A review of the FOPs for the BMS ensured compliance with the
components outlined in the center’s FOPs. The center uses point cards to document youth
progress, and a review of point cards confirmed youth receive their rewards and are being held
accountable for their actions daily. The FOPs prohibit the use of group punishment and there
were no indications or instances of inappropriate use of restrictions or group punishment
displayed during the week of the annual compliance review. Nine staff were interviewed, and all
were able to articulate the center’s BMS, which included a level system. All staff gave examples
of rewards the center grants, and how youth are able to get these rewards. Eight of the nine
staff stated they believe the center's BMS is effective; however, the remaining staff indicated the
new BMS system is not effective because it does not allow a youth who is only in the center for
twenty-one days to achieve any level three rewards. All nine staff confirmed they speak to youth
to discuss the consequences for not following the center rules, they afford youth an opportunity
to explain their behavior, and they speak with youth about alternative acceptable behaviors. All
nine staff were able to explain how supervisors provide feedback to staff regarding the
implementation of the BMS, citing they receive feedback through conversation, retraining, and
discussions at shift briefings. All nine interviewed staff stated they receive feedback on the
implementation of the BMS, as needed, and one staff added weekly. All nine staff indicated
levels can be taken away as a consequence, each confirmed they have never witnessed
detention staff take meals, snacks, clothing, education, or medical care from a youth because
they were acting out, and they all stated they have never observed another staff encourage a
youth to beat up another youth. An interview with the superintendent confirmed the new BMS
tracks youth behavior and consists of three levels which provide extra privileges to youth as
they increase their level. Nine youth were interviewed, and all gave positive ratings for the BMS
ranging from fair to very good. All youth were able to explain the difference between each level,
and provide examples of incentives, such as extra snacks, extra telephone calls, later bedtimes,
and extra telephone calls. Eight of the nine youth stated staff use the BMS system fairly and the
remaining youth indicated certain staff will drop a level without a reason. All nine youth
confirmed youth are never allowed to punish other youth. Five of the nine youth stated they
were sent to their rooms for punishment, as a result of fighting or disrupting the classroom, they
all received a level reduction, and they all said the consequences were fair. The remaining four
youth stated they have never been sent to their room as punishment and have not received
consequences. All nine interviewed youth stated they never witnessed handcuffs or leg irons
being used on out of control youth to prevent them from hurting themselves or hurting others.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
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The center has facility operating procedures requiring ten-minute checks to be conducted when
youth are secured in their rooms. The center has eighty surveillance cameras, and seventy
were operational during the week of the annual compliance review. The center’s video
surveillance system can store video recordings for up to thirty days. An electronic wand system
is used in the center to document and collect data of all ten-minute visual checks. Staff use an
electronic wand with sensors on the outside of every room during sleeping hours, and a
designee uploads the collected data and downloads it to a wand report which is reviewed on a
weekly basis. During the annual compliance review week, a video review of nine samples of
video over nine different days including samples from each living module, revealed staff
conducted ten-minute checks as required; a discrepancy of three minutes past the ten-minutes
was observed on one occasion, two minutes past the ten-minutes was observed on one
occasion, and one minute past the ten-minute mark was observed on three occasions. These
video reviews were compared with the wand reports, and confirmed to be accurate. A weekly
review of management oversight was completed. Nine staff were interviewed, and all stated
room checks are conducted every ten minutes when a youth is placed in their room for sleeping
or non-punishment reasons. An interview with the superintendent found when a youth is placed
in a room, whether for sleeping or other reasons, staff shall conduct visual observations to
ensure safety and security, and the electronic wand check system is utilized by the center.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures ensuring staff always know the exact number and
location of all youth under their supervision. During the annual compliance review week, staff
were observed conducting counts before and after every movement. Counts were also
observed during youth transitions from the classrooms to the dining hall for meals and from the
dining hall to their assigned housing areas. Nine staff were interviewed, and all staff stated
counts are conducted at the beginning and the end of each shift. All nine staff provided various
reasons as to when emergency counts are conducted citing when visibility is hindered, such as
an electrical outage, and after a major disturbance. A sample of one full day of logbooks was
reviewed for each month during the annual compliance review period, which confirmed the
logbook entries contained all head counts, counts at the beginning of each shift, following an
emergency, following a population change, randomly at least once on each shift, and for youth
movements.
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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 addressing logbook maintenance and reviews. The
center has a separate logbook for each housing module and master control. All logbooks were
bound with numbered pages, with the date documented on the top of each page. All entries
included the times of events in a.m./p.m. format, name of the staff and youth involved, a brief
description of the events, and the initials of the staff making the entry. All entries impacting
safety and security, to include medical and special needs alerts, were highlighted. Logbook
reviews included superintendent reviews, juvenile justice detention officer supervisor (JJDOS)
reviews, and reviews by the superintendent or staff in charge of the center’s daily tour of youth
living areas. A sample of twelve days of master control logbooks were reviewed from February
2025, through January 2026 and contained emergency situations, incidents which included
notification to the Department’s Central Communications Center (CCC) and Florida Abuse
Hotline, right interaction (RI) incidents, drills, receipt of medical or mental health care, population
counts at the beginning and end of each shift, population counts as center counts changed,
counts following emergency situations, group movement, admissions and releases, the
presence of law enforcement, searches, and the names of youth in confinement or on
precautionary observation with the times they began and ended. The superintendent was
interviewed and stated the superintendent or designee shall review all logbooks, excluding the
visitor’s logbook, at a minimum of weekly and review the entries for the last seventy-two hours.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures describing the center’s key control process,
issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys,
and the reporting and replacement of damaged keys. Observations during the week of the
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annual compliance review confirmed when detention staff enter the center, their personal keys
are secured on the non-secure side of the center or given to master control prior to being issued
a key set by the master control operator. Visitors and contracted staff secure personal keys in a
locker outside of master control. A review of the key inventory verified the key rings on the
inventory matched the actual key rings in use. The key storage box is opened by the on-duty
supervisor whenever keys are being issued or when staff return keys. Observation of key
issuance logs confirmed all restricted keys are only issued to authorized staff. All facility keys
were confirmed to have been maintained on a tamper-resistant ring. The emergency key rings
are located in a secured red box in master control. Only the superintendent or their designee
has access to the emergency key box. The master key inventory includes each key ring
number, number of keys on each ring, the capability of each key, and who each key ring is
issued to. All facility key rings are color-coded, depending on what area they access. Shift
reports were reviewed, and all included the date and time key rings were issued, the name of
the staff issuing the key ring, the staff receiving the key ring, and the time the key ring was
returned. During the week of the annual compliance review, staff were observed carrying issued
keys on their person and in their pockets at all times. Staff did not allow youth to handle keys,
and were not allowed to remove keys from the facility without authorization. During the annual
compliance review period, there were no instances of any lost keys or any key control issues. A
sample of five key rings was reviewed and compared with the key check-out log. All sets of keys
were present on the key log, matched the number of keys listed on the key ring tag, and
matched the number of keys on the inventory. Three staff were informally interviewed during the
annual compliance review, and all knew the number of keys on their rings as well as the
function of each key. An informal interview was conducted with the master control operator, who
was able to explain the process of restricting the use of certain keys, such as medical, youth
records, and youth property, only to staff assigned to those areas. Nine staff were interviewed,
and all staff were able to articulate the center’s key control process and were able to identify
which keys were restricted. The superintendent was interviewed and advised permanent keys
are not issued to any staff.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains facility operating procedures for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has nine vans; however, only
seven are in use and utilized to transport youth. The seven vans were inspected the week of the
annual compliance review to ensure they were locked when not in use, and all were secured.
The maintenance mechanic provided documentation of an annual inspection for each van which
was completed by a certified mechanic. Monthly inspections consisting of checking each
vehicle’s water coolant, lights, oil, emergency equipment, brakes, horn, interior, exterior, and
cleanliness of the vehicle were conducted by the maintenance mechanic and were documented
on SharePoint. Each inspection also included review of the tires, batteries, windshields, wipers,
windows, mirrors, and a thorough check for damages to the vehicles. An additional physical
inspection of all the vehicles was conducted to ensure each vehicle contained the appropriate
number of seatbelts, a seatbelt cutter, window punch, current fire extinguisher, and a first-aid kit.
Each vehicle was equipped with a transport logbook to document all youth transports. Each
logbook included documentation of the vehicle being checked for contraband and the required
equipment, the van’s destination, the number of youth, youth and staff names, start time and
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end time for each transport. A transport observation was completed during the week of the
annual compliance review, which confirmed all the required elements. Nine youth were
interviewed, and all youth stated they feel staff are driving safely when transporting youth and
none of the youth have ever witnessed anyone place contraband in a transport vehicle.
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 maintains facility operating procedures (FOPs) ensuring all tools and equipment
related to maintenance and the kitchen are properly maintained, stored, and inventoried. The
FOP also prohibits youth from having access to any tools, including kitchen and/or medical
equipment. According to the center’s FOP, youth are allowed to use cleaning items such as
mops, brooms, and other common household items when completing general cleaning under
staff supervision. During the annual compliance review week, an observation of youth utilizing
cleaning tools was unable to be conducted. Observations were made of the tool room,
maintenance shed, and kitchen. Sharps in the kitchen are secured in a locked cabinet when not
in use. A review of monthly inventory sheets since the last annual compliance review confirmed
no maintenance or kitchen tools were missing. The food service director maintains an itemized
inventory of kitchen tools. All items, including knives, are inventoried daily upon kitchen staff
reporting for duty. An informal interview with the maintenance mechanic indicated all service
vendors and technicians are searched prior to entering the secure area of the center and are
always accompanied either by the maintenance mechanic, or by staff. If youth are in the area to
be serviced, all youth are removed from the area, the area is placed out of service, and youth
are not allowed back until work in the area is complete and cleared by staff. Each vendor will
ensure they exit the work area with the tools they entered with. A review of the inventory sign-
out sheet used to document the issuance and return of maintenance tools found no
discrepancies. A sample of ten tools was reviewed to confirm accurate inventory, and all tools
were accounted for; all tools were secured and had marking for easy identification. Nine
interviewed staff were able to articulate the center’s practice for damaged or missing tools. Eight
of nine staff indicated youth are not allowed to use any tools at the center, while the remaining
staff stated youth can use mops and brooms. Nine youth were interviewed. Five of nine youth
stated they use mops and brooms, with one youth adding scrub brushes, and the remaining four
youth indicated they do not use any tools. The superintendent was interviewed and stated the
maintenance mechanic, the superintendent, and the captain have access to class A facility
tools. During an informal interview with maintenance staff and kitchen staff, the maintenance
mechanic stated all tools are accounted for and if ever there is a missing tool, it gets reported
immediately.
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
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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 maintains facility operating procedures (FOPs) ensuring the proper use, storage,
disposal, and inventory of all chemicals including poisonous, flammable, and toxic materials.
The FOP also ensures limited access to flammable, toxic, caustic, and poisonous items. Only
authorized staff are permitted access to and are able to use flammable, toxic, caustic, and
poisonous items. Youth are strictly prohibited from handling or using hazardous chemicals
under any circumstances. During the annual compliance review week, the center’s Safety Plan
was reviewed, which corresponded to the center’s FOPs. No toxic materials were observed in
any area accessible to youth during the week of the annual compliance review. Documentation
during the annual compliance review period was reviewed and found inventories are maintained
for all flammable, toxic, caustic, and poisonous items in the center. Only authorized personnel
are permitted access to the area where items are kept. All nine interviewed youth confirmed
they do not handle chemicals or have access to flammable, toxic, caustic, or poisonous items.
All nine interviewed staff stated youth are not permitted to clean with substances which are
toxic, flammable, or poisonous. A sample of five chemicals was reviewed, the inventory was
confirmed accurate, and each item had a corresponding safety data sheet (SDS) located
nearby.
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 maintains facility operating procedures ensuring the proper disposal of hazardous
items and toxic materials in accordance with Occupational Safety and Health Administration
(OSHA) standards. No chemical spills or disposal of flammable, toxic, caustic, or poisonous
materials were reported during the annual compliance review period. The maintenance
mechanic was informally interviewed and confirmed the center is equipped with a grease trap,
and it is properly disposed of by an outside contractor. The maintenance mechanic verified all
hazardous materials are disposed appropriately.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures to govern the use of confinement for youth. There
were a total of 2,239 youth placed in confinement under twenty-four hours during the annual
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compliance review period, and fifteen were reviewed. All youth in confinement were afforded
three meals a day plus school and evening snack, if they were confined during those times. All
fifteen youth had access to mental health care and were afforded a shower. Twelve of the
fifteen youth were provided with education materials and the remaining three youth were not
confined during school hours. All reports confirmed the youth’s right to grieve a placement in
confinement. All reviewed reports included supervisor approval prior to each confinement, the
reason confinement was necessary was explained to each youth, and each youth was placed in
a confinement room alone. All reports stated the room was searched prior to the youth being
placed in it. All reports showed a supervisor conducted an initial confinement review within two
hours of placement and a supervisor conducted additional reviews with the youth at a minimum
of three hours and documented the reviews in the Department’s Facility Management System
(FMS). Supervision for each youth was documented on a Visual Observation Report (VOR) for
the entire duration of the confinement, to include five-minute checks for the first hour and
behavior codes for observations made of the youth. All confinement reports were fully
completed before the end of the shift. All reports reflected the supervisor/staff continuously
provided counseling to the youth and considered removing the youth from confinement as soon
as possible. All confinement reports were reviewed within the required forty-eight hours by the
superintendent or designee. All windows and cameras were free of obstructions/scratches, so
each youth may be visually observed. An interview with the superintendent confirmed the
center’s confinement practice. The superintendent also advised the use and appropriateness of
confinement is tracked through confinement reports, supervisor reviews, and administrative
reviews of confinement which are completed monthly by regional detention management. Nine
staff were interviewed, and all confirmed youth in confinement are provided education materials
if the confinement occurs during school hours. All staff were familiar with the step-by-step
process of placing a youth in confinement, to include completing a confinement report, five and
ten-minute checks, and searching the confinement room.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures which require the center to conduct and document
Continuity of Operations Plan (COOP) drills at a minimum, twice a year, with one drill being
completed prior to the start of hurricane season. A review of the center’s drill binder confirmed
two COOP drills were conducted within the required time frames, one on May 30, 2025, and one
on August 20, 2025. Both drills simulated the evacuation of the center in response to an
impending storm scenario. Each drill contained all the required elements, to include the type of
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drill, date, start and end time, shift, detailed information of the drill, recommendations for
improved emergency response, and review. The superintendent was interviewed and confirmed
the center’s comprehensive safety/emergency program is the COOP plan.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures to address escape drills and escape
prevention. Quarterly escape drills were conducted on each shift, as required, and documented
in the center’s logbook. Nine in-service and nine pre-service training records were reviewed,
and each staff completed training in security and escape prevention annually. Nine staff were
interviewed, and eight of nine confirmed completing escape drills since 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 a disaster plan, fire prevention, and evacuation plan addressing fire prevention
and safety in the center. The center conducted monthly fire drills on each shift, as required. The
center is running on twelve-hour shifts; however, drills were conducted and documented in the
logbook on three shifts, exceeding the requirement. Fire evacuation plans were posted
throughout the center, identifying the primary and secondary exit routes, locations of fire
extinguishers, and locations of first-aid kits. All fire extinguishers received an annual inspection,
as required. Nine staff were interviewed, and all confirmed they participated in fire drills since
the last annual compliance review and the fire drills occur at least monthly. Nine youth were
interviewed and six reported they had been instructed on fire procedures, and the remaining
three youth stated they had not been.
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
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manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) which address illegal contraband,
prohibited items, and how to reduce the introduction of contraband into the center. A review of
the center’s FOP and observations during the annual compliance review week verified
contraband attestation forms are available in the lobby as part of the visitor’s log, and all visitors
entering the center are required to complete a separate contraband attestation form. A video
review confirmed visitors were electronically searched prior to entering the secure area of the
center. Only clear bags are permitted on the secure floor, and all bags, cases, jacket pockets,
and shoes were searched. All personal keys, personal cellular telephones, and other
contraband items are prohibited in the secure areas of the center. An observation of a new
admission into the center was conducted, and verified staff wore gloves during the search of the
youth, which was conducted individually in a private area by the same gender staff, and not in a
group setting. Youth room searches are documented on shift reports and are uploaded
electronically into the Department’s Facility Management System (FMS). Youth rooms are
searched upon each youth’s release and prior to placing a new youth in the room. A review of
random shift reports for one day each month of the annual compliance review period verified
youth room searches were documented and completed during each awake shift as required. A
review of the Department’s Central Communications Center (CCC) reports since the last annual
compliance review confirmed there was one instance of contraband found at the center. The
contraband and the call to the CCC were documented in the master control logbook.
Documentation verified incident reports were completed identifying findings and disposition of
the contraband found. The confiscated item was secured, and hand delivered to the supervisor.
The incident involved illegal contraband, documentation revealed the shift supervisor
documented the chain of custody for the contraband item, and local law enforcement was
contacted for the item considered illegal as defined by Florida Statute. A review confirmed all
sixty-two staff records contained contraband attestation forms. The superintendent was
interviewed and confirmed the center’s procedures for searching youth and added throughout
each search, staff shall continue to treat youth with dignity and respect to reduce the potential
feelings of embarrassment youth may encounter. He added if anyone attempts to introduce
contraband into the center local law enforcement will be contacted to confiscate the item and
investigate.
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source: DJJ