summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Collier Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3315 Tamiami Trail East
Naples, Florida 34103]
Review Date(s): November 4-7, 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:
Nicos Antonakos, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cleo Burks, Monroe Regional Juvenile Detention Center, Assistant Superintendent (Standard 5)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (interviews)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Douglas Kane, Saint Lucie Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Collier Regional Juvenile Detention Center MQI Program Code: 1046
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Collier County / Circuit 20 Number of Beds: 40
Review Date(s): November 4-7, 2025 Lead Reviewer Code: 180
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 60
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Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 60
1 .0 1
1 .0 2
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1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
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s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a tis fa c to
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a tis fa c to
S ta ff C o d e o f C o n d u c t S a tis fa c to
In c id e n t R e p o rtin g (C C C ) * S a tis fa c to
R ig h t In te ra c tio n s (R I) S a tis fa c to
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a tis fa c to
In -S e rv ic e T ra in in g S a tis fa c to
G rie v a n c e s S a tis fa c to
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a tis fa c to
D a ta T re n d A n a ly s is S a tis fa c to
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 60
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 2 - Y o u th M a n a g e m e n t
A d m is s io n S a tis fa c
O rie n ta tio n S a tis fa c
C la s s ific a tio n S a tis fa c
N o tific a tio n o f J P O C irc u it G a n g R e p re s e n ta tiv e S a tis fa c
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty S a tis fa c
R e le a s e S a tis fa c
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa c
R e v ie w o f Y o u th in S e c u re D e te n tio n S a tis fa c
D a ily A c tiv ity S c h e d u le S a tis fa c
E d u c a tio n a l A c c e s s * S a tis fa c
C a re e r E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 60
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In d ic a t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A ) S a
L ic e n s e d M H /S A C lin ic a l S ta ff * S a
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff S a
M H /S A A d m is s io n S c re e n in g S a
M H /S A E v a lu a tio n S a
T re a tm e n t a n d D is c h a rg e P la n n in g S a
M H /S A T re a tm e n t S a
S u ic id e P re v e n tio n P la n * S a
S u ic id e P re v e n tio n S e rv ic e s * S a
S e c u re O b s e rv a tio n * S a
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * S a
S u ic id e P re v e n tio n T ra in in g * S a
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * S a
E m e rg e n c y C a re P la n * S a
C ris is A s s e s s m e n ts * S a
B a k e r a n d M a rc h m a n A c ts * S a
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra
m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to d o
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Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 60
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
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4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * S a tis fa
F a c ility O p e ra tin g P ro c e d u re s S a tis fa
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm S a tis fa
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n S a tis fa
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa
H e a lth -R e la te d H is to ry S a tis fa
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g S a tis fa
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g S a tis fa
S ic k C a ll P ro c e s s S a tis fa
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re S a tis fa
O ff-S ite C a re /R e fe rra ls S a tis fa
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s S a tis fa
M e d ic a tio n M a n a g e m e n t S a tis fa
P s y c h ia tric S e rv ic e s * S a tis fa
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s S a tis fa
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n S a tis fa
P re n a ta l C a re /E d u c a tio n S a tis fa
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth* Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance 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 Satisfactory
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 60
Program Overview
The Collier Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Naples, Florida. The center serves youth in Lee, Hendry, Glades,
and Charlotte counties in Circuit 20. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
forty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are managed by the Collier County School District.
The center’s management team includes the superintendent, two assistant superintendents, two
administrative assistants, seven juvenile justice detention officer (JJDO) supervisors, fourteen
JJDO IIs, twelve JJDO I’s, a training coordinator, a chaplain, a food service director, and three
food service workers. Mental health and healthcare services are provided through the
contracted provider, VitalCore Health Strategies, LLC. Mental health services are provided by a
licensed mental health counselor (LMHC) who serves as the designated mental health clinician
authority (DMHCA). In addition to the DMHCA, the center has one regional licensed supervisor,
and the center has five-licensed full-time therapists on-site. One of the licensed mental health
positions is filled by a licensed clinical social worker which is a travel therapist. A licensed
psychiatrist provides psychiatric services for applicable youth in the center. 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 medical doctor (MD) who
serves as the designated health authority (DHA), one advanced practice registered nurse
(APRN), one registered nurse (RN) manager, two RNs, one licensed practical nurse (LPN), and
one medical records clerk (MRC). The medical clinic maintains nursing coverage Monday
through Sunday from 8:00 a.m. to 5:00 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 two living modules
which are divided by male and female. There are sixty-four security cameras at the center, of
which all were operational. Overall, the center was clean, well maintained and had no graffiti.
The Florida Abuse Hotline and the Department’s Central Communication Center (CCC)
numbers were posted throughout the center. Grievance forms were available for youth in all the
living areas. Behavior management system (BMS) posters were posted throughout the center.
Youth records and personal property were secured. The center has two automated external
defibrillators (AEDs) which are located in master control and in the medical office and were
operational. Observations verified staff were properly supervising youth. Youth and staff were
properly attired. Youth were observed participating in school. The grounds and landscapes were
maintained. There were no unpleasant odors noted during the tour. Youth medical and mental
health records were secured. A perimeter tour found fencing to be secure. At the time of the
annual compliance review, the center had one vacancy, which included a JJDO I.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 60
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures ensuring initial background screenings are
conducted for all newly hired staff, contracted providers, mentors, interns, and volunteers. The
Annual Affidavit of Compliance with Level 2 Screening Standards was submitted January 10,
2025. The Annual Affidavit of Compliance with Level 2 Screening Standards for school district
teachers was submitted to the BSU/Clearinghouse on January 10, 2025. A review of the initial
background screenings for ten newly hired staff, revealed the center received background
screening results from the Department’s BSU/Clearinghouse prior to each staff’s date of hire.
There were six new volunteers and three contracted staff applicable for background screenings
since the last annual compliance review. All required documentation was reviewed prior to hire
for each staff and volunteer. Each staff and volunteer had a completed background screening
prior to working with the center. None of the reviewed staff were applicable for a break in
service. None of the staff were applicable for a background screening exemption. The center
utilizes an ergometric pre-employment assessment tool for all direct care applicants. Nine staff
were applicable for being a direct care staff, and each record included a copy of the pre-
employment assessment passing score, which was maintained in accordance with policy. One
staff was not a direct care staff and did not require a pre-employment assessment. Reviewed
documentation validated the center added all applicable staff to the Clearinghouse Employee
Roster. Additionally, the contracted provider staff had an eligible rating in the Clearinghouse.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all staff, volunteers, and contracted
providers with access to youth undergo a criminal history background rescreening every five
years from the initial date of employment. A review of the staff roster found the center had four
staff eligible for a five-year rescreening since the last annual compliance review. Reviewed
documentation confirmed each applicable staff’s rescreening was completed and submitted to
the Department’s Background Screening Unit (BSU)/Clearinghouse within the required time
frames.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 60
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures to ensure staff adhere to the center’s 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 who received disciplinary actions and three staff who received
commendations was conducted. Three reviewed staff had substantiated code of conduct
violations and all three staff received additional training. Each of the three staff’s personnel
records revealed each staff signed a code of conduct. The code of conduct addressed officer
professionalism, poor performance, negligence, insubordination, conduct unbecoming of a
public employee, and misconduct. In each instance, management took immediate corrective
action to address conduct when staff violated policies and procedures. A review of three staff
found each received a certificate of commendation. Five youth were interviewed, and two youth
stated they have never been stopped from reporting abuse at the center, and three youth
reported they never had to report abuse. Each of the five youth reported staff are respectful
when talking with them and to other youth. All five youth reported they have never heard staff
use profanity when speaking to them or other youth. All five youth reported they have never
been threatened or heard staff threaten other youth. All five interviewed youth indicated they
feel safe in the center. All five youth reported they have never exchanged emails, telephone
numbers, or social media contact information with staff. Five interviewed staff were able to
explain the process for allowing staff and youth to call the Florida Abuse Hotline or the
Department's Central Communication Center (CCC), to report suspected abuse. All five staff
indicated they have never observed a co-worker using profanity when speaking to youth and
indicated they have never heard a staff using profanity directed towards youth. All five staff
stated the working conditions at the center were very good. An interview with the superintendent
confirmed the staff code of conduct is to ensure staff communicate and interact with youth in a
manner which provides a role model of socially accepted behaviors. If staff violate this policy an
investigation is initiated for accountability.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 60
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures 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 114 reportable incidents during the annual
compliance review period. A review of eleven incidents showed all were reported to the CCC
within two hours of the incident or when staff became aware of the incident. Each of the incident
reports were documented in the center’s logbook. A review of the center’s internal
incident/grievance reports revealed there were no additional incidents which should have been
reported to the CCC. An interview with the superintendent indicated whenever reportable
incidents occur, it shall be reported to the CCC within two hours of the staff learning or gaining
knowledge of the incident.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures pertaining to the use of the Right Interactions (RI)
model, in accordance with Florida Administrative Code. The center had a total of 103 RI
incidents since the last annual compliance review. A review of nine RI incident reports
confirmed each of the nine reviewed RI Reports were completed by the end of the staff’s
workday. Each of the reviewed reports contained statements from all the staff involved. None of
the incidents resulted in serious injury to the youth or staff or needed to be reported to the
Florida Abuse Hotline. All nine RI Reports were reviewed and processed by a supervisor or an
RI instructor. Each of the RI Reports confirmed a post-RI interview was conducted with the
youth by the center’s administration within thirty minutes after the incident. None of the youth
were applicable for a post-RI medical review. None of the incidents resulted in the use of
mechanical restraints. A review of internal incident/grievance reports and logbooks for the
compliance review period confirmed there were no additional RI incidents which did not have a
report. Each of the reviewed RI Reports were reviewed by the superintendent or designee within
seventy-two hours. The center’s RI rate during the previous quarter was 17.48, which is above
the statewide Detention RI rate of 12.59. Five interviewed staff reported the staff try to talk to
youth prior to using RI or mechanical restraints. An interview with the superintendent indicated
the use of physical and mechanical restraints is tracked through the Department’s Juvenile
Justice Information System (JJIS).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 60
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures addressing the training and certification
requirements for all new staff. Phase One training consists of instructor-led and web-based
courses. Phase Two consists of 120 hours of academy instructor-led training. A review of five
staff training records for pre-service training indicated each of the five staff completed all
required training within 180-days of hire and the 120 hours of training at the academy. None of
the reviewed staff records qualified as returning direct care and state support staff who returned
less than one year from separation from the Department.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures which require 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 in addition to the
twenty-four hours of in-service training. The center provides in-service training to staff through a
combination of the Department’s Learning Management System (SkillPro) and instructor-led
classes. Five staff training records were reviewed for in-service training, which included three
direct care staff and two supervisory staff. Each of the reviewed staff records confirmed each
staff completed the required twenty-four hours of the mandatory training topics which are to be
completed annually. The policy requires supervisory staff to complete eight hours of supervisory
training annually. Two staff were applicable for a minimum of eight hours of supervisory training
and each staff completed the required minimum hours. All training was documented in SkillPro.
Reviewed documentation confirmed the center has a licensed registered nurse (RN) who
provides in-service training annually, for the education on girls’ healthcare, to all non-healthcare
staff involved in the supervision or treatment of girls. The center has an annual in-service
training calendar which is updated as changes occur. The in-service training plan was approved
by the Department’s assistant secretary for Detention Services on December 2, 2024, and by
the director of the Department’s Office of Talent, Leadership, and Culture (TLC) on December 5,
2024. The interviewed superintendent stated the management training received included Real
Colors for Leaders, Interview Do’s and Don'ts, Motivational Interviewing in Juvenile Justice,
Collaborative Conversations, Stakeholder Messaging, Real Leadership, and Change
Management. Staff training includes SkillPro trainings, cardiopulmonary resuscitation (CPR),
first-aid, and Right Interactions (RI).
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1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures in place related to youth grievances to ensure each
youth has the right to grieve and ensure all youth are treated fairly, respectfully, without
discrimination, and their rights are protected. The grievance process is posted throughout each
living module and is explained to each youth during the admission and orientation process. The
center keeps blank grievance forms on the youth living modules which are available for youth
upon request. The center’s staff will then input the grievance into the Department’s Facility
Management System (FMS) within the Department’s Juvenile Justice Information System
(JJIS). The process includes an informal phase, formal phase, and the appeal phase. The
center had one documented grievance during the annual compliance review period which was
resolved within the specified time frames. An interview with the superintendent confirmed the
center’s grievance process, once a youth has completed a grievance form, the youth and staff
sit down to see if the matter can be resolved. If the issue is not resolved, a supervisor
intervention would be the next step. If the matter is not resolved at the supervisor level, then
administration steps in and assists with the matter. The superintendent stated all grievances are
uploaded into JJIS. Five youth were interviewed, and each youth was able to explain the
grievance process. One youth rated the grievance process as good, one rated the process as
fair, and three stated they had never filed a grievance. Five staff were interviewed, and all staff
were knowledgeable and could explain the center’s grievance process.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures outlining the process of entering and sharing alerts.
The center’s practice is to appropriately enter, downgrade, or discontinue alerts in the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been previously identified prior to the youth’s admission. A review of five youth
records confirmed alerts were documented in accordance with the center’s policy. The reviewed
youth were applicable for nineteen separate alerts. Each reviewed youth record documented
alert types, and the name/title of staff removing/updating alerts. Each alert was documented in
the logbook. Documented alerts were accurately entered and matched the alerts in JJIS. All
applicable alerts were downgraded and removed by the medical staff and/or the mental health
staff, as applicable. A copy of the alerts was provided to the supervisors and detention staff at
the start of each shift, and the alerts are reviewed with staff during each shift briefing. A copy of
the alerts was maintained with the logbook and was accessible to all staff. Reviewed
documentation confirmed the alerts are discussed during shift briefings. In addition, alerts are
posted in the kitchen and kitchen staff have access to the alerts. A video observation of a shift
briefing meeting was conducted during the annual compliance review week. Video observation
confirmed alert sheets were distributed to staff during the shift briefing. There were no additional
alerts found which should have been entered into the alert system. An interview with the
superintendent confirmed all medical alerts are entered into JJIS. The information is printed
every day and provided to staff at the shift briefings. Five interviewed staff stated they are
informed of youth alerts during shift briefings, alert boards, logbooks, JJIS alerts, and by email.
Administration informs staff about issues within the center through shift briefings, center
meetings, logbooks, and email. Five interviewed staff indicated the process for communicating
information within the center is very good.
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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 practice in place regarding data trend analysis. The center uses Department
report cards, reviews data from an interactive data visualization platform, web-based
collaboration and document management platform, and the Department’s Juvenile Justice
Information System (JJIS) daily. All information and reports are reviewed and shared with staff
during briefings and supervisor meetings. The center’s administration utilizes weekly meetings
with providers and stakeholders to share the data to understand trends and strategies to
improve the center. The collected data is analyzed carefully, the stakeholders brainstorm to find
new ways to improve the center's behavior management system (BMS) and practices.
Reviewed documentation supported this practice.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures to ensure all youth are admitted to the center in
accordance with Florida Administrative Code. A review of five youth case management records
was conducted. Each reviewed record included an arrest affidavit/custody order, a Detention
Risk Assessment Instrument (DRAI), and a Suicide Risk Screening Instrument (SRSI). All five
youth records included documentation each youth was full-body search and electronically
searched by a juvenile justice detention officer (JJDO) of the same gender as the youth. Each
youth record reflected the youth were offered telephone calls and none of the youth refused to
make the call. All five records documented a meal was provided to each youth upon intake.
Documentation supported all five youth received medical, and mental health screenings upon
admission. An observation of one youth intake was conducted during the annual compliance
review week. The youth was full-body and electronically searched by a JJDO of the same
gender. The youth was offered a telephone call and spoke with their parent/guardian.
Additionally, the youth was given a lunch. During the admission process, the youth received an
orientation to the center verbally and in writing, which included all required elements. Each
reviewed youth record indicated staff followed all the procedures.
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2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures to ensure all youth admitted to the center receive
an orientation process within twenty-four hours of being admitted into the center. Youth
orientation must include, both verbal and written orientation to the center’s rules and
regulations, grievance procedures, the process for visitation and telephone calls, the availability
and process for accessing medical, mental health and substance abuse services, how to access
the Florida Abuse Hotline and the Department's Central Communications Center (CCC),
expectations for behavior and related consequences for failing to meet those expectations,
possible new law violations for destruction of property, youth rights, and Prison Rape
Elimination Act (PREA) related information. A review of five youth case management records
was conducted. Each reviewed record confirmed the center provided an orientation to all youth
within twenty-four hours of admission and contained a signed orientation acknowledgement for
each youth. An observation of one youth intake was conducted during the annual compliance
review week. The youth was full-body and electronically searched by a juvenile justice detention
officer (JJDO) of the same gender. The youth was given snacks in the morning and was
provided a meal at lunchtime. During the admission process, the youth received an orientation
to the center verbally and in writing, which included all required elements. Observations
reflected staff followed the center’s policy and procedures. Five youth were interviewed, and
each reported staff explained the rules and regulations, daily schedule, education services,
visitation, abuse reporting, and behavior management system within twenty for hours of
admission to the center.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures regarding classification for the center to provide the
highest level of safety and security. A review of five youth case management records indicated
each youth’s classification process included an arrest affidavit/custody order, a Detention Risk
Assessment Instrument (DRAI), and a Suicide Risk Screening Instrument (SRSI). The
considerations on the classification form included mental illness, intellectual disabilities, physical
disabilities, history of violent behavior, gang affiliation, criminal behavior, history of sexual
offenses, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening
results, medical issues, identified or suspected suicide risk issues, escape, security, and history
of human trafficking. The completed classification process documented consideration of all the
required topics prior to making room assignments, including the gender of the youth, height,
weight, age, and level of aggression. An interview with the superintendent reported the center is
notified of any gang related information by email and through the Department’s Juvenile Justice
Information System (JJIS) alert system. Before placing a youth in a room, a review of the Face
Sheet, mental health status, physical health status, cognitive performance, age, the VSAB is
conducted to ensure the youth can be placed in a room. None of the five case management
records reviewed were applicable for suspected gang involvement. The superintendent remains
informed on identifying and recognizing gang activity by reviewing alerts, emails, and internal
case management records.
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2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures to address the screening process for youth newly
admitted into the center and to determine whether the youth is suspected or documented to be
a gang member or gang affiliated. The policy requires the center to share suspected gang
related information by email with the juvenile probation officer (JPO) designated as the circuit’s
gang representative. An email communication is sent to the JPO with pictures and
documentation of all suspected gang related activities. A review of five youth case management
records found none were applicable for suspected gang affiliation. A review of the alerts in the
Department's Juvenile Justice Information System (JJIS) confirmed the center did not have any
youth documented as a suspected gang member during the annual compliance review period.
During the review period the center admitted two youth with documented gang affiliation;
however, one was a transfer from another detention center, and the youth was previously
identified in 2023 for the gang alert, and the other was identified at another detention center in
March of 2025, prior to having been transferred to this center. The center’s administrative staff
enter all suspected gang affiliation alerts into JJIS, when applicable. An informal interview with
the superintendent confirmed there is currently no gang liaison for the center; however, the
administration staff is responsible for sharing the gang related information to the JPO.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures to ensure each youth's personal property is
maintained securely and returned to the youth in a timely manner upon their release. The
youth’s property is itemized and documented on the Property Receipt form in the Department’s
Juvenile Justice Information System (JJIS). A review of five youth itemized personal Property
Receipt forms confirmed each included the youth and staff signature and letter of
acknowledgement regarding unclaimed property. Five youth case management records were
reviewed, and none were applicable for the valuable Property Receipt form. Three additional
records were requested and reviewed for valuable property. Each personal item of value at the
center was verified and secured in a clear tamper-proof property bag. The bags included the
date, youth’s name, the youth’s Department identification number (DJJID), and a listing of items
in the bag, and bags were placed in the drop safe. The center maintains a drop safe logbook.
Documentation supported all valuable property is placed in a clear tamper-proof bag, logged
into the drop safe logbook with date, time, DJJID, name of the youth, name of the juvenile
justice detention officer (JJDO) securing the property, and the officer's initials. The center's
practice is to place the clear bag into a drop safe, which is under video surveillance twenty-four
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hours a day. No youth refused to sign a Property Receipt form. All personal property such as
clothes and shoes are placed in property bags and placed into the secured property room. Each
youth’s personal Property Receipt form and valuable Property Receipt form is then placed in the
youth’s active record. Observations of youths’ personal property revealed each youth’s personal
property had the youth’s DJJID and a completed inventory form. Reviewed documentation of
three youth’s valuable property verified the valuable property was documented in the drop safe
logbook for each youth. Observations indicated the valuable property was stored in a clear
tamper-proof bag for all three youth. An observation of a youth’s admission into the center
during the annual compliance review validated the center’s process for securing and storing
youth property. The center’s supervisors are the designated staff who have access to the
youth’s personal property. A review of the Department's Central Communications Center (CCC)
reports since the last annual compliance review verified there were no incidents reported to the
CCC regarding youth property. Five youth were interviewed, and each reported staff check their
personal property, and they signed a form stating their personal property was correct. An
interview with the superintendent indicated all youths’ personal and valuable property is
inventoried on the Property Receipt form and signed by both the youth and admission staff.
Youth personal property is kept and secured in the center’s property room under constant video
surveillance. When any property is held outside of thirty days a letter is sent to the
parent/guardian for retrieval. If the parent/guardian fails to pick up the property, then staff follow
the facility operating procedures for proper disposal. If the youth or parent/guardian cannot be
located, the superintendent or designee ensures all money and property are counted and
inventoried. A money order is then sent to the regional fiscal manager. The regional fiscal
manager will then forward the money order to the Department’s headquarters designee. A
record shall exist for any property disposed of or cash forwarded to headquarters.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures for releasing youth from secure detention. The
center’s policy requires each youth’s court order to be reviewed and verified prior to release.
Five youth case management records were reviewed, and two were applicable for release
procedures. One additional closed case management record was requested and reviewed for
release. A review of the three applicable closed youth records indicated the on-duty supervisor
reviewed all related paperwork and the youth’s identification was verified prior to release. Each
youth was released to a parent/guardian and a copy of the identification for each
parent/guardian was present in each of the records. None of the reviewed records were for
youth with an endangered person alert. Reviewed documentation confirmed youth and their
parent/guardian were reminded of future court dates, and all parties signed applicable release
forms. A review of the Department's Juvenile Justice Information System (JJIS) confirmed each
youth’s date of admission and release correlated with the dates documented in the case record.
During the annual compliance review week, an observation of a release was observed. A copy
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of the parent/guardian’s identification card was made and placed in the youth’s record. The
youth was searched and taken to the area for release processing. All personal property was
returned to the youth. The youth and parent/guardian signed the release documentation and
were provided with a copy of the youth’s court documentation.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures requiring each youth's personal property to be
maintained securely and returned to the youth in a timely manner upon their release. Five youth
case management records were reviewed, and none were applicable for release of youth
personal property, medication, and/or aftercare instructions; therefore, three closed case
management records were requested and reviewed. All three closed youth records confirmed
the youth and parent/guardian signed the Property Receipt form upon release. Each reviewed
record contained a copy of the parent/guardian identification card confirming the youth was
released to the appropriate person. All three closed youth records were applicable and
supported the receipt of medication form was signed by the person receiving the youth using the
Department’s Health Discharge Summary Transfer Note form. Reviewed documentation
confirmed each youth and parent/guardian were reminded of any health or welfare issues
including any medical, mental health, and/or substance abuse needs. An informal interview with
the center’s superintendent reported the center did not have any property held for more than
thirty days since the last annual compliance review. Observations of a youth property release
during the annual compliance review week confirmed the youth received their property and
signed the Property Receipt form.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures requiring detention reviews to be conducted weekly
for securely detained youth and to ensure proper management of youth and appropriate sharing
of information. Detention review meetings take place at the center every Thursday. The
detention review meeting is conducted through video conferencing in the center’s conference
room. During the annual compliance review week, an observation of a detention review meeting
was conducted. All required departments and agencies were represented at the meeting.
Observations revealed the detention review meetings are led by the center’s detention review
specialist/juvenile justice detention officer II (JJDOII). Attendance included in-person
participation from staff members including representatives from the center’s medical and mental
health departments, in addition to floor staff. Participating virtually were representatives from the
Department which included juvenile probation officers (JPOs). During the meeting, all aspects of
the youth were discussed and included youth releases, legal status, detention status, medical
and mental health status, and the youth's behavior in the classroom and in the center. A review
of documentation in the Department’s Facility Management System (FMS) confirmed the
required participants were in attendance. Additionally, detention review records contained sign-
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in attendance sheets, youth alerts, and detention review notes. Reviewed documentation
supported detention review meetings were held weekly at the center during the annual review
period. An informal interview with the center’s superintendent reported education staff, medical
and mental health staff, JPO supervisors, and detention staff participate in the detention review
meetings.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures requiring the establishment of a daily activity
schedule. The center’s policy requires the daily activity schedule to specify the days and times
of youth activities. During the tour of the center, the daily activity schedule was observed posted
in the living areas. A review of the activity schedule identified times for wake-up and personal
hygiene, mealtimes, visitation, physical and indoor recreation activities, including at least one
hour of large muscle exercise daily, and activities which promote education and life skills. The
daily schedule included bedtimes, groups, and open program time including games and reading.
Observations made of youth engaged in various activities throughout the review week which
included school, meals, sick call, and treatment team meetings showed the schedule was
followed. Five interviewed youth reported the center has a daily activity schedule and the daily
schedule is followed. Five interviewed staff reported the center has a daily schedule which is
followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center’s education component is directly managed by the Collier County School District.
School operates on a year-round basis distributed over twelve months with a minimum of 330
minutes of daily instruction or twenty-seven and one half hours of weekly instruction. The center
had an activity schedule, and this timetable was aligned with the daily academic schedule. A
video review was conducted of four separate classes on two random dates and identified the
youth had arrived and exited from the classes at the scheduled times. Additionally, the videos
displayed the classes were being conducted with minimal disruptions. A review of twelve
samples from the center’s logbooks for adherence to the education schedule was completed.
With the exception of one date, the logbook entries showed the youth were being escorted to
and from class which included the transition from lunch to class. On the date showing the
exception, identified youth had left their last class twenty-five minutes before the scheduled
conclusion time. Five youth were interviewed, and each stated the center was preparing them
for a high school equivalency diploma (GED), high school, vocational school and/or college. The
five youth verified they attend school Monday through Friday while at the center. An interview
with the superintendent verified classes were conducted with minimal interference. Five
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interviewed staff stated the classes were being conducted during the day with minimal
interference or interruption.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to deliver career education to youth, and for youth
to attend appropriate career education classes. The center provides career education
programming to all participating youth based upon their age and assessed cognitive abilities.
The provided instruction is categorized as a Type 1 career and vocational curriculum. This
classification, which stresses soft skills, places an emphasis upon the youth’s individual
decision-making skills as well as improving their interpersonal communication skills. This
component provides the youth exercises which prepare them for employment readiness, such
as resume building, in addition to activities centered upon the investigation of career choices
based upon their individual interests. Five youth were interviewed and asked to identify the
classes they were taking while at the center. Five stated they were enrolled in history, math,
reading, and social studies. In addition, four youth responded they were taking science and life
skills classes, while three youth stated they were taking a career choice class.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures 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 DMHCA is a licensed mental health counselor (LMHC) and has an 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. The DMHCA is scheduled to be on-site
Monday through Friday from 8:00 a.m. to 4:00 p.m. A review of the contract requirements and
the mental health sign-in logbook since the last annual compliance review confirmed the
DMHCA was on-site, as required. The DMHCA is available seven days a week, twenty-four
hours a day, by way of telephone for consultation. The center has a back-up DMHCA in the
event of scheduled leave and/or absences, who is one of the full-time clinical staff. The back-up
DMHCA is a licensed mental health counselor (LMHC), licensed in the State of Florida, with an
expiration date of March 31, 2027. An interview with the DMHCA indicated they are responsible
and accountable for ensuring appropriate coordination and implementation of mental health and
substance abuse services in the center and they shall promote consistent and effective
services. Additionally, the DMHCA stated the mental health staff meets with the superintendent,
assistant superintendent, and juvenile justice detention officers daily.
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 clinical
supervisor ensures the licensed clinical staff are performing services based on their education,
training, and experience. The center had five licensed mental health staff contractual positions,
in addition to the designated mental health clinician authority (DMHCA). One of the licensed
mental health positions is filled by a licensed clinical social worker (LCSW) who was a travel
therapist. Copies of all licenses were provided and are kept in a binder in the mental health
office. A review of the licensed clinicians’ credentials indicated 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 remaining two clinicians were LCSWs with an active license in the
State of Florida expiring on 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. 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 service staff during the annual compliance review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures whereby mental health and substance abuse
needs of youth are identified through a comprehensive screening process, in which referrals are
made when youth are identified with mental health and/or substance abuse needs or are
identified as a possible suicide risk. A review of five 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). A review of five youth records found
documentation of each having a mental health, substance abuse, and suicide risk screening
utilizing the SRSI and the MAYSI-2, which were completed during the admission process in
JJIS. Each SRSI was reviewed by mental health clinical staff, who documented their summary
and recommendations in the screening results section. One of the five reviewed youth records
were applicable for positive “YES” responses on the SRSI. The youth was placed on suicide
precautions and a mental health referral was completed, which documented the need for an
Assessment of Suicide Risk (ASR). The applicable youth’s SRSI screening included a “YES” for
open or closed suicide risk alerts in JJIS. The results of the MAYSI-2 indicated a need for
further assessment for one youth, the referral was made, and the superintendent/designee was
notified. The center’s admission practice is to place each youth on suicide precautions until they
are evaluated by mental health staff. Each of the reviewed SRSIs and MAYSI-2s were
completed by trained staff. None of the reviewed MAYSI-2s indicated the need for further
assessment. All reviewed MAYSI-2s were valid screenings.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures regarding mental health and substance abuse
evaluations. Five youth records were reviewed for a mental health and substance abuse
comprehensive assessment, and four youth were applicable. The four youth were identified as
in need of a mental health and substance abuse evaluation after admission and were referred to
the center’s provider. Three of the four applicable youth had a new mental health and/or
substance abuse evaluation completed by the center’s provider. One youth had an updated
mental health and/or substance abuse evaluation, which was completed by the center’s
provider. The new and updated evaluations included the dates of completion, and were
completed within fourteen days of admission. Additionally, treatment recommendations
corresponded to all diagnosed mental health or substance-related disorders. Each evaluation
was documented as a Comprehensive Mental Health/Substance Abuse Evaluation (SAMH) and
was maintained in the Department’s electronic medical record. There were no youth applicable
for having comprehensive assessments completed by a community provider. During an
interview, the designated mental health clinician authority (DMHCA) stated, the process for
obtaining the comprehensive mental health and/or substance abuse assessment is for the
therapist to obtain any past assessments, and review them prior to speaking with the youth
pertaining to the SAMH or SAMH update. Additionally, the mental health staff observe youth
prior to completing assessments.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures for mental health and substance abuse treatment
and discharge planning. The provider’s contract requires the superintendent and designated
mental health clinician authority (DMHCA), or mental health/substance abuse clinical staff to
ensure the development and review of an initial and/or individualized treatment plan (ITP) for
each youth receiving mental health/substance abuse treatment in the center. Five youth mental
health and substance abuse records were reviewed, and only one was applicable for mental
health and substance abuse treatment services, due to being admitted on psychotropic
medication. An additional two youth records were reviewed. Three applicable youth had a
mental health orientation held within fourteen days of admission. Each of the three applicable
youth required a treatment plan. Each of the three reviewed applicable youth’s initial treatment
plan was documented on the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form and created within seven days of the onset of treatment. Each initial treatment plan
documented the reason for referral for treatment, the initial Diagnostic and Statistical Manual,
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Fifth Edition (DSM-5) diagnosis/symptoms, treatment goals, methods of treatment including
group or individual counseling, the medication the youth was prescribed at admission, and
psychiatric services to be delivered, including the frequency of services. The mental
health/substance abuse professionals’ signatures and youths’ signatures were present on each
initial treatment plan. All three youth were assigned to a mini-treatment team whose members
were involved with the development of the initial treatment plan. All three of the youth records
had an ITP developed by the thirty-first day after the youth’s admission. One additional youth
who was a transfer from another center with an initial plan had an individualized plan completed
by the center. Each ITPs contained the DSM-5 diagnosis, treatment focused symptoms,
treatment goals, and the youth’s strengths and needs. A review of the documented ITPs
indicated three youth had prescribed psychotropic medications listed at the time the plan was
developed. Each plans had progress notes documenting the youth received treatment services
as stipulated in their treatment plans. ITP documentation confirmed both records contained the
youths’, mental health/substance abuse professionals’, and treatment team members’
signatures. It is the center’s practice to have the parent/guardian participate by telephone, and
to document their participation in the ITP. Three youth had a total of six thirty-day periods
requiring ITP reviews. Reviewed documentation confirmed clinical staff, the youth, a licensed
mental health professional, and treatment team members reviewed and signed all six ITP
reviews. It is the center’s practice to have the parent/guardian participate by telephone for ITP
review meetings and to document participation on the review forms. Both ITP reviews included
treatment and services provided by a licensed psychiatrist. None of the youth were alleged
victims of a Prison Rape Elimination Act (PREA) event needing additional services. Three
reviewed applicable records required a discharge plan which was documented on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form upon the
youth’s discharge. A copy of the Mental Health/Substance Abuse Treatment Discharge
Summary was provided to the youth, parent/guardian, and assigned juvenile probation officer
(JPO). All documentation practices adhered to the Department’s statewide electronic medical
records policies, which included completion on the day of service, signed by the licensed mental
health professional, and uploads with additional documentation completed within fourteen days.
At the time of the annual compliance review the center only had two discharge plans applicable.
The center’s practice is to complete a discharge plan for each youth requiring a discharge plan
at the time of release. During the annual compliance review, a mini-treatment team meeting was
observed. All mental health staff and the youth were in attendance. Additionally, the
parent/guardian participated by phone. An interview with the DMHCA indicated the process for
ensuring services are provided includes the DMHCA keeping a daily list of all youth in the center
and tracking their admission date and tentative release date. Additionally, a board with the youth
currently receiving services is monitored and updated daily, to ensure all services are provided
for youth in the center. The DMHCA stated the process used to review and update the
individualized treatment plans includes the treatment plans being updated every thirty days. The
physical board helps track and keep up with the due dates. Youth treatment progress is
discussed during treatment team meetings and appropriate changes are made, if needed. The
youth, mental health therapist, and superintendent or assistant superintendent sign treatment
plans.
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3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility procedures ensuring mental health and substance abuse treatment
planning concentrates on providing mental health treatment and/or substance abuse treatment,
which reduces or alleviates the youth’s symptoms of mental disorder or substance abuse
impairment and enables youth to function adequately in the juvenile justice setting. Each youth
identified as needing mental health treatment, including treatment with psychotropic medication
or substance abuse treatment, must be assigned to a mini-treatment team. Five youth mental
health and substance abuse records were reviewed for mental health and substance abuse
treatment services, three youth were applicable for initially receiving treatment services and
were assigned to a mini-treatment team, while one initially refused and later participated in the
development of their individualized treatment plan. Reviewed documentation indicated the mini-
treatment team consisted of mental health clinical staff, one staff from a different service area,
youth, and the youth’s parent/guardian who appeared by telephone. When applicable, each
youth received either individual, group, or family counseling according to the frequency required
by their plan. Four reviewed mental health and substance abuse records contained the proper
consents for mental health and/or substance abuse treatment services and progress notes were
documented in the Department’s electronic medical records. During the annual compliance
review week, there was a review of video observations completed which confirmed groups were
being conducted as scheduled. The mental health staff had adequate access to youth and
confidential space to provide treatment services. A review of sign-in sheets confirmed group
therapy was limited to ten or fewer youth with mental health diagnoses for mental health groups
and fifteen or fewer youth for youth with substance abuse diagnoses for substance abuse
treatment groups. Three interviewed youth stated the mental health and substance abuse
services they were receiving was good, and two stated it was very good. During an interview the
DMHCA stated the mental health and/or substance abuse providers meet with the detention
administration daily. The DMHCA stated the process used for individualized mental health
treatment planning includes plans being developed for youth receiving mental health treatment
services in detention, which includes therapist talking with youth about things they feel would be
beneficial to learn and/or work on while in detention.
3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures and a Suicide Prevention Plan, which was
approved and reviewed by the designated mental health clinician authority (DMHCA) and the
superintendent annually. The plan outlines the center’s procedures addressing the identification
and assessment of youth at risk of suicide, use of suicide precautions, staff training, and the
process by which any youth identified as having suicide risk factors at any time must be placed
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on suicide precautions and receive an Assessment of Suicide Risk (ASR). The plan identifies
the levels of supervision, referral process, communication, notification, and documentation
requirements. The center has an established review process for every serious suicide attempt
or serious self-inflicted injury. The multidisciplinary review includes the circumstances
surrounding the event, all relevant training received by involved staff, center procedures
relevant to the incident, pertinent medical and mental health services involving the victim,
possible precipitating factors, and any recommendations for changes in policy, training, physical
plant, medical or mental health services, and/or operational procedures.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures and a Suicide Prevention Plan outlining
requirements to safely screen, refer, assess, monitor, and protect youth with elevated risk of
suicide, using the least restrictive means possible. Any youth identified as having suicide risk
factors by screening, information obtained from the youth, or staff observations must be placed
on suicide precautions and receive an Assessment of Suicide Risk (ASR). Five youth mental
health and substance abuse records were reviewed and one was applicable for having an
elevated suicide risk factor during the admission process, and two youth were applicable for
placement after admission as part of the center’s standardized process of assessing all youth
with previous alerts. Each applicable youth was placed on precautionary observation (PO)
during the admission screening process. Reviewed documentation confirmed, prior to the ASR,
each youth was on constant supervision. The Suicide Precautions-Observation Log for each
applicable youth was completed in its entirety, including documenting safe housing areas, and
was signed by all required parties. The superintendent or designee was notified immediately of
each applicable youth suicide risk. Each ASR was completed by a licensed mental health
professional. No youth were released prior to receiving an ASR or applicable Follow-Up ASR or
released while on suicide precautions. Each applicable youth’s ASR was completed within
twenty-four hours, as required and each assessment included recommendations for supervision
and follow-up. A conference was held between the designated mental health clinician authority
(DMHCA) and the superintendent to reduce the level of supervision for each youth’s
discontinuation of suicide precautions. A review of the master control logbook, emails, and the
youth’s ASRs documented supervisory staff were provided instructions related to the suicide
risk assessment findings and suicide precaution decisions for each youth. Further review of the
logbooks indicated they documented the beginning and ending times of the youth placed on
precautions. A review of the alerts in JJIS indicated the alert was entered and removed
appropriately. Documentation confirmed the discontinuation of close supervision was conducted
according to the center’s Suicide Prevention Plan. The interviewed DMHCA stated all mental
health staff conduct suicide risk screenings, and the Assessment of Suicide Risk and follow-ups
are used. If a youth is screened and determined they need to go on PO status, the youth is
placed on PO status by administration or mental health staff informing the master control
operator and the center’s administration. The mental health staff are notified through a referral,
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by telephone, or a center staff will discuss a youth with mental health staff verbally in-person.
Mental health staff and the DMHCA are on call twenty-four hours daily for any needed support
and for all crisis and/or emergencies. Five interviewed staff stated if a youth expresses suicidal
thoughts, they are responsible for notifying the mental health authority, placing the youth on
constant sight and sound supervision, documenting the supervision, searching the youth and
their room for sharp objects, and notifying the supervisor. Five youth were interviewed, and
three youth stated they had been placed on suicide watch while at the center, and staff watched
the youth the entire time. Two youth stated they had not been placed on suicide watch.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures regarding secure observation. The policy requires
youth placed on suicide precautions to remain under secure observation if less restrictive
methods are not effective. Five youth records were reviewed, and two records were applicable
for placement in secure observation. One additional record was reviewed. Each of the secure
observation rooms was designated in writing. A review of the Department's Juvenile Justice
Information System (JJIS) indicated each youth had a Health Status Checklist completed prior
to placement in secure observation. Each reviewed secure observation log was completed
entirely. A new Assessment of Suicide Risk (ASR)/Follow-Up ASR was completed within eight
hours for each youth being placed into secure observation and the youth’s parents/guardians
were notified of the status changes. Each youth’s observation log documented mental health
staff provided supportive counseling services. Further review indicated each of the youth in
secure observation had their level reduced only after a conference with the superintendent and
licensed mental health professional. Additionally, the youth’s discontinuation of secure
observation and step-down to close supervision documentation was confirmed after review of
the center’s logbook and the youth’s mental health record. An interview with the center’s
superintendent indicated the center uses secure observation for potentially suicidal youth.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures regarding Suicide Precautions-Observation Logs
which details the process to monitor and protect youth with an elevated risk of suicide in the
least restrictive means possible. A review of five mental health and substance abuse records
found one was placed on precautionary observation (PO) upon admission to the center, and two
youth were applicable for placement after admission as part of the center’s standardized
process of assessing all youth with previous alerts. The Suicide Precautions-Observation Logs
were maintained for the duration of the youth’s placement on PO. Reviewed documentation
reflected staff observations did not exceed the required intervals and were documented in real-
time. Each applicable Suicide Precautions-Observation Log was reviewed and signed by the
shift supervisor and mental health clinical staff. Safe housing areas were clearly documented on
each log. Observations of camera footage during the week of the annual compliance review
confirmed appropriate supervision of youth on PO was maintained by staff.
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3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures outlining the process for all staff who work with
youth to be trained in suicide precautions. Staff must participate in mock suicide drills quarterly
on each of the three shifts. A review of five pre-service and five in-service staff training records
validated each staff completed at least six hours of annual training on suicide prevention and
implementation of suicide precautions. Reviewed documentation of mock suicide drills
completed since the last annual compliance review indicated the center completed drills on
Alpha, Bravo, and Charlie shifts monthly, exceeding the requirement. An informal interview with
the assistant superintendent confirmed the center has two suicide response kits, which are co-
located with first-aid kits in master control and medical. The suicide response kits included a
rescue tool, needle nose pliers, and wire cutters. Reviewed documentation and video footage
indicated the center’s mock suicide and mental health prevention drills were simulated by the
center. The training included mock suicide drills held no less than quarterly on each shift, for all
staff who come in contact with youth. No program youth were used in drill simulations. The
center provided semi-annual training on emergency response procedures which included mock
training in emergency responses to suicide attempts or incidents of serious self-inflicted injuries.
Center staff who were not present during a drill had the opportunity to review each drill scenario
and procedures in an effort to understand the process and receive the necessary training to
respond to an incident of a suicide attempt or incident of serious self-inflicted injury. Five
interviewed staff reported the suicide kits are located in master control and medical.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures and a Combined Emergency Services Plan,
ensuring the center responds 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 center. The plan
outlines the process for handling a notification and alert system, means of referral to include
youth self-referral, communication, supervision levels, documentation, and review, as required.
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3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures regarding an Emergency Care Plan outlining
mental health and substance abuse emergency procedures and ensuring youth who are
believed to be an imminent danger to themselves or others because of mental illness or
substance abuse impairment receive emergency mental health or substance abuse services.
The plan addressed immediate staff response, notifications, communication, supervision of
youth, transport for emergency mental health evaluation and treatment under Chapter 394
Florida Statute, Baker Act, transportation for emergency mental health evaluation and treatment
under Chapter 397 Florida Statute, Marchman Act, documentation, training, and review. The
policy and plan were signed by the superintendent on August 8, 2023, and the designated
mental health clinician authority (DMHCA) on August 8, 2023. There were no updates to the
plan. A copy of the plan is located within the superintendent’s office, clinical office, and mental
health office.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures to ensure youth in crisis are administered a Crisis
Assessment. Three youth mental health and substance abuse records were reviewed, and all
were applicable for a Crisis Assessment. All three youth’s Crisis Assessments documented a
reason for the assessment and a Mental Status Examination and interview. The Crisis
Assessments consisted of documentation for determination of danger to self/others, initial
clinical impressions, supervision, treatment recommendations, and follow-up evaluation
recommendations. Each record had notifications to the parent/guardian for follow-up treatment.
A review of the mental health alerts in the Department's Juvenile Justice Information System
(JJIS) confirmed two youth were applicable and were placed on precautions after the
completion of a Crisis Assessment. One of the three youth were identified by the direct care
staff or clinical staff for having acute emotional or behavior problems, or acute psychological
distress, and was appropriately referred for an assessment. The licensed mental health
professional completed the Crisis Assessment immediately or within two hours for emergencies,
or within twenty-four hours based on the needs of all three youth. Two of the three youth were
applicable for being an alleged Prison Rape Elimination Act (PREA) victim receiving mental
health treatment services.
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3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures for Baker and Marchman Acts. The policy 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. Three youth records were reviewed, and all youth were applicable for having a Baker
Act documented. A review of precautionary observation (PO) log documentation for all three
applicable youth showed all were placed on one-to-one supervision until the youth’s authorized
release. While pending off-site transport, a suicide risk alert was opened for each youth. Each
youth had a completed mental health referral for a Mental Status Examination and was placed
on suicide precautions upon re-admission from their Baker Act. Assessment of Suicide Risk
documentation confirmed all three youth’s supervision levels were maintained until youth were
properly transitioned to a lower level of supervision, after the completion of an assessment, and
after a conference between the licensed mental health staff and the superintendent or designee.
Discontinuation of the mental health alerts in the Department's Juvenile Justice Information
System (JJIS) was completed for all three youth as required.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures requiring a contractual agreement with a licensed
physician to serve as the designated health authority (DHA). The center maintains a contract
with VitalCore Health Strategies, LLC, who subcontracts with an osteopathic physician (DO) to
serve as the center’s DHA. The DHA holds an unrestricted, clear, and active license which
meets all requirements for independent and unsupervised practice in the State of Florida
expiring March 31, 2026. The center utilizes an advanced practice registered nurse (APRN) who
has a Collaborative Practice Protocol (CPP) in place with the physician who is serving as the
program’s DHA. A review of sign-in and sign-out logs during the annual compliance review
period confirmed the DHA was on-site at least two hours once a week, with a week defined as
the seven-day period beginning on Sunday and ending on Saturday. The DHA is on-call twenty-
four hours a day, seven days a week. The center does have a back-up DHA who can be utilized
if the DHA was on vacation or had scheduled absences; however, the center has not utilized the
back-up DHA. Reviewed documentation confirmed the provider’s tele-medicine policy regarding
the practitioner utilizing sign-in and sign-out logs. The center maintains a tele-medicine log and
the use of tele-medicine services were approved by the Department. During an interview with
the DHA, it was confirmed Comprehensive Physical Assessments (CPAs) are completed for
youth who have been admitted to the center, which includes a full review of their medical
history, allergies, medications, as well as any acute issues they may be having. Periodic
evaluations are completed depending on the chronic conditions the youth may have. The DHA
evaluates sick calls on youth with acute issues. The DHA periodically reviews standing
protocols which are used in certain situations when nursing staff are not able to evaluate the
patient. The DHA indicated they are on-site at least once every nine days; however,
occasionally will be on site more often. The DHA communicates mostly with telephone calls and
may occasionally communicate through email. The DHA is available by telephone daily. The
DHA provides on-site clinical services in addition to supervision and assistance to the APRN.
The DHA reviews all orders given while they were off-site during their on-site visits. If there is a
youth who had a sick call and an off-site order was placed, the youth will be seen in-person.
Depending on the medical needs of the youth, they are assigned a Medical Grade. The Medical
Grade will determine how often the youth will need to be seen. If a youth has a high grade, then
they will be evaluated in-person more often. The DHA emails and coordinates with the
supervisor of the center and the regional director to arrange for coverage when on vacation or
during scheduled absences. The DHA reported having no concerns with healthcare at the
center.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures (FOPs) for all health-related protocols utilized. The
designated health authority (DHA) and superintendent signed and dated all respective treatment
protocols, policies, and procedures. A review of all treatment protocols was conducted and
confirmed signatures and dates of the DHA and superintendent. The reviewed documentation
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indicated the DHA reviewed, signed, and dated the FOPs on May 29, 2025, the superintendent
signed on August 8, 2023, and the psychiatrist signed on May 29, 2025. The nursing staff
reviewed, signed, and dated all nursing protocols on January 22, 2025. An annual review of
medical policies, procedures, and protocols was conducted as required, with the exception of
the superintendent. Remaining signatures confirmed individuals from there assigned disciplines
signed and dated a cover page listing all FOPs, signifying they have read the FOPs and any
new health-related Department policies on May 29, 2025. Reviewed documentation confirmed
the psychiatrist reviewed FOPs, or other protocols related to psychiatric services and
psychotropic medication management. All FOPs for health-related procedures and treatment
protocols were being utilized at the center. All newly employed healthcare personnel receive a
comprehensive clinical orientation to the Department’s health care policies and procedures,
given by a registered nurse (RN) or designated, licensed healthcare professional. The approval
of treatment protocols or standing procedures were written and authorized by the DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) or Limited Consent for Evaluation and Treatment form is
completed authorizing specific treatment for youth in the custody of the Department. A review of
five Individual Healthcare Records (IHCRs) confirmed four youth were applicable and had an
AET signed and dated by each youth’s parent/guardian. Each had the original AET form filed in
the youth’s IHCR. Each AET was obtained prior to providing medical services. Each reviewed
AET form was signed by a Department representative and was valid. None of the reviewed
youth were in the care of the Department of Children and Families (DCF). One youth was over
the age of eighteen and had a documented release of information in their IHCR. During an
interview, the nurse confirmed the process for determining the validity of AETs The youth’s
parent, legal guardian, or court may revoke or modify the AET at any time. The nurse reported
when a youth turns eighteen or is legally emancipated and remains in the custody of the
Department, the AET signed by the parent/guardian is immediately invalidated. The youth will
provide consent at the point of contact of healthcare services for themselves. At this time,
information may be provided to the parents/guardians only with the youth’s authorized consent.
Additionally, the regional general counsel’s office must be consulted if this is the case for a
developmentally disabled youth.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures outlining requirements 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. Three of five reviewed youth Individual
Healthcare Records (IHCRs) were applicable and confirmed documentation of parental
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET) and consent by the parent/guardian. Reviewed documentation
confirmed each written notification was sent utilizing the Department’s Parental Notification of
Health-Related Care form. One of five reviewed IHCRs confirmed the youth was taking
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psychotropic medications at the time of admission. Reviewed documentation confirmed staff
witnessed a telephone calls and conversations to the youth’s parent/guardian for psychotropic
medications. Each youth had vaccinations/immunizations. Four youth’s IHCRs were applicable
for new medication being ordered and the progress notes documented contact with the youth’s
parents/guardians. Three youth were applicable for psychotropic medications prescribed during
their stay and reviewed Clinical Psychotropic Progress Notes (CPPNs) confirmed when new
medication was ordered, there was documentation of attempted contact to the parent/guardian
in the progress notes. The Acknowledgement of Receipt of the CPPN form was sent to the
parent/guardian regardless of telephone notifications for each youth. Three IHCRs were
applicable and documentation confirmed whenever a new psychotropic medication was
prescribed or discontinued, or the drug dosage was significantly changed, the
parent’s/guardian’s verbal consent for psychotropic medication was documented on page three
of the CPPN. Each IHCR had written parental notification/consent showing an attempt to obtain
the signed parent/guardian consent. One youth was eighteen years of age, therefore, was not
applicable for parent/guardian consent. During the week of the annual compliance review, there
were no youth in the care of the Department of Children and Families (DCF). Reviewed
documentation confirmed all vaccines were verified within thirty days of each youth’s admission
and there were no youth applicable for exemptions. During an interview with the nurse, it was
reported written parental consent, or a documented verbal witnessed informed consent is
required in certain circumstances. The appropriate Parental Notification of Health-Related Care
form will be used for consent purposes. Verbal attempt/successful contact with the
parent/guardian to obtain informed consent shall be documented utilizing the informed consent
chronological progress note with the electronic signature of a witness. Written parental
notification is not required for treatment or services which are court ordered. The nurse reported
notification of care without the need for special consent shall be accomplished by attempting
verbal contact with the parent/guardian to notify them of care. The nurse reported all staff have
the ability and responsibility to activate emergency services if or when youth appear to be in a
situation which may indicate an emergency health event. The nurse reported there is no need to
send notification or Acknowledgement of Receipt of Clinical Psychotropic Progress Note to a
parent or legal guardian for medication previously prescribed to the youth prior to being
admitted to the detention center and the psychiatrist/psychiatric advanced practice registered
nurse (APRN) has ordered medications to continue. The nurse reported vaccinations are not
provided on-site. The nurse reported immunization records are obtained through Florida Shots.
Immunization history shall be provided to the practitioner for review on an annual basis until all
mandatory vaccinations have been administered. If a parent/guardian claims exemption and
does not consent to vaccinations for religious reasons, then they must complete the Religious
Exemption from Immunization form.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures ensuring each youth is screened upon admission
for healthcare concerns which may need a referral for further assessment by healthcare staff.
Five reviewed youth Individual Healthcare Records (IHCRs) confirmed the Medical and Mental
Health Admission Screening form was completed on the date of each youth’s admission. Each
were completed by a juvenile justice detention officer (JJDO). Each screening was reviewed
with the youth by a licensed medical staff within twenty-four hours. Reviewed documentation
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confirmed notification to the DHA was documented in the youth’s IHCR/electronic medical
record (EMR). None of the reviewed youth had a change in physical custody; therefore, none
required an admission re-screening. Two of the five reviewed youth received a qualitative urine
pregnancy screening test, and the chronological progress notes included documentation of
verbal and/or written consent. During an interview with the nurse, it was reported direct care
staff may conduct the screening; however, if a licensed nurse is on duty at the time of
admission, the nurse will conduct the screening, if available. Otherwise, it is expected the entry
screening will be reviewed with the youth by the licensed nurse within twenty-four hours of
admission to the center. The nurse reported the youth’s intake packet is the method used to
notify medical staff when youth are admitted to the center. The nurse reported direct care staff
or the licensed nurse on duty completes the admission screening within twenty-four hours of
admission. At the completion of the review of the Medical and Mental Health Screening form,
the licensed nurse shall print their name and credentials, sign their name, document the date
and time the review was completed, and initial any additional information added to the screening
tool. The nurse reported a change in physical custody within secure detention requires a
completed re-screening by the receiving center; however, does not require a full completion of
the intake process.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures (FOPs) for youth to be oriented to the general
process of healthcare delivery services at the center. Reviewed documentation confirmed the
center’s FOPs included access to medical care, sick calls, what constitutes an emergency and
when to notify staff, medication process to include side effect monitoring, the right to refuse care
and how it is documented, what to do in the case of a sexual assault or attempted sexual
assault, the non-disciplinary role of the health care providers and general infection
control/hygiene. Reviewed documentation in each of the five youth Individual Healthcare
Records confirmed each youth received a general healthcare orientation. The health education
topics were documented on each youth’s Health Education record. Each youth with chronic
conditions was educated on their medical condition. Documentation supported all youth with a
diagnosed chronic medical condition who were prescribed medications received instructions
and education related to those chronic medical conditions and prescribed medications.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures ensuring the designated health authority (DHA) is
notified when youth are admitted to the center requiring emergency care or routine notification in
accordance with Department requirements. Three of five reviewed Individual Healthcare
Records (IHCRs) confirmed the youth were identified with known or suspected chronic
conditions. Each had evidence of a referral to the physician/advanced practice registered nurse
(APRN). None of the youth were identified as in-need of emergency care upon admission.
Reviewed documentation confirmed notification to the DHA/designee was documented in each
youth’s chronological progress notes within their Individual Healthcare Record (IHCR). The DHA
was notified within twelve hours of admission and no later than noon the day following
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admission for each youth. Reviewed documentation confirmed one of five reviewed youth was
currently taking psychotropic medication upon admission and the psychiatrist was notified. The
interviewed nurse reported the DHA or designee shall be notified when a youth is admitted with
a serious or chronic condition. The nurses are responsible for this notification. The notifications
to the DHA are documented on the admission chronological progress note.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures ensuring the standard Department Health-Related
History (HRH) form shall be completed by the nursing staff for all youth admitted into the
physical custody of the center. Five reviewed Individual Healthcare Records (IHCRs) confirmed
HRH forms were completed within seven calendar days of each youth’s admission. Each HRH
form was completed prior to the Comprehensive Physical Assessment (CPA)/focused
evaluation, as evidenced by a signature and date. Each HRH form was completed by a licensed
nurse and reviewed by the designated health authority (DHA). Each reviewed HRH form
documented signatures and dates for the most current admission. During an interview with the
nurse, it was confirmed the medical staff is responsible for completing the HRH form.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures (FOPs) ensuring each youth admitted shall receive
and/or shall have on record a current Comprehensive Physical Assessment (CPA) and Health-
Related History (HRH) form completed no later than seven calendar days of admission into the
center. Five reviewed youth Individual Healthcare Records (IHCRs) confirmed each youth’s
physical assessment was completed on the Department’s CPA form. Each had a current CPA
on file at admission. The Medical Grade was documented on each CPA. Reviewed
documentation confirmed a current CPA with no changes in the youth’s medical condition was
utilized. Each CPA was reviewed as the youth was examined and signed off as reviewed by the
physician. Each section of the CPA was marked with an “O” or an “X”. Reviewed documentation
confirmed none of the youth were applicable for refusing any part of the exam. The
Department’s Problem List was updated for each youth. Five reviewed youth records confirmed
each Tuberculosis Skin Test (TST) formerly purified protein derivative (PPD) test was
documented in the IHCR within the last year. Each youth’s results of the TST were documented
on the CPA and Infectious and Communicable Disease (ICD) forms and completed within
seventy-two hours. None of the youth required further evaluation. A review was completed of
the center’s FOPs for appropriate documentation of when any part of the exam is not conducted
and/or refused by the youth. The center’s FOPs were reviewed for Tuberculosis screening and
re-screening processes. During an interview with the nurse, it was confirmed the CPA shall only
be reviewed with the completion of a focused note, up to six times, before a new CPA shall be
initiated to avoid confusion on the youth’s condition and to ensure clear documentation of the
current condition. The nurse reported if no record of a prior TST result within the past twelve
months is located or identified after a youth enters a detention center, the TST will be
administered within seven days of admission. The test may only be administered if there is a
valid consent for treatment on record and with a Practitioner Order. The nurse reported
gynecological exams are not routinely completed at the center.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures ensuring all youth entering the center are clinically
screened, evaluated, and treated, if necessary, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). Five reviewed youth Individual Healthcare Records
(IHCRs) confirmed each youth was sexually active and was clinically screened and evaluated
for STIs. One of five reviewed youth required further evaluation. Documentation confirmed the
referral was documented on the STI form and testing was ordered; however, the youth refused
further testing. There were no applicable youth who were out of the Department’s custody for
over thirty days and/or required a re-screening, and none of the youth required a gynecological
exam. Reviewed documentation confirmed there was evidence each youth was offered
counseling, testing, and if indicated, treatment/referral for HIV. Two of five youth received HIV
testing and documentation for consent from the youth was obtained. The HIV test results were
filed in the youth’s electronic or hard copy records. Reviewed documentation confirmed pre-
test/post-test counseling was documented on the individual Health Education Record and/or in
the progress notes. The youth’s confidentiality was protected by not including the youth’s HIV
status or any other STI diagnosis on the program’s internal alert system. During an interview
with the nurse, it was confirmed all sexually active youth will be clinically screened by nursing
staff and evaluated for STI’s. The screening shall be completed within twenty-four hours of a
youth’s admission to the detention center. Youth may consent to their own screening, testing,
and treatment according to Florida Administrative Code. Youth have the right to request or
decline HIV testing. It shall be offered to each youth with or without risk factors identified.
Requested HIV testing shall be completed within thirty days of the request or by the next
available testing, whichever comes first for all youth with identified risk factors. After screening,
youth will be referred to the designated health authority (DHA) or advanced practice registered
nurse (APRN) to determine if testing is indicated. Orders for testing shall be documented as
Practitioner Orders in the electronic medical record (EMR). If orders are obtained for testing the
youth will be added to the STI log to be tested at the next available opportunity. The results of
STI tests will be noted on the Infectious and Communicable Disease (ICD) form and the lab
results will be located in the IHCR behind the corresponding tab as well as uploaded to the EMR
after being reviewed by a practitioner. The nurse reported re-screenings should be conducted if
the sexually active youth has been out of the Department’s custody and/or symptoms are
present or if the youth reports recent sexual activity. Documentation of results shall be
documented on the ICD form. HIV results shall be filed in the IHCR behind the corresponding
tab as well as uploaded to the EMR after being reviewed by a practitioner. A copy shall be
provided to the youth upon release from the detention center. If HIV results are maintained in a
sealed envelope, proof of review by a practitioner is documented on the envelope, and it is not
permitted for reviewers to unseal the envelope. The provider may provide alternative proof the
results have been reviewed by the practitioner. All youth at risk for HIV infection will be offered
counseling and testing within twenty-four hours of admission to secure detention after the
completion of the HIV Youth Consent form. The center’s provider staff will provide the services
or shall collaborate with the local county health department or other community providers to
provide services. A certified HIV counselor or licensed medical professional must conduct HIV
counseling. Five interviewed youth reported they can ask for an HIV test at the center.
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4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures (FOPS) ensuring 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. Five youth Individual Healthcare Records
(IHCRs) were reviewed, however, only one was applicable. Two additional records were
requested for review. The three applicable reviewed youth IHCRs confirmed youth’s sick calls
were documented on the Sick Call Referral Log. None of the three applicable youth presented
with a similar sick call complaint three or more times within a two-week period. Each youth
completed a Sick Call Request form which was completed by the center’s nurse. Each Sick Call
Request form was filed in the youth’s IHCR in reverse chronological order. None of the reviewed
youth were in restricted housing of any kind. Each sick call form was documented in accordance
with Florida Administrative Code. Each reviewed sick call was documented on the Sick Call
Index. All dates listed on the Sick Call Index corresponded to the completed Sick Call Request
forms located in the IHCRs. A review of the daily schedule, posted schedule, and nurse
interview indicated sick calls are conducted daily and youth are seen within at least twenty-four
hours of submitting a sick call. The center’s approved treatment protocols are for both the
registered nurse (RN) and licensed practical nurse (LPN) level staff. The center provides sick
calls daily from 9:00 a.m. to 10:00 a.m. and 4:00 p.m. to 5:00 p.m. Monday through Sunday.
The center’s sick call hours were posted on the clinic wall. Only licensed nurses conduct all sick
calls. When there’s not a licensed nurse on-site, the center has procedures whereby the shift
supervisor reviews all sick call requests as soon as possible and within four hours after the
request is submitted. A review of the FOPs confirmed the procedures for when youth are in
room restriction or confinement and request a sick call. During the week of the annual
compliance review, the center did not have any sick calls. During an interview with the nurse, it
was confirmed sick call is the official method for a youth to request health care services for an
illness or injury. This is the health care delivery system component intended to provide care in
response to complaints of illness or injury of a non-emergent nature; however, require some
form of assessment and/or decision-making. In this situation, a sick call shall be submitted
electronically using the electronic medical record (EMR). The nursing or practitioner level staff
will conduct sick call seven days a week and at a minimum once each day, and each request
shall be addressed within twenty-four hours from the time it was submitted. Licensed practical
nurses (LPNs) providing nursing services must do so under the direction of a registered nurse
(RN), advance practice registered nurse (APRN), or a physician and hold an active license.
They may provide nursing care pursuant to written treatment protocols appropriate for LPNs
who are developed, approved, and signed by the designated health authority. If an LPN
completes sick call without the presence of an RN or higher licensure level on-site, an RN or
higher licensure level must review the completed sick call and provide guidance and support if
needed. The DHA does not conduct sick calls if sick calls are scheduled when they are on-site.
Sick calls are conducted in the medical clinic. Sick call hours are from 9:00 a.m. to 10:00 a.m.
and 4:00 p.m. to 5:00 p.m. daily Monday through Sunday. Youth presenting with similar sick call
complaints three or more times within a two-week period require a referral to the DHA or APRN.
The DHA has approved treatment protocols. The nurse reported youth in restricted housing of
any kind will have the supervisor on each shift question the youth about medical related issues
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and document such questioning on the shift report daily. If the youth have an issue which is
non-emergent the shift supervisor will input the sick call request into the EMR or take the youth
to the nursing staff, if available. Four of five interviewed youth reported they can be seen
immediately once they make a sick call request. One youth reported they never made a sick call
request. Five interviewed youth reported the nurse conducts sick calls and one of the five youth
also reported staff conducts sick calls. Five interviewed staff reported the doctor and nurse
conduct sick calls. Additionally, two reported staff conduct sick calls, and two reported the
supervisors conduct sick calls.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures ensuring a comprehensive process for the
provision of episodic care and first-aid care. Three of five reviewed youth Individual Healthcare
Records (IHCRs) confirmed there were indications the youth required on-site first-aid or
episodic care. Each applicable youth received episodic care or first-aid by a licensed healthcare
staff which was provided on-site by the licensed healthcare staff who documented the nature of
the complaint either in problem-oriented subjective, objective, assessment, and plan (SOAP)
elements or standard narrative charting. The findings of the care was included for each youth.
Reviewed documentation confirmed treatment rendered was documented for each youth. None
of the youth needed a referral to off-site care. Reviewed documentation confirmed the
education/instruction to youth was documented, the findings of the person rendering care was
included, youth were placed on the alert list, and the parental notification was made and
documented. Reviewed documentation confirmed an entry in the Episodic Care Log was
completed for each youth. Each youth received a follow-up evaluation from a licensed
healthcare staff the next time a licensed staff was on-site, or sooner if warranted. The center’s
first-aid kits are located in master control, sub control, B1 living unit, B2 living unit, G living unit,
all four transportation vans, in the maintenance truck, in the state vehicle, kitchen, intake, and in
medical. The center has four first-aid kits used for transportation. Observations confirmed first-
aid kits were all fully stocked with designated health authority (DHA) approved contents. The
center has a process for ensuring contents are maintained and stored in accordance with
guidelines, to prevent expiration or deterioration, and are replenished as needed. Medical staff
conduct weekly checks, inventory of contents are conducted, expiration dates are documented,
and when needed, contents are replenished. Medical staff ensure inventories and logs match
each month. Reviewed documentation confirmed all kits were being monitored as required. The
center has two automated external defibrillators (AEDs) located in the medical office and in
master control. The AED procedures are located in the medical logbook and in master control.
The medical staff check to ensure the AED batteries and pads are operable. AEDs were
monitored by nursing staff and reviewed documentation reflected monitoring is conducted, as
required. The nursing staff checked the expiration dates in front of the Monitoring and Quality
Improvement (MQI) regional monitor. During the week of the annual compliance review, the
nursing staff conducted a self-test of the AED in front of the MQI regional monitor and there
were no issues discovered during the AED test. The expiration date of the AED batteries in
medical and master control was March 12, 2029. It was observed the color of the AED battery
light indicator was green. The last date the AED batteries were changed was on March 12,
2025. The expiration date of the AED pads in master control was July 28, 2027, and December
28, 2025 for the AED in medical. The AED pads were last changed on July 28, 2025. Reviewed
drills simulated episodic care events which call for immediate first-aid, AED, and/or
administration of cardiopulmonary resuscitation (CPR) techniques and the initiation of the
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emergency procedures to follow when a life-threatening emergency occurs. The center
maintains documentation for emergency drills. A list of emergency numbers, including the
Poison Information Control Center, was posted and accessible for non-licensed and licensed
staff and were inaccessible to youth. Reviewed documentation confirmed authorized direct care
staff were appropriately trained on the administration of the epinephrine auto-injector. A review
of five staff records confirmed all staff training requirements were met regarding episodic care,
first-aid, and CPR. A review of the center’s emergency medical drills reflected drills included the
demonstration of first-aid and the AED. All drills were conducted for each shift on a monthly
basis for the last twelve months. The center’s policy on the use, access, and inventory of
NARCAN indicated it is used for the usage of medication overdose. The nursing staff and
supervisors have access to NARCAN. The center stores NARCAN in the locked medication
cart. Each staff with access to NARCAN has been trained on when and how to use NARCAN by
the nurse. The instructions for the use of NARCAN are located on the box. The center’s
inventory process for NARCAN is for the inventory to be conducted weekly by the medical staff.
During an interview with the nurse, it was confirmed first-aid kits are on all living units, master
control, sub control, intake, medical clinic, all vehicles, kitchen, and administration. The nurse
reported if on-site episodic care is provided by a licensed health care professional,
documentation shall be in such a manner which conforms to professional standards SOAP note
format. Episodic care may be provided on the living units for youth who are in restricted housing
if it has been determined safety and security may not be able to be maintained if the youth is
removed from the living unit. Episodic care may be provided by non-licensed staff when needed
if nursing staff are not on-site. Care shall be provided as guided by the non-healthcare staff
protocols, which are reviewed by the designated health authority (DHA) annually, and according
to first-aid training received. Documentation of the care provided shall be completed utilizing the
Report of On-Site Health Care by Non-HealthCare Staff form and shall be completed in its
entirety. Once the form is completed, it shall be placed on the nurse’s desk in the clinic for
review by nursing staff at the next available opportunity. The Summary of Off-Site Care form is
how youth who are sent off-site for emergency care are tracked. Emergency drills are held
monthly on each shift. The list of emergency numbers is posted in the medical clinic and on two
nurses’ desks. A medical drill is emailed to detention and medical staff. Five interviewed staff
reported they are able to call 9-1-1 if necessary. Three of five interviewed youth reported they
would rate the medical care at the center as very good, and two youth reported the medical care
at the center was good.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures for the provision of off-site emergency and non-
emergency referrals for medical care and treatment. Five youth Individual Healthcare Records
(IHCRs) were reviewed; however, none were applicable. Three additional records were
requested for off-site first-aid or emergency care. Reviewed documentation confirmed the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. Each off-
site emergency care event was documented on the Episodic Care Log. Parental notification
efforts were documented. All discharge and other applicable documents were filed in the IHCR.
Reviewed documentation confirmed the designated health authority (DHA) was notified of each
emergency event, and documentation included the date, time, and manner of notification.
Reviewed documentation confirmed the DHA or designee reviewed and signed/initialed all off-
site care findings, instructions, and information. None of the youth required follow-up testing,
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referrals, and/or appointments. During an interview with the nurse, it was confirmed for all youth
who require routine off-site medical or off-site emergency care, the Summary of Off-Site Care
form shall be utilized and filed in the IHCR. All hospital orders are followed through review of all
Summary of Off-Site Care forms, returning off-site orders, and progress notes for all events in
each youth’s IHCR. All documents are placed in the doctor’s folder to be reviewed and signed.
A nurse is assigned to the doctor to assist and ensure all paperwork is completed in a timely
manner. The DHA or designee shall document the review of all off-site care findings,
instructions, and information. The provider shall ensure actual dictation and documents are
requested from the outside provider. The nursing staff document follow-up testing, referrals, and
appointments in the electronic medical record (EMR) under the Practitioner’s Order and
incidental chronological notes in subjective, objective, assessment and plan (SOAP) format.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures ensuring youth who have been identified with a
chronic illness receive regularly scheduled evaluations and necessary follow-ups. Three of five
reviewed youth Individual Healthcare Records (IHCRs) confirmed youth were identified with a
chronic condition. None of the youth had a communicable disease. One of the three applicable
youth was taking prescribed medication on an on-going basis. All three youth were undergoing
treatment for a physical health condition. Two of the three reviewed youth were classified with a
Medical Grade of two through four. None of the youth were identified as pregnant. One of the
three applicable youth received periodic evaluations at least every ninety days. Two youth
weren’t applicable to receive periodic evaluations due to being in center under ninety days;
however, each received an evaluation. Progress notes were reviewed for documentation of
each completed periodic evaluation. None of the youth were taking anti-tuberculosis (TB)
medication. Reviewed documentation confirmed each youth received an evaluation conducted
off-site, and the evaluation was documented on the Summary of Off-Site Care form and filed in
the IHCR’s chronological progress notes. The designated health authority (DHA) followed up
with each youth after receiving off-site care and signed off on the documents. Reviewed
documentation confirmed there were no indications of any lapses in care or missed periodic
evaluations. The Department’s Problem List was updated as required and all periodic
evaluations were tracked. During an interview with the DHA, the center’s process for periodic
evaluations was confirmed. During an interview with the nurse, it was confirmed all youth with
chronic conditions will have periodic evaluations and an identified plan of care. All youth with
identified chronic illnesses shall be tracked to ensure thorough periodic monitoring of all vital
signs, body systems, diagnostic, and laboratory tests performed.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures which outline the process of how medications are
to be received, stored, inventoried, and administered in a safe and effective manner. Five youth
Individual Healthcare Records (IHCRs) were reviewed; however, only one youth was applicable.
Two additional records were requested for youth taking medication at admission, and
medication being verified prior to being admitted into the center. Reviewed documentation
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confirmed prescription verifications were included in the chronological progress notes, in the
IHCR/electronic medical record (EMR) or utilizing the Prescription Medication Verification
Checklist. The designated health authority (DHA) or designee, and when applicable, the
psychiatrist, was contacted to obtain the order to resume the specified medications prescribed
prior to admission. Reviewed documentation confirmed all medications had a current, valid
order, and were administered pursuant to a current prescription. Reviewed documentation
confirmed when current medications were continued, discontinued, changed, or newly ordered,
the DHA placed an order on the Practitioner Order form. Reviewed documentation confirmed
prescription verifications were documented in the chronological progress notes in each youth’s
IHCR or the Medication Receipt Transfer Disposition form was utilized, as required. None of the
youth were applicable for restricted housing. Three youth were applicable for over-the-counter
(OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form.
Reviewed documentation confirmed OTC medications not listed on the AET form were
administered according to approved protocols or Practitioner’s Orders. Each Medication
Administration Record (MAR) clearly indicated medication start and stop dates. There were no
instances where trained non-healthcare staff assisted in the delivery of medications. There were
no undocumented explanations for a lapse or errors in medication administration. Reviewed
documentation confirmed the nursing staff documented side effect monitoring weekly on each
MAR. The MAR contained all required elements to include the youth’s name, Department
identification number, date of birth, youth allergies, precautions, Medical Grade, medical alerts,
and a current picture of the youth. Each youth initialed each provided medication entry. None of
the MARS indicated a refusal for medications. There were no standing, emergency treatment, or
pro re nata (PRN) orders for psychotropic medications. During the week of the annual
compliance review, an observation of a medication administration was conducted. The youth’s
verbal consent was obtained prior to observation. Medication delivery was the sole responsibility
of the nurse during the time of administration. It was observed the youth was escorted to the
medical station area by the assigned officer. The nurse identified themselves and stated why
the youth was there and prepared and administered the medications. The nurse did verify each
youth’s allergy and alert status. The nurse and youth initialed each MAR. It was observed staff
observed the youth to make sure medication was swallowed. Prescription medications were not
pre-poured from original packaging and placed in another container for subsequent
administration. During an interview with the nurse, it was confirmed only medications from a
licensed pharmacy with a current, patient specific label intact on the original medication
container may be accepted into the center. All medications shall have a current, valid order and
are given pursuant to a current prescription or Practitioner Order. Non-licensed staff will refer to
the DHA for further guidance and document on the Prescription Medication Verification
Checklist. The standard Department MAR shall be used to document all medication and
treatment. The MAR shall clearly indicate start and stop times. A paper version of the MAR may
only be used in situations in which the Department’s Juvenile Justice Information System (JJIS)
is not operational, when medications are administered during a transport, in situations where the
electronic MAR is not available, or if a youth is in restricted housing and it has been deemed by
detention administration it is unsafe for the youth to be escorted to the clinic for medication
pass. The paper MAR shall include all signatures and requirements as the electronic MAR.
Medications/prescriptions are procured through a contracted pharmacy unless an emergency
requires medication to be procured from the local pharmacy. Two of five interviewed youth
reported the nurse gives them their medications and three youth reported they do not take
medication. Two of five interviewed staff reported they give medication to youth and three
reported they do not give medication to youth. The center’s disposal process was confirmed
during an interview with the nurse in regard to medication management which includes medical
waste being removed by a vendor and medications being destroyed in conjunction with the
contracted pharmacy consultant during their monthly visit.
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.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures (FOPs) regarding psychiatric services to include
psychiatric evaluation, psychiatric consultation, medication management, and medical
supportive counseling provided to youth with a diagnosed Diagnostic and Statistical Manual,
Fifth Edition (DSM-5) mental disorder and/or substance-related disorder. The center’s services
are provided by an advanced practice registered nurse (APRN) who works under the clinical
supervision of a psychiatrist as specified in the collaborative practice protocol with the
supervising psychiatrist. Reviewed documentation confirmed a current and updated copy of the
official collaborative practice protocol between the supervising psychiatrist and psychiatric
APRN was stored on-site where the psychiatric APRN provides psychiatric services. The
center’s psychiatrist’s license expiration date is March 31, 2026. The contract was reviewed for
tele-medicine/tele-psychiatry inclusion. During an interview with the designated mental health
clinician authority (DMHCA), it was confirmed they met with the psychiatrist to discuss youth
receiving psychiatric services every Tuesday from 1:00 p.m. to 3:00 p.m. Five youth records
were reviewed; however, only one youth was applicable. Two additional records were requested
for youth who entered the center on psychotropic medication or who were referred for a
psychiatric interview. Each youth received an initial diagnostic interview within fourteen days of
the youth’s admission to the center. Reviewed Initial Diagnostic Psychiatric Interviews included
the reason for referral, history, a Mental Status Examination, DSM-5 diagnosis, treatment
recommendations specific to mental health and/or substance abuse diagnoses, and prescribed
medication. Each initial psychiatric interview documented the medication name, and an
explanation of the need for psychotropic medication. Reviewed documentation confirmed an in-
depth psychiatric evaluation was conducted on all referred youth within thirty days of
referral/admission. Each stated reasons and factors leading to the referral and history,
developmental history, medical history including medical disorders, head trauma and prenatal
exposure to alcohol/drugs, substance abuse history, school history, social history, emotional
development, peer relations, family relationships, interests/talents, traumatic experiences,
physical/sexual abuse, neglect, witnessing violence, and other forms of trauma. Each evaluation
stated the history of psychiatric illness, psychotropic medication management, mental health
treatment and/or substance abuse treatment, an assessment of symptoms, the nature and
complexity of the youth’s behavioral difficulties, functional impairments, subjective distress, and
identification of individual, family and/or environmental factors which may potentially account for,
influence, or improve the youth’s difficulties. Each reviewed Initial Diagnostic Psychiatric
Interview confirmed diagnostic formulation, treatment recommendations and intervention(s) for a
youth in order to assist in stabilizing the psychiatric disorder, prescribed medication and
frequency of medication monitoring/management, explanation of the need for psychotropic
medication related to the youth’s diagnosis, target symptoms, potential side effects, risks, and
benefits of taking the medication, most recent applicable therapeutic serum drug levels, and
signature of the practitioner conducting the psychiatric evaluation. Reviewed documentation
confirmed the Clinical Psychotropic Progress Note (CPPN), page three, was completed if new
psychotropic medication is prescribed or there are any changes to the existing prescription.
Each CPPN was clearly identified as a “Psychiatric Evaluation”. Each youth record applicable
for prescribed psychotropic medications included identifying data, diagnosis, target symptoms of
each medication, evaluation and description of effect of prescribed medication on target
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symptoms, dosage, range, frequency, route, reason for changes in medication and/or dosage,
side effects, and youth’s adherence to the medication regime. Additionally, each record included
height, weight, blood pressure, most recent serum drug levels, laboratory findings, telephone
contact with the youth’s parent/guardian to discuss medication, signature of the psychiatrist, and
documented monitoring of Tardive Dyskinesia on a monthly basis. Each record contained a
valid Authority for Evaluation and Treatment (AET) form and a written parent/guardian
authorization to continue psychotropic medications. The center is approved for the use of tele-
psychiatry, and each youth consented to participate.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as sharps and stock medications shall be secured and
inventoried by using a routine perpetual inventory descending count as each sharp is utilized
and disposed of or when the medication is utilized.
The center has facility operating procedures requiring any medical equipment classified as
sharps and stock medications to be secured and inventoried by using a routine perpetual
inventory descending count as each sharp is utilized and disposed of or when the medication is
utilized. Observations confirmed the medical equipment classified as sharps, to include
syringes, needles, scissors, and suture removal kits, were secured and inventoried utilizing a
routine perpetual inventory descending count as each sharp was utilized and disposed. All
medications were identified and secured in the locked area designated for storage of
medications. The medication cart was clean and organized with stock items separate from youth
specific medications.. All medications were stored in a separate, secured area, inaccessible to
youth. The center did not have any narcotics or other controlled medications, requiring storage
behind two locks, during the week of the annual compliance review. Oral medications were not
stored with injectable or topical medications. Medications which required refrigeration were
stored in a secured refrigerator, which is used for medication only. The center had perpetual
and weekly inventories of all sharps and stock over-the-counter (OTC) medications conducted.
All non-health care staff were trained by a registered nurse or higher in the delivery and
oversight of medication self-administration. During the time of the annual compliance review
week, the center did not have any controlled medications to be reviewed. A review of three OTC
medications was conducted, and each inventory was accurate and kept perpetually and weekly.
There were no discrepancies found. A review of three sharps verified all three matched the
count on the perpetual inventory. There were no discrepancies found. It is the center’s practice
for the nurse to investigate and report any inventory discrepancies. The center’s process for the
disposal and destruction of expired and/or discontinued medications is for the medication to be
destroyed when the pharmacy consultant is on-site. The pharmacy consultant and nurse sign off
on the disposal log once the medication is destroyed. The interviewed nurse confirmed the
center’s disposal process. Additionally, the program maintains a copy of a pharmacy consultant
license on-site.
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4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures and an approved plan for exposure control and
infection control ensuring staff, youth, volunteers, and visitors are not exposed to infectious and
communicable diseases, according to Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control (CDC) and Prevention guidelines. Five
reviewed youth Individual Healthcare Records (IHCRs) confirmed each youth received infection
control education. Each youth received infection control education within seven days of
admission, which included hand-washing techniques, universal/standard precautions,
prevention/transmission of communicable diseases, vaccinations, and CDC guidelines for
infection control. The Exposure Control Plan was written in accordance with OSHA guidelines
and included a risk assessment list of all job classifications in which staff have the potential for
occupational exposure, list of all job classifications in which some staff have the potential for
occupational exposure, and a list of tasks or procedures which would cause the staff in the job
classifications listed to have occupational exposure. Additionally, the plan included methods of
compliance for infection control practices, and engineering and work practice controls for
availability of hand washing facilities, procedures for proper disposal of needles and other
sharps, procedures for maintaining the work site in a clean and orderly manner, use of specified
signs and labels to communicate hazards to staff, procedures for handling of contaminated
laundry, procedures for post-exposure evaluation and follow-up, and a system of medical record
keeping for staff with an occupational exposure. The infection control procedures put in place
included prevention, containment, treatment, and reporting requirements related to infectious
diseases, according to OSHA and the CDC guidelines. The infection control procedures
included common, infectious diseases of childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, Tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), infectious diseases caused by blood-borne pathogens, other
outbreaks or epidemics caused by any other infectious agent, outbreaks of pediculosis and/or
scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA), other antibiotic-resistant micro-
organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures in the workplace.
The center’s process for needle stick post-exposure evaluation consists of counseling,
evaluation of reported illness, and providing information to the individual who was exposed. The
Hepatitis B immunization is made available for staff. The staff have access to protective
equipment. The center had no reported instances in which infectious diseases and sexually
transmitted infections (STIs) were required to be reported to the local health department. There
were no instances requiring a report to the Department’s Central Communications Center
regarding exposure since the last annual compliance review. The nurse reported all records are
maintained as confidential for a ten-year period, as required. Pre-service and in-service training
for all staff was completed on the center’s specific Exposure Control Plan. During an interview
with the nurse, it was confirmed a copy of the Exposure Control Plan is available to the nursing
staff.
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4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures ensuring access to prenatal care for all pregnant
youth. A review of five youth records showed none were applicable for prenatal care/education.
During the annual compliance review week, the center had one pregnant youth available for
review. Reviewed documentation confirmed prenatal care began immediately upon determining
the youth was pregnant and continued until discharge/transfer and through postpartum. The
designated health authority (DHA) or designee provided routine, focused medical evaluations of
the youth’s pregnancy every thirty days, or sooner if ordered. Prenatal care was provided at
recommended intervals. The youth was placed on the internal alert system for vital nutrition and
health awareness for staff. A second alert was entered into the center’s internal alert system
regarding the youth’s sleeping arrangements. The medical doctor conducted a focused medical
evaluation at least every thirty days. When the youth complained about issues related to
pregnancy, the DHA or designee was immediately notified. Reviewed documentation confirmed
there was daily monitoring for danger signs of pregnancy complications and a documented plan
for post-birth psychological and physical care. Education was provided relating to pregnancy
and alcohol and drug use, smoking, nutrition, sexually transmitted diseases (STDs),
contraception, prenatal, birthing process, postpartum care, basic baby care, feeding, diapering,
bathing, child/infant development, and parenting skills. The youth received nutritious food in
quantities appropriate for a pregnant youth, as ordered by the practitioner. The licensed
healthcare professional staff provided routine monitoring of the pregnant youth’s nutritional and
weight status during the course of pregnancy. Reviewed documentation confirmed all education
was documented in the Individual Healthcare Record (IHCR) in the Health Education record. A
licensed nurse provided in-service education on youth’s prenatal healthcare annually to all non-
healthcare staff involved in the supervision or treatment of youth. In-service training included
observation and monitoring of emergency care needs and symptoms of possible miscarriage.
The center has nursing protocols and treatment plans for pregnant youth. Five staff pre-service
and five in-service training records documented completion of related education topics. During
an interview with the nurse, the center’s practices for youth requiring prenatal care were
confirmed. One of five interviewed youth reported receiving prenatal, obstetrical, or
gynecological services when needed at the center. The remaining youth reported they did not
require and were not receiving prenatal services.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures to address active supervision of youth. During the
annual compliance review, youth supervision was observed each day of the review. Youth and
staff observations were conducted in the classrooms and in the cafeteria. There were always
one or more staff with each group of youth. 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 which supported active
supervision. The juvenile justice detention officers and master control operators communicated
to receive authorization for all movement within the center. The master control logbooks for the
past twelve months were reviewed.g 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. Five staff were interviewed and all five responded 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 has facility operating procedures requiring a uniform behavior management system
(BMS) which offers a set of rewards, privileges, and consequences for behavior. The center has
a system of rewards, privileges, and consequences to motivate youth to meet and exceed the
center’s expectations. During a tour of the living units and intake area, observations verified
posters of the BMS were posted on the walls of the living areas and within the in-intake area of
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the center. Each poster specified clearly appropriate and inappropriate behaviors, rules, norms,
and expectations. A calendar is posted to provide the youth with rewards and privileges which
can be earned monthly. The review of logbooks and other documentation confirmed youth were
receiving incentives. Observations of the logbook verified consequences and level drops were
documented. There was no documentation found for incidents of inappropriate use of corporal
or group punishment or restrictions. Five staff interviews were conducted, and each staff was
able to explain the difference between each level and how youth can move from level to level.
Five interviewed staff stated youth are rewarded for good behavior and following the rules.
Rewards included canteen, movie nights, games, and special visitation. All five staff stated the
rewards and privileges were fair and consistent with BMS guidelines. All five staff also reported
when youth received consequences for inappropriate behavior, the individual youth is spoken to
by staff about their behavior and the consequences which are going to be imposed because of
their behavior. Youth are given the opportunity to explain their behavior, and staff are allotted
time to counsel youth and suggest alternative behaviors. Supervisors remind staff during
briefings and set expectations on living units to go over the BMS with youth. All five interviewed
staff indicated the BMS should be utilized to remind youth about their behavior in other settings,
and the BMS is discussed daily with staff and youth. All five staff indicated basic needs cannot
be taken from youth, and only levels can be taken, according to the facility operating
procedures. All five staff stated they have not observed snacks, telephone calls, showers, or
any basic needs taken away from youth. All five staff indicated they have not seen staff use
BMS incentives for youth to engage in physical altercations with other youth. Two of the five
interviewed youth rated the BMS as very good, two rated the BMS as good, and one youth rated
the BMS as fair. All five youth were able to explain how the level system works, each youth
stated level one and two are basically the same, and level three is when youth receive rewards
and privileges. All five youth stated they are rewarded for good behavior and when on level
three. Youth stated they receive extra food, more time on the telephone, and they are allowed to
participate in special events. Each youth stated staff respect them when they reach level three,
which comes with additional privileges. Five youth indicated staff treat them the same with
rewards, and extra privileges when demonstrating good behavior. All five interviewed youth
verified youth are never allowed to punish other youth. Each of the five interviewed youth stated
they were sent to their room as a punishment for negative behavior, not following directions, or
fighting. All five youth stated the door was shut and locked when they were placed in their room
for non-compliance. Each youth stated the consequences they received were fair. All five youth
stated points and levels can be taken away for negative behavior. All five youth stated they were
never placed in handcuffs or leg irons other than during transportation. The interviewed
superintendent verified the center uses a level system to monitor each youth’s behavior.
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5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks. The center uses
handwritten observation forms to document ten-minute checks. A review of the documentation
and surveillance video was conducted for four randomly selected dates during the thirty days
prior to the review, across two shifts, and on two different youth living modules. All checks were
conducted according to policy. In addition, written documentation of checks was reviewed for
the other eleven months of the review period. The reviewed checks were consistently
documented in periods of ten minutes or less and there was documentation of weekly
management oversight. Five staff were interviewed, and all five responded room checks are
conducted at least every ten minutes when a non-suicidal youth is placed in their room.
Interviewed staff were knowledgeable of the requirements and policy for ten-minute checks and
room checks. The interviewed superintendent responded checks are conducted every ten-
minutes or less when a youth is in a room.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures in place to ensure staff know the exact number of
youth and the location of youth under their supervision. Observations during the annual
compliance review week verified staff were conducting counts as required. A review of one full
day from each month throughout the annual compliance review period of master control
logbooks confirmed the census count of youth was accurate with the written beginning
population count and ending count. Each shift conducted multiple head counts during the shift
and at least one random count. Counts were documented following drills and disturbances.
Counts of new admissions and releases were documented in the master control logbook. When
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counts are not correct, five staff stated all movements cease, another count is taken, the master
control operator reviews the logbook, and a supervisor is notified. All movement is stopped until
the count is corrected. Living module counts are recorded in each living unit’s logbook. Five staff
were interviewed about emergency counts, and each indicated they would conduct an
emergency count when there is a missing youth, and when visibility is hindered suddenly. Four
staff indicated an emergency count would be conducted after a major disturbance, and two staff
stated after every code, movement, drills, and disruptions.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures in place regarding logbook maintenance and
reviews. The center maintains separate logbooks in master control and for each living unit, in
addition to one for visitors, and one for contracted staff. A review of logbooks for the last twelve
months 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, a brief
description of the event, and the initials of the staff making the entry. Logbook entries included
a.m. or p.m. following the time entry. All entries for the last twelve months revealed safety and
security of the center, including medical, special needs, and mental health alerts were
highlighted. Reviewed logbooks reflected all errors were struck through with a single line and
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, presence of law
enforcement, the name of youth placed in confinement, including the time confinement began
and the time confinement ended, and the name of youth placed on precautionary/secure
observation, including the time precautionary/secure observation began and the time
precautionary/secure observation was discontinued. The superintendent or designee reviewed
the logbooks on a weekly basis. The juvenile justice detention officer supervisor (JJDOS)
documented review of the logbooks maintained at master control when assuming responsibility.
The JJDOS documented review of the logbooks maintained in each living area daily. The
JJDOS reviewed the logbook maintained in the assigned living area when accepting
responsibility for the living area at shift change. The superintendent or designee are responsible
for touring the youth living areas at least once during each shift and documentation showed the
tours were documented in the living unit logbooks. The interviewed superintendent verified the
role the administrator has regarding logbooks.
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5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures in place detailing the requirements of the center’s
key control, to include the issuance of keys to staff, inventory and tracking, key restrictions,
storage, missing or 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 to which the keys are 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 to. Emergency keys
which provide egress through exterior doors are stored in the foyer near master control which
staff can access. In an informal interview, the master control staff verified the key distribution
process. A review of the Key Control Log of distribution and collection of keys confirmed the
issuance of keys and key rings, were documented on the Key Control Log on each shift with the
date and time of issuance, name of the staff issuing the key, name of staff receiving the key
ring, and the time each was returned. An observation of the distribution and collection of keys at
shift change could not be conducted due to twelve-hour shifts from 7:00 a.m. through 7:00 p.m.;
however, the master control staff described in detail the process for the distribution of keys. Key
issuance and return were documented on the daily shift reports. During the annual compliance
review, staff were observed carrying the keys on their person and youth did not have access to
the center’s keys. The center keys carried by three staff were examined and were confirmed to
have the correct number of keys on the ring, as well as the correct assigned key ring number
documented for the shift. A review of the master key control inventory confirmed the inventory
report matched the actual key rings in use. There was one reported incident of a damaged key
since the last annual compliance review. Procedures were followed within the scope of the
policy. The key was removed to be repaired and was placed back in circulation on November 5,
2025. The superintendent confirmed there were no incidents of any staff taking their keys home
with them, or key control issues which required reporting to the Department’s Central
Communications Center since the last annual compliance review. Personal keys are stored in
master control in the non-secure area of the center. Five staff were interviewed and said
restricted keys include keys which access medical records, the youth property area, youth
mental health records, youth case management records, and access to the kitchen. All five staff
could articulate the daily process for tracking keys at the center, including the usage of a Key
Control Log.
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5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures in place for transportation procedures and
operation of Department vehicles. The center uses four vehicles for transporting youth.
Documentation supported the maintenance mechanic completed monthly vehicle checks. A
review of the vehicle maintenance invoices revealed all vehicles received an annual inspection
within the previous year. All vehicles had the appropriate number of seat belts, a seat belt
cutter, a window punch, a fire extinguisher, and a first-aid kit with approved items. Reviewed
documentation found each vehicle was inspected prior to transport. The use of tobacco
products or electronic vaping devices is prohibited by facility operating procedures. Logbook
documentation for all vans was reviewed during the annual compliance review week, and all
logbooks included the acknowledgement of the van being searched before the trip, the
destination, the number of youth and staff names, the name of the officer riding in the back of
the van, time the transport began, and the time the transport ended. An observation of pre-
transport activities was unable to be completed as no transports occurred during the annual
compliance review week. A security check was conducted of all vehicles during the week of the
annual compliance review, and all were locked when not in use. Five youth were interviewed,
and all five youth stated they feel staff are driving safely when transporting youth. All five youth
stated they have not seen anyone placing 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 has facility operating procedures in place addressing tool inventory and
management. All tools were secured behind a locked door in the maintenance workshop which
is accessible to the maintenance staff and administrators. Tools are stored on shadow boards
and are marked with a number to identify them as Department property. The center maintains a
perpetual inventory of tools. All tools are checked out prior to use and checked in after they are
returned. Interviewed maintenance staff indicated inventory is conducted monthly and forwarded
to the superintendent or designee for review. In addition, the maintenance staff confirmed all
vendors are accompanied by center staff at all times in the secure area of the center. Kitchen
tools including knives and scissors are stored in a locked box in the kitchen. A perpetual
inventory of kitchen tools is maintained, and counts are documented at the beginning of the day,
midday, and at the end of the day. All kitchen tools are checked out prior to use and checked in
after they are returned. All tools were accounted for, and inventory sheets were reviewed. There
were no tools missing or documented as being missing from the center, and there were no tools
in the center not listed on the inventory. The center does not allow youth to use tools, including
kitchen tools, and medical equipment. Youth are allowed to use mops, brooms, and other
common household items, under direct staff supervision. An informal interview with
maintenance and kitchen staff determined when a tool is damaged or missing the practice is to
inform the superintendent immediately, secure the broken tool, if applicable, and/or begin a
search for the missing tool. During the annual compliance review week, a sample of ten tools
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from the kitchen and maintenance were reviewed. All ten tools were secured, were marked for
easy identification, accurately inventoried, and the inventories were signed by the
superintendent or designee. The superintendent was interviewed and reported only
maintenance and administration staff have access to center tools. Five interviewed staff
reported if a tool is damaged or missing, they would notify a supervisor, administration, and
maintenance staff. All five staff reported youth are only allowed to use mops, scrub brushes,
and brooms with supervision. Five interviewed youth reported they are only allowed to use
mops and brooms.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s biohazardous material, bodily
fluids, or human waste.
The center has facility operating procedures to address the inventory of flammable, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
secure areas with limited access. Safety Data Sheet (SDS) logbooks are in the location where
the chemicals are stored. Inventories of flammable, toxic, caustic, and poisonous items are
maintained by the maintenance mechanic. Five SDSs and inventories were compared to the
items on-site and were found to be accurate and complete. The center has a written policy and
procedures for toxic materials which prohibits youth access to flammable, toxic, caustic, or
poisonous items. Youth are not permitted to access any materials which are flammable, toxic,
caustic, and/or poisonous. No toxic materials were observed stored in the center in any place
accessible to youth during the four walk-through tours conducted the week of the annual
compliance review. The superintendent confirmed flammable, toxic, and/or caustic materials are
stored in the maintenance department under lock and key and are only accessible to
administrators and maintenance staff. Five interviewed staff confirmed youth are not allowed to
clean with substances which are toxic, flammable, or poisonous. Five youth were interviewed
and four stated they use cleaning agents after the staff spray the cleaning agent. One youth
stated they did not use cleaning agents.
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5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures which address the proper use, storage, and
disposal of flammable, toxic, caustic and poisonous items. The plan addresses what procedures
to follow in the event of a chemical leak or spill. The maintenance mechanic confirmed materials
are disposed of by evaporation, compaction, or taken to a local solid waste and hazardous
management center. The kitchen has a container outside to store grease, and it is disposed of
by a local vendor. Biohazardous medical materials are disposed of by a vendor on a monthly
basis. The superintendent stated there have been no chemical spills or leaks within the annual
compliance review period.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures to address requirements for behavioral
confinement for less than twenty-four hours. The center had 258 confinements lasting less than
twenty-four hours during the annual compliance review period. Fifteen confinements were
reviewed. Documentation indicated all youth rights were afforded in each instance including
three meals a day, school, an evening snack, access to mental healthcare as needed,
daily shower, clean clothing, and bedding. The center documents confinements under twenty-
four hours in the Facility Management System (FMS) within the Department’s Juvenile Justice
Information System (JJIS). All fifteen reports documented the confinement rooms were
searched prior to each youth being placed. All fifteen reports documented the initial
confinements were reviewed by the juvenile justice detention officer supervisor (JJDOS) within
one hour to determine the appropriateness of the use of confinement. Documentation indicated
all fifteen youth were supervised while in confinement with the supervision documented on the
Visual Observation Report (VOR) Log at least every five minutes for the first hour and every ten
minutes thereafter. All fifteen reviewed confinements were applicable for affecting the youth’s
attendance in school, and in each instance school personnel were notified, and educational
materials were provided. All fifteen reviewed confinements documented a review was conducted
by the supervisor at least every three hours, including the reason for continued confinement
based on severity of rule infraction and past disciplinary history or behavior confinement on all
reports. All fifteen reports were reviewed by the superintendent or designee within forty-eight
hours excluding weekends and holidays. Five staff were interviewed, and all five stated when a
youth is placed in confinement, staff must search the confinement room prior to placing the
youth, staff must conduct and document ten-minute room checks while the youth remain in
confinement, and a confinement report must be completed when a youth is placed in
confinement. All five staff reported youth in confinement are provided with educational materials
during school hours. A superintendent interview was conducted. The superintendent stated
confinements are tracked in JJIS and are reviewed by supervisors and administration. The
superintendent stated a review is done every day for the use of confinement. In addition, no
lockdowns or restraints have been utilized during the annual compliance review period. In the
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event a lockdown or restraints were needed, regional detention administration would be notified
immediately.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures to manage various emergencies and disaster
events. Two Continuity of Operations Plan (COOP) drills were conducted within the prior year.
Hurricane drills were conducted in May 2025 and August 2025. One of the drills was conducted
in May, just prior to the beginning of hurricane season. There were written scenarios and drill
forms, critique forms, and emails used to document the drills. Five staff were interviewed and
asked what drills they have participated in in the last twelve months. Five staff responded they
have participated in a major disturbance drill, an escape drill, a weather drill, and a fire drill. Four
staff responded they have participated in a flooding drill, in a hostage situation drill, and a
chemical spill drill. Three staff responded they have participated in a bomb threat drill, and a
terrorism drill. The superintendent stated the COOP describes the process for the relocation and
continued operations of a center during an emergency or disaster.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures to address escape drills and escape prevention.
The policy requires the center to conduct quarterly escape drills. The escape drill documentation
for the past twelve months was reviewed. The center completed quarterly escape drills without
exception. A total of thirty-six drills were conducted covering four quarters. The documentation
of the drills included scenarios, as well as the dates and times of the drills. The drill
documentation form included the signatures of the supervisor and the staff coordinating the drill.
Drills are reviewed with staff at the shift briefings. Recommendations and critiques of the drills
were included in each report. A review of the logbooks revealed all escape drills were
documented in the logbook as required. Five staff were interviewed and asked what drills they
have participated in in the last twelve months. Five staff responded they have participated in an
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escape drill. Training records of five staff were reviewed and all five staff had received escape
prevention training during the previous year.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a Fire Prevention and Evacuation Plan which addresses fire prevention and
safety of the program. The plan was reviewed and approved by the local fire official. A review of
documentation supported the center conducts fire drills every month, on each shift, for the prior
twelve months. A total of thirty-six drills were conducted covering twelve months. The
documentation on the drill forms included scenarios and the dates and times of the drills. The
fire drills were documented in the master control logbooks. Staff sign-in sheets were used to
document staff participated in the drills. Five staff were interviewed and all five responded they
have participated in fire drills in the prior twelve months. All five staff responded fire drills take
place at least monthly. All five interviewed youth stated they had been instructed on what to do
in the event of a fire. Training records of five staff were reviewed and all five staff had received
fire prevention training during the previous year.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures addressing illegal contraband and prohibited items.
Upon admission to the detention center, youth are searched by detention staff. During the
annual compliance review week, a search was observed, and the staff thoroughly searched the
youth with gloves on and reported the search to master control. Since the last annual
compliance review, there were no full body searches conducted by the center outside of the
initial full body search at admission. During the annual compliance review week electronic
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searches were conducted on all people entering the center. All bags, cases, jacket pockets, and
other items were searched. All personal keys were collected by master control before entering
the secure area. Personal cellular telephones and other contraband items were prohibited.
Additionally, all visitors sign a contraband attestation form upon entry. Five staff records were
reviewed, and each staff had a contraband attestation statement on record. Room searches are
completed upon releasing a youth and prior to placing a new youth in a room. Additionally, room
searches were conducted on each awake shift. A review of room search documentation was
conducted for one day each month during the annual compliance review period and confirmed
both awake shifts completed and documented room searches on the shift reports located on a
shared network drive. Since the last annual compliance review there were no instances which
compromised the safety or security of the center. Any instances would be reported to the on-
duty supervisor and to the Department’s Central Communications Center (CCC) in a timely
manner. If contraband were discovered, it would be documented in the master control logbook.
Incident reports would be completed if contraband was discovered in the center. Law
enforcement would be notified when necessary. Confiscated items would be secured by either
the on-duty supervisor or administration and then turned over to law enforcement. The chain of
custody would be documented on incident reports by the shift supervisor. The regional director
or designee would be notified regarding contraband in the center. The superintendent was
interviewed and stated in the event contraband is recovered, law enforcement is contacted.
Searches are conducted for staff prior to entering the secure area of the center. Youth are
searched prior to admission, before leaving the dining hall, after visitation, and room searches
are conducted twice a day at minimum.
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report_type: QI Detention

file_name: CollierDetention - Final-FY2526 (1).pdf