summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Brevard Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
5225 Dewitt Ave.
Cocoa, Florida 32927
Review Date(s): March 5-8, 2024
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:
Nicos Antonakos, Office of Accountability and Program Support, Lead Reviewer (Standard 1
and Interviews)
Cindy Jones, Office of Education, Deputy Director of Education (Standard 2)
Welton Sanders, Palm Beach Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Yvrose Sylvain, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Brevard Regional Juvenile Detention Center MQI Program Code: 244
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Brevard County / Circuit 18 Number of Beds: 40
Review Date(s): March 5-8, 2024 Lead Reviewer Code: 180
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
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 60 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 60 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 60 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * 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 6 of 60 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
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 Screening & 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 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 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 60 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures 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 8 of 60 (Revised July 2023)
Program Overview
The Brevard Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Cocoa, Florida. The center serves youth in Brevard County in Circuit
18. The center is co-located with the Juvenile Assessment Center. Male and female youth who
are detained pending adjudication, disposition, or placement in a residential commitment
program are housed in the forty-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 Brevard
County School District. The center’s management team includes the superintendent, two
assistant superintendents, one administrative assistant, seven juvenile justice detention officer
(JJDO) supervisors, and twenty-two JJDOs. Mental health and healthcare services are provided
through the contracted provider, VitalCore Health Strategies, LLC. Mental health services are
provided by one designated mental health clinician authority (DMHCA) and six licensed mental
health professionals. 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 a medical doctor (MD) who is the designated health authority (DHA), one registered
nurse (RN), one licensed practical nurse (LPN), and one advanced practice registered nurse
(APRN). The medical clinic maintains nursing coverage seven-days a week from 7:00 a.m. to
7:30 p.m., Monday through Friday, and from 7:00 a.m. to 5:30 p.m. on weekends. Food services
are provided by Department staff and include menus, meal planning, meal schedules, special
diets, nutritional analysis, daily allowance, food preparation, health certifications, food product
standards, sanitation, and cleaning. Staff are responsible for the custody and control of youth in
their care, providing youth supervision twenty-four hours a day, seven days a week. The center
has three living modules which are divided by male and female. There are fifty-nine security
cameras at the center, of which fifty-eight were operational. A tour of the center was conducted
during the annual compliance review week, and observations verified the center was clean and
maintained. The lobby has new flooring, guest bathrooms are dated; however, they are clean
and functional. The exterior of the building has new stucco and has been repainted. The air
conditioning unit has been replaced, the roof has been replaced, and new fencing has been
installed. The outside landscaping was maintained. The youth living modules have peeling paint
and there was some graffiti on the walls. The doors to the youth rooms have peeling paint and
the plexi-glass windows had scratches. Bathrooms in the living modules were clean; however,
they were very dated and some still had porcelain toilets and sinks. The regional director was
aware of the on-site observations and needed improvements. There were no signs of insect
infestation. At the time of the annual compliance review, the center had fourteen vacancies,
which included four JJDO Is, nine JJDO IIs, and one food service worker.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 60 (Revised July 2023)
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 maintains a written policy and procedures requiring compliance with the
Department’s background screening requirements. The Annual Affidavit of Compliance with
Level 2 Screening Standards was submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse on January 25, 2024, meeting the annual requirement. The Annual
Affidavit of Compliance with Level 2 Screening Standards for school district teachers was
submitted to the BSU on January 4, 2024. A review of the initial background screenings for eight
newly hired staff and two volunteers found the center received background screening results
from the Department’s BSU/Clearinghouse prior to each staff’s/volunteer’s start date and a
criminal history report was reviewed. None of the reviewed staff or volunteers were applicable
for a background screening exemption. None of the eight staff or two volunteers were applicable
for a break in service. The center utilizes an ergometric pre-employment assessment tool for all
direct care applicants. A review of eight direct care staff records indicated each staff completed
a pre-employment assessment tool and received a passing score. A copy of the pre-
employment assessment was maintained within each staff’s record. The center added the two
applicable staff and volunteers to the Clearinghouse roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center maintains facility operating procedures to ensure all staff, contracted providers, and
volunteers with access to youth undergo a criminal history background check every five years.
The center had three staff applicable for a five-year rescreening since the last annual
compliance review. Each staff’s rescreening was completed and submitted to the Department’s
Background Screening Unit (BSU)/Clearinghouse within the required time frames. There were
no volunteers or contracted staff applicable for a five-year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 60 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center maintains facility operating procedures addressing the staff code of conduct. Staff
are required to adhere to the code of conduct which prohibits any type of abuse, profanity,
threats, harassment, intimidation, horseplay, or personal relationships with youth. A review of
five staff personnel records documented each staff had signed a code of conduct prohibiting any
form of abuse, profanity, threats, harassment, or intimidation. The code of conduct also
addressed officer professionalism, poor performance, negligence, insubordination, conduct
unbecoming of a public staff, and misconduct. Protective Action Response (PAR)/Right
Interactions (RI) Reports and the Department’s Central Communication Center (CCC) reports
were reviewed for violations related to code of conduct. The center provided five staff records
which contained disciplinary actions for violations of code of conduct and five staff records
which contained commendations. A review of five staff records verified each staff received
substantiated violations of the code of conduct and management’s response included two
written reprimands, two oral reprimands, and a resignation. A review of five staff records verified
each staff received employee of the month. Five youth were interviewed, and each stated they
had never been stopped from reporting abuse since they have been at the center. Each youth
stated staff are respectful when talking to youth and do not use profanity. Each youth stated
they have never heard staff threaten youth at the center. All five-youth stated they feel safe at
the center. Each youth stated they have never exchanged emails, telephone numbers, or social
media contact information with staff. Five staff were interviewed, and each stated they would
allow a youth to make a telephone call to the Florida Abuse Hotline or the CCC if the youth
request to make an abuse call. Three staff stated they would notify the supervisor, two staff
stated the youth can make the call from the intake area, and one staff stated they would call
master control, document the logbook, and put in an incident report in the Department’s
Juvenile Justice Information System (JJIS). Each of the five staff stated they have never heard a
coworker using profanity when speaking with youth. All five staff stated they have never
observed a coworker using threats, intimidation, or humiliation when interacting with youth. One
staff stated working conditions were very good at the center, three stated good, and one stated
fair. The interviewed superintendent stated staff interact with youth in a manner which provides
a role model of socially accepted behaviors. Staff will not be verbally abusive, demeaning, or
humiliate any youth. Staff should not use profanity in the performance of their job. Youth are
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 60 (Revised July 2023)
afforded an opportunity to use the telephone for the purposes of reporting verbal abuse,
physical abuse, sexual abuse, and sexual harassment to the Florida Abuse Hotline or a local
advocacy center.
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 maintains facility operating procedures to ensure when a reportable incident occurs
the center notifies the Department’s Central Communications Center (CCC) within two hours of
becoming aware of the incident. The center had fifty-six reportable incidents since the last
annual compliance review. A review of six incidents found all were reported to the CCC within
two hours of the incident. Each incident was documented in the center’s CCC logbook. A review
of the center’s internal incident/grievance reports found there were no additional incidents which
should have been reported to the CCC and were not. The center’s superintendent was
interviewed and stated whenever a reportable incident occurs, the superintendent or designee
will notify the CCC within two hours of the incident, or within two hours of becoming aware of the
incident.
1.05 Protective Action Response (PAR) Satisfactory Compliance
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 PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center maintains facility operating procedures to ensure the use of physical intervention
techniques are in accordance with Florida Administrative Code. Any time a staff uses a physical
intervention technique, such as countermoves, control techniques, takedowns, or application of
mechanical restraints, with the exception of regular transports, a Protective Action Response
(PAR)/Right Interactions (RI) Report is completed. The center had a total of 266 PAR/RI
incidents since the last annual compliance review. A review of nine PAR/RI Reports found all
involved staff completed appropriate statements by the end of their shift. None of the reviewed
PAR/RI Reports resulted in serious injury of youth or staff and none required a PAR/RI medical
review. One of nine reviewed reports indicated a youth alleged abuse and the Florida Abuse
Hotline was contacted immediately. Each reviewed PAR/RI Report was reviewed by a
supervisor or a PAR/RI certified instructor. Each of the nine PAR/RI Reports documented a
post-PAR/RI interview was conducted with the youth by the center’s administration within thirty
minutes of the incident. None of the reviewed records were applicable for the use of mechanical
restraints. The superintendent or designee reviewed each PAR/RI Report and made comments
when needed within seventy-two hours. A review of internal incident/grievance reports and
logbooks indicated there were no additional PAR/RI incidents which did not have a report. The
center’s PAR/RI rate during the previous quarter was 22.24, which was above the statewide
Detention PAR/RI rate of 15.17. Five staff were interviewed, and each staff reported staff they
use verbal interventions with youth prior to using PAR/RI. An interview with the center’s
superintendent revealed PAR/RI mechanical restraints are stored in a secure area which is
designated by the superintendent. All PAR/RI incidents are monitored and tracked through the
PAR/RI Reports. A report will be generated any time an officer places their hands on a youth,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 60 (Revised July 2023)
with the exception of the sole use of the straight arm, close, or extended escort. In the event a
PAR/RI technique is not able to be used due to the rapid escalation of dangerous behavior, a
detailed description of the use of physical intervention shall be documented on the PAR/RI
Report with subsequent entries reflecting the appropriate level of PAR/RI used.
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 maintains facility operating procedures regarding pre-service training. Staff are
trained in accordance with Florida Administrative Code. Detention staff satisfy pre-
service/certification requirements specified by Florida Administrative Code within 180-days of
hire. Phase One training consists of instructor-led and web-based courses. Phase Two training
consists of 120 hours of academy instructor-led training. A review of five applicable staff training
records for pre-service training indicated each staff completed all required trainings within 180-
days of hire and a new staff orientation was completed within eighteen days of hire. Reviewed
documentation confirmed each applicable staff completed all trainings required by the
Department prior to having contact with youth. All pre-service training was documented in the
Department’s Learning Management System (SkillPro). The center did not have any returning
direct care staff applicable for the specified training when returning less than one year from
separation.
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 maintains facility operating procedures which require staff to complete twenty-four
hours of in-service training each calendar year after completion of pre-service certification
training. The policy also requires supervisors to complete eight hours of supervisory training
annually. The center provides in-service training to staff through a combination of the
Department’s Learning Management System (SkillPro) and instructor-led classes. Five staff
training records were reviewed for in-service trainings, including three direct care staff and two
supervisory staff. All five staff records reflected staff completed the mandatory training topics
except for one staff who did not complete the active shooter training. Two staff were applicable
for a minimum of eight hours of supervisory training. Each staff completed the required eight
hours of supervisory training. All trainings were entered into SkillPro. The center has an annual
in-service training calendar which is updated as changes occur. The in-service training was
approved by the Department’s regional director on November 29, 2022. The interviewed
superintendent stated they were trained in Certified Public Management (CPM), leadership and
development, quality customer service, communication, and the delivery of constructive
criticism. In addition, staff receive training in Protective Action Response (PAR)/Right
Interactions (RI), cardiopulmonary resuscitation (CPR), suicide prevention, professionalism,
universal precautions, fire safety, and cyber safety along with additional trainings.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 60 (Revised July 2023)
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 maintains facility operating procedures to guarantee each youth has the right to file a
grievance and ensure all youth are treated fairly, respectfully, without discrimination, and their
rights are protected. The grievance process is displayed in each living module and explained to
each youth during the admission and orientation process. Grievance forms are accessible to
youth on each module of the center. The initial step in the grievance process is the informal
phase where the juvenile justice detention officer (JJDO) and the youth try to resolve the issue
using effective communication. If the grievance is not resolved, the grievance is entered into the
Department’s Facility Management System (FMS) on behalf of the youth by the staff. The
written grievance will be submitted to the JJDO supervisor within two-hours, beginning the
formal grievance process. Next, the appeal phase requires a response from the superintendent
or designee. The center did not have any formal grievances since the last annual compliance
review. The interviewed superintendent stated youth cannot be denied the opportunity to file a
grievance. Youth are not punished for filing a grievance, whether it is substantiated or
unsubstantiated. Special needs youth are provided access to the same grievance procedures
as other youth. Staff verbally explain the process and help the youth fill out the grievance form,
if needed. Limited English proficient youth shall be afforded assistance, if needed. Five youth
were interviewed regarding the grievance process and each youth stated there is a form on the
living module for youth to fill out and then give to the staff. All five youth reported they never filed
a grievance. Five staff were interviewed and were able to explain the center’s grievance
process. Each staff stated they allow the youth to fill out the form and then turn in the form to the
supervisor.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 60 (Revised July 2023)
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 to address entering an alert into the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been previously identified prior to the youth’s admission. The alerts entered into
JJIS are verified by medical staff, juvenile justice detention officer (JJDO) supervisors, or the
mental health staff, as applicable. Five youth records were reviewed for medical, mental health,
and medication alerts. Each reviewed youth record documented all alerts were accurately
entered into JJIS. The reviewed youth were applicable for eleven separate alerts. The JJIS
alerts are printed daily by the on-duty supervisor, copies are provided to all staff during their
shift, and all staff have access to the alert system. Reviewed documentation indicated alerts
were discussed during shift briefings. During the center tour, observations verified the kitchen
staff have access to the alert list and it was posted in the kitchen. An observation of a shift
briefing meeting was not conducted during the annual compliance review week due to the
annual compliance review team not being on-site during the briefings. All applicable alerts were
downgraded and removed by the medical staff and/or the mental health staff. The interviewed
superintendent stated staff enter alerts at admission based off of information provided by the
youth, the parent/guardian, law enforcement officer, the juvenile assessment center officer, and
healthcare staff. Healthcare staff review the alerts and ensure they are up to date. Medical
alerts include all routine prescribed medications, allergies/allergic reactions, medication
interactions, head trauma/injury, pregnancy, chronic medical conditions, activity limitations or
precautions, and medication side effects. Medical alerts are updated when information is
obtained during admissions, upon return from off-site medical appointments, and anytime new
information is received. Five staff were interviewed, and each staff reported being informed of
youth alerts through the shift debriefing and JJIS alert forms. All staff reported management
informed the staff about issues within the center through shift debriefing meetings, by email, and
during staff meetings.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 60 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a structured method for analyzing data trends. The Department conducts a
Detention Services Report Card which ensures all centers provide a high-quality effective
service for youth and families. The report card is a comprehensive review of policy compliance
conducted through site visit observations and desk top audits. Department headquarters staff
work with centers to identify strengths and areas which need improvement. The report card
includes information based on drills, center inspections, center meetings, and operations. The
report card assigns a grade for the center with recommendations for improvement. The
information is then shared with center staff through monthly management meetings and daily
shift briefings. A review of report cards, surveys, meeting agendas, and data collection software
confirmed the center’s practices. The center also participates in the community advisory board
meetings, in which information is shared with stakeholders at least quarterly.
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Office of Accountability and Program Support Page 16 of 60 (Revised July 2023)
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, full body visual 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 his/her
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 regarding youth admission. A review of five active
case management records indicated all five Admission Wizards documented the review of an
arrest affidavit, Detention Risk Assessment Instrument (DRAI), and the Suicide Risk Screening
Instrument (SRSI). Reviewed documentation confirmed all five Admission Wizards included a
full body search conducted by a staff of the same gender. Each Admission Wizard documented
all youth were offered a telephone call to their parent/guardian and each youth was offered a
meal upon admission. Each record documented a medical/mental health/substance abuse
screening was completed upon admission. During the annual compliance review week, an
observation of a youth admission was conducted. All required procedures of the process were
followed. The youth was afforded the opportunity to make a phone call to their parent/guardian,
and a meal was provided.
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Office of Accountability and Program Support Page 17 of 60 (Revised July 2023)
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 old 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 regarding youth orientation. Five youth case
management records were reviewed, and each youth was provided an orientation within twenty-
four hours of admission and signed the brochure provided by the center. During the annual
compliance review week, an observation of a youth orientation was completed. All procedures
were followed and consistent with the center’s operating procedures for youth orientation. The
youth was informed of the center’s rules and regulations, grievance procedures, visitation hours,
telephone call procedures, how to access mental health and medical services, access to the
Florida Abuse Hotline and the Department’s Central Communications Center (CCC), behavior
expectations and consequences, possible new law violations, youth rights, and Prison Rape
Elimination Act (PREA) related information. During the observation, the required PREA
videotape was played for the youth to watch. Five youth were interviewed, each youth stated
during the orientation process the rules and regulations, daily schedule, education services,
visitation, abuse reporting, and the behavior management system (BMS) were explained.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 60 (Revised July 2023)
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;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures to ensure all youth are classified upon admission to
provide the highest level of safety and security. All youth room assignments are based on the
youth’s classification. A review of five youth case management records reflected the youth’s
gender, height, weight, age, and level of aggressiveness were reviewed prior to sleeping room
assignment. Identified special needs included mental illness, intellectual disabilities, physical
disabilities, history of violent behavior, gang affiliation, criminal behavior, history of sexual
offenses, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening
results, medical, suicide, escape, and security risks. The center’s classification process
considered mental illness, intellectual disabilities, or physical disabilities for each of the five
youth records reviewed. Each youth was assigned to a room based on the classification
procedures and may be reclassified if there are any changes in behavior or status. The
superintendent indicated he is informed through admission, alerts, weekly audits, and juvenile
probation officers of all gang and associated gang members. A formal interview with the
superintendent indicated each youth is assigned to a room based on their classification and are
reclassified if changes in behavior or status are observed. Living unit/room assignments are
documented in the Department’s Juvenile Justice Information System (JJIS). There are no more
than two youth allowed to occupy a room. Any exceptions to this must be approved in writing.
Youth with a history of committing sexual offenses, a history of being a victim of a sexual
offense and/or abuse, or youth determined to be physically or sexually aggressive are not to be
placed in a room with any other youth.
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Office of Accountability and Program Support Page 19 of 60 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures to ensure each newly admitted youth is screened to
determine if the youth is a gang member or affiliated with a gang. Five youth case management
records were reviewed and one was applicable for gang identification. An additional closed case
management record was provided by the center and reviewed. There were no additional
applicable youth since the last annual compliance review. The center’s captain is the gang
representative who communicates all suspected gang activity to local law enforcement and the
assigned juvenile probation officer (JPO) by email. Reviewed documentation supported emails
were sent as required. The center communicates all suspected gang affiliation with the circuit
gang representative. The captain shares suspected gang behavior of youth with the JPO and
the chief probation officer (CPO). The center maintains a gang unit tracking log which was
reviewed and confirmed the center’s practice of documenting identified gang members. The
alert information is entered into the Department’s Juvenile Justice Information System (JJIS).
Both applicable records documented the required gang alerts in JJIS. The center’s gang
representative was interviewed and was knowledgeable of the center’s gang notification
procedures.
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 to ensure a youth's personal property is maintained
securely. Five youth case management records were reviewed and each record documented
the youth’s property was inventoried by the admitting juvenile justice detention officer (JJDO)
and entered into the Department’s Juvenile Justice Information System (JJIS). A Property
Receipt form was printed and signed by the youth and the JJDO in all five records reviewed. All
five youth case management records contained a letter of acknowledgment regarding
unclaimed property signed by each youth. Currency and other personal items of value are
placed in a clear tamper-proof bag and placed in a drop safe, which is under camera
surveillance. The tamper-proof bags are labeled with the youth’s name, Department
identification number, and a listing of the items in the bag. A log is maintained to document
items placed in the drop safe and includes the date, time, youth’s name, name of the officer who
secured the property, and the officer’s initials. None of the reviewed records indicated the youth
refused to sign the Property Receipt form. The personal property was placed in an assigned
bag, as documented on the Property Receipt form, and the form was placed in all five active
youth records reviewed. The superintendent stated when a youth is admitted to the center with
valuable property, the valuable property is documented in JJIS. The property is then placed in a
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Office of Accountability and Program Support Page 20 of 60 (Revised July 2023)
safe which is under camera surveillance until the youth is released from the center. The youth’s
clothes and other non-valuable property are also logged into JJIS and stored in a secured mesh
bag until the youth is released. Valuable property is stored in a safe located in the intake office
under video surveillance. Only supervisors and administration have access to the valuable
property. A review of the Department’s Central Communications Center (CCC) incident reports
since the last annual compliance review indicated there were no incidents regarding youth
property. One youth admission was observed during the annual compliance review week and
the intake staff followed all guidelines to include having the youth sign the bag, dropping the bag
in the safe, and logging the property in the logbook. Five youth were interviewed and
acknowledged staff checked the youth’s personal property and staff then had youth sign a
Property Receipt form acknowledging their property was correct. An interview with the
superintendent indicated all youth valuables are stored in a locked cabinet in camera view with
a logbook and only supervisors and administrative staff had access to the valuable property.
Five interviewed youth stated upon arrival to the center, staff checked their personal property,
and each signed a form stating their personal property listed was correct.
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 regarding the release of youth in secure detention.
Three closed youth case management records were reviewed. Each record had a copy of the
Department’s Detention Release form, which documents the supervisor has reviewed all
paperwork related to the youth’s release and court documents. All three youth had their
identification verified prior to release. The parent/guardian identification was verified prior to
release for each youth, with a photocopy of the parent’s/guardian’s identification being placed in
each youth’s case management record. None of the reviewed records identified the youth as an
endangered person. Each youth and the person to whom the youth was released were
reminded of future court dates and signed the release forms. The date of admission and the
date of release documented in each youth’s record correlated with the dates documented in the
Department’s Juvenile Justice Information System (JJIS). All three closed case management
records indicated all required parties signed all applicable forms. During the annual compliance
review week, a release was observed and confirmed the releasing staff was following the
center’s procedures.
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Office of Accountability and Program Support Page 21 of 60 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures regarding the release of youth personal property,
medication, and aftercare instructions. Three closed youth case management records were
reviewed. Each record contained a Property Receipt form signed by the youth and
parent/guardian upon release. Each record contained documentation verifying the youth was
released to an appropriate person to include a copy of their identification. The center had three
incidents of youth property being held for more than thirty days requiring disposal. All three
property disposals were documented. A copy of the notice of disposal, which was sent to each
parent/guardian, was provided for review. On the thirty-first day, all property was donated to a
local charity, a receipt was given to the center for all items accounted for, all money was added
together, and a money order was made and sent to the regional office. During the annual
compliance review week, a youth released with property was observed. The shift supervisor
retrieved the youth’s property from the safe and the youth and the parent/guardian signed the
appropriate documentation for taking custody of the property. The parent’s/guardian’s
identification was confirmed by the issued driver’s license and a copy was made. All the center’s
release procedures were followed during the observation of the youth release.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures regarding the review of youth in secure detention.
The center has an officer assigned as the detention review specialist (DRS). An observation of
the weekly Detention Review for youth in secure detention was conducted during the annual
compliance review week by video conference. The circuit’s juvenile probation officers (JPOs),
JPO gang representative, education staff, medical and mental health staff, the DRS, and
detention center administrative staff were present during the observed weekly detention review.
All participants who attended the detention review signed a meeting roster. All participants
shared information regarding youth court dates, release dates, medical, mental health, and
educational concerns, committed youth, evaluations, and needs for the youth during the
Detention Review. All documents including meeting minutes and sign-in rosters are uploaded
into a shared network drive weekly. A review of the documentation for the annual compliance
review period confirmed all required participants attended the meetings since the last annual
compliance review. A review of twelve months of Facility Management System (FMS) uploads
showed all participants attended and signed the attendance logs. An interview with the
superintendent indicated Detention Reviews are held on a weekly basis on Thursdays at 9:30
a.m. The assigned DRS or staff designated to facilitate Detention Reviews conduct a Detention
Review on a weekly basis and address every youth reflected on the census for secure
detention. Detention Reviews are to be completed in person or, at a minimum, through video
conferencing.
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Office of Accountability and Program Support Page 22 of 60 (Revised July 2023)
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures regarding the daily activity schedule. During the
annual compliance review week, a tour of the center was conducted, and the daily activity
schedule was posted on all the youth living modules. Youth were observed attending school,
eating lunch, and participating in outside recreation in accordance with the schedule. The
center’s daily activity schedule includes daily expectations in accordance with the behavior
management system (BMS), wake-up/personal hygiene, education, mealtimes, visitation, indoor
and outdoor recreation, shift changes, bedtimes, groups, and open program time. Visitation is
held twice a week for youth. A review of the center’s logbook confirmed the center adheres to
the daily activity schedule. Five youth were interviewed, and each youth indicated the center
has a daily schedule which is followed. Five staff were interviewed, and all reported the daily
activity schedule is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures in place to provide for educational access. Brevard
County School District provides educational services and approves the 250-day calendar, which
incorporates ten days of teacher planning and/or training. Youth earn course credits for
completion of their education and training experience. The daily school schedule reflects three
blocks of daily instruction, which meets the required minimum of twenty-five hours of instruction
each week. Randomly selected logbook entries were reviewed for adherence to the school
schedule since the last annual compliance review. The logbook entries showed the daily school
schedule was followed with little deviation. Video footage was reviewed for three randomly
selected days and the reviewed video footage showed the youth were being moved to the
classrooms timely and the education schedule was followed. Five staff, five youth, and the
superintendent were interviewed, and all confirmed there is minimal interference in educational
access. The youth revealed the school schedule is followed Monday through Friday, as
required. Each youth reported they were being well or very well prepared to return to school,
post-secondary school, or employment. An interview with the superintendent confirmed the
center’s practices regarding educational access.
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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 in place which support implementing career
education. The center offers career education programming which meets the requirements of a
Type 1 program which incorporates communication, interpersonal, and decision-making skills,
as well as life skills and activities through career-related instruction in class. Five youth were
interviewed, four youth reported taking science, math and reading. Youth also reported they
were participating in history and English classes. One youth reported they were a graduate and
were working on a workbook during school hours.
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Office of Accountability and Program Support Page 24 of 60 (Revised July 2023)
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 maintains facility operating procedures requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA), who is
responsible for the coordination and implementation of mental health and substance abuse
services. The Department maintains a contract with VitalCore Health Strategies, LLC. to provide
mental health and substance abuse services to all applicable youth in the center. The DMHCA
is a licensed mental health counselor (LMHC) who holds a clear and active license in the State
of Florida, with an expiration date of March 31, 2025. The DMHCA is a full-time staff and
scheduled to be on-site forty hours each week, Tuesday through Friday, between the hours of
9:00 a.m. to 5:00 p.m. and Saturdays from 7:00 a.m. to 3:00 p.m. A review of the mental health
sign-in logbook since the last annual compliance review confirmed the DMHCA was on-site, as
required. The DMHCA is available seven days a week, twenty-four hours a day, by way of
telephone for consultation. A review of the VitalCore Health Strategies, LLC. job description
found the DMHCA oversees all clinical and administrative operations ensuring clinical integrity,
quality, and contract compliance. The center has a back-up DMHCA in the event of scheduled
leave and/or absences, which is one of the full-time clinical staff. The back-up DMHCA is a
licensed clinical social worker (LCSW), in the State of Florida, with an expiration date of March
31, 2025. An interview with the DMHCA indicated they are responsible for the overall direction,
coordination, and evaluation of the mental health department, and six licensed therapists. The
DMHCA works directly with the psychiatrist and provides weekly updates on applicable youth
receiving services, discussing behaviors, progress, and applicable medications.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The contractual
licensed positions, in addition to the designated mental health clinician authority (DMHCA),
include six licensed mental health staff and one psychiatrist. A review of the licensed clinicians’
credentials indicated all six held a clear and active license in the State of Florida, with an
expiration date of March 31, 2025. The contract with VitalCore Health Strategies, LLC. provides
for a full-time regional clinical mental health director, in addition to the DMHCA, to serve as a
senior manager responsible for all operations of all central region detention centers. The
regional clinical mental health director provides detention center-specific technical assistance.
The regional clinical mental health director is a licensed clinical social worker (LCSW), in the
State of Florida, with an expiration date of March 31, 2025. The regional clinical mental health
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Office of Accountability and Program Support Page 25 of 60 (Revised July 2023)
director and the DMHCA are responsible for ensuring all mental health staff are qualified based
on education, training, and experience.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. All mental health
services are provided by a licensed mental health professional and the center does not have
any non-licensed mental health clinical staff. The mental health department was operating
without the Chapter 397 license at the time of the annual compliance review. Reviewed
documentation indicated only the licensed mental health counselors were facilitating all
substance abuse treatment and groups. An informal interview with the designated mental health
clinician authority (DMHCA) reported all mental health services are consistently monitored for
the provision of services provided to each youth at the center.
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 maintains facility operating procedures to ensure the mental health and substance
abuse needs of youth are identified through a comprehensive screening process in which
referrals are made when youth are identified with mental health and/or substance abuse needs
or are identified as a possible suicide risk in accordance with Florida Administrative Code. A
review of five youth mental health and substance abuse records indicated while each youth was
in the Juvenile Assessment Center (JAC), the juvenile probation officer (JPO) completed the
mental health, substance abuse, and suicide risk screenings utilizing the Suicide Risk Screening
Instrument (SRSI) and the Massachusetts Youth Screening Instrument, Second Version
(MAYSI-2). Reviewed documentation supported the center’s staff reviewed all prior
documentation completed by the JPO when each youth was admitted to the center. The juvenile
justice detention officer (JJDO) will then review each youth’s MAYSI-2 results, Face Sheet, and
alerts upon admission. The JJDO will then complete their assigned section of the SRSI. The
SRSI and MAYSI-2 were completed electronically in the Department’s Juvenile Justice
Information System (JJIS) for each youth. All five SRSIs were reviewed by a licensed mental
health professional with their documented recommendation. Each of the five SRSIs had
completed entries, which included an accurate referral selection in the “Screening Results”
sections. Each youth was applicable for positive “Yes” responses on the SRSI form, was placed
on suicide precautions, and a mental health referral was completed, which documented the
need for an Assessment of Suicide Risk (ASR). All five reviewed records documented a need
for further assessment and each youth was referred for further clinical assessments. Two of the
five reviewed MAYSI-2s had all negative responses and both were marked as an invalid
screening and referred for comprehensive assessment on the MAYSI-2 referral section. There
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were no youth identified with having a positive suicide ideation subscale on the MAYSI-2. All
five reviewed youth were applicable for a comprehensive assessment. Documentation
supported each youth was referred for a comprehensive assessment, which were all completed
by the licensed mental health staff.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center maintains facility operating procedures outlining a process for identifying the mental
health and substance abuse needs of youth through a comprehensive screening process. Youth
with identified needs are referred for a further in-depth mental health and/or substance abuse
evaluation. The center utilizes the Department’s Mental Health and Substance Abuse Referral
Summary form. All five youth were applicable for a comprehensive mental health and substance
abuse evaluation. Three applicable youth required an updated evaluation completed by the
center’s provider and each was conducted by the youth’s thirty-first day. Two applicable youth
received a new mental health and substance abuse evaluation completed by a community
provider, containing all required elements. All five youth mental health and substance records
supported each youth was screened, and a referral was made for a comprehensive mental
health and substance abuse evaluation based on the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2). All five youth were recommended for treatment services
which corresponded to all diagnosed mental health or substance-related disorders.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center maintains facility operating procedures outlining a process for mental health and
substance abuse treatment and discharge planning. The provider’s contract requires the
superintendent and designated mental health clinician authority (DMHCA), or mental
health/substance abuse clinical staff to ensure the development and review of an initial and/or
individualized treatment plan for each youth receiving mental health/substance abuse treatment
in the center. Five youth mental health and substance abuse records were reviewed for mental
health and substance abuse treatment services. Four of the five youth records had an initial
treatment plan in place within seven days of initiation of treatment which was developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. The remaining youth
did not enter the center on psychotropic medication; therefore, an initial treatment plan was not
required. Each of the four initial treatment plans contained the reason for treatment referral, the
initial Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis,
initial treatment methods and goals, and psychiatric services. The medications the youth were
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taking were documented as required. Each of the plans were signed by the youth and the mini-
treatment team members. All five reviewed records were applicable for individualized treatment
plans (ITPs). All five youth had a completed Individualized Mental Health and Substance Abuse
Treatment Plan developed within thirty-one days of the youth’s admission, on the Department’s
form, including all required elements. Each youth’s ITP documented a DSM-5 diagnosis,
treatment-focused symptoms, treatment goals, and strengths/needs. None of the records were
applicable for pharmacological interventions beyond the psychotropic medications. Each ITP
was signed and dated by all required team members. Four of the five youth records were
applicable for an ITP review completed every thirty days by the treatment team. The ITP
reviews for all four youth were signed by all treatment team members and the reviews indicated
each youth refused services. No youth were applicable for having been an alleged victim of a
Prison Rape Elimination Act (PREA) incident. Three closed youth mental health and substance
abuse records were reviewed for a mental health/substance abuse treatment discharge
summary. A review of the three applicable closed youth records confirmed each documented
the Department’s Mental Health/Substance Treatment Discharge Summary form was completed
for each youth. Reviewed documentation supported a copy was provided to each youth,
parent/guardian, and emailed to each youth’s assigned juvenile probation officer (JPO). A mini-
treatment team meeting was unable to be observed due to the scheduled hours and day of the
meeting during the week of the annual compliance review.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The provider’s contract requires mental health and substance abuse treatment planning to focus
on provisions of treatment to reduce or alleviate youth’s symptoms of mental disorder or
substance abuse impairment and enable youth to function adequately in the juvenile justice
setting. Five youth records were reviewed for mental health and substance abuse treatment. All
records indicated the youth required treatment and were assigned to a mini-treatment team.
Each youth’s mini-treatment team consisted of mental health clinical staff, medical staff, direct
care staff, administrative staff, youth, and the youth’s parent/guardian. Each reviewed youth
record was applicable for treatment with individual therapy, group, and/or supportive counseling
sessions. Reviewed chronological progress notes validated youth were receiving treatment
services as stipulated on the treatment plans. One reviewed youth was applicable for inclusion
of substance abuse treatment. Documentation supported the youth was receiving individual
substance abuse treatment services. Reviewed records supported each youth had an Authority
for Evaluation and Treatment (AET) and proper consent forms for substance abuse treatment
and information release. Each youth record contained progress notes documented on the
Department’s Counseling/Therapy Progress Notes form. In all five youth records there was
monthly documentation of the licensed mental health staff consistently encouraging the youth to
participate in mental health and substance abuse services; however, the youth consistently
rejected participation in treatment. There were no noted substance abuse groups conducted
since the last annual compliance review due to youth refusing substance abuse treatment
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services. A review of the center video footage for mental health groups confirmed licensed
therapists conducted group sessions with the youth on February 10, 22, and 29, 2024. A review
of group therapy sign-in sheets from March 18, 2023 to February 29, 2024, confirmed mental
health groups were conducted weekly with the exception of five weeks. The center reported
mental health groups were not conducted for five weeks due to direct care staff shortages. An
interview with the designated mental health clinician authority (DMHCA) confirmed the center
conducts groups for the required frequencies and length of time. Five youth were interviewed
regarding their rating of the center’s mental health and substance abuse services. Two rated
services as very good, two rated services as good, and one reported not receiving mental health
and substance abuse services.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains facility operating procedures outlining the provision of psychiatric services
to youth in need, to include psychiatric evaluation, consultation, medication management, and
medical supportive counseling. Psychiatric services are provided to youth determined to be in
need of services, as indicated by symptoms of mental disorder or substance-related disorder, or
to youth who are treated with psychotropic medication after their admission to the center. The
center maintains a contract with VitalCore Health Strategies, LLC. for the provision of a licensed
psychiatrist to provide psychiatric services for applicable youth in the center. VitalCore Health
Strategies, LLC. maintains an independent contract for psychiatric services with a medical
doctor to serve as the center’s psychiatrist. The psychiatrist is a medical doctor and maintains a
clear and active license in the State of Florida, which expires on January 31, 2025. VitalCore
Health Strategies, LLC. maintains an independent contract for psychiatric services with an
osteopathic physician (DO) to serve as the back-up psychiatrist in the event the psychiatrist is
on scheduled leave or not at the center due to an illness. The back-up psychiatrist maintains a
clear and active license in the State of Florida, under Chapter 459, which expires on March 31,
2026. The back-up psychiatrist was not utilized during the annual compliance review period.
The center does not utilize a psychiatric advanced practice registered nurse (APRN). The
psychiatrist is available for consultation, twenty-four hours a day, seven days a week.. A review
of the medical and mental health sign-in logbook validated the psychiatrist provided weekly
services for two hours each week for the annual compliance review period. The designated
mental health clinician authority (DMHCA) indicated they meet with the psychiatrist weekly and
the psychiatrist is on call twenty-four hours a day for any emergency needs. A review of five
mental health and substance abuse records indicated four of the youth were applicable for
receiving psychiatric services. All four youth were admitted with prescribed psychotropic
medications and each youth received an in-depth psychiatric evaluation, which was
documented on the Department’s Clinical Psychotropic Progress Note (CPPN) and completed
within fourteen days of admission. All four youth had an initial psychiatric interview. Each
evaluation documented the reason for referral, history, Mental Status Examination, Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment
recommendations, continuation of prescribed medications, explanation for the need of
psychotropic medications, frequency of medication monitoring/management, and the
psychiatrist’s signature. Each reviewed evaluation included page three of the CPPN outlining
medication target symptoms, side effect descriptions, medication name, dosage, and frequency.
Each youth record documented the psychiatric evaluation was conducted within thirty days of
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the youth’s referral/admission. All reviewed mental health and substance abuse documentation
was completed utilizing the required Department forms. Three of the four youth required the
monitoring of Tardive Dyskinesia, which was conducted monthly. All four applicable youth
records had a current Authority for Evaluation and Treatment (AET) consent for continuation of
the psychotropic medication. The contract was reviewed and confirmed the inclusion of tele-
psychiatry. A review of the center’s Tele-Psychiatry Log validated the psychiatrist is providing
weekly services, as required, through tele-psychiatry. Documentation supported all four youth
agreed to participate in tele-psychiatry and parent/guardian consent was obtained.
3.09 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 maintains a written Suicide Prevention Plan to safely screen, refer, assess, monitor,
and protect youth with elevated risk of suicide in the least restrictive means possible. The plan
details all required suicide prevention procedures and is reviewed and signed by the designated
mental health clinician authority (DMHCA) and superintendent. The plan addresses
identification and assessment of youth at-risk of suicide, staff training of at least six hours,
suicide precautions, levels of supervision, referral process, communication, notification,
documentation, immediate staff response, and review process as required by Florida
Administrative Code. The center’s plan includes an established review process for every serious
suicide attempt or serious self-inflicted injury and a mortality review for a completed suicide
which included circumstances surrounding the event, center procedures relevant to the incident,
all relevant staff training, pertinent medical and mental health services involving the victim,
possible precipitating factors, and any recommendations as needed.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center maintains a written Suicide Prevention Plan to safely screen, refer, assess, monitor,
and protect youth with an elevated risk of suicide in the least restrictive means possible. A
review of five youth mental health and substance abuse records showed five youth were
applicable for having been placed on precautionary observation (PO) at the time of admission
until an Assessment of Suicide Risk (ASR) was completed. One was identified through self-
reporting and four were identified as at-risk based on the admission screenings. Reviewed
documentation showed all five youth records had a new suicide alert placed in the Department’s
Juvenile Justice Information System (JJIS). Documentation showed an ASR was completed
within twenty-four hours by a licensed therapist for each youth, using the Department’s form.
Each youth began on constant supervision as a result of the Suicide Risk Screening Instrument
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(SRSI) and after the completion of the ASR, all five youth were placed on standard supervision.
A review of all five youth’s Suicide Precaution Observation Logs confirmed each was completed
in their entirety to include documented safe housing areas and all required signatures.
Documentation supported the mental health professionals were involved in the process for each
youth. None of the five youth were released while on PO. The staff completed a mental health
and substance abuse referral for each youth due to the youth being identified as having a risk of
suicide. The superintendent and designated mental health clinician authority (DMHCA) were
notified for each youth. None of the five records were applicable for a Follow-Up ASR due to all
youth being stepped down following the initial ASR. Each ASR included recommendations for
supervision and follow-up services. Each ASR documented a conference was held between the
licensed mental health professional and the superintendent pertaining to reducing the level of
supervision. A review of the center’s logbooks revealed the starting and ending time of each
youth’s precaution period was documented in the logbook. The staff entered in JJIS the date
and time each youth was placed on and discontinued on PO. Documentation supported the
DMHCA and the superintendent consulted prior to each youth being stepped down from PO.
None of the five reviewed records were applicable for placement in secure observation (SO).
The center provided three additional applicable youth records where youth were placed on SO.
Reviewed records supported each youth placement was authorized by a supervisor and the
DMHCA. The secure room was designated in writing and the Department’s Health Status
Checklist was completed, as required. Staff completed the Suicide Precaution Observation Logs
in their entirety and in real time. A new ASR was completed when each youth was placed in SO
and a Follow-Up ASR was completed within eight hours of placement. Documentation
supported each youth’s parent/guardian and juvenile probation officer (JPO) were notified of the
placement. None of the youth were placed on SO beyond twenty-four hours. The mental health
staff provided supportive counseling while each youth was on SO. Documentation supported a
conference was held with the superintendent and licensed mental health counselor prior to the
reduction of supervision level for each youth. A review of the center’s logbooks validated the
youth placed on precautions had documentation regarding the beginning and ending times of
their precaution periods. An informal interview with the DMHCA and an interview with the
superintendent revealed when a youth is on PO and actively trying to harm themself or others,
the youth will be placed on SO.. Interviews with five youth were conducted. Two youth stated
they had been placed on suicide precautions while at the center and both youth confirmed staff
watched them at all times. The remaining three youth reported never being placed on PO at the
center. Five staff were interviewed and each reported staff are responsible for notifying mental
health staff, documenting supervision, notifying the supervisor, and placing the youth on
constant sight and sound supervision when a youth expresses suicidal thoughts.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center maintains a written Suicide Prevention Plan which details the process to safely
screen, refer, assess, monitor, and protect youth with elevated suicide risk in the least restrictive
means possible. A review of five youth mental health records showed all were applicable for
having been placed on precautionary observation (PO) and each had a Suicide Precaution
Observation Log maintained. Each youth’s log was documented in real time. The review of the
Suicide Precaution Observation Logs for all five youth found the staff were documenting the
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youth’s behavior at thirty-minute intervals or less. None of the youth were applicable for having
warning signs documented on the logs. Safe housing areas were clearly documented on each
log. All five youth’s Suicide Precaution Observation Logs included the signature of the mental
health staff and the center’s shift supervisors. Observations of video surveillance footage for
three random dates and corresponding documentation of youth placed on PO confirmed each
youth was placed on constant supervision and was placed in the day room. Staff were present
at all times while the youth were 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.
The center maintains a Suicide Prevention Plan outlining the training requirements for all staff
who work with youth. Suicide prevention trainings are completed and documented in the
Department’s Learning Management System (SkillPro). Five pre-service and five in-service staff
training records were reviewed. All reviewed staff records documented staff completed two-
hours of web-based training in SkillPro and four hours of instructor-led suicide prevention
training. Reviewed documentation of suicide drills conducted since the last annual compliance
review showed the center completed drills on each shift monthly. Documentation showed
twenty-six applicable staff participated in a suicide drill for the first six months and twenty-eight
applicable staff participated in a suicide drill for the second six months. Documentation showed
twenty-eight applicable direct-care staff participated in at least one cardiopulmonary
resuscitation (CPR) drill annually. An informal interview with the center’s training coordinator
reported the staff participation during suicide and CPR drills is tracked on the center’s suicide
mock drill attendance tracker logs. Reviewed tracking logs supported the center’s practice.
Additionally, the drills are discussed at the monthly staff meetings. The center has four suicide
response kits, co-located with first-aid kits, which were located in each module and master
control. Five staff were interviewed and each staff indicated suicide response kits are located in
master control, two indicated one is kept on each living module, the training room, the medical
office, and one indicated one is in the shift supervisor office.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center maintains a mental health Crisis Intervention Services and Emergency Care Plan
outlining the response procedures for youth in crisis. The plan was approved by the
superintendent and the designated mental health clinician authority (DMHCA) on August 9,
2023. The plan details crisis intervention procedures including a notification and alert system,
means of referral including youth self-referral, communication, supervision, documentation, and
review.
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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 maintains a Crisis Intervention Services and Emergency Care Plan outlining mental
health and substance abuse emergency procedures and ensuring youth who are considered an
imminent danger to themselves or others because of mental illness or substance abuse
impairment receive emergency mental health or substance abuse services. The plan was
approved by the superintendent and the designated mental health clinician authority (DMHCA)
on August 9, 2023. The center’s plan includes procedures for immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services (Baker Act or Marchman Act), documentation, review, and
training. A copy of the plan was located in the mental health office, medical office, and the
center’s administration office, which is accessible to all staff.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has a written Emergency Care Plan stipulating the response procedures for youth in
crisis and the administration of a Crisis Assessment. None of the five reviewed youth were
applicable for Crisis Assessments. The center reported there was only one youth applicable for
a Crisis Assessment since the last annual compliance review. A review of the applicable Crisis
Assessment revealed it documented the reason for assessment, a Mental Status Examination
and interview, determination of danger to self and others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
evaluation, and notification to the parent/guardian of follow-up treatment. The assessment was
completed by a licensed mental health professional within the required time frame. The youth
was placed on precautions after completion of a Crisis Assessment and a mental health alert
was entered into the Department’s Juvenile Justice Information System (JJIS). The youth was
identified by staff as having acute emotional or behavioral problems, or acute psychological
distress. The Crisis Assessment was completed within twenty-four hours of the youth’s identified
crisis. The Crisis Assessment was not based off of a Prison Rape Elimination Act (PREA)
allegation.
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3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center maintains a written Emergency Care Plan outlining mental health and substance
abuse emergency procedures for youth who are believed to be an imminent danger to
themselves or others because of mental illness or substance abuse impairment. Three Baker
Act incidents were reviewed. Upon re-admission to the center from the Baker Act, each youth
was placed on suicide precautions. Documentation supported a mental health referral was
completed for a Mental Status Examination to be conducted by licensed mental health staff in
each youth record. A review of documentation confirmed each youth was maintained under
constant supervision until approval was granted for transition to a lower level of supervision.
Documentation supported supervision levels for the three youth were reduced following an
appropriate assessment and consultations between licensed mental health staff and the
superintendent. For each youth, a suicide risk alert was documented in the Department’s
Juvenile Justice Information System (JJIS). The discontinuation of the alerts and precautions
were based upon an Assessment of Suicide Risk for each youth. The center had no applicable
Marchman Act proceedings since the last annual compliance review.
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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 contractual agreement with a
licensed physician to serve as the designated health authority (DHA). The center maintains a
contract with VitalCore Health Strategies, LLC., (VitalCore) which subcontracts with a medical
doctor (MD) to serve as the center’s DHA. The MD holds an unrestricted license which expires
on January 31, 2025, which meets all requirements for independent and unsupervised practice
in the State of Florida. The MD has specialty training in internal medicine, with experience in
adolescent health. The DHA ensures all medical and mental health policies and protocols are
reviewed and signed annually and ensures all appropriate medical staff receive training on all
medical policies. The MD serves as the center’s DHA and is clinically responsible for the
medical care of all youth. A review of the contract with VitalCore, effective March 17, 2022,
indicated the DHA is required to be on-site each week for four hours a week, in accordance with
Florida Administrative Code. A week is defined as the seven-day period beginning on Sunday
and ending on Saturday. There shall be no more than nine days between on-site visits. The
DHA is responsible for conducting periodic evaluations, Comprehensive Physical Assessments
(CPAs), sick call referrals, and administrative duties. The DHA is responsible for communication
with the center and the medical staff regarding the youth’s medical needs. The DHA is available
on-call twenty-four hours a day, seven days a week for consultation. The DHA is on-site on
Monday or Tuesday for three hours at least weekly. Reviewed attendance logs since the last
annual compliance review supported the DHA was on-site weekly as required. The center
utilizes an advanced practice registered nurse (APRN), who is on-site once a week and holds
an unrestricted license in the State of Florida, with an expiration date of July 31, 2024. The
APRN has Collaborative Practice Protocols in place with the DHA. The APRN and DHA signed
the collaborative agreement renewal on July 7, 2023. The APRN is on-site on Saturday’s from
9:00 a.m. to 3:00 p.m. on a weekly basis. The back-up MD, who provides coverage when the
DHA is on scheduled absences or vacation, holds an unrestricted license in the State of Florida,
which expires on January 31, 2026. The back-up provided services for one week during the
annual compliance review period. A tele-health agreement was established between VitalCore
and the Department for DHAs from other centers to oversee the center’s APRN completing the
CPAs and sick calls, and being on call for evaluation consultations and episodic, first-aid, and
emergency care. A log of tele-health services was maintained at the center. An interview with
the DHA confirmed their role in providing youth with CPAs, sick call care, episodic care, and
periodic evaluations. The DHA confirmed being on-site one day each week for two hours and
being available to staff twenty-four hours a day and seven days each week. Communication
with the center’s staff regarding medical needs is done through telephone calls, email, and
Electronic Medical Records (EMRs). The DHA reported off-site care is reviewed with the
center’s nursing staff and documented in a chronological progress note, with new orders given
as needed. Any youth with an active/acute medical condition is reviewed and discussed during
DHA clinic visits.
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4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center maintains facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. Reviewed documentation reflected the designated health authority
(DHA) reviewed, signed, and dated the FOPs, on August 14, 2023. Reviewed documentation
supported the superintendent signed and dated the updated FOPs on March 28, 2023.
Reviewed documentation validated the registered nurse (RN) signed the cover page on
February 26, 2024, the advanced practice registered nurse (APRN) signed on March 5, 2024,
and the psychiatrist signed in April 2022. All other medical staff documented their review of the
center’s VitalCore Health Strategies, LLC. (VitalCore) healthcare FOPs and protocols on a
cover page which were signed and dated between February 13, 2023 and March 5, 2024. The
center’s treatment protocols were signed and dated by the DHA on February 13, 2024. The
center’s non-healthcare staff protocols were signed and dated by the DHA on August 14, 2023.
VitalCore has an established comprehensive clinical orientation for all newly employed
healthcare staff which includes the Department’s healthcare policies and procedures. A review
of each medical staff’s training records verified each newly employed medical staff received the
clinical orientation conducted by a registered nurse (RN).
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center maintains facility operating procedures ensuring parents/guardians are afforded the
right to give or withhold consent regarding the healthcare provided to the youth. A review of five
youth Individual Healthcare Records (IHCRs) found three were applicable for requiring a signed
Authority for Evaluation and Treatment (AET). All three applicable IHCRs contained the signed
AET, and one of the three IHCRs required a Limited Consent for Evaluation and Treatment
(LCET) due to involvement with the Department of Children and Families (DCF). One IHCR had
a LCET, and the remaining had a court order and a LCET. Each applicable AET was obtained
prior to providing medical services to the youth. The five applicable signed AETs were clearly
marked as a “copy” on the form. The interviewed nurse indicated the AET is signed by the
parent/guardian and witnessed by a Department representative prior to providing medical
services. The nurse added the AET is valid as long as the youth has remained under any type
of supervision, custody, or other form of legal control by the Department. The nurse will notify
the juvenile probation officer (JPO) if a new AET is required, to enlist their assistance in
obtaining an updated AET. If the youth is in DCF custody, then the case worker is contacted to
obtain a limited AET. If the youth is eighteen years or older, the youth is responsible for
authorizing their healthcare and to authorize release of their healthcare information. In addition,
the youth give verbal consent and sign/initial for treatment and/or medications rendered.
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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 outlining requirements for parental/guardian
notification of significant changes in the youth’s condition and for obtaining written consent from
the parent/guardian when new medications and treatments are prescribed. A review of five
youth Individual Healthcare Records (IHCRs) found two youth were applicable for prescribed
over-the-counter medications not covered by the Authority for Evaluation and Treatment (AET).
Both reviewed IHCRs supported the center notified the parent/guardian of significant changes in
the youth’s condition and obtained applicable consent when new medications and/or treatments
were prescribed. Each of the reviewed applicable IHCRs contained the chronological progress
notes documenting the parents/guardians were notified by telephone and followed up with a
written Parental Notification/Consent form showing an attempt to obtain the signed
parent/guardian consent. Three of the five reviewed youth were taking psychotropic medications
at the time of the annual compliance review. Three of the five reviewed records had new
medication ordered and there was documentation of attempted contact to the parent/guardian in
the progress notes. Three of the youth records documented a written parental/guardian notice
was sent regardless of telephone notification. None of the youth were prescribed a new
psychotropic medication. None of the youth were in the care of the Department of Children and
Families (DCF), where there was a termination of parental/guardian rights. Four of the five youth
vaccines were verified within thirty days of their admission and one youth was discharged prior
to verification. No youth were applicable for a religious exemption for vaccinations. An interview
with the nurse reported parental/guardian notification is made to inform the parent/guardian of
significant changes in the youth’s condition and obtain consent when new medications are
ordered, medications are stopped, youth are sent off-site for treatment, and treatments are
prescribed. Notifications are first done verbally and followed with a written notification. The
nurse contacts the parent/guardian as soon as a change occurs or an order is obtained when
notification is required. Whenever a new psychotropic medication is prescribed, discontinued, or
the drug dosage is significantly changed, the parent’s/guardian’s verbal consent for
psychotropic medication is documented on the Clinical Psychotropic Progress Note (CPPN).
The nurse was able to explain the procedures staff are to follow when a medical emergency
arises. Immunization records are obtained and verified through the Florida Shots website and
are reviewed upon a youth’s admission. When a parent/guardian presents a certified
documentation of exemption from immunization, the nursing staff and designated health
authority (DHA) will review and upload the document in the youth’s Electronic Medical Record
(EMR).
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 maintains facility operating procedures requiring each youth, at the time of
admission, to receive a Facility Entry Physical Health Screening and the Department’s Medical
and Mental Health Admission Screening (MMHS) in the Department’s Juvenile Justice
Information System (JJIS). A review of five youth Individual Healthcare Records (IHCRs) found
each contained a MMHS form completed on the date of admission by a juvenile justice
detention officer (JJDO) and reviewed and signed by the JJDO supervisor. Each MMHS
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indicated the screening was reviewed by a registered nurse (RN) within twenty-four hours. Each
screening was completed in JJIS. Three additional youth IHCRs with rescreenings were
provided. Each youth had a change of custody while in the center and the center completed the
healthcare admission rescreening for one of the three youth. The remaining two youth were
emergency situations; therefore, a re-screening was not required. The center had
documentation from the hospital with recommendations for each youth. The one applicable
rescreening was conducted by a JJDO and was reviewed by the nurse within twenty-four hours.
None of the three youth were applicable for a qualitative urine pregnancy screening test. An
interview with nursing staff confirmed youth are seen the day of admission. If a youth is admitted
after the nurse is gone, the youth will be seen the following day. The center’s staff notify medical
staff when a youth is being admitted and complete a MMHS form. The nurse reported the
supervisor completes the admission screening and the nurse will sign on the third page of the
admission screening form, indicating a review of the form.
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 requiring all youth to be oriented to the
general healthcare delivery services at the center. A review of five youth Individual Healthcare
Records (IHCRs) supported each contained a completed Department Health Education form
documenting the youth’s orientation to the center’s healthcare services. Each youth received a
general healthcare orientation on the day of admission to the center. Reviewed documentation
supported each youth’s orientation included all required elements. Additionally, youth are
oriented on the non-disciplinary role of the healthcare providers, availability of healthcare staff,
dental hygiene, sexually transmitted infections, personal hygiene, immunizations, infection
control, nutrition, self-examinations, and a review of healthcare contacts.
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 maintains facility operating procedures which require notification to the designated
health authority (DHA) of all youth admitted with chronic health conditions or youth in need of
emergency care. A review of five Individual Healthcare Records (IHCRs) indicated there were
four youth identified with a suspected chronic medical condition. In each instance, the DHA was
notified within twelve hours of the youth’s admission and a notification was documented in the
IHCR. There were no youth identified as in-need of emergency care upon admission. Each of
the five youth records documented the advanced practice registered nurse (APRN) or the DHA
was notified of the youth’s admission and the notification was documented on the nursing
admission chronological notes in each IHCR. After notification, it was confirmed none of the
youth had a chronic condition. Two youth were taking psychotropic medications at the time of
admission and the psychiatrist was notified. An interview with the nursing staff reported when a
youth is admitted with a serious or chronic condition, the nurse contacts the DHA by telephone
as soon as the youth is seen in the nursing office. This information is documented on the intake
log, as well as the admission form.
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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 maintains facility operating procedures requiring completion or review and updating
of the Department’s standard Health-Related History (HRH) form. A review of five youth
Individual Healthcare Records (IHCRs) found each contained a HRH form completed
electronically by a licensed nurse within seven days or less of the youth’s admission to the
center. All five of the HRH forms were reviewed by the designated health authority (DHA) or
advanced practice registered nurse (APRN) and were maintained in each youth’s IHCR. Each of
the applicable HRHs were completed before the Comprehensive Physical Assessment (CPA)
and reflected the most current admission into detention. The nursing interview confirmed the
HRH is completed by the medical staff within seven days of the youth’s admission.
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 requiring a Comprehensive Physical
Assessment (CPA) form to be completed or updated for all applicable youth admitted to
determine the health and well-being of each youth. A review of five youth Individual Healthcare
Records (IHCRs) validated each youth had a current CPA on record at admission. Each of the
CPAs were completed and included all required elements. One of the five reviewed youth
records indicated a refusal to a portion of the examination and contained a signed refusal form
reflecting the refused portion of the CPA. The Department’s Problem List was updated as
needed. A review of five youth IHCRs validated each of the youth had a tuberculosis (TB)
screening completed. There were no applicable IHCRs reviewed which contained a refusal for
the TB examination. There were no applicable youth with any symptoms of active TB in the
center at the time of the annual compliance review. The results of the TB tests were
documented on the CPA’s and Infectious and Communicable Diseases (ICD) forms. During the
interview with nursing staff it was reported the CPA is completed for new youth within seven
days of admission. A new CPA is needed every two years if a youth is Medical Grade one and if
a youth’s Medical Grade changes a new CPA is needed within a year. The TB screening shall
be completed within seventy-two hours of admission if one is not documented in the IHCR
within the last year.
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 (FOPs) requiring all youth to be evaluated
and treated, if necessary, for sexually transmitted infections (STIs). A review of five youth
Individual Healthcare Records (IHCRs) indicated three youth were applicable and were
screened for STIs. Each applicable youth required further evaluation and were referred. Each of
the applicable youth’s screening results were documented on the Department’s STI form and
Infectious and Communicable Disease (ICD) form located in the IHCR. Two of the three youth
were ordered for STI testing. One of the two records contained testing results, clinical
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evaluations, and diagnosis which was documented on the ICD form and filed in the lab section
of the IHCR. One youth refused testing. None of the reviewed youth were applicable for a
gynecological exam. A review of five youth IHCRs found none of the youth were out of the
Department’s physical custody for more than thirty days. The center maintains FOPs providing
each youth with the opportunity to receive counseling, testing, and treatment for human
immunodeficiency virus (HIV). Documentation showed three youth were offered counseling,
testing, and treatment/referral for HIV. One youth consented to HIV testing. Documentation
supported the youth received HIV testing while at the center. The results were filed in the IHCR
in a sealed envelope marked “CONFIDENTIAL” consistent with Florida Administrative Code
requirements. The youth was released from the center prior to the delivery of post-test
counseling. Five youth were interviewed, and each stated they can ask for a HIV test. During
the interview with nursing staff, it was reported STI screenings, evaluations, referrals, and tests
are documented on the ICD form as well as a progress note. Youth are required to read and
sign a HIV form to indicate whether they consent or do not consent to being tested. If the youth
consents, they are added to the HIV testing log. Documentation of the pre/post-test counseling
is documented in the IHCR. The advanced practice registered nurse (APRN) is providing HIV
pre-test counseling, testing, and post-test counseling. The APRN meets with the youth
individually and does the HIV pre-test counseling and testing then the youth is later brought
back to go over the results and receive post-test counseling. When the test is reviewed, the
DHA signs the log and the ICD form is updated indicating the youth was tested. The post-test
counseling is documented on the Health Education Record form. When a youth needs a
rescreening, the nurse will complete a new screening form and the form is reviewed by the
designated health authority (DHA).
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 maintains facility operating procedures regarding sick call processes and requests.
The center conducts sick call seven days a week to respond to a youth’s medical illness or
injury of a non-emergent nature by a healthcare professional. Postings throughout the center
indicate sick call takes place seven days a week from 8:00 a.m. to 10:00 a.m. The shift
supervisors and authorized staff are trained by a registered nurse (RN) on the center’s sick call
procedures and are to review the sick call requests in the absence of the healthcare
professionals. Youth who require a sick call will inform staff of their complaint and staff will
generate a sick call request in the Department’s Juvenile Justice Information System (JJIS).
When the level of need for the youth cannot be determined, the on-call practitioner/designated
health authority (DHA) shall be contacted for guidance and referral to the emergency room or
off-site emergent care. The nurse reported youth notify staff of the medical complaint and staff
enter the sick call in the JJIS. The nurse checks the sick call list twice a day and then has
twenty-four hours to see the youth. The licensed practical nurse (LPN) and RN complete sick
calls. When the LPN completes the sick call, the RN has twenty-four hours to review the form,
or the LPN will call the DHA for review. The DHA will conduct sick calls when on-site. All sick
calls are conducted in the nurse’s clinic daily from 8:00 a.m. to 10:00 a.m., and as needed.
When a youth presents with a similar sick call complaint three or more times within a two-week
period, the youth is referred to the DHA or advanced practice registered nurse (APRN). The
nurse reported the DHA has approved the treatment protocols. When a youth has been placed
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in restricted housing/confinement and has medical complaints, the nurse will meet with the
youth every twenty-four hours which is documented in an episodic note. A review of five youth
Individual Healthcare Records (IHCRs) indicated none of the youth had submitted sick call
requests. The center provided an additional three IHCRs for review. Documentation in each of
the three IHCRs indicated the sick call was conducted by the registered nurse (RN) within
twenty-four hours. It was documented on the Sick Call Referral Log when the sick call was
submitted prior to the beginning of the nursing shift. Two of the three were not entered in the
Facility Management System (FMS) because the youth submitted the request after the nurse
printed or entered sick calls. There were no instances in which a youth presented with a similar
sick call complaint three or more times within a two-week period or of a youth complaining of
any severe pain with which staff were unfamiliar. There were no applicable youth for an
immediate referral and/or notification to the DHA. Sick call forms documented the nature of the
complaint, assessment, and plan to include subjective, objective, assessment, and plan (SOAP)
note format. A review of three Sick Call Request forms verified they were in the youth’s IHCR in
reverse chronological order. All applicable sick call events were documented on the Sick Call
Index and dates correlated. A sick call observation was conducted during the annual
compliance review week. The youth was escorted by direct care staff to the clinic. The RN
discussed the nature of the sick call with the youth. The youth was seen in the medical clinic for
privacy which contains an examination table and equipment to perform sick calls. Five staff
were interviewed and four indicated the nurse and supervisor review sick calls. Two staff
reported the nurse conducts sick call and three reported staff conduct sick call. Five youth were
interviewed, four youth reported never requesting a sick call, and one youth reported being seen
within one day. The one youth reported the nurse conducted the sick call.
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 ensuring a comprehensive process of
episodic care, first-aid treatment, and emergency care. Five youth Individual Healthcare
Records (IHCRs) were reviewed, of which four were applicable for episodic or first-aid care
events. Each applicable IHCR documented problem-oriented elements which were used to
capture pertinent information pertaining to the nature of the youth’s ailment including
identification of the subjective, objective, assessment, and plan (SOAP) elements to address the
complaint for each incident. A review of the applicable youth IHCRs indicated the center had no
applicable episodic care events conducted by non-healthcare staff. Each reviewed applicable
record had a documented progress note containing all required elements. None of the four
applicable IHCRs contained an off-site care referral. Three of the four applicable IHCRs
contained follow-up plans for future care, alert list documentation, and/or parental/guardian
notifications. Each of the four youth received episodic or first-aid care and the licensed
healthcare staff documented the care on the Episodic Care Log. The center has eighteen first-
aid kits strategically located in areas frequented by youth. Four of these kits are designated for
the center’s transport vehicles. Observations of three first-aid kits from the medical office,
master control, and one vehicle verified each kit was stocked with approved supplies with no
expired contents. Reviewed documentation confirmed the kits were monitored monthly by the
nursing staff and were replenished as needed. The center has two automated external
defibrillators (AEDs) located in the medical clinic and master control. Each AED is equipped with
automated instructions. The medical staff monitor the AEDs monthly to ensure the devices are
operable. A review of the AED check logs since the last annual compliance review validated this
practice. The AEDs are maintained by a contracted provider who checks the devices on an
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annual basis to ensure they are operable and the battery and pads have not expired. During the
annual compliance review week, observations were conducted while the nurse completed a
self-test on the devices with no issues. The AED batteries were last replaced in April 2023 and
are monitored by the contracted provider annually, with an expiration date of August 2025. The
AED pads were last changed in April 2023 and each have an expiration date of August 2028.
The center conducts emergency medical drills at least once quarterly on each shift, and
emergency drills including cardiopulmonary resuscitation (CPR)/AED are conducted at least
once a year on each shift. A review of quarterly emergency drills from March 11, 2023 to March
5, 2024, verified the center conducted drills as required. Emergency contact numbers were
observed to be posted in the medical clinic. Five staff training records verified staff received
CPR/AED/first-aid training. A review of five in-service and five pre-service training records
supported each staff received the required training on the center’s Emergency Care Plan. A
review of supervisory staff records documented each received training on the administration of
an epinephrine auto injector. Reviewed documentation supported the designated health
authority (DHA), the advanced practice registered nurse (APRN), and all nursing staff
maintained current certifications in CPR and AED. Documentation confirmed all nursing staff
and authorized supervisory staff are trained in the NARCAN® procedures and NARCAN® is
stored within the medication cart. The procedures for NARCAN® require all staff to be trained
on administration and the NARCAN® must be stored in a locked cart only accessible to
authorized staff. Four of the five interviewed youth reported the medical services are very good
and one youth reported not receiving medical services at the center. Each of the five
interviewed staff reported being able to call 9-1-1 if necessary. The nurse reported the first-aid
kits are located on all modules, classrooms, intake, kitchen, master control, staff lounge,
supervisor’s office, and vehicles. The nurse explained episodic care is provided by licensed staff
and is entered in the youth’s Electronic Medical Record (EMR) in an episodic care progress
note. When staff provide episodic care, the care is documented on the Report of On-Site Care
by Non-Healthcare Staff form. When Episodic care is provided by off-site staff, a follow-up
evaluation is required by medical staff when the youth returns to the center. The off-site
emergency care is documented in the EMR off-site care log.
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 to provide for referrals and coordination of
medical services to ensure youth have timely access to off-site care services. A review of five
Individual Healthcare Records (IHCRs) found one youth was applicable for off-site care;
therefore, two additional applicable youth records were reviewed. Each applicable youth was
taken off-site for medical care. Two of the three applicable youth were taken off-site due to
emergency off-site care, and one had a scheduled appointment. The designated health
authority (DHA) was notified of each healthcare event. A Summary of Off-Site Care Consultation
Report form was completed, and discharge documentation was filed in the youth’s IHCR. Each
reviewed applicable IHCR contained discharge documentation and instructions. The remaining
two youth records included recommendations from the hospital which were signed by the
physician. The DHA documented a review of the off-site care findings, instructions, and
information for each applicable youth. Each instance of off-site emergency care was
documented on the Episodic Care Log. One of the three applicable youth required follow-up
care and the necessary referrals were tracked as needed. The nurse reported off-site care is
documented in the EMR. The nursing staff review the orders with the DHA and the DHA gives
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orders to follow while in the center. The DHA reviews all off-site care findings, instructions, and
information each time the DHA is on-site.
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 maintains facility operating procedures to ensure youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. The frequency
of the periodic evaluation is determined by the youth’s condition, clinical needs, and clinically
appropriate medical standards. Youth are screened during the intake process for medical
conditions warranting periodic evaluations and follow-up care. A review of five youth Individual
Healthcare Records (IHCRs) indicated none were identified with a chronic condition. None of
the reviewed youth were diagnosed with a communicable disease. A review youth alerts during
the annual compliance review period and an informal interview with the registered nurse (RN)
verified the center did not have any applicable youth with chronic conditions since the last
annual compliance review. The nurse reported alerts are entered in the Department’s Juvenile
Justice Information System (JJIS) and the designated health authority (DHA) is notified of and
sees youth with chronic conditions. These youth are placed in the chronic condition binder
and/or medical tracker.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center maintains facility operating procedures ensuring all medication and pharmaceutical
products are procured, dispensed, administered, and stored safely, accurately, and in
accordance with state, federal, and industry standards. The center’s nursing staff verify all
medications to ensure each has a current, valid order, and are given according to a current
prescription or practitioner’s order. Nursing staff are to verify medication with the
parent/guardian when they deliver the medication to the center. The Medication Receipt,
Transfer, and Disposition form is used to document medication received in the original
packaging from a licensed pharmacy with a current, legible, patient-specific label affixed. Youth
who are taking medication while in the care of the center will have medication administered by
the healthcare professionals. The center utilizes the Department’s Medication Administration
Record (MAR) for each youth receiving either prescription medications on a routine basis or
over-the-counter (OTC) medications. A review of five youth Individual Healthcare Records
(IHCRs) identified four youth who were taking prescribed medication upon admission and were
applicable for medication management. The nurse verified medications for each of the youth
admitted to the center. Each applicable IHCR contained documentation indicating the
medication was verified by a licensed pharmacist or the designated health authority (DHA). In
each instance, the DHA was contacted to obtain an order to resume the medication and consent
was documented in the youth’s IHCR. The four applicable youth records indicated the youth
were taking medications which were administered according to the DHA’s order and resumed
the specified medications prescribed prior to admission. None of the youth were in restricted
housing requiring medication. Each of the four reviewed records verified all medication and
treatment was documented in the MAR which included the start and end times. Each of the
MARs included all required elements. Four applicable reviewed youth records indicated there
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were no lapses or errors in administered medication. Reviewed policy and procedures indicated
when a youth refuses the medication administration, the refusal will be clearly documented on
the MAR and the Department’s Refusal of Treatment form will be completed. Four reviewed
records indicated none of the youth refused medication. The registered nurse (RN) clinical
manager provides training to the non-licensed healthcare staff. A review of supervisory training
records verified each of the authorized staff were trained in medication administration.
Reviewed documentation indicated non-healthcare staff administered medication to one of the
five youth reviewed. The center maintains a list of staff who are required to have access to the
clinic and medications. The center utilizes a licensed psychiatrist who provides tele-psychiatry
for medication management. Four of the five youth were applicable for having a current
psychiatric medication. Reviewed documentation confirmed the DHA and/or psychiatrist were
notified upon admission. Three of the five youth entered the center on psychotropic
medications. Each applicable youth record contained an Initial Diagnostic Psychiatric Interview
completed within fourteen days of admission. Each youth was applicable to receive medication
monitoring every thirty days. The center did not have any standing orders for psychotropic
medications, no pro re nata (PRN) orders for psychotropic medications, or emergency treatment
orders for psychotropic medications. The center has authorized and trained supervisory staff to
assist youth with self-administration of medication in the absence of the healthcare
professionals. One of the reviewed youth records indicated a non-healthcare staff assisted in
the delivery of OTC medications when licensed medical staff were not on-site. Medication
administration for one youth was observed during the annual compliance review week.
Medication administration is scheduled every day at 8:00 a.m. and 5:00 p.m. and is held in the
medical office. Observations confirmed the youth was escorted to the medical clinic by the
juvenile justice detention officer (JJDO). Observations supported the youth approached the
nurse administering medication individually and the nurse adhered to the Six Rights of
Medication Delivery/Administration by requiring the youth to identify themself, identify the
medication prescribed, and list applicable side effects. The nurse then gathered the prescribed
medication and placed it in a small cup. None of the medication was pre-poured from the
original packaging or placed in another container for subsequent administration. The nurse
poured a cup of water and handed it to the youth, who then took the medication. The nurse had
the youth open their mouth for inspection prior to the youth’s departure. Observations of
medication storage indicated all medications were separated by type, stored in a locked area
designated for storage, and inaccessible to youth. The center maintains a contract with a
licensed pharmacy who comes on-site to dispose of all biohazardous material. The interviewed
nurse reported when a youth arrives with the medication, a medication receipt is filled out. The
nurse reviews the medication to ensure it is from a licensed pharmacy with a patient specific
label on the original medication container. Medications shall have a current, valid order and are
given as ordered on the current prescription or Practitioner Order form. The DHA or psychiatrist
shall be contacted to obtain the order to resume the specified medications the youth is
prescribed prior to admission. One of the five interviewed staff reported administering
medication, the remaining four staff reported they do not administer medication. Four of the five
youth reported not taking medication and the remaining youth reported the nurse administers
medication.
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4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains facility operating procedures requiring medications and any medical
equipment classified as sharps to be secured and inventoried. The medications are kept in a
locked compartment in the medication cart which is also locked. The center has a secure
refrigerator inside the locked medical office. All medication requiring refrigeration is stored in a
secured refrigerator used for medication only. Nursing staff track daily temperatures of the
refrigerator. A review of three over-the-counter (OTC) medications verified the counts were
accurate. The center’s practice is for two nursing staff to conduct shift-to-shift inventory counts
of all controlled medications. All controlled medications are maintained within the locked
medication cart within a separate locked storage box. Observations verified all controlled
medications are stored in the second locked medication box. An inventory review of three
controlled medications was conducted and counts were accurate. The final count, actual count,
and shift to shift counts matched the inventory log and there were no discrepancies. A review of
the daily inventory of prescribed, stock, and OTC medications determined inventories were
completed as required since the last annual compliance review. The center maintains an
inventory of all sharps and medical equipment classified as sharps. Items designated as sharps
are stored in a designated locked cabinet in the medical clinic and are inaccessible to youth.
Any medical equipment classified as sharps are secured and inventoried utilizing a routine
perpetual inventory with descending count as each sharp is utilized and disposed. A review of
three random sharps found the inventory counts were accurate. A review of the perpetual
inventory since the last annual compliance review found the sharps inventory counts to be
accurate. An informal interview with nursing staff validated the center’s practice and procedures
for when inventory discrepancies occur. The center maintains a perpetual daily inventory of
medications to include prescribed and OTC medications. Documentation of each individual
dosage of medication administered to youth is maintained on the Medication Administration
Record (MAR) to document the distribution of medications. Observations of the medical clinic
indicated it is secured and only accessible to the healthcare professionals and approved
supervisory staff. The juvenile justice detention officer supervisors (JJDOSs) are trained by the
registered nurse (RN) to assist youth with self-administration of medications and, in an
emergency, the epinephrine auto injector. The center maintains a contract with a licensed
pharmacist. The center maintains a copy of a pharmacy consultant license on-site. The center’s
disposal practice for controlled medications and non-controlled medications is for the licensed
consultant pharmacist and the on-site nurse to dispose of the expired medication(s) utilizing a
chemical medication disposal agent. All disposals are documented on the Disposition and
Destruction of Medications form. An interview with the nursing staff confirmed the center's
process for the security and disposal of all medication at the center
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4.17 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 maintains facility operating procedures for infection control. The procedures
addressed youth education, needle stick post-exposure evaluation, as well as for staff to have
access to personal protective equipment (PPE) and Hepatitis B immunizations. A review of five
Individual Healthcare Records (IHCRs) indicated all youth received infection control training
within seven days of admission which included hand-washing techniques, universal precautions,
and prevention/transmission of communicable diseases. A review of the Infection Control Plan
verified it followed the Centers for Disease Control and Prevention (CDC) guidelines on infection
control. The plan also addressed common childhood infectious diseases, self-limiting, episodic
contagious illnesses, viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B and C,
human immunodeficiency virus (HIV), bloodborne pathogens, other outbreaks and epidemics,
outbreaks of pediculosis, methicillin-resistant staphylococcus aureus (MRSA) and other
antibiotic-resistant micro-organisms, food-borne illnesses, bioterrorism agents, chemical
exposure in the workplace, and protocols for needlestick post-exposure intervention and
treatment. The center has a list of job classifications in which staff have the potential for
occupational exposure. In addition, a list of tasks or procedures, which would cause the staff in
the job classifications to have occupational exposure. A review of the center’s Exposure Control
Plan indicated it was written in accordance with Occupational Safety and Health Administration
(OSHA) standards and included all required elements of risk assessment and methods of
compliance. A review of the center’s infection control procedures indicated it was written in
accordance with the OSHA and CDC guidelines and included all required elements of
prevention, containment, treatment, and reporting requirements related to infectious diseases.
The nurse reported the Exposure Control Plan is available to nursing staff and is located in the
exposure plan binder. The register nurse conducts the infection control training for staff which is
held annually. The center uses the local county health department for dental, prenatal, and HIV
treatment. The registered nurse (RN) stated the center’s process for needle stick post-exposure
evaluation included making a call to the Department’s Central Communications Center (CCC),
informing administration staff, contacting the medical doctor (MD), processing paperwork,
reviewing camera footage, and transportation to the hospital. Center staff have access to
protective equipment. The superintendent was informally interviewed and stated staff can be
referred to receive the Hepatitis B immunization if needed. There were no instances in which
infectious diseases required the center to contact the local health department or the CCC since
the last annual compliance review. A review of five in-service and five pre-service training
records verified each staff was trained on the Exposure Control Plan.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
A review of five Individual Healthcare Records (IHCRs) indicated none were applicable for
prenatal care/education. An interview with the designated health authority (DHA) verified there
were no applicable youth requiring prenatal services at the center during the annual compliance
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review period. A review of five training records verified each staff received training in youth
healthcare, including observation and monitoring of emergency care needs/symptoms of
possible miscarriage. The nurse reported prenatal care is set up for the youth once it has been
determined the youth is pregnant, obstetrician care is scheduled, the youth is started on a
pregnancy diet, and youth are educated. Female youth entering the center are tested for
pregnancy as long as the youth verbally consents, as ordered by the DHA. The registered nurse
provides non-licensed staff education on girl’s healthcare. Topics such as shaken baby
syndrome, difference of breast feeding and bottle feeding, what to expect with body changes,
and dietary needs are included in the training. Five youth were interviewed, and each reported
they did not need prenatal services.
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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 which outline supervision of youth requirements. The youth
are supervised by staff at all times. Observations of staff supervising youth were conducted each day
of the annual compliance review week. Active supervision was maintained during all observations. The
center uses a bound logbook in each living unit and one in master control. The logbooks are used to
document all movements, head counts, and any major incidents occurring in the center. All movements
were controlled by master control, and staff cannot move youth within the center unless cleared by master
control. Located in master control and in each living module unit is an erasable white board which is used
to track the daily census of youth and the youth behavior management system (BMS) levels. The
census is updated, as needed, when youth are admitted and/or released from the center. Headcounts
are documented in the master control logbook, within each living module logbook, and in the Department’s
Juvenile Justice Information System (JJIS). The center has a daily activity schedule which is posted
throughout the center. During the annual compliance review week, all staff were always aware of the
location of youth in their care. Staff were observed supervising youth during school hours, lunch time, line
movement, and shift change. Five interviewed staff stated there were enough staff to provide for the
safety and security of the staff and youth at the center.
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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 in place to ensure rewards, privileges, and consequences
to encourage youth to fulfill the center’s expectations. During a walkthrough of the center, behavior
management system (BMS) posters were observed to be posted throughout the building in all common
areas where youth may be able to review them. Reward calendars were posted alerting the youth of
rewards and privileges they can earn. Youths' names and levels were posted on a dry erase board for
all youth to be able to see their progress. Staff maintain a BMS data sheet for each youth to
capture the youth’s behaviors throughout the day. The center maintains a logbook to
document all youth who participated in level three rewards and included the days and times of
the events which took place. Reviewed documentation verified there were no instances of
inappropriate use of restrictions or group punishments. Five staff were interviewed and each
stated the BMS uses a level system and BMS posters are posted throughout the center. Two
staff stated the BMS utilizes a point system and three staff stated the BMS is located in the
youth orientation handbook. Each staff stated youth can move up levels by following the
center’s rules, by respecting property, by respecting their peers, and conducting their daily
hygiene. Five interviewed staff stated youth can earn rewards such as utilizing canteen,
receiving extra snacks, watching movies, using the incentive room to play video games,
earning extra visitation, and earning extra phone calls. Three staff stated nothing can be taken
away from youth as a consequence, and two staff stated the youth can receive a level freeze.
Each of the five interviewed staff stated the BMS is effective. Each of the five interviewed staff
stated youth are informed of the consequences being imposed, youth have the opportunity to
explain their behavior, and staff speak with youth about alternative acceptable behaviors. Five
interviewed staff stated supervisors provide feedback on the use of the BMS to staff on a daily
basis. Supervisors review the BMS logbooks, talk with staff one on one, and discuss the BMS
during the daily briefings. All five staff stated they have never seen a co-worker take away
meals, snacks, clothing, education, or medical care from a youth as a consequence for
negative behavior. Each staff stated they have never observed any staff encouraging youth to
beat up other youth. Five interviewed youth rated the BMS as very good or good. Each youth
was able to explain the difference of each level and how to move from level to level. The
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interviewed youth stated they earn rewards such as video game access, snacks, and extra
phone calls, and staff give rewards fairly to all youth. All five interviewed youth stated youth
are never allowed to punish other youth. Three youth stated they have been sent to their
rooms for punishment reasons and two youth stated no, they were never sent to their rooms.
The three youth who were sent to their room as a consequence stated the door was locked
and a staff was monitoring them. Four out of five interviewed youth stated the consequences
they received for negative behavior were fair and one youth stated they have never received
consequences. Each interviewed youth confirmed the center did not use handcuffs or leg cuffs
for out-of-control youth. The interviewed superintendent confirmed the center follows their
policy regarding the BMS.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures to ensure ten-minute checks are conducted when
youth are in their rooms for sleeping or other reasons. The center has a total of fifty-nine surveillance
cameras and fifty-eight were operational during the annual compliance review week. A work order was
submitted to have the one camera repaired. The cameras have a recording capacity of thirty days. When
conducting room checks, staff must pause at each room door and observe youth in the room to ensure
there are no issues with the youth. The center utilizes an electronic wand system to document room
checks. A review of documentation and surveillance coverage was conducted for three different
modules. Two reviews of ten-minute checks on “B” shift were conducted for youth in confinement, and
five video reviews were conducted on “C” shift for youth in their sleeping quarters, totaling fifteen checks. All
reviewed checks were conducted within the ten-minute time frame with the exception of one check which was
one minute late. These observations were conducted on four different days and times. The reviews were
completed with the corresponding ten-minute log sheets which were completed in real time. Staff were
observed pausing at each room to observe the youth. A review of sample ten-minute check logs
throughout the annual compliance period verified checks were conducted every ten-minutes as
required. Documentation verified administration staff conducted weekly ten-minute log checks to
ensure fidelity. Five staff were interviewed, and all indicated room checks are conducted every ten
minutes. An interview with the superintendent verified staff conduct visual sight and sound checks
every ten-minutes of youth assigned to their living module unit.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures to ensure headcounts are conducted as
required. Staff must always know the exact number and location of all youth under their
supervision. Head counts are conducted throughout the day, called into master control, and
documented in the center's master control and living module logbooks. There are to be no youth
movements until master control confirms the counts, reconciles the count, and authorizes center
activities to resume. A review of the master control logbooks and living unit logbooks since the
last annual compliance review verified headcounts are documented at the beginning and end of
each shift, following any emergency situations, whenever a population change occurs, and
randomly on each shift. An observation of youth movement was conducted which verified the
staff called the number of youth being moved into master control and received confirmation prior
to moving the youth. Five staff were interviewed, and each stated counts are conducted at the
beginning of each shift, end of each shift, and during all movement. If counts are not correct, all
activities are stopped, and a recount is done. Five staff stated emergency counts are conducted
when a youth is believed to be missing, when visibility is hindered, during an electrical outage,
and when there is a major disturbance.
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Office of Accountability and Program Support Page 51 of 60 (Revised July 2023)
5.05 Logbook Maintenance 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 center maintains facility operating procedures regarding logbooks. The center maintains separate
logbooks in master control and for each living module, sign-in logbooks for visitors, and one for contracted
and education staff. A review of logbooks since the last annual compliance review revealed each logbook
was bound with numbered pages, all entries included the date and time of the event or incident, the name
of the staff and youth involved, and the initials of the staff making the entry. All reviewed entries revealed
the safety and security of the center, including medical, special needs, and mental health alerts were
highlighted. Reviewed logbooks reflected all errors were struck through with a single line, voided, and
initialed by the person correcting the error. There was one instance where the supervisor did not
comment regarding the corrected error, which was discussed with administration during the annual
compliance review week. The reviewed master control logbooks included emergency situations,
incidents, fire and escape drills, population counts at the beginning and end of each shift, group
movements, admissions and releases, presence of law enforcement, name of youth placed in
confinement including the time confinement began and the time confinement ended, and name of youth
placed on precautionary/secure observation including the time precautionary/secure observation began,
and time precautionary/secure observation ended. Logbook documentation also indicated adherence to
the educational schedule. Documentation verified the supervisor reviewed the master control logbook
when accepting responsibility for the center and reviewed the living area logbooks daily.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center maintains facility operating procedures regarding logbook reviews. The master
control and module logbooks for the last twelve months were reviewed. The supervisors review
the logbooks each shift, including the master control logbook when accepting the shift, to
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document they are aware of current relevant situations in the center. The officer assigned to the
modules conducted reviews of the logbook upon accepting the shift and documented the pages
reviewed. Logbooks contained documentation to support the superintendent or designee toured
the youth living modules at least once during each shift. Reviewed documentation for the annual
compliance review period found the superintendent or designee reviewed the logbooks weekly;
however, there were six instances where the master control logbooks were not reviewed by the
superintendent or designee. The interviewed superintendent confirmed the superintendent or
designee reviews all logbooks at a minimum of weekly and reviews the entries for the last
seventy-two hours. The reviewed documentation must be highlighted in yellow. A supervisor
must review the master control logbook, going back seventy-two hours, and document their
presence in the living area logbooks for every shift.
5.07 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.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center maintains facility operating procedures to ensure and maintain an inventory of all the
center keys. The center keys are maintained on a color-coded, tamper-resistant ring with a tag
identifying the ring number and the number of keys on the ring. The center keys are locked and
secured in the supervisor's office in a key box only accessible by the shift supervisor and
administration. Observations and an informal interview with the assistant superintendent verified
all restricted keys are secured in the supervisor key box. Emergency keys providing egress
through exterior doors are stored in master control and a key inventory binder is maintained in
the maintenance office for each key. The inventory identifies the ring number, number of keys
assigned to the ring, the location assigned to the keys, and the staff assigned to the keys. When
staff enter the center, personal keys are placed in a locked key box located in master control
prior to entering the secure area of the center. Keys are distributed after shift briefing by the shift
supervisor. Staff sign the key logbook and inform the shift supervisor which key they need for
their shift. The assigned key is issued to staff who are on duty. Once the shift is over, the staff
return their work keys to the master control operator, the shift supervisor retrieves the keys and
secures them in the key box in the supervisor's office. A review of the master inventory key log
indicated the inventory log matched the actual key rings in use. A review of the key log indicated
keys are distributed as required by the shift supervisor. Observations verified staff carry their
assigned keys on their person at all times, youth were not allowed to carry center keys, and staff
did not remove keys from the center. A review of the Department’s Central Communication
Center (CCC) reports since the last annual compliance review verified there were no instances
of deficiencies related to key control. A random review of three staff and their assigned keys
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Office of Accountability and Program Support Page 53 of 60 (Revised July 2023)
confirmed they matched the key log. Each interviewed staff knew the function of each key on
the key ring. Five staff were interviewed and verified the medical records, youth property area,
mental health records, case management records, and kitchen keys were restricted. Each
interviewed staff reported they knew the key control process and were able to explain the
process for reporting missing or damaged keys as outlined in the policy. An interview with the
superintendent verified the center follows the key control policy.
5.08 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 which is used to transport youth. The center’s maintenance
mechanic is responsible for the weekly and monthly vehicle inspections. The transportation
supervisor has been designated to complete the vehicle checks daily to ensure all vehicles are
equipped and readily available to drive. The center has a total of six vehicles used to transport
youth, and one vehicle used for center staff transportation. Reviewed documentation verified
each vehicle had an annual safety inspection conducted by a certified automobile mechanic. All
seven vehicles have the appropriate number of seatbelts, a seatbelt cutter, a window punch, up-
to-date fire extinguishers, and a first-aid kit with approved items by the designated health
authority (DHA). A binder is maintained for each vehicle which contains the vehicle mileage log,
mechanical restraint key, gas card, vehicle registration, vehicle policy, and daily check list.
Weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventive maintenance check sheets. Prior to each transport, a pre-trip
vehicle inspection is conducted by the transporting staff and documented in the vehicle logbook.
An observation of a youth transport was conducted. Prior to transporting youth, staff inspected
the vehicles for contraband, conducted a fuel check, maintained copies of transportation
procedures in the vehicle, verified the seatbelts were operational, ensured the security screen
was secure, confirmed the vehicle folder included the logs, vehicle and mechanical restraint
keys, gas credit card, and vehicle registration. In addition, staff had a center-issued cellular
telephone, documented the inspection in the logbook, ensured the vehicle was secured at all
times, ensured the youth were searched prior to being placed in the vehicle, and ensured youth
and staff were wearing their seatbelts. A check of seven center vehicles found the side door of
two vehicles were not secured and a state vehicle was not locked. Staff immediately locked the
vehicles and it was reported to the superintendent during the annual compliance review week.
Five youth were interviewed and each stated they felt safe when staff were transporting youth.
Each youth verified they never observed anyone placing contraband in a transport vehicle.
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center has facility operating procedures to ensure all tools and equipment related to
maintenance and the kitchen area are properly maintained, stored, and inventoried. All tools
were in a secured area which is accessible by the maintenance staff, supervisors, and
administrators. Tools are stored on a shadow board which allows the easy identification of
missing tools. The center maintains a perpetual inventory of tools. A review of the inventory logs
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Office of Accountability and Program Support Page 54 of 60 (Revised July 2023)
included documentation of the issuance and return of tools. Kitchen tools including knives and
other sharps were stored in a locked box in the kitchen area. A perpetual inventory of kitchen
tools was maintained and counts were documented throughout the day. Observations of the tool
room and the kitchen verified all tools were secured when not in use. A review of the tool
inventory lists verified there were no tools found to be missing. There were no tools which were
not listed on the inventory sheets. In an informal interview, the maintenance mechanic verified
service vendors are accompanied by center staff at all times when in the secure area of the
center. An informal interview with the maintenance mechanic confirmed when tools are lost and
when a work project is completed, the area is cleaned and inspected for contraband prior to
allowing youth access. The food service staff and maintenance staff were informally
interviewed. The staff were able to explain the process for missing or damaged tools. A review
of ten unique tools in the maintenance room and the kitchen verified each was secured, had
marking for easy identification, the inventory was accurate, and the inventory log was signed by
the superintendent or designee. In a formal interview, the superintendent stated if a tool goes
missing it is reported to the superintendent immediately. Tools are placed back on the shadow
board after the repair or project is completed and signed back into the tool logbook. Broken or
defective tools are documented in the tool logbook and removed for repair, replacement, or
immediate disposal. While waiting for a new tool or a tool to be repaired, a tag stating damaged
or vacant (if disposed) is placed on the shadow board. Five interviewed staff stated if a tool is
damaged or missing, they would complete an incident report, notify the supervisor, document in
the logbooks, call the Department’s Central Communication Center (CCC), review video
footage, and conduct searches.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center has facility operating procedures regarding youth access or use of any tools. Youth
may use Class B tools which include mops, brooms, buckets, and other common household
items. When youth are using Class B tools they are under direct supervision. One youth was
observed wiping down the dining room table with a pre-soaked dish towel which was provided
by staff. Staff were observing the youth while the youth was conducting cleaning duties. Four of
the five youth interviewed stated they are allowed to use tools such as mops and brooms when
doing general cleaning, and one youth stated they do not use any tools. Four of five interviewed
youth stated they did not use any cleaning chemicals, two youth stated staff spray the cleaning
chemicals and youth wipe it up. Five staff were interviewed and each stated youth are allowed
to use mops and brooms.
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Office of Accountability and Program Support Page 55 of 60 (Revised July 2023)
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
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 Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS 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.
The center has facility operating procedures regarding inventory of all flammables, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
secure storage areas with limited access. Safety Data Sheets (SDS) and logbooks are located
where the chemicals are stored in a secured shed outside of the center which is inaccessible to
youth. Monthly Inventories of flammable, toxic, caustic, and poisonous items are maintained by
the maintenance staff and reviewed and signed by the superintendent or designee. The
inventories were compared to the items on-site and were found to be accurate and complete. A
review of five unique chemicals found the chemicals were secured, the actual count matched
the ending count on the inventory list, and the SDS were present for each item reviewed.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
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 to ensure limited access to flammable, toxic,
caustic, and poisonous items. These Items can only be used by authorized staff. The center
maintains a list of authorized staff who have approved access to the chemical storage.
Chemical storage is located outside the secure area of the center. Youth are not permitted to
use or handle hazardous chemicals. Five youth were interviewed and each stated they do not
have access to flammable, toxic, caustic, and poisonous items. Five staff were interviewed and
each stated youth are not allowed to clean with any type of cleaning agent such as bleach,
laundry soap, window, or toilet cleaner. One staff stated staff spray down the areas in need of
cleaning with the cleaning agent and the youth will wipe it down.
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5.13 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 to ensure flammable, toxic, caustic, and
poisonous items are disposed of according to the manufacturers Safety Data Sheet (SDS). The
maintenance mechanic at the center reported there have been no chemicals disposed of during
the annual compliance review period. The center’s food director reported the center does not
utilize grease for cooking. All kitchen liquid waste is disposed in the kitchen drain. Reviewed
documentation and an informal interview with the maintenance mechanic verified there were no
toxic spills during the annual compliance review period. The maintenance mechanic stated all
chemicals are used up and the center did not dispose of any chemicals during the annual
compliance review period.
5.14 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 which outline the process of placing youth in
confinement under twenty-four hours. The procedure requires staff to 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 two designated confinement rooms; however,
they do not use the designated confinement rooms. The center utilizes the youth’s assigned
sleeping rooms for confinement. If staff are unable to utilize the youth’s sleeping room, then they
will use the designated confinement rooms. During the annual compliance review period the
center had a total of four hundred eighty-nine confinements. Twenty youth confinement records
were reviewed. Each of the twenty reviewed youth confinement records contained
documentation which ensured each youth had the right to have three meals a day plus evening
snack, access to mental health care as needed and requested, daily showers, clean clothing,
mattress/bedding, education materials during school hours, and right to grieve a confinement
placement. Documentation verified the supervisor approved the confinements, staff placed only
one youth in the confinement room, the room was searched, and documentation of the search
was entered in the Department’s Facility Management System (FMS) prior to placing a youth in
confinement for all twenty reviewed records. A review of twenty Visual Observation Reports
(VORs) verified staff were observing youth in confinement at least every five minutes for the first
hour. After the first hour, youth were observed according to the Detention Supervision Matrix.
Nine of the twenty reviewed records documented a physical injury was observed and a
healthcare professional was immediately notified for an assessment and treatment, which was
documented in the youth’s Individual Healthcare Record. Each of the reviewed confinement
records documented the reason for the confinement was explained to the youth. All twenty
reviewed records verified the supervisor conducted an initial confinement review with the youth
within one hour of the incident, a full report was completed before the end of shift, the
supervisor conducted additional reviews with the youth at a minimum of every three hours, and
all reviews were entered in FMS. All twenty reviewed confinement reports documented staff and
supervisors continually counseled the youth and considered removing the youth from
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confinement as soon as the youth was able to safely rejoin the population and was no longer a
threat to safety. Reviewed documentation verified the confinement did not interfere with
visitation in any of the reviewed records. The center did not have any pregnant youth in
confinement under twenty-four hours during the annual compliance review period. An
observation of the confinement rooms verified the cameras and plexi-glass windows were free
of obstructions; however, there was peeling paint in the rooms. Some plexi-glass windows had
scratches; however, the youth were still visible in the confinement room. The interviewed
superintendent stated behavioral confinement is an immediate, short-term, crisis management
strategy for use during situations in which one or more youth's behavior imminently and
substantially threatens the physical safety of others or compromises security. The
superintendent or designee reviews all confinement reports within forty-eight hours, excluding
weekends and holidays, and determines whether each confinement was appropriate or
inappropriate. Five staff were interviewed and each stated the process for placing a youth in
confinement includes conducting a room search, completing a confinement report, conducting
five-minute checks the first hour, and conducting ten-minute checks after the first hour. All five
interviewed staff stated youth are provided education materials when placed in temporary
confinement during school hours.
5.15 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.
5.16 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 a Continuity of Operations Plan (COOP) which requires drills to be conducted
and documented, at a minimum of twice a year, with one drill being completed prior to the
hurricane season. Reviewed documentation verified the center conducted two drills during the
annual compliance review period, and one was completed prior to hurricane season. The
Emergency Drill Reporting form included the type of drill, date and time of the drill, participants,
a brief scenario, findings and recommendations, and reviewer comments. Five staff were
interviewed and each stated they participated in COOP drills during the annual compliance
review period. The superintendent was interviewed and stated each center has a planned and
comprehensive approach to effectively manage emergencies and disaster events including
those which require the center to relocate its youth and staff while maintaining operations,
safety, and security.
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5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures regarding developing, implementing, and
maintaining an Escape Prevention Plan. A review of the center’s Escape Prevention Plan
verified it included the Department’s established policies and procedures regarding escapes. A
review of the center’s drills confirmed escape drills were conducted quarterly during the annual
compliance review period. The Emergency Drill Reporting form included scenarios, a synopsis
of the incident, start and end date and time of drill, detailed information of problems and
concerns during the drill, and a staff sign-in attendance roster. Logbooks were reviewed and
revealed each escape drill was documented in the logbook. A review of five staff training
records confirmed the staff were trained in escape prevention annually. Five staff were
interviewed and each stated they participated in an escape drill since the last annual
compliance review.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has facility operating procedures for the implementation of disaster preparedness
and fire prevention plans. A review of the Emergency Drill Reporting forms since the last annual
compliance review verified fire drills were conducted monthly on each shift with the exception of
one drill which was not conducted during the month of July 2023 for “A” shift. The Emergency
Drill Reporting forms contained all the essential elements which included the type of drill, a
synopsis of the incident, start and end date and time of the drill, detailed information of problems
and concerns during the drill, and a staff sign-in attendance roster. A review of the logbooks
verified the reviewed fire drills were documented. Observations confirmed the annual inspection
of fire extinguishers was completed as reported. Five staff were interviewed and each stated fire
drills take place at least monthly, and each participated in a fire drill. Five youth were
interviewed and each stated they were instructed on what to do in case of a fire.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 59 of 60 (Revised July 2023)
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures which addresses illegal contraband, prohibited items, and how
to reduce the introduction of contraband into the center. A review of the center’s policy and observations
during the annual compliance review week verified prior to admission, a full body search and electronic
search is completed. In addition, searches are conducted when deemed appropriate by the shift
supervisor, when there is a reasonable suspicion a youth is harboring contraband, and during center-wide
initiatives to reduce the introduction of contraband. An observation of a new admission into the center
verified staff wore gloves during the search. There were two same-gender staff present when the search
was conducted. The observation verified the search was conducted individually in a private area and not in
a group setting. A review of the center’s policy and observations verified staff and visitors were electronically
searched when entering the secure area of the center. All bags, cases, jacket pockets, and shoes were
searched. All personal keys, personal cellular phones, and other contraband items were prohibited in the
secure area of the center. Youth room searches are documented on the shift reports and are uploaded
electronically. A review of random shift reports for one day for 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 found there were five instances 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. Confiscated items
were secured and hand delivered to the supervisor. Reviewed documentation showed the shift supervisor
documented the chain of custody for the contraband items and the regional director was notified. Local law
enforcement was contacted for the items considered illegal as defined by Florida Statute. An interview with
the superintendent stated staff shall be diligent in their efforts to prevent the introduction of contraband into
the center. Staff are to stay alert at all times, be observant in all supervision, and conduct appropriate
search techniques which greatly enhances the ability to maintain safe and secure centers, staff, and youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 60 of 60 (Revised July 2023)

report_type: QI Detention

file_name: Brevard Detention-FINAL-FY2324.pdf