state: FL

summary: QI Detention - FY24-25 - 7 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
St. Lucie Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
1301 Bell Avenue
Fort Pierce, Florida 34982
Review Date(s): May 6-9, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Yvrose Sylvain, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Interviews)
Peter Keelan, Office of Education, Southeast Region (Standard 2)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tyler Mocere, Detention Center Superintendent, Brevard Regional Juvenile Detention Center
(Standard 5)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Alissa Spearman, Assistant Detention Center Superintendent II, Collier Regional Juvenile
Detention Center (Standard 5)
Program Name: St. Lucie Regional Juvenile Detention Center MQI Program Code: 225
Provider Name: State Operated Contract Number: N/A
Location: Saint Lucie County / Circuit 19 Number of Beds: 50
Review Date(s): May 6-9, 2025 Lead Reviewer Code: 125
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
Limited Ratings Failed Ratings
2.10 Educational Access*
3.13 Suicide Prevention Training *
3.15 Emergency Care Plan *
4.12 Episodic/First Aid Care/Emergency Care
4.18 Prenatal Care/Education
5.03 Ten-Minute Checks*
5.15 Fire Drills
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 54 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 54 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
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 54 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
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 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Limited
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Limited
3.16 Crisis Assessments * Satisfactory
3.17 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 54 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Limited
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 Limited
* 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 54 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
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* Limited
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Limited
5.16 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 54 (Revised July 2023)
Program Overview
The St. Lucie Regional Juvenile Detention Center is a state-owned detention center, operated
by the Department, located in Fort Pierce, Florida. The center serves youth in St. Lucie, Martin,
Indian River, and Okeechobee counties in Circuit 19. The St. Lucie Juvenile Assessment Center
(JAC) is connected to the center. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-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 St. Lucie County School District.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, and
forty-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), three licensed mental health counselors,
one statewide psychologist, and one counselor. Clinical services provided by the center include
mental health and substance abuse evaluations, mental health treatment planning, individual,
group and family therapy, mental health crisis intervention services, on-site psychiatric services,
and availability for substance abuse services for youth with co-occurring disorders. Medical
services are provided by one designated health authority (DHA), one advanced practice
registered nurse (APRN), one full-time registered nurse (RN) serving as the clinical manager,
two full-time registered nurses (RNs), and one full-time licensed practical nurse (LPN).
Additionally, the center had a part-time RN, who is utilized on weekends and as needed. The
medical clinic maintains nursing coverage seven days a week, from 7:00 a.m. to 8:00 p.m. on
weekdays and on weekends from 8:00 a.m. to 4:30 p.m. Food services are provided by
Department staff and include menus, meal planning, meal schedules, special diets, nutritional
analysis, daily allowance, food preparation, health certifications, food product standards,
sanitation, and cleaning. Staff are responsible for the custody and control of youth in their care,
providing youth supervision twenty-four hours a day, seven days a week. The center has three
living modules which are divided by male and female. There are sixty-four security cameras at
the center, of which sixty-one were operational. The three cameras which were not operational
were in areas where youth do not access. The center was observed to be clean and free from
insect infestation. Common areas, living modules, bathrooms, classrooms, kitchen, and dining
areas were observed to be clean, organized, and well maintained. A tour of the center was
conducted during the annual compliance review and observations found there was graffiti on
several rooms in the male modules and one room in the female module. At the time of the
annual compliance review, the center had ten vacancies, which included five juvenile justice
detention officer Is (JJDOI), three juvenile justice detention officer IIs (JJDOII), and two juvenile
justice detention officer supervisors (JJDOS).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 54 (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 facility operating procedures (FOPs) 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 8, 2025, 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 14, 2025. A review of records for eleven center staff, four contracted staff,
one teacher, and one volunteer confirmed each staff and volunteer received an initial
background screening prior to contact with youth and confidential records. Documentation
reflected a criminal history report was reviewed for each of the staff and the one volunteer.
None of the reviewed records were applicable for obtaining an exemption prior to working with
youth. The center utilizes an ergometric pre-employment assessment tool for all direct care
applicants. A review of the eleven direct care staff records indicated each staff completed a pre-
employment assessment and received a passing score. A copy of the pre-employment
assessment was maintained within the staff’s records. The one applicable volunteer was added
to the Clearinghouse Employee Roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center maintains facility operating procedures (FOPs) to ensure all staff, contracted
providers, and volunteers with access to youth undergo a criminal history background check
every five years. The center had six staff and two volunteers applicable for a five-year
rescreening since the last annual compliance review. Each staff and volunteer rescreening was
completed and submitted to the Department’s Background Screening Unit (BSU)/Clearinghouse
prior to their anniversary date. There were no 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 54 (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 (FOPs) 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
three staff personnel records confirmed each staff had signed a code of conduct prohibiting any
form of abuse, profanity, threats, harassment, or intimidation. The code of conduct addressed
officer professionalism, poor performance, negligence, insubordination, conduct unbecoming of
a public employee, and misconduct. Right Interactions (RI) Reports and the Department’s
Central Communication Center (CCC) reports were reviewed for violations related to the code of
conduct. A review of three staff who received disciplinary actions for violations of the code of
conduct during the annual compliance review period was conducted. Reviewed documentation
found management took immediate action regarding the staff involved incident by initiating an
internal investigation in all incidents. Documentation supported two staff received training and
one received a written reprimand for violations of the code of conduct. Three staff who received
commendations during the annual compliance review period were reviewed. The center had
one staff who received juvenile justice detention officer supervisor (JJDOS) of the year, one
administrative assistant staff received support staff of the year, and one JJDO received elite
accolade of the year in December 2024. Seven 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. Four interviewed youth stated staff occasionally
use profanity when speaking to youth, two youth reported never having heard another staff
using profanity while speaking with youth and one reported hearing another staff using profanity
while speaking to youth once. Each youth stated they have never heard staff threaten youth at
the center. All seven-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. All
seven interviewed staff explained the process for allowing staff and youth to call the Florida
Abuse Hotline or the CCC to report suspected abuse. Each of the seven staff stated they have
never heard a co-worker using profanity when speaking with youth. All seven staff stated they
have never observed a co-worker using threats, intimidation, or humiliation when interacting
with youth. Seven staff were asked about the working conditions at the center. Three staff
stated working conditions were good, two stated very good, and two stated fair. An interview
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 54 (Revised July 2023)
with the center’s superintendent reported the statewide code of conduct is used. If any abuse is
alleged towards youth, it is called in to the Florida Abuse Hotline, the CCC, and the staff is
removed from youth contact. An investigation will be conducted and upon completion of the
investigation staff will face disciplinary action if warranted.
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 (FOPs) 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 ninety-three reportable incidents since
the last annual compliance review. A review of nine incidents found the center reported each to
the CCC within two hours of the incident. Each incident was documented in the center’s
logbook, when applicable. 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.
During an interview with the center’s superintendent, it was reported whenever a reportable
incident occurs, staff are required to contact the CCC within two hours of gaining knowledge of
any reportable incident and contact the Florida Abuse Hotline with any allegations or
suspected child abuse.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center maintains facility operating procedures (FOPs) to ensure staff use physical
intervention techniques in accordance with the Florida Administrative Code requirements. The
center had ninety-three Right Interaction (RI) incidents during the annual compliance review
period. A review of nine RI Reports indicated all were completed the same day as the RI
incident and contained statements from each staff involved. All nine RI Reports were reviewed
by a supervisor, a post-RI interview was conducted by an administrator, and each was reviewed
by the superintendent/designee within the required time frame, except for one RI Report where
a post-RI interview was not conducted. None of nine incidents were applicable for a medical
review due to the post-RI interviews. None of the reviewed RI Reports indicated serious injury to
the youth or staff. None of the nine incidents required mechanical restraints. A review of internal
incident/grievance reports and logbooks indicated there were no additional incidents which
required a RI Report. The center’s RI rate during the previous quarter was 7.68, which is below
the statewide Detention RI rate of 13.49. An interview with the superintendent indicated all RI
Reports must be completed the same day. In addition, the superintendent stated RI Reports and
related video are reviewed by an administrator within seventy-two hours excluding weekends
and holidays. Seven staff were interviewed, and each indicated staff utilize verbal interventions
prior to using physical restraints or mechanical restraints on a youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 54 (Revised July 2023)
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 (FOPs)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 seven staff training records
for pre-service training indicated four staff completed all required trainings within 180-days of
hire and new staff orientation was completed within thirty days of hire. Three reviewed staff
records supported the staff were in Phase One training at the time of the annual compliance
review week. All pre-service trainings were documented in the Department’s Learning
Management System (SkillPro). The center did not have any returning direct care staff
applicable for 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 (FOPs) which require staff to complete
twenty-four hours of in-service training each calendar year after completion of pre-service
certification training. The policy 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. Seven staff
training records were reviewed for in-service training, including four direct care staff and three
supervisory staff. Six of the seven reviewed records reflected staff exceeded the required
twenty-four hours of in-service training, and one staff completed twenty-one hours. Each of the
seven reviewed training records verified staff completed human trafficking, Prison Rape
Elimination Act (PREA), sexual harassment, professionalism, interpersonal communication, and
ethics including standards of conduct. Six of the seven reviewed training records verified staff
completed active shooter preparedness and trauma responsive practices. Six of the seven
reviewed training records verified staff completed cardiopulmonary resuscitation (CPR), first-aid,
and automated external defibrillator (AED). Five of the seven completed Right Interactions (RI)
training. One staff was unable to complete training due to being placed on worker’s
compensation light duty and one staff did not complete the training. Five of the seven completed
information security awareness, mental health and substance abuse, and two staff did not
complete the trainings. Three supervisory staff records were reviewed, and each exceeded the
required eight hours of supervisory trainings. Five of the seven reviewed staff had all trainings
documented into SkillPro, and for two staff all the trainings were not documented. The center
has an annual in-service training calendar which is updated as changes occur. The in-service
training plan was approved by the center’s superintendent, the assistant secretary for Detention
Services, and the director of the Department’s Office of Talent, Leadership, and Culture. An
interview with the superintendent was conducted and it was reported detention staff complete
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 54 (Revised July 2023)
twenty-four hours of annual in-service training, as identified in Florida Administrative Code,
beginning the calendar year after the staff has completed pre-service certification training.
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 (FOPs) to ensure 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 posted in each living module and explained
to each youth during the admission and orientation process. A written grievance is submitted to
the juvenile justice detention officer supervisor (JJDOS). If the staff is unable to resolve the
issue, the formal grievance process begins. The appeal phase requires a response from the
superintendent or designee. Grievance forms are electronically maintained in the Department’s
Facility Management System (FMS). Each grievance is forwarded to the on-duty JJDOS within
the required time frame, through FMS, and the youth is informed of the findings. The
superintendent or designee then reviews the completed grievance form within seventy-two
hours of receipt, excluding weekends and holidays. A review of FMS and an informal interview
with the superintendent verified there were six grievances submitted during the annual
compliance review period. Five grievances were reviewed, and each grievance was resolved in
the formal phase by the superintendent within the seventy-two-hour time frame. An interview
with the superintendent was conducted and it was reported there are three phases to the
grievance process which include the informal phase, in which staff attempts to resolve the
complaint using verbal communication skills. The formal phase in which youth submit in writing
their complaint and the juvenile justice detention officer (JDO) will enter the grievance in the
FMS on behalf of the youth. Within two hours, the supervisor will document findings on the
grievance form and advise the youth of what actions, if any, may be taken. During the appeal
phase, the superintendent reviews the grievance form at a minimum, within seventy-two hours.
Seven youth were interviewed and all seven knew the process for submitting a grievance. Each
of the seven-youth indicated they have never filed a grievance. Seven staff were interviewed,
and each indicated they understood and were able to explain the grievance process and
procedures. All grievances are uploaded and remain in FMS.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 54 (Revised July 2023)
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 (FOPs) 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 identified prior to the youth’s admission. Alerts are entered, downgraded, or
discontinued in JJIS by the appropriate staff members on the date identified and/or when the
alert is no longer applicable. Seven youth records were reviewed for medical, mental health,
and security alerts. Each reviewed youth record documented all alerts were accurately entered
into JJIS. The center's practice is to have a copy of the detailed alert list for all direct-care staff
during each shift briefing. Additionally, all staff have access to the alert system. Reviewed
documentation indicated alerts were discussed during shift briefings. An observation of a shift
briefing meeting verified the juvenile justice detention officer supervisor (JJDOS) discussed
youth alerts with the incoming staff and gave the staff a copy of the alerts. Observations verified
kitchen staff have a copy of all youth alerts. All applicable alerts were downgraded and removed
by the medical staff and/or the mental health staff. An interview with the superintendent was
conducted and it was reported the center’s superintendent ensures critical and special alerts are
reviewed and responded to appropriately. Upon completion of the Admission Wizard, staff
ensures all critical and special alerts are listed in JJIS. The JJIS alert report is reviewed daily by
the supervisors and administrators to ensure it correctly reflects the status of the youth. The
JJDOS ensures the detailed alert list is read aloud during shift briefings. Medical and mental
health staff review alerts to ensure each alert is correctly tracked and managed. If there are any
alerts which require special care of youth on their living module by staff, alerts are to be
documented in the initial acceptance of the logbook for the youth’s designated living area. When
a JJDOS receives changes to the alert list, they notify the staff affected by changes. Seven
interviewed staff stated they are informed of youth alerts during shift briefings and they receive a
youth alert form, and two staff stated alerts are entered into the logbook. Each staff stated
management informs them of issues at the center during staff briefings. Additionally, the staff
stated they were informed of issues during meetings, through an alert board, and two staff
stated they were informed by email. Five staff stated communication at the center is very good
and two reported communications at the center is good.
Florida Department of Juvenile Justice Detention Annual Compliance Report
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a structured method for analyzing data trends. The Department conducts a
Detention Services Report Card which ensures all centers provide high-quality effective services
for youth and families. The report card is a comprehensive review of policy compliance
conducted through site visit observations and desk 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 quarterly meetings. A
review of report cards, surveys, meeting agendas, and data collection software confirmed the
center’s practices. The center’s report card information is shared with staff, management,
providers, and stakeholders on a continuous basis through emails, verbally, and through
monthly and quarterly meetings.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center maintains facility operating procedures (FOPs) to ensure proper screening,
evaluation, and documentation is provided for each youth admitted into secure detention in
accordance with Florida Administrative Code. Seven active youth case management records
were reviewed, and each record had a Secure Detention Admission Wizard completed in the
Department’s Juvenile Justice Information System (JJIS), which contained all the required
admission elements. All seven reviewed active youth records contained the arrest affidavit.
Each record had a completed Detention Risk Assessment Instrument (DRAI) and a Suicide Risk
Screening Instrument (SRSI). The reviewed documentation confirmed all seven-youth received
a full-body frisk and/or electronic search by an officer of the same gender as the youth, and
each youth record documented all youth were offered a meal. All reviewed youth records
documented the youth completed a call to their parent/guardian. All reviewed active youth
records documented the youth received medical, mental health, and substance abuse
screenings upon admission. During the annual compliance review week, there were no
admissions of youth into the center.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
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The center maintains facility operating procedures (FOPs) to ensure each youth admitted is
notified within twenty-four hours of the center’s rules and regulations, grievance procedures,
visitation, telephone calls, available medical, mental health and substance abuse services and
how to access them, how to access the Florida Abuse Hotline or the Department’s Central
Communication Center (CCC) for youth eighteen years of age or older, possible new law
violations for destruction of property, youth rights, expectations for behavior, and related
consequences for failing to meet behavior expectations. Seven active youth case management
records were reviewed. Seven youth records had documentation showing an orientation was
provided within twenty-four hours of admission, and each youth signed an orientation
acknowledgement brochure. One youth record was missing the youth’s name, Department of
Juvenile Justice identification number (DJJID), and date on the orientation paperwork. Each
reviewed youth record documented the orientation was explained to the youth verbally and in
writing by a juvenile justice detention officer (JJDO). The brochure covered information related
to rules and regulations, grievance procedures, visitation, telephone calls, access to medical,
mental health, and substance abuse services, access to the Florida Abuse Hotline and CCC,
behavior expectations and related consequences, possible new law violations for destruction of
property, youth rights, and Prison Rape Elimination Act (PREA) related information. During the
annual compliance review week, there was no observation of the youth orientation process
completed due to no youth being admitted during the time of the review. The center has an
orientation videotape for PREA. Seven youth interviews were conducted, and each youth
reported they were familiar with the orientation process.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center maintains facility operating procedures (FOPs) ensuring all youth admitted to the
center are classified by the admitting officer to provide the highest level of safety and security. A
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review of seven active youth case management records confirmed information concerning the
youth’s history and status as well as all other required documentation was included. The center
considers several factors such as gender, height, weight, age, level of aggression, mental
illness, intellectual disabilities, physical disabilities, history of violent behavior, gang affiliation,
criminal history, history of sexual offenses including sexual battery charges, vulnerability to
victimization and sexually aggressive behavior (VSAB) screening results, medical, suicide risk
identified or suspected, escape, and security risks prior to placing the youth into a room. The
seven reviewed active youth case management records documented youth were assigned to a
room based on their classification and were reclassified if changes in behavior or status were
observed. The youth with a history of committing sexual offenses or youth identified as a victim
of a sexual offense are not to be placed in a room with any other youth. The superintendent
remains informed of how to identify and address local gangs through posted alerts and
documentation in youth case management records. The center and the circuit have a gang
liaison. An interview with the superintendent confirmed the center’s classification process.
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 maintains facility operating procedures (FOPs) to ensure gang information is shared
with the identified juvenile probation officer (JPO) assigned as the circuit’s gang representative
to communicate suspected gang activity. The center’s assistant superintendent serves as the
gang representative and communicates with the JPO gang liaison and law enforcement officer
(LEO) by email when a youth is identified as a suspected gang member or gang member and
shares all information regarding suspected gang activity. Seven active youth case management
records were reviewed and none of the youth were applicable. An additional youth record was
requested and provided by the center for review. Only one youth record was applicable for
being a gang member during the annual compliance review period. The reviewed email
communication contained photographs of gang insignia or graffiti and a corresponding email
message to local law enforcement and the assigned JPO. The alert information was entered
into the Department’s Juvenile Justice Information System (JJIS). During the week of the annual
compliance review, an informal interview was conducted with the superintendent who confirmed
the center’s practice. The center’s gang representative indicated any information received
regarding gang updates is forwarded to the center’s superintendent for the proper distribution to
the center’s supervisors and staff.
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.
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The center maintains facility operating procedures (FOPs) to ensure the proper safe handling
and security of each youth’s personal property, including valuables, which are collected and
secured at the time of a youth’s admission. Seven active youth case management records were
reviewed. One of the seven youth records was missing the youth’s name on the property letter
and three youth records were missing youth and staff signature on the receipt form.. The seven
reviewed records contained a letter of acknowledgement regarding unclaimed property signed
by the youth and staff. Five of the seven youth records reviewed had valuable property which
was placed in a clear tamper-proof bag with the youth’s name, Department of Juvenile Justice
identification number (DJJID), date, staff name, and signature of the youth and staff. Four of the
five applicable youth records reviewed for valuable property had youth and staff signatures on
the property receipt form. The valuable property is placed in a drop safe which is under video
surveillance twenty-four hours a day. The center has a drop safe logbook to document the time,
youth’s name, name of the officer securing the property, and the officer’s initials. Personal
property such as clothes and shoes is placed in the property bags and then placed into secured
lockers. The information documented on the bag included the date, the youth’s name, the
DJJID, and a list of the items in the bag. During the time of the annual compliance review, there
were no admission of youth into the center. Three applicable youth case management records
were reviewed for storage and security of valuable personal property. Each contained a
completed inventory form, which was documented in the safe’s logbook and property was
stored in a clear tamper-proof bag. Property was stored according to policy, and access to
property was limited to designated staff, and secured in a locked room under video
surveillance. A review of the Department’s Central Communications Center (CCC) reports since
the last annual compliance review found no incidents regarding youth property. Seven youth
interviews were conducted, and each youth reported upon admission, the staff checked their
personal property and had them sign a Property Receipt form. An interview with the
superintendent regarding personal property confirmed all youth have their personal property
inventoried upon admission and valuable youth property is stored in a secured property room
which is under video surveillance and has limited access to only supervisors and administration.
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 maintains facility operating procedures (FOPs) addressing youth releases. The
juvenile justice, detention officer (JJDO) and the assigned juvenile justice detention officer
supervisor (JJDOS) completing the release shall verify the court authorization prior to releasing
the youth. Proper care must be taken to ensure all case information is reviewed to prevent the
negligent release of a youth. The JJDOS is responsible for verifying there are no holds, court
orders, or any other legal reasons not to release the youth from the center. Each
parent/guardian is notified and confirms the release. A copy of the parent/guardian photo
identification card is placed in the youth’s case management record prior to release. A review of
three applicable closed youth case management records revealed each record contained an
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eight-step youth release checklist utilized for each youth release. Each reviewed record
contained the appropriate documentation signed by the youth’s parent/guardian or person
taking custody of the youth and a copy of the photo identification card of the person taking
custody of the youth was placed in the youth’s record. Each of the reviewed records contained
documentation confirming the youth and person whom the youth is being released to were
reminded of any future court dates and signed all applicable release forms. Each reviewed
record documented the youth’s admission, and termination dates correlated with the information
in the Department’s Juvenile Justice Information System (JJIS). During the time of the annual
compliance review, a release observation was completed. The youth was being released from a
residential program and was transported to the detention center. The youth was released with
an electronic monitor (EM) to their parent/guardian. The youth's parent/guardian was present at
the center and brought the youth's charged EM battery. A copy of the parent/guardian’s
identification was taken. The youth and parent/guardian signed the youth's property form. The
youth was then released to their parent/guardian with their medication and personal property.
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 maintains facility operating procedures (FOPs) to ensure the youth’s released from
detention and retrieval of personal property, the releasing office, the youth, and the youth’s
parent/guardian review and sign the Property Receipt form and account for all the youth’s
personal property. The center ensures there are provisions in place to ensure the prescribed
medications, along with medical instructions, accompany detained youth upon release. Three
closed youth case management records were reviewed. The three reviewed records
documented each youth and parent/guardian signed the Receipt of Property form upon release.
Each reviewed record documented the youth and the person to whom the youth was being
released to were reminded of any health or welfare issues including medical, mental health
and/or substance abuse needs, and any pending appointments. After thirty days of a youth’s
release, a Notice of Impending Disposal of Property is mailed to the youth’s last known address.
Personal property not claimed is considered as abandoned and is disposed of according to the
center’s FOPs and Florida Administrative Code. During the annual compliance review, each
reviewed record documented a Notice of Impending Disposal of Property letter was mailed to
the youth and parent/guardian with a copy of the signed Property Receipt form. Each reviewed
record indicated the center followed the disposal process. During the annual compliance review
week an observation of a youth property release was conducted and confirmed the center’s
practice.
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 maintains facility operating procedures (FOPs) to ensure the center conducts
Detention Reviews on a weekly basis to ensure proper management of youth placed in secure
detention and the appropriate sharing of information. The youth are held is secure detention for
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the shortest time possible. The superintendent appoints staff to coordinate reviews. Observation
of the detention center review process and the Detention Secure Log review was conducted
during the week of the annual compliance review. There were no discrepancies found during the
review. The Detention Reviews are conducted on a weekly basis, occurring every Wednesday
at 9:00 a.m. to address the status of each you in secure detention. Reviewed Detention Review
documentation since the last annual compliance review confirmed all required participants
attend the meeting either in person, virtual conference, or by telephone. An interview with the
superintendent regarding the weekly Detention Reviews for secure detention and home
detention placement youth, indicated the center follows all (FOPs).
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 maintains facility operating procedures (FOPs) ensuring youth participate in
constructive activities. The center will maintain a daily schedule which is posted in all living
areas, includes weekdays, weekends, and holidays, and incorporates both structured and free
time. Observations confirmed the center provides and maintains a weekday, weekend, and
holiday schedule, which is posted in all living areas. The schedule indicated the time frames of
each daily activity provided to the youth on a regular basis including wake-up, personal hygiene,
mealtime, visitation at a minimum of twice a week, recreation, physical activities including at
least one hour of daily large muscle exercise outdoors, indoors activities which promote
education, problem solving and life skills, shift change, bedtimes, groups, and open program
time. Seven youth were interviewed, and each reported the center has a daily activity schedule
and the schedule is followed. Seven staff were interviewed, and each reported the center’s daily
scheduled is followed.
2.10 Educational Access (Critical) Limited 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 maintains facility operating procedures (FOPs) to ensure educational access for
youth. The Saint Lucie County School District provides educational services and approves the
250-day calendar, which incorporates ten days of teacher planning and/or training. The daily
school schedule reflects five hours of instruction each day, which meets the required minimum
of 300 minutes of instruction each day. Three random days of video footage were reviewed for
educational access which confirmed education classes were facilitated as scheduled. A review
of logbooks for one random day from each month from May 22, 2024, to April 2, 2025, for start
and stop times was completed. Documentation confirmed the school schedule was followed for
nine of the twelve random days reviewed. For three randomly chosen days school started thirty
minutes late. Documentation did not reflect why the school schedule was not followed for the
three randomly selected days. Documentation confirmed the school schedule was followed
when youth transitioned from education classes at the correct time for eight of the twelve
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random days reviewed. Documentation did not reflect why the school schedule was not followed
for the four randomly selected days when youth transitioned from education classes.
Additionally, documentation showed medication administration was conducted during school
hours on several occasions in March and April 2025. Seven youth interviews were completed.
Six of the seven youth confirmed there is minimal interference in educational instruction, and
one youth reported classes were being interrupted due to medication administration and
counseling purposes. Five of the seven interviewed youth indicated the center is preparing them
very well for high school, vocational school, employment, and/or college, and two stated the
center is preparing them well. Seven staff were interviewed, and six stated there is minimal
interference of educational instruction. One staff reported medication administration can occur
during school hours. An interview with the center’s superintendent was conducted and it was
reported there is minimal interference in educational instruction.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center maintains a written policy and procedures to provide career education. The center
provides career education programming which meets the requirements of a Type 1 program and
incorporates communication, interpersonal and decision-making skills, as well as life skills and
activities through the personal career and social development class. Seven interviewed youth
reported taking core classes such as history, the high school equivalency diploma (GED)
practice test, and virtual classes.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains facility operating procedures (FOPs) 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 contract
requires a full-time licensed professional to serve as the DMHCA for forty hours each week. The
DMHCA is a licensed mental health counselor (LMHC) with a clear and active license in the
State of Florida, with an expiration date of March 31, 2027. The DMHCA is a full-time staff and
scheduled to be on-site forty hours each week, Monday through Friday from 8:00 a.m. to 4:00
p.m and available seven days a week, twenty-four hours a day, by way of telephone for
consultation. A review of the mental health sign-in logbook since the last annual compliance
review confirmed the DMHCA was on-site, as required. The center has a back-up DMHCA in
the event of scheduled leave and/or absences, who is a full-time clinical staff. The back-up
DMHCA is a licensed clinical social worker (LCSW), licensed in the State of Florida, with a
license expiration date of March 31, 2027. An interview with the DMHCA verified the DMHCA
must be on-site at least once a week for a sufficient time period to ensure appropriate
coordination and implementation of mental health and substance abuse services is taking place.
The DMHCA meets with mental health/substance abuse (MH/SA) staff on a daily, and monthly
basis. Daily meetings allow the DMHCA to follow-up with staff on daily tasks, pressing issues of
the day, and with specific youth. Monthly meetings allow the DMHCA to review documentation
and to discuss any new policies and procedures needing to be implemented.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The center requires
mental health and substance abuse services to be provided by individuals with appropriate
qualifications. The clinical supervisor ensures the licensed clinical staff are performing services
based on their education, training, and experience. The center has three licensed mental health
staff contractual positions, in addition to the designated mental health clinician authority
(DMHCA). Copies of all licenses were provided and were on-site for review in the mental health
office, as required. A review of the licensed clinicians’ credentials indicated all three clinicians
had an active license in the State of Florida for a licensed mental health counselor (LMHC) with
an expiration date of March 31, 2027. The informally interviewed DMHCA stated all mental
health staff are licensed; therefore, a Chapter 397 license was not needed.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. The center does not
have a Chapter 397 license with the Department of Children and Families. All mental health
services are provided by licensed mental health professionals, and the center does not have
any non-licensed mental health clinical staff. Reviewed documentation indicated only the
licensed mental health counselors were facilitating all substance abuse treatment and groups. In
an informal interview, the designated mental health clinician authority (DMHCA) stated all
mental health staff are licensed; therefore, a Chapter 397 license was not needed. There were
no reported vacancies for clinical services during the annual compliance review week.
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 (FOPs) to ensure the mental health and
substance abuse needs of youth are identified through a comprehensive screening process.
The center’s FOP requires referrals to be 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 seven youth mental health and substance abuse
records indicated each youth was processed at the Juvenile Assessment Center (JAC). The
juvenile probation officer (JPO) conducts the intake process by completing 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) in the
Department’s Juvenile Justice Information System (JJIS). The juvenile justice detention officer
(JJDO) reviewed each youth’s MAYSI-2 results documented on the Department’s form, Face
Sheet, and alerts upon admission. The JJDO completed their assigned section of the SRSI for
all seven youth. All seven SRSIs were reviewed by a nurse and/or mental health professionals.
Each SRSIs had completed entries, which included an accurate referral selection in the
“Screening Results” section. All seven reviewed records had a positive “YES” response on the
SRSI and indicated each youth was placed on suicide precautions and a mental health referral
was completed, which documented the youth’s need for an Assessment of Suicide Risk (ASR).
All seven reviewed youth records were applicable for suicide precaution placements based on
an open or closed suicide risk alert in JJIS. All seven MAYSI-2s were completed by trained
staff. All seven reviewed records’ SRSIs and MAYSI-2s indicated further assessment was
needed. One of the seven records was applicable for having all negative responses marked no
by the screener, invalidating the screening. All seven reviewed MAYSI-2s indicated further
assessment was required and the superintendent or designee was notified of the referrals made
for assessments. Each of the youth’s MAYSI-2s indicated an elevated suicide risk subscale and
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each youth was placed on suicide precautions and referred for an ASR. All seven reviewed
MAYSI-2s indicated the need for a comprehensive assessment. Documentation verified the
screener referred the youth to mental health clinical staff for a comprehensive assessment to be
completed.
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 (FOPs) outlining the process to identify the
mental health and substance abuse needs of youth through a comprehensive screening. The
center’s FOP requires the youth with identified needs to be referred for a further, in-depth
mental health and/or substance abuse (MH/SA) evaluation. Five of seven reviewed youth
records indicated each youth was identified after admission and referred for an evaluation. Two
youth were identified and referred to the center provider for a MH/SA evaluation; however, were
not in the center long enough to receive an evaluation. One youth was applicable for a
Substance Abuse and Mental Health Assessment (SAMH) and a new SAMH was completed by
the youth’s thirty-first day at the center. The one applicable SAMH included treatment
recommendations made for all diagnosed mental health or substance related disorders. The
Comprehensive Mental Health/Substance Abuse Evaluation consisted of the SAMH in the
Department’s Electronic Medical Record (EMR). Four youth records were applicable for
obtaining a new or updated MH/SA evaluation completed by a community provider. The center
obtained the MH/SA evaluation by the community provider, and each was uploaded into each
youth’s mental health record. All four evaluations obtained from a community provider
contained treatment recommendations which corresponded to all diagnosed mental health or
substance-related disorders and all the required elements including signature of the licensed
mental health professional (LMHP). An interview with the designated mental health clinician
authority (DMHCA) indicated the juvenile probation officer (JPO) will have to request the
comprehensive mental health and/or substance abuse assessment based on the initial
screening or behavior due to the youth’s history of charges to best determine what course of
action would best support the youth, through a community provider to complete an in-depth
assessment. The DMHCA will search the youth’s Juvenile Justice Information System (JJIS)
record to see if a comprehensive evaluation was completed within the thirty days of the youth
being committed to a program. The assessment is uploaded in the youth’s EMR. If the youth
does not have one in the system, the JPO would be contacted by email to inquire about the
assessment. If the assessment has not been completed within the thirtieth day of the youth’s
stay in the center, mental health staff will complete a SAMH in the EMR.
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
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treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center maintains facility operating procedures (FOPs) for mental health and substance
abuse treatment and discharge planning. The provider’s contract requires the superintendent
and designated mental health clinician authority (DMHCA), or mental health/substance abuse
(MH/SA) clinical staff to ensure the development and review of an initial and/or individualized
treatment plan (ITP) for each youth receiving mental health/substance abuse treatment in the
center. Seven youth mental health and substance abuse records were reviewed, and five youth
received a mental health orientation held within fourteen days of admission and required a
treatment plan. The remaining two youth were not in the center long enough for a mental health
orientation at the time of the annual compliance review. Four of the five applicable youth had an
initial treatment plan (ITP) in place within seven days of the onset of treatment. The remaining
youth received an individualized treatment plan within seven days of the onset of treatment.
Each applicable ITP was documented on the Department’s Initial Mental Health/Substance
Abuse Treatment Plan form which had all required information. Each ITP indicated the reason
for referral for treatment, the initial Diagnostic and Statistical Manual, Fifth Edition (DSM-5)
diagnosis/symptoms, treatment goals, methods of treatment, including group or individual
counseling, the medication the youth was admitted on, and psychiatric services including the
frequency. The mental health/substance abuse professional’s signature and youth’s signature
was present on each ITP. Each youth was assigned a mini-treatment team, and all required
staff were involved with the development of the ITP including the youth and parent/guardian,
when available.
A review of seven youth mental health and substance abuse records found five youth had an
individualized treatment plan developed for youth receiving mental health and/or substance
abuse treatment in the center by the thirty-first day of the youth’s admission. Each plan included
the DSM-5 diagnosis, symptoms which were treatment focused, treatment goals, strengths and
needs, and progress notes validating the youth was receiving treatment services as stipulated
on the treatment plan. Four of the five applicable individualized treatment plans included
psychotropic medications listed in the ITP and matched the psychotropic medications the youth
was prescribed at the time the treatment plan was developed. A review of the five individualized
treatment plans verified each was signed by the youth, MH/SA staff, treatment team members,
and the parent/guardian participated when possible. A review of five applicable individualized
treatment plans verified each plan was reviewed every thirty days by the treatment team.
Documentation confirmed the youth, licensed mental health professionals, parent/guardian, and
treatment team members reviewed and signed each-treatment plan monthly review. Each of
the five applicable treatment plans included treatment and services provided by a licensed
psychiatrist. None of the youth were applicable for having been an alleged victim of a Prison
Rape Elimination Act (PREA) incident, requiring additional services. A review of seven youth
records found three youth had previous stays and discharges from the center and each of the
three youth received a signed discharge plan documented on the Department’s Mental
Health/Substance Abuse (MH/SA) Treatment Discharge Summary Form. Documentation
showed a copy of the MH/SA Treatment Discharge Summary was offered to the youth and
parent/guardian; however, each youth refused MH/SA services upon discharge from the center.
All three youth records had documentation showing the completion of services and signature of
the licensed mental health professional. There was no additional documentation required to be
uploaded within fourteen days. Three youth mini-treatment team meetings were observed
during the annual compliance review. The mini-treatment team consisted of mental health staff,
medical staff, a school representative, direct care staff, the youth, the chaplain, and the
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parent/guardian, when available. Some of the topics discussed consisted of the youth’s school
progress, medication management, their level within the behavior management system, and
their relationship with family members. During an interview, the DMHCA explained the process
of creating the youth’s individualized treatment plan. According to the DMHCA, once a youth
has met with the psychiatrist or has exceeded twenty-one days in the detention center, a youth
will be invited to attend a treatment team. During the treatment team meeting, mental health
and/or substance abuse services are introduced and offered to the youth. Youth who are in
services are met within thirty days of their treatment target date to review the youth’s progress
and update their treatment if needed. Youth will attend each treatment team meeting.
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 has facility operating procedures (FOPs) in place for mental health and
substance abuse treatment planning to focus on treatment provisions to reduce or alleviate
youth’s symptoms of mental disorder or substance abuse impairment and enable youth to
function adequately in the juvenile justice setting. Seven youth mental health and substance
abuse records were reviewed, and five were applicable for receiving initial mental health and
substance abuse treatment services. All five reviewed youth records included documentation
the youth required treatment, and each was assigned to a mini-treatment team which consisted
of clinical mental health staff, one staff from a different service area, the youth, and the youth’s
parent/guardian when available. Each reviewed record contained documentation of the youth
receiving mental health treatment in the form of individual therapy, group, family, and/or
supportive counseling sessions. Two of the five records indicated the youth received substance
abuse treatment in the form of group, individual, and/or supportive counseling sessions.
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’s
record contained progress notes documented on the Department’s Counseling/Therapy
Progress Notes form. A review of the center’s video footage for mental health groups confirmed
licensed therapists conducted group sessions with the youth on April 18, 2025, and May 5,
2025. A review of mental health/substance abuse group sign-in sheets confirmed the groups
were conducted according to the schedule. Documentation verified mental health staff had
adequate access to youth and had a confidential space to provide treatment services. In
addition, sign-in sheets confirmed mental health groups were limited to ten or fewer youth and
substance abuse treatment groups were limited to no more than fifteen youth. An interview with
the designated mental health clinician authority (DMHCA) confirmed the DMHCA ensures youth
who are in the center past twenty-one days or more, unless behavior warrants mental health
and/or substance abuse (MH/SA) services within the twenty-one days in the center, are offered
MH/SA services. Youth are informed of MH/SA services during the intake process. Within
fourteen days in the center the youth will be invited to participate in treatment, and a treatment
team meeting prior to their thirtieth day in the center. During the treatment team meeting, youth
will be able to accept or decline services. Once a youth accepts MH/SA services, the youth will
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discuss the treatment interventions they would like to work on while in the center. Youth and
clinical staff review the comprehensive evaluation and process any new information from the
youth. The comprehensive evaluation and youth input will be utilized to compose the youth’s
individualized treatment plan. Youth and clinical staff will meet weekly to work on objectives and
goals on the treatment plan. Clinical staff will conduct groups which target goals on the youth’s
treatment plan. Additionally, each youth who is determined by a mental health clinical staff or
substance abuse clinical staff to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in a center must be assigned to a
mini-treatment team. The mini-treatment team is responsible for developing, reviewing and
updating initial and individualized mental health treatment plans or initial and individualized
substance abuse treatment plans for youth receiving mental health or substance abuse
treatment while in the center. The mini-treatment team must be composed of at least a mental
health clinical staff or substance abuse clinical staff and one other staff person from a different
service area such as administrative, supervisory, or medical staff. The mini-treatment team
meetings must include the youth. The youth’s parent/guardian must be included in the mini-
treatment team meeting when possible. MH/SA staff provide individual sessions and group to all
youth who have accepted mental health services. Youth who have been offered MH/SA
services and declined are still met on a weekly basis to check-in and offered mental health
services. Youth who are in the center and who have not attended treatment team, can request
to meet with mental health staff through referral, and MH/SA staff can provide clinical support.
Seven youth were interviewed regarding how they would rate MH/SA services at the center.
Five youth stated they were declining MH/SA services, and two would like to start receiving
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 (FOPs) summarizing the provision of
psychiatric services to youth in need, to include psychiatric evaluation, consultation, medication
management, and medical supportive counseling. The FOP requires the center to provide
psychiatric services to the youth determined to need 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. A review of the psychiatrist’s license confirmed they
maintain a clear and active license with an expiration date of March 31, 2026. The center did not
utilize a back-up psychiatrist since the last annual compliance review; however, the designated
mental health clinician authority (DMHCA) reported any youth requiring mental health services
are referred to a local provider in case the psychiatrist is not available. The center did utilize
tele-psychiatry since the last annual compliance review. The interviewed designated mental
health clinician authority (DMHCA) indicated they meet with the psychiatrist weekly and as
needed.
A review of seven mental health and substance abuse records indicated four youth were
applicable for entering the center on psychotropic medication or were referred for a psychiatric
interview. All four initial diagnostic psychiatric interview contained a reason for the referral,
medical, mental health and substance abuse history, a Mental Status Examination, Diagnostic
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and Statistical Manual of Mental Disorders (DSM-5) diagnosis, and treatment recommendations.
Each of the four youth were prescribed medication at the center. The need for psychotropic
medication and frequency was documented for each youth receiving prescribed medication. A
review of the Clinical Psychiatric Progress Note (CPPN) indicated an in-depth psychiatric
evaluation was conducted on all referred youth within thirty days of referral/admission. All four
referrals indicated the factors and reason for the referral. Each referral listed the youth’s health
and mental health history. All four reviewed records confirmed the youth had a history of
psychiatric illness, psychotropic medication management, mental health treatment, and/or
substance abuse treatment. All four reviewed CPPNs indicated the practitioner conducting the
psychiatric evaluation signed the CPPN. None of the reviewed youth records required the CPPN
page three completed when new psychotropic medication was prescribed or there were any
changes to the existing prescription. However, each reviewed evaluation included page three of
the CPPN and documented the side effect descriptions, medication target symptoms,
medication name, dosage, and frequency, each prescribed psychotropic medication including
the name, dosage and quantity of the medication, the side effects, youth’s adherence to the
medication, height, weight, blood pressure, most recent serum drug levels, the dated signatures
from the psychiatrist, and frequency of monitoring for Tardive Dyskinesia. None of the reviewed
youth records required telephone contact with a parent/guardian on the CPPN because there
were no changes in medication indicated. All four applicable youth records had a current
Authority for Evaluation and Treatment (AET) consenting for the continuation of the
psychotropic medication. One youth was eighteen years of age while in the center and was
responsible for authorizing their health care and authorizing to release their healthcare records.
Reviewed documentation verified the standard of psychiatric care was delivered through tele-
psychiatry the same as rendered in-person. Documentation showed tele-psychiatry was only
utilized for youth who agreed to participate in the tele-psychiatry session and the parent/
guardian provided consent. The reviewed designated mental health clinician authority (DMHCA)
interview confirmed mental health/substance abuse (MH/SA) staff provided individual sessions
and group sessions to all youth who have accepted mental health services. In individual
sessions youth and MH/SA staff can discuss triggers and coping skills. MH/SA staff will provide
psycho-educational group on mental health and address relapse prevention for substance
abuse treatment.
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 facility operating procedures (FOPs) requiring a Suicide Prevention Plan.
The plan details the center’s procedures to safely screen, refer, assess, monitor, and protect
youth with elevated risk of suicide in the least restrictive means possible. The FOP requires the
suicide prevention procedures to be reviewed and signed by the designated mental health
clinician authority (DMHCA) and the superintendent. The policy and plan were approved by the
superintendent and the DMHCA on August 15, 2023. The plan elements include identification
and assessment of youth at-risk of suicide utilizing the Department’s Assessment of Suicide
Risk (ASR) and Follow-Up ASR forms, staff training of at least six hours annually on suicide
precautions, levels of supervision, the referral process, communication, notification,
documentation, immediate staff response, and a review process. The center’s plan includes an
established review process for every serious suicide attempt or serious self-inflicted injury and a
mortality review for a completed suicide, which includes circumstances surrounding the event,
center procedures relevant to the incident, all relevant staff training, pertinent medical and
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mental health services involving the victim, possible precipitating factors, and any
recommendations for policy changes 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 facility operating procedures(FOPs) requiring suicide prevention services.
The FOPs address supervising, observing, monitoring, and housing youth identified through
screenings, documentation, and observation as being at-risk for suicide, and protect youth with
an elevated risk of suicide in the least restrictive means possible. A review of seven youth
mental health and substance abuse records showed all seven 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. Each youth was identified as at-risk based on the admission
screenings or staff observations. Documentation revealed an ASR was completed using the
Department’s form. Each youth had a constant level of supervision prior to the completion of the
ASR. The Suicide Precautions-Observation (PO) Logs were completed in their entirety and
indicated a licensed mental health professional was involved. None of the youth were released
prior to receiving an ASR or released while on suicide precautions. Each record indicated the
staff documented a consultation with the designated mental health clinician authority (DMHCA)
or licensed mental health (MH) professional on the mental health/substance abuse referral
summary. Each reviewed record documented the immediate notification of suicide risk to the
superintendent or designee. A review of the PO logs indicated the date and time of the referral
and the date and time the youth was place on suicide precautions coincided. Each of the ASRs
were completed within twenty-four hours and had documentation of a conference held by the
superintendent and DMHCA to reduce the level of supervision. None of the reviewed youth
required a Follow-Up ASR to be completed prior to the removal of the youth from PO. The
discontinuation of close supervision was documented in accordance with the center’s suicide
prevention plan. A review of the center’s logbooks revealed the starting and ending time of each
youth’s precaution period was documented. Each ASR was documented as completed by a
licensed MH professional. A review of the Department's Juvenile Justice Information System
(JJIS) confirmed the appropriate youth alerts were entered in the system. An interview with the
DMHCA verified prior to revising a youth's supervision level, the licensed MH professional
meets with the superintendent/designee. The communications regarding the youth’s supervision
level are documented in the Electronic Medical Record (EMR), on the ASR, and psychiatric
note. In the center, master control and detention staff are informed by radio and then staff
document in all logbooks. Seven interviewed youth confirmed they were placed on suicide
watch and staff were observing the youth all the time the youth were on PO. Seven staff were
interviewed, all staff stated if a youth expresses suicidal thoughts, staff will notify the MH
authority, inform the supervisor, place the youth on constant sight and sound supervision, and
keep documentation of supervision.
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3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center maintains facility operating procedures (FOPs) regarding secure observation. The
FOP requires youth placed on suicide precautions to remain under secure observation if less
restrictive methods are not effective. Seven youth records were reviewed, and two youth were
applicable for placement in secure observation; therefore, one additional record was reviewed.
Documentation verified the youth’s placement in secure observation was authorized by the
superintendent and the designated mental health clinician authority (DMHCA). Each of the
secure observation rooms were designated in writing. Reviewed documentation indicated all
three youth had a completed Health Status Checklist form completed prior to placement in
secure observation. All three reviewed Suicide Precautions-Observation Logs were completed
in their entirety. None of the reviewed youth stayed in secure observation more than eight hours
after placement; therefore, a new Assessment of Suicide Risk (ASR)/Follow-Up ASR was not
required. In an informal interview with the DMHCA it was explained, the youth’s parent/guardian
was not notified of the youth’s potential suicide risk because all three youth were stepped down
to close supervision. One record was applicable and indicated the juvenile probation officer
(JPO) was notified of the youth’s potential suicide risk as indicated by the ASR. None of the
youth were placed in secure observation beyond twenty-four hours. All three youth’s
observation logs documented proper supervision of the youth as required, and mental health
staff provided supportive counseling services while each youth was on secure observation
status. Reviewed documentation for three youth in secure observation had their level reduced
only after a conference with the superintendent/licensed mental health (MH) professional.
Additionally, each youth was discontinued from secure observation and placed on close
supervision. A review of the center’s logbook and youth records confirmed the center’s practice.
3.12 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 facility operating procedures (FOPs) for the process to safely screen,
refer, assess, monitor, and protect youth with elevated suicide risk in the least restrictive means
possible. A review of seven youth mental health and substance abuse records verified all seven
youth were applicable for having been placed on suicide precautions. Each youth had a
maintained Suicide Precautions-Observation (SPO) Log for the duration the youth was on
suicide precautions. Each youth’s log was documented in real time and not exceeding thirty-
minute intervals. The review of the Suicide Precautions-Observation Logs for each youth found
the staff were documenting the youth’s warning signs and staff notified the superintendent and
mental health staff. Each log was reviewed and included the signature of the mental health staff
and the center’s shift supervisors. Each log documented safe housing requirements.
Observations of video footage for two dates and documentation of youth placed on
precautionary observation (PO) confirmed each youth was placed on constant supervision and
staff were always present while the youth were on PO.
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3.13 Suicide Prevention Training [Detention Staff] (Critical) Failed Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center maintains facility operating procedures (FOPs) to address suicide prevention
training. The FOP requires all staff who work with youth to be trained to recognize verbal and
behavioral cues indicating suicide risk, suicide prevention, and implementation of suicide
precautions. Seven in-service and seven pre-service staff training records were reviewed. All
seven reviewed pre-service staff records documented staff completed suicide awareness and
prevention training. Only two of the seven in-service training records documented staff
completed suicide awareness and prevention training. The center has a total of three suicide
response kits which are in master control, the supervisor’s office and in medical. All suicide
prevention kits include the recure tool, wire cutters, and needle nose pliers. The suicide kits are
co-located with the first-aid kits. A review of video footage and corresponding documentation of
two mental health drills conducted on April 18, 2025, verified they were simulated correctly.
Reviewed documentation of mock suicide drills conducted for the past twelve months showed
the center completed drills on all three shifts at least quarterly. A review of completed drill
documentation found seventeen of twenty-four suicide drills noted the drills were not simulated.
Additionally, notes stated the drills were not completed correctly. Inconsistencies included not
bringing the suicide and first-aid kits, staff not participating or taking the drill seriously, and staff
not completing the forms correctly. There was no documentation provided indicating staff who
were not present during a quarterly drill had the opportunity to review each drill scenario,
procedures, and critique to understand the process and receive the necessary training to
respond to an incident of a suicide attempt or incident of serious self-inflicted injury.
Furthermore, seventeen of twenty-four drills did not document the appropriate contacts were
made during the drills. Seven interviewed staff all stated they have access to the suicide
response kits, including the recue tool located in master control, medical, and the administration
offices.
3.14 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 facility operating procedures (FOPs) regarding crisis intervention services
and a combined Emergency Services Plan. The policy requires the center’s staff to respond to
youth in crisis in the least restrictive means possible and to protect the safety of the youth and
others while maintaining control and safety of the center. Assessments should be completed by
a mental health clinician to determine the severity of the youth’s distressing symptoms, level of
risk to self or others, and recommendations for treatment and follow-up care. Documentation
and a review of the combined Emergency Services Plan confirmed the plan consisted of the
notification and alert system, means of referral, including self-referral, communication,
supervision, and documentation.
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3.15 Emergency Care Plan [Detention Staff] (Critical) Limited 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 facility operating procedures (FOPs) to address the emergency care plan
which stipulates the response procedures for youth in crisis. The center’s plan includes
procedures for immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health or substance abuse services, transport
for emergency mental health evaluation and treatment under Chapter 394 (Baker Act), and the
transport for emergency substance abuse assessment and treatment under Chapter 397
(Marchman Act). A review of seven in-service training records found none received Emergency
Care Plan training. The emergency care plan was updated and signed on August 15, 2023. A
copy of the approved plan is maintained in the center’s FOP binder in master control, in the
administration office, and the center’s local computer drive. The emergency services plan is
accessible to all staff.
3.16 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 maintains facility operating procedures (FOPs) regarding Crisis Assessments. The
FOP requires a Crisis Assessment for any youth demonstrating acute psychological distress.
Seven youth records were reviewed, and none were applicable for a Crisis Assessment. An
additional three records were reviewed. The assessment was completed the same day the
youth was determined to be in crisis and was documented on the Department’s Crisis
Assessment form. The Crisis Assessment included a reason for assessment and a Mental
Status Examination and interview. The Crisis Assessment contained documentation none of the
youth were a danger to self/others. The Crisis Assessment contained documentation which
included initial clinical impressions, supervision and treatment recommendations, follow-up
evaluation recommendations, and notification to the parent/guardian regarding follow-up
treatment. The licensed mental health professional completed the Crisis Assessment within two
hours for emergency, or within twenty-four hours based on the needs of the youth. Reviewed
records confirmed all three youth were alleged victims relating to allegations of a Prison Rape
Elimination Act (PREA) event and youth were offered mental health treatment services.
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3.17 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 facility operating procedures (FOPs) for Baker and Marchman Acts. The
FOP requires youth 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. Seven youth records were reviewed, and none of the youth were
applicable for requiring Baker Act or Marchman Act procedures. Three additional youth records
were reviewed. A review of precautionary observation (PO) log documentation for all three
applicable youth showed each was placed on one-to-one supervision. Each youth had a
completed mental health referral for a Mental Status Examination (MSE) and was placed on
suicide precautions upon re-admission from a Baker Act. All three of the youth’s supervision
levels were maintained based upon the Assessment of Suicide Risk (ASR), and discontinuation
of the mental health alerts was completed in the Department's Juvenile Justice Information
System (JJIS) when applicable. No youth were applicable for Marchman Act services.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains facility operating procedures (FOPs) to ensure clinical services are
provided to all youth in the center. The center retains a contract with VitalCore Health
Strategies, LLC which subcontracts with a licensed physician to serve as the center’s
designated health authority (DHA). The DHA holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida with a license
expiring on January 31, 2026. The center has an advanced practice registered nurse (APRN)
whose license expires July 21, 2026. The APRN has a signed collaborative practice protocol in
place with the DHA with an initiated date of June 14, 2023, and was renewed on January 22,
2025. A review of the sign-in and sign-out logs during the annual compliance review period
confirmed the DHA was on-site at least two hours each week, with a week defined as the
seven-day period beginning on Sunday and ending on Saturday. The DHA is available twenty-
four hours a day, seven days a week for acute medical concerns, emergency care, and
coordination of off-site care. When the DHA was on vacation or on a scheduled absence, the
center utilized two back-up DHAs. The back-up DHAs both had an active license to practice in
the State of Florida with an expiration of January 31, 2027, and March 31, 2026. During an
interview, the DHA reported completing the Comprehensive Physical Assessments (CPA), FOP
development, completing sick call, reviews, and chronic care cases. Reviewed documentation
found the center utilized tele-health appointments twice during the annual compliance review
period and provided tele-health logs which documented the name of the youth, date and time of
service, and the type of service provided.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center maintains facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. The designated health authority (DHA) reviewed, signed, and dated
all FOPs on July 2, 2024, and the superintendent signed on May 5, 2025. The center’s
psychiatrist does not come on-site; therefore, a signature of the FOPs is not required. Reviewed
documentation confirmed the nurses reviewed, signed, and dated the FOP cover page
treatment protocols on July 2, 2024, October 15, 2024, March 29, 2025, and May 5, 2025.
Reviewed documentation showed FOPs for all health-related procedures and treatment
protocols were utilized at the center. Reviewed documentation found all newly employed
healthcare staff received a comprehensive clinical orientation to the Department’s health care
policies and procedures, given by a registered nurse (RN) and the approval of treatment
protocols or standing procedures were written and authorized by the DHA.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center maintains facility operating procedures (FOPs) to 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. A review of seven
youth Individual Healthcare Records (IHCRs) reflected each record contained an AET. Three
out of seven IHCRs contained a copy of the signed AET and documented “copy” on the form.
Reviewed documentation indicated each AET form was valid and signed by a Department
representative. One youth recently turned eighteen years of age and had a signed AET.
Reviewed documentation found the center’s practice is once the youth reach eighteen years of
age, the youth will provide consent for medical services. During an informal interview, the nurse
reported all efforts are made to obtain a valid AET. The nurse reported contacting the assigned
juvenile probation officer (JPO) to assist in obtaining the parent/guardian signature. In the event
the JPO is unable to obtain a signature from the parent/guardian, the superintendent or
designee will sign a Limited Consent for Evaluation.
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 (FOPs) to ensure the parent/guardian is
notified of significant changes in the youth’s condition and obtain consent when new
medications and treatments are prescribed. A review of seven youth Individual Healthcare
Records (IHCR) reflected one record contained documentation of parental notification for an
over-the-counter (OTC) medication beyond those covered by the Authority for Evaluation and
Treatment (AET). Reviewed documentation confirmed three of the seven youth were taking
psychotropic medications at admission. Two youth records were applicable for having a new
medication order and two were applicable for significant changes to existing medications, and
each documented parental notification consent. When applicable, telephone attempts were
documented in the progress notes. Reviewed documentation confirmed each of the seven
reviewed IHCR’s verified vaccines within thirty days of the youth’s admission. None of the youth
were applicable for a Religious Exemption from Immunizations. An interview with the nurse
verified the center’s practice for obtaining parental consent and documenting attempted parental
notifications.
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 (FOPs) to ensure each youth receives a
healthcare admission screening utilizing the Department’s Medical and Mental Health
Admission Screening form. A review of seven youth Individual Healthcare Records (IHCRs)
found each contained a Medical and Mental Health Admission Screening form completed on the
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date of the youth’s admission by the juvenile justice detention officer (JJDO) and was reviewed
by the licensed nurse within twenty-four hours. Each screening form was completed in the
Department’s Juvenile Justice Information System (JJIS). Reviewed documentation confirmed
the designated health authority (DHA) was notified of each youth’s admission. One of the seven
youth were applicable for a healthcare admission rescreening. Reviewed documentation
confirmed a rescreening was completed by the JJDO and reviewed by the nurse within twenty-
four hours of the screening. A review of three youth’s IHCR included documented verbal/written
consent to receive a qualitative urine pregnancy screening test. An interview with the center’s
nurse confirmed the center’s practice for completing an admission screening within the required
timeframe.
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 (FOPs) to ensure all youth are oriented to the
general process of healthcare delivery services at the center. Seven youth Individual Healthcare
Records (IHCRs) were reviewed for youth orientation to healthcare services. Each reviewed
IHCR included documentation to support the youth received a general healthcare orientation
within twenty-four hours of their admission to the center. A review of each youth’s Department
Health Education Record confirmed all required elements were addressed during the orientation
process.
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 (FOPs) to ensure the designated health
authority (DHA) is notified when youth admitted to the center require emergency care or routine
notification. The center’s practice is to notify the DHA of the admission of any youth with a
chronic medical condition, psychotropic medication, or medical concern. A review of seven
youth Individual Healthcare Records (IHCRs) showed three were applicable for known or
suspected chronic conditions upon admission. Each applicable youth’s record included a
referral to the physician/advanced practice registered nurse (APRN). Six of the seven youth
records included notification to the DHA documented in the chronological progress notes within
the required timeframe. During an interview, the nurse provided the required timeframe and
practice for notifying the DHA when youth are admitted with a chronic condition or require
emergency care.
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 (FOPs) regarding the Health-Related History
(HRH) form which indicates the HRH form shall be completed no later than seven days following
the date of the youth’s admission. A review of seven Individual Healthcare Records (IHCRs)
confirmed the HRH was completed within seven calendar days of the youth’s admission and
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Office of Accountability and Program Support Page 38 of 54 (Revised July 2023)
was updated/completed prior to the Comprehensive Physical Assessment (CPA), as evidenced
by signature and date. Reviewed documentation indicated each HRH form was reviewed by a
licensed nurse or practitioner. An interview with the center’s nurse confirmed the center’s
practice.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures (FOPs) to ensure each youth in the center
has a completed Comprehensive Physical Assessment (CPA) upon their admission into the
center. A review of seven Individual Healthcare Records (IHCRs) was completed and five
contained a current CPA on file at the time of admission and two records required a new CPA.
Six of the seven CPAs were completed or reviewed within seven days of the youth’s admission
and signed by the designated health administrator (DHA) or the advanced practice registered
nurse (APRN). One youth’s CPA expired on February 1, 2025, and was not updated until May 7,
2025. This information was shared with the administration staff during the review. Each CPA
was completed in full to include the Medical Grade, Tanner Stage, cardiovascular, body mass
index, visual acuity field, and most recent Tuberculosis Skin Test (TST). All sections of the CPA
were marked with an O, or an X. A review of each reviewed CPA found the DHA documented
“asymptomatic/not clinically significant” for sections nineteen through twenty-four for male and
female youth where applicable. The Department’s Problem List was updated, as required. All
seven youth had at least one verified Tuberculosis Skin Test (TST) formerly purified protein
derivative (PPD) test documented in the IHCR within the last year. The results of the TSTs were
documented on the CPA and Infectious and Communicable Disease (ICD) forms matched.
Each Tier I Tuberculosis (TB) screening was completed within the required timeframe. An
interview with the nurse confirmed the DHA completed the CPA within seven days of the youth’s
admission.
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) in place to ensure all youth entering
the center are clinically screened, evaluated, and treated, if necessary, for sexually transmitted
infections (STIs) and human immunodeficiency virus (HIV). A review of seven Individual
Healthcare Records (IHCRs) confirmed each youth was clinically screened and evaluated for
STIs. Four youth records indicated a need for further evaluation and a referral was initiated.
Three youth did not require further testing. Four youth screening results, clinical evaluations,
and diagnoses were documented on the infectious and communicable disease (ICD) form,
including HIV results of the youth’s IHCR. Reviewed documentation confirmed each applicable
youth was offered counseling, testing, and if indicated, treatment/referral for HIV. Each
applicable youth received HIV testing and there was evidence of documented consents from
each youth obtained by the center. Reviewed documentation confirmed pre-test/post-test
counseling was documented on the individual health education record and/or was in the youth’s
progress notes and the youth’s confidentiality was protected by not including the youth’s HIV
status or any other STI diagnosis on the center’s internal alert system. Seven interviewed youth
reported they can request HIV testing.
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Office of Accountability and Program Support Page 39 of 54 (Revised July 2023)
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 (FOPs) ensuring all youth will be able to
make sick call requests and have their complaints treated through the sick call system. A review
of seven Individual Healthcare Records (IHCRs) reflected six youth were applicable for sick
calls. Each applicable youth’s’ sick call was documented on the Sick Call Referral Log. Each
sick call request was completed by the nurse in accordance with Florida Administrative Code.
There were no instances of a youth presenting with a similar sick call complaint three or more
times. None of the six applicable youth had complaints of severe pain staff was unfamiliar with
and/or the youth’s medical condition could not be determined. An observation of the center
found postings indicating sick call is held from 11:00 a.m. to 1:00 p.m., and 4:00 p.m. to 6:00
p.m. An interview with the nursing staff confirmed sick call is provided by the nurse within
twenty-four hours or sooner. However, the center has procedures in place for the shift
supervisor to review all sick call requests as soon as possible and within four hours after the
request is submitted. During the week of the annual compliance review, one sick call was
observed. The youth was escorted to the medical clinic by a direct care staff. The youth’s verbal
consent was obtained prior to observation. The youth was seen in a private area with no other
youth present to hear or see the examination. The medical staff was able to maintain privacy
while the officer was located by the door of the medical area. Seven youth were interviewed.
Two youth reported the nurse conducts sick call, and they can see the nurse within the required
time frame. Five youth reported never submitting a sick call request. Seven interviewed staff
reported the nurse completes sick call.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Limited Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center maintains facility operating procedures (FOPs) ensuring a comprehensive process of
episodic care, first aid treatment, and emergency care. The center utilizes an Episodic Care
Report to document episodic care and first-aid treatment. A review of seven Individual
Healthcare Records (IHCRs) showed five youth required on-site first-aid or episodic care with
dates and times noted. Each applicable youth received episodic care or first-aid by a licensed
nurse. Each applicable IHCR documented problem-oriented elements which were used to
capture pertinent information pertaining to the nature of the youth’s complaint including
identification of the subjective, objective, assessment, and plan (SOAP) to address the
complaint for each incident. None of the reviewed occurrences of episodic care required referral
to off-site care. A review of the Episodic Care Log Report found all entries were completed.
When applicable, a plan for follow-up care was documented. The center maintains two
automated external defibrillators (AEDs). The AED batteries and pads are checked by medical
and an outside medical provider, to confirm each are operable. One is in the medical clinic and
the other is in master control. The AED procedures are stored with the AED, and each AED
provides audible instructions when utilized. The AEDs are made with an internal battery, and an
observation of the AED’s light had an indication of green. During the annual compliance review
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nursing staff checked the expiration dates, conducted a self-test of the AEDs, and there were no
issues discovered. The batteries in both AEDs expire August 25, 2025, and the pads expire
August 20, 2028. The AED pads were changed on January 12, 2021. The center maintains
eleven first-aid kits located in the Juvenile Assessment Center (JAC), foyer, supervisor’s office,
master control, and the remaining six are in each van when in use. An observation of three
randomly selected first-aid kits was conducted. Each first-aid kit contained a monthly checklist
log on the outside of the kit confirming the nurse checked all content and none were expired.
Observations of the medical clinic confirmed emergency contact telephone numbers were
posted inaccessible to youth. An interview with the nurse confirmed the center’s policy on the
use, access, and inventory of NARCAN®. The nurse reported medical staff and supervisors are
the only staff with access. NARCAN® training was embedded within the Department’s Learning
Management System (SkillPro) cardiopulmonary resuscitation (CPR) course. The center’s
nurses are responsible for conducting and simulating staff trainings on NARCAN® and its use
with an instructor-led class for the supervisors trained and approved for medication
administration. An observation of the medical cart found the center stores NARCAN® in a
locked container inside of the medical cart. Reviewed documentation confirmed the nurse
retains a weekly inventory of the NARCAN®. Reviewed documentation showed authorized
direct care staff were trained on the administration of the epinephrine auto-injector. A review of
seven staff training records found each staff completed episodic and first-aid training. However,
there was no documentation to support each staff completed emergency care training. A review
of quarterly mock emergency drills for the past twelve months found the center’s practice is to
conduct monthly emergency drills on each shift. However, five out of twenty-three emergency
drills confirmed the drills were conducted at least once a month on each shift and documented
use of life saving techniques such as CPR at least once during the review period. Eight drills
documented they were not simulated in the drill review comments. For eighteen drills reviewed
documentation found the training staff documented staff needs additional training on drills, staff
are not taking drills seriously, and/or staff were not participating in drills. Seven youth were
interviewed. One youth stated the nurse takes a while when asked to rate the medical care.
Another youth reported medical care was good. Five youth reported never receiving medical
care. Seven interviewed staff stated they can call 9-1-1 as needed.
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 (FOPs) to provide timely referrals and
coordination of medical services for youth requiring off-site care. A review of seven youth
individual healthcare records (IHCRs) found no youth were applicable; therefore, three
additional IHCRs were selected for review. Each applicable record included the Summary of
Off-Site Care Consultation Report form. Reviewed documentation found the off-site non-
emergent care incident was documented on the Episodic Care Report. When applicable,
parent/guardian notification was documented. None of the off-site care events were applicable
for discharge documents due to the event being non-emergent. Two of the three youth needed
follow-up testing, referrals, or appointments. Reviewed documentation confirmed the designated
health authority (DHA) reviewed and signed/initialed all follow-up appointment documents.
Reviewed documentation confirmed the referrals were tracked and the youth received the
appropriate follow-up care. An interview with the center’s nurse confirmed the center’s practice
for off-site care, referrals, and follow-up care.
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Office of Accountability and Program Support Page 41 of 54 (Revised July 2023)
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 (FOPs) to ensure youth identified with
chronic conditions receive regularly scheduled evaluations and necessary follow-up care. Youth
are screened during the intake process for medical conditions warranting periodic evaluations
and follow-up care. A review of seven youth Individual Healthcare Records (IHCRs) found four
youth were identified with a chronic medical condition and/or taking prescribed medications.
Four youth were classified with a Medical Grade two through four. One of the four youth was
placed on the center’s chronic conditions list. Three youth were not applicable. Two youth
received periodic evaluations at least every ninety days as needed, and progress notes were
completed for each completed periodic evaluation. One youth’s periodic evaluations were
missed for the month of April. The nurse advised it was an oversight during the annual
compliance review. Two of the four applicable youth periodic evaluations were conducted prior
to renewing a prescription medication which expired. None of the reviewed youth had an
evaluation conducted off-site. Reviewed documentation confirmed the Problem List for each
youth was updated, as required. An interview with the nurse in comparison to the center’s
Chronic List Report confirmed periodic evaluations are tracked by medical staff. In addition, an
interview with the designated health authority (DHA) validated periodic evaluations are
conducted every ninety days.
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 (FOPs) requiring medication to be stored,
inventoried, and provided in a safe and effective manner to youth. The center’s practice is for
nursing staff to verify all medications have a current, valid order and are administered according
to a current prescription or practitioner’s order. Nursing staff verify medication with the
parent/guardian when they deliver the medication to the center. A review of seven Individual
Healthcare Records (IHCRs) confirmed three youth were taking medication at admission. The
prescription verification was included in the chronological progress note, in the IHCR/electronic
medical record (EMR) or utilizing the Prescription Medication Verification Checklist form.
Reviewed documentation confirmed the nursing staff verbally notified the designated health
authority (DHA) of each admission on the youth’s day of admission. Documentation showed the
DHA or psychiatrist resumed the prescribed medication for each youth. When current
medications were continued, discontinued, or changed, the reviewed records indicated the DHA
placed an order on the Practitioner Order form, as required. One youth was applicable for
restricted housing while taking prescribed medications. Reviewed documentation confirmed the
youth received all prescribed medication on time. All three applicable youth had over-the-
counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form
which were administered according to approved protocols or practitioner’s order and the
standard Department Medication Administration Record (MAR) was used to document all
medications and treatment. The center utilizes the standard MAR for each youth receiving either
prescription medications on a routine basis or OTC medications which included all required
elements. Reviewed documentation reflected the staff initialed each administered medication
entry and each applicable youth documented their initials on the MAR. The center maintains
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FOPs to ensure the usage of the MAR by licensed healthcare staff and non-licensed staff. Each
reviewed MAR clearly documented the youth’s name, Department of Juvenile Justice
identification number (DDJID), date of birth, youth allergies, precautions, Medical Grade,
medical alerts, and current picture of the youth. The MAR clearly indicated medication start and
stop dates, refusals, and nursing staff documented weekly side-effect monitoring. No youth
required parenteral medication. Documentation confirmed the DHA or psychiatrist was notified
upon admission for each of the three youth who were currently prescribed psychotropic
medications. Two youth’s IHCRs confirmed the psychiatrist conducted an initial diagnostic
psychiatric interview within fourteen days of admission. One youth refused to complete the initial
diagnostic psychiatric interview within the required timeframe. All three youth received a
medication monitoring/review every thirty days as required. Observation of a medication
administration was conducted during the week of the annual compliance review, and no issues
were identified. An interview with the nurse confirmed the center’s practice regarding medication
management and the center’s disposal process. Additionally, the nurse reported staff trained in
medication administration are trained to do so by a registered nurse. Seven youth were
interviewed and reported not taking medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains facility operating procedures (FOPs) ensuring medical equipment
classified as medications/sharps are secured and inventoried by using a routine perpetual
inventory. An observation of the medical clinic displayed the medication cart was clean and
organized with stock items separate from youth-specific medications. Narcotics and controlled
medications were secured in a separate locked area inside of the medication cart, behind two
locks. Injectable, topical, and liquid medications were stored separately and securely
maintained. The oral medications were stored separate from injectable and topical medications.
Medications which required refrigeration were stored in a secured refrigerator, which is used for
medication only. The center’s perpetual and weekly inventories of all sharps and stock over-the-
counter (OTC) medications were conducted as needed pursuant to the Board of Pharmacy
regulatory requirements, and there was a shift-to-shift inventory count of all controlled
substances documented on the youth’s individualized Controlled Medication Inventory Record,
as required. A review of three OTC medications was conducted and confirmed the inventories
were accurate. A review of three controlled medications was conducted, and each medication
count was accurate. A review of three sharps was observed, in which perpetual inventories
were accurate with verified weekly inventory. All counted medications and sharps matched the
ending inventory numbers documented. During an informal interview, the nurse reported being
responsible for maintaining a perpetual inventory of all medications and sharps. Additionally, the
nurse was able to explain the disposal process of expired and/or discontinued medications.
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
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Office of Accountability and Program Support Page 43 of 54 (Revised July 2023)
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 (FOPs) requiring the implementation of
infection control procedures including prevention, containment, treatment, and reporting
requirements related to infectious diseases, according to the Occupational Safety and Health
Administration (OSHA) federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. A review of seven youth Individual Healthcare Records (IHCRs) reflected
each youth received infection control training within twenty-four hours of admission. The
infection control training included all elements required by the Department. Reviewed
documentation supported the Exposure Control Plan/Infection Control Plan was written in
accordance with OSHA guidelines. The center’s process for needle stick post-exposure
evaluation involves contacting the regional supervisor, documenting, proving appropriate care,
and contacting the Department’s Central Communications Center (CCC). When applicable,
infectious diseases which needed to be reported to the local health department and/or CDC
were reported. Seven staff training records were reviewed. Five out of seven staff were missing
exposure control training for the 2024 fiscal year. Five staff completed infection control training,
and two staff did not complete infection control training.
4.18 Prenatal Care/Education [Contract Provider] Limited Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center maintains facility operating procedures (FOPs) for the care of pregnant youth to
include procedures for medical issues, nutrition, education, and medication. The center had two
pregnant youth since the last annual compliance review. Each youth had the provision of
prenatal care begin immediately, which continued through discharge from the center. A review
of the youth’s Individual Healthcare Records (IHCRs) indicated the youth received prenatal care
as recommended by the primary doctor including off-site medical prenatal, obstetrical, or
gynecological appointments, when applicable. One of the two youth was in the center for more
than thirty days, and the designated health authority (DHA) and/or advanced practice registered
nurse (APRN) provided routine focused medical evaluations of the youth’s pregnancy every
thirty days or sooner. A review of the record indicated prenatal care was provided at
recommended intervals and the youth was placed on the center’s internal alert system for the
provision of all nutrition and staff health awareness. Reviewed documentation indicated the
youth was monitored daily for signs of pregnancy complications. Each youth had documented
plans for post-birth psychological and physical care. Reviewed healthcare education information
supported the pregnant youth received pre-natal education to include alcohol and drug use,
smoking, nutrition, sexually transmitted infections (STI), contraception, prenatal care, birthing
process, postpartum care, basic baby care, child/infant development, and parenting skills. An
interview with the nurse indicated prenatal care is provided by an obstetrician and/or
perinatologist once it is determined the youth is pregnant. The DHA collaborates with the
obstetrician and/or perinatologist in the oversight and management of the youth's pregnancy.
Periodic evaluations for pregnant youth are conducted no less than every four weeks until the
eighth month of pregnancy. Additionally, the nurse stated pregnant youth receive a periodic
evaluation every two weeks in the eighth month, and weekly thereafter. Seven in-service
training records were reviewed and reflected none of the staff completed girls’ healthcare
training.
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Office of Accountability and Program Support Page 44 of 54 (Revised July 2023)
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 maintains facility operating procedures (FOPs) to address active supervision of
youth. During the annual compliance review week, youth supervision was observed each day.
Youth and staff observations on the living module and in the classrooms were conducted.
Detention staff maintained continuous sight supervision of all youth in their assigned area. The
interactions between staff and youth demonstrated active supervision. Staff were positioned in
the areas supporting active supervision. The juvenile justice detention officers (JJDOs) and
master control operators communicated to receive authorization for all movement within the
center. A review of master control logbooks since the last annual compliance review verified
there was documentation to support headcounts were conducted on a consistent basis during
the beginning and ending of each shift and prior to youth movement. Seven staff were
interviewed and five reported they think there are enough staff at the center to provide for the
safety and security of the youth and staff. Two staff reported they do not think there are enough
staff at the center to provide for the safety and security of the youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center maintains facility operating procedures (FOPs) addressing the behavior
management system (BMS) to ensure the safety and security of youth and staff, which offers
rewards, privileges, and consequences for youth behaviors. Observations conducted during the
annual compliance review week revealed the center has the BMS posted in both living modules
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and the cafeteria. Staff maintain a BMS data sheet for each youth to capture youth behavior
throughout the day. The center has an incentive calendar outlining the daily incentives for the
month. The center’s BMS prohibits the use of group punishment, corporal punishment, and the
use of drugs to control youth behavior. Youth are informed of the BMS during the admission
process through an orientation. A review of the youth data sheets revealed staff were consistent
in completing the data sheet on a regular basis. Seven youth were interviewed regarding the
BMS. Four youth stated the BMS is very good. Three youth stated the BMS is good. All seven
youth were able to explain the difference between each level and how to progress from level to
level. Seven interviewed youth stated BMS rewards included extra snacks, extra hygiene
products, extra phone calls, later bedtime, and participating in special parties. All seven
interviewed youth stated staff are fair when distributing rewards. All seven interviewed youth
stated youth are never allowed to punish other youth. Five of seven interviewed youth stated
they were sent to their room for punishment reasons, two youth stated they were not sent to
their room. Documentation provided verified the five youth were placed in confinement due to
behavior. All seven interviewed youth stated consequences they received were fair. Five youth
stated they lost a level due to negative behavior, and two stated they never received
consequences or had anything taken away. All seven youth stated handcuffs and leg irons are
not used to control youth at the center. Seven interviewed staff were able to explain the center’s
BMS. All seven staff stated youth who earned their level receive extra minutes on their
telephone calls, games, extra snacks, and participate in parties. The interviewed staff stated
nothing can be taken away from a youth consequently and only points and levels can be taken
away. Each interviewed staff believed the BMS at the center is effective. All seven staff stated
staff speak with youth about the consequences being imposed due to negative behavior and
discuss with youth alternative behaviors. Each staff stated youth are given an opportunity to
explain their behaviors. Seven interviewed staff stated supervisors give them feedback on the
implementation of the BMS during daily shift briefings, weekly, and as needed. Seven
interviewed staff stated they have never seen a co-worker take anything away from youth due to
behavior issues. Each staff stated they have never seen a co-worker encouraging youth to beat
up another youth. The interviewed superintendent stated the BMS is a three-tiered BMS and
used as a tool to provide rewards, privileges, consequences for negative behaviors, and to
encourage youth to exhibit positive and appropriate behaviors.
5.03 Ten-Minute Checks (Critical) Limited 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 (FOPs) addressing ten-minute checks to
ensure ten-minute checks are conducted when youth are in their rooms for sleeping purposes,
shift change, and confinement. The center has a total of sixty-four cameras with a recording
capacity of thirty days. Three of the cameras were not operational at the time of the annual
compliance review week. The non-functioning cameras were not in an area where youth are
situated. A review of the documentation and surveillance coverage was conducted for three
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randomly selected dates for each sleeping quarter during the thirty days prior to the review,
across each shift for the two different youth living modules. Documentation and observation of
video footage supported in one youth living module the ten-minute checks were not conducted
with fidelity for the three randomly selected dates. The ten-minute checks were conducted
between nineteen to thirty minutes late. The center was placed on a deficiency prior to the
annual compliance review and during the annual review week the same problem was identified.
A total of twelve ten-minute checks were conducted for the module and nine checks were not
conducted as required. The second youth living module documentation and observation of video
footage supported the ten-minute checks were conducted within the policy for the three
randomly selected dates. Reviewed documentation supported the superintendent or designee
conducted a ten-minute check management oversite once a week during the annual compliance
review period. Seven staff were interviewed and reported they are knowledgeable of the
requirements for ten-minute room checks when youth are placed on the sleeping quarter. All
interviewed staff stated they conduct room checks when a youth is placed in their room every
eight-to-ten-minutes. During an interview with the superintendent, it was reported ten-minute
checks are conducted any time a youth is secured in their sleeping room, staff conduct a visual
check on the youth every ten minutes or less. These checks are documented by an electronic
tracking system.
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 (FOPs) in place to ensure staff always know
the exact number and location of all youth under their supervision. A logbook review of one full
day from each month throughout the annual compliance review period was conducted.
Documentation confirmed the census counts of youth are written at the beginning and at the
end of each shift. Counts were documented following youth movements, emergencies,
disturbances, and drills. Census counts were documented upon any change of population.
Living module counts were recorded in their assigned module logbooks. Observations during
the annual compliance review week verified counts were conducted as required. Seven staff
were interviewed, and all seven staff reported youth counts are conducted at the beginning of
shift and at the end of shift. Five staff stated before and after school, and before and after
meals. Five staff reported emergency counts are conducted when a youth is believed to be
missing. Two staff reported emergency counts are conducted when visibility is hindered, such
as an electrical outage. Six staff reported emergency counts are conducted after a major
disturbance.
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5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center maintains facility operating procedures regarding logbooks. The center maintains
separate logbooks in master control and for each living module, as well as one for visitors, and
one for contracted staff. A sample of logbooks for one day each month during the annual
compliance review period was reviewed. Documentation revealed each logbook was bound with
numbered pages, all entries included the date and time of the event or incident with the name of
the staff and youth involved, and a brief description of the event and the initials of the staff
making the entry. Entries included safety and security of the center, including medical, special
needs, and mental health alerts which were highlighted. Reviewed logbooks reflected all errors
are struck through with a single line and dated and initialed by the person correcting the error.
Reviewed master control logbooks included emergency situations, incidents, fire and escape
drills, population counts at the beginning and end of each shift, group movements, admissions
and releases, name of youth placed on precautionary/secure observation, the time
precautionary/secure observation began, and the time precautionary/secure observation was
discontinued. The juvenile justice detention officer supervisor (JJDOS) reviews the logbooks
when accepting the shift to document they are aware of current relevant situations in the center.
The superintendent or designee reviewed the logbooks on a weekly basis. The juvenile justice
detention officer (JJDO) assigned to the module reviews the logbook upon accepting the shift.
The superintendent was interviewed and reported logbooks are reviewed weekly by
superintendent and daily by JJDOS.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center maintains fity operating procedures (FOPs) on key control. The FOP addresses key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or
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lost keys, and reporting and replacement of damaged keys. All keys are stored on a tamper-
resistant key ring which inhibits the removal of keys and is color coded specific to the position
the key is assigned. The center maintained a master key inventory which accounts for all key
rings by ring number, the number of keys on each ring, the capability of each key, and to whom
the keys are assigned and issued. Emergency keys which provide egress through exterior doors
are stored in master control. A review of the Key Control Logs confirmed the issuance of keys
and key rings was documented on the Key Control Logs for each shift with the date and time of
issue, name of the person issuing the key, name of person receiving the key ring, and time
returned. During the annual compliance review week, staff were observed always carrying the
keys on their person and youth did not have access to center keys. A review of the master key
control inventory revealed the inventory report matched the actual key rings in use. There were
no reported incidents during the annual compliance review period of lost keys or staff taking
keys home after their shift. If keys were to be taken home by staff, the staff are required to
return the keys to the center within two hours of discovering the keys were taken home.
Personal keys are stored in staff lockers, visitor lockers or secured in the administrative front
area. Observations verified staff placed their personal keys in designated lockers prior to
entering the secure area of the center. Master control/supervisors would issue center keys to
staff and document on the Key Control Logs. A random check of five different sets of center
keys compared to the inventory list indicated the keys were accounted for, the key tag matched
the number of keys on the key ring, and the ring was documented on the key log. A random
check of three staff verified the number of keys on their key ring matched the inventory and
each staff knew the function of each key. Seven interviewed staff stated there are restricted
keys including keys which access medical records, the youth property area, kitchen, mental
health records, and case management records. All seven interviewed staff was able to articulate
the daily process for key control at the center. An interview with the superintendent verified a list
of permanent issued keys is maintained by the superintendent.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains facility operating procedures (FOPs) in place for transportation and
operation of Department vehicles. The center has a total of five vehicles used to transport youth.
Each transportation vehicle had documentation of an annual maintenance inspection completed
by a certified mechanic. Documentation showed the mechanic inspected the tires, lights, and
brakes ensuring the vehicles were safe to transport youth. Reviewed documentation verified the
center’s maintenance staff conducted monthly visual checks for all transportation vehicles.
During the monthly maintenance checks, staff visually checked the vehicle water coolant, lights,
oil, emergency equipment, brakes, horn, interior/exterior, and cleanliness. In addition, the tires,
battery, windshield and wipers, windows, mirrors, and vehicle damage were visually inspected.
The inspections were documented on the Monthly Inspection forms which were maintained
digitally by the maintenance staff. Each inspected vehicle had the appropriate number of
seatbelts and a current fire extinguisher. Transportation staff take the emergency transport kit
prior to transporting youth which included the window punch, first-aid kit, and seatbelt cutter. 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
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card, and vehicle registration. In addition, staff had a center issued cellular telephone,
documented the inspection in the logbook, ensured the vehicle was always secured, ensured
youth were searched prior to being placed in the vehicle, and ensured youth and staff were
wearing seatbelts. Documentation provided for each transport supported the vehicle’s logbook
documented acknowledgement the vehicle was checked, destination, number of youth being
transported, staff names, the name of the officer riding in the back of the van, and the time the
transport began and ended. A check of five center vehicles found all were locked when not in
use. Seven youth were interviewed, and each youth stated they feel staff are driving safely
when they are being transported. Each youth stated they have never seen anyone place
contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains facility operating procedures (FOPs) requiring all tools and equipment to
be properly maintained, secured, and inventoried. A perpetual inventory is maintained for all
tools in the maintenance shed. A review of the inventory logs confirmed they included
documentation of the issuance and return of tools. Kitchen tools included knives and other
sharps which were stored in a locked box in the kitchen area. An inventory of kitchen tools is
maintained, and counts are documented at the beginning of the day, midday, and at the end of
the shift. Observations of the tool room and the kitchen verified all tools were secured when not
in use. A review of five tools and 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. Five tools were
randomly selected, and each tool was secured, marked for easy identification on the shadow
board, inventoried accurately, and the inventory was signed by the superintendent/designee.
During an informal interview, the assistant superintendent verified service vendors are always
accompanied by center staff when in the secure area of the center. The center’s FOP and an
informal interview with maintenance and kitchen staff stated if tools are lost, they would fill out a
maintenance disposal form, search for the tools, and if it is not recovered call the Department’s
Central Communications Center (CCC). During an informal interview, the superintendent stated
access to tools is limited to the maintenance mechanic and the center’s administrators, and
tools are kept outside on a shadow board away from the building. Seven youth were interviewed
with six youth stating they used mops and brooms and one stating they do not use any tool.
One youth stated they use scrub brushes but are always supervsied. Seven staff were
interviewed, and the staff reported youth are only allowed to use scrub brushes, mops, and
brooms. All seven staff were able to articulate the processes if a tool goes missing. The
interviewed superintendent stated only the maintenance mechanic and administrators have
access to the Class A tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
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poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center maintains facility operating procedures (FOPs) to ensure the proper inventory and
limited access to flammable, toxic, caustic, and poisonous items. A review of the Continuity of
Operations Plan (COOP) found it includes the Safety Plan. Five chemicals were reviewed
during the annual compliance review and the center maintained the corresponding safety data
sheets (SDS), and complete and accurate inventories of the chemicals reviewed. Flammable,
toxic, caustic, and poisonous items were observed to be stored in areas inaccessible to youth
only accessible by authorized personnel. All seven interviewed youth stated they did not have
access to flammable, toxic, caustic, and poisonous items. Seven staff were interviewed, and all
seven staff confirmed youth do not handle any flammable, toxic, caustic, or poisonous items.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains facility operating procedures (FOPs) to ensure the proper use, storage,
and disposal of flammable, toxic, caustic, and poisonous items. During the annual compliance
review period the center did not have any instances of chemical spills or disposal of any
flammable, toxic, caustic, or poisonous items. The kitchen has a container designated for
disposable grease. The superintendent stated the grease trap is disposed of on an as needed
basis by the contracted plumber.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains facility operating procedures (FOPs) outlining the process of placing youth
in confinement under twenty-four hours. The FOPs require 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. Fifteen confinement reports were reviewed during the annual
compliance review. Review of each confinement report confirmed all rooms were searched prior
to youth being placed in confinement, all non-fixed items were removed from the room, and
each documented approval by a juvenile justice detention officer supervisor (JJDOS).
Observations of the confinement rooms indicated some windows had minimal scratching;
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however, did not interfere with visual checks of youth placed in confinement. Each confinement
report 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 the right to
grieve being placed into confinement for under twenty-four hours. Documentation verified the
supervisor approved each confinement, 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. All fifteen Visual
Observation Reports verified staff were observing youth in confinement at least every five
minutes for the first hour of confinement. After the first hour, youth were observed according to
the Detention Supervision Matrix. None of the reviewed records documented a physical injury
was observed prior to placing youth in confinement. Each of the reviewed confinement records
documented the reason for the confinement, which was explained to the youth. All fifteen
reviewed records verified the supervisor conducted an initial confinement review with the youth
within one hour of the incident. Full reports were 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 fifteen reviewed confinement reports documented staff and
supervisors continually counseled the youth and considered removing the youth from
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 confinements did not interfere with
visitation. The center did not have any pregnant youth in confinement under twenty-four hours
during the annual compliance review period. Seven staff were interviewed and all seven knew
the steps for placing a youth in confinement and confirmed all youth are afforded educational
access while in confinement. The interviewed superintendent confirmed theJJDOS reviews the
confinement within one hour and documents the need to continue confinement and
administrators review confinements within forty-eight hours of the conclusion of the confinement
and document appropriateness.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains faciltity operating procedures (FOPs) to manage weather emergencies
and natural disaster events including the Continuity of Operations Plan (COOP). The plan
requires COOP drills to be conducted twice annually with one taking place before hurricane
season. A review of documentation confirmed the center conducted two COOP drills and one
took place prior to the start of hurricane season. All reviewed documentation contained type of
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drill, date and time, participants, brief scenario, and findings and recommendations. The
superintendent confirmed the center has a COOP in place which includes emergency plans for
a multitude of emergencies.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures (FOPs) to address escape drills and an
Escape Prevention Plan. The FOP requires the center to conduct escape drills on a quarterly
basis. A review of escape drills for the last twelve months since the last annual compliance
review confirmed the center has conducted escape drills on a quarterly basis. Seven staff
records were reviewed with six staff being trained in escape prevention annually, one staff did
not have escape prevention training. Each time an escape drill was conducted it was
documented in the master control logbook. Seven staff were interviewed and all seven reported
participating in fire drills since the last annual compliance review. Six reported participating in
escape and weather drills. Four reported participating in medical/mental health drills and COOP
drills. Three staff reported participating in major disturbance drills.
5.15 Fire Drills Limited 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 maintains facility operating procedures (FOPs) for the implementation of disaster
preparedness and fire prevention plans. According to the procedures, the center is required to
conduct fire drills monthly. After review of the fire drill records, there were a total of six missing
drills since the last annual compliance review. First shift was missing drills from January,
February, March, and April 2025. Second and third shift were missing fire drills from March
2025. All reviewed fire drills had documentation in the master control logbook. All fire
extinguishers had undergone a completed annual inspection, as required. Seven staff were
interviewed, and all seven confirmed fire drills are completed monthly. Seven youth were
interviewed, and four youth stated they have participated in a fire drill and three youth stated
they have never participated in a fire drill.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
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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 maintains facility operating procedures (FOPs) for searches and to ensure
contraband is prevented from entering the secure area of the center. The FOP includes
procedures for electronic, frisk, strip, room, and staff/visitor searches. During the annual
compliance review week, a search of a youth before a transport was observed. The staff
member wore gloves and thoroughly searched the youth prior to placing the youth on the
vehicle for transport. There were no strip searches conducted since the last annual compliance
review aside from those conducted at the time of admission. Searches of staff and visitors prior
to entering the secure area of the center were observed. All observed people entering the
center were electronically searched, all clear bags, cases, jacket pockets, and other items were
searched, and all prohibited items were secured prior to entering the center. A sample of shift
reports since the last annual compliance review was reviewed, and it was determined room
searches are completed daily on each shift. There were ten instances of contraband being
found at the center during the annual compliance review period, all were reported to the
Department’s Central Communications Center (CCC) within the required time frame, and an
incident report was completed for each occurrence. The center’s visitors log contains a
contraband attestation statement and requires all visitors entering the center to complete a
separate contraband attestation form. Seven staff records were reviewed and all seven had
signed contraband attestations. Eleven newly hired staff records were reviewed and all eleven
had signed contraband attestation forms in their records. Nine instances of contraband entering
the center were reviewed. A review of logbook documentation confirmed the center documented
the confiscation of contraband and contacted the Department’s Central Communications Center
(CCC). A review of the Department’s Facility Management System (FMS) confirmed all incident
reports regarding contraband were entered into the system. Confiscated items were handed to
the on-duty supervisor and law enforcement was contacted for the illegal contraband entering
the center. Shift supervisors documented the chain of custody of confiscated items. The CCC
and the regional director were notified for all instances of illegal contraband entering the center.
The superintendent was interviewed and confirmed if contraband is found in the center the
process to report it is to call law enforcement and the CCC.
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source: DJJ

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 3.13

rating: Failed Compliance

rule: Indicator 3.15

rule: Indicator 4.12

rule: Indicator 4.18

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.15

excerpt: Fire Drills