summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
-
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Okaloosa Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
4488 Straight Line Road
Crestview, Florida 32539
Review Date(s): July 15-18, 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:
Stephanie Solano, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Ken Myers, Office of Education, Education Coordinator Circuit 1 (Standard 2)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Molly Stewart, North Detention Regional Office, DJJ Operations Analyst (Standard 5)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Okaloosa Regional Juvenile Detention Center MQI Program Code: 828
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Okaloosa County / Circuit 1 Number of Beds: 35
Review Date(s): July 15-18, 2025 Lead Reviewer Code: 209
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 56
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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 56
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
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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
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a
S ta ff C o d e o f C o n d u c t S a
In c id e n t R e p o rtin g C C C * S a
R ig h t In te ra c tio n s (R I) S a
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a
In -S e rv ic e T ra in in g S a
G rie v a n c e s S a
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D a ta T re n d A n a ly s is S a
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a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 56
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 to r R a tin g s
S ta n d a rd 2 - A s s e s s m e n t a n d P e rfo rm a n c e P la n
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 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 a n d H o m e 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
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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 56
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3 .0 3
3 .0 4
3 .0 5
3 .0 6
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3 .1 2
3 .1 3
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3 .1 5
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le rt fo rm b e in
In d ic a to r R a tin g s
S ta n d a rd 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 rv ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
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
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
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 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 56
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
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* 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 to r R a tin g s
S ta n d a rd 4 - H e a lth S e rv ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * S a tis fa c to ry
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c to ry
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa c to ry
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c to ry
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm S a tis fa c to ry
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n S a tis fa c to ry
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa c to ry
H e a lth -R e la te d H is to ry S a tis fa c to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g S a tis fa c to ry
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g S a tis fa c to ry
S ic k C a ll P ro c e s s S a tis fa c to ry
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 c to ry
O ff-S ite C a re /R e fe rra ls S a tis fa c to ry
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s S a tis fa c to ry
M e d ic a tio n M a n a g e m e n t S a tis fa c to ry
P s y c h ia tric S e rv ic e s * S a tis fa c to ry
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s S a tis fa c to ry
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n S a tis fa c to ry
P re n a ta l C a re /E d u c a tio n N o n -A p p lic a b
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 d
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
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 56
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D e p a
o p e ra te s b e
d o s o w ill re
In d ic a t o r R a t in g s
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th * S a tis fa c to ry
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t* S a tis fa c to ry
T e n -M in u te C h e c k s * S a tis fa c to ry
C e n s u s C o u n ts a n d T ra c k in g S a tis fa c to ry
L o g b o o k M a in te n a n c e a n d R e v ie w s S a tis fa c to ry
K e y C o n tro l S a tis fa c to ry
V e h ic le s a n d M a in te n a n c e S a tis fa c to ry
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s * S a tis fa c to ry
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs S a tis fa c to ry
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs N o n -A p p lic a b le
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills S a tis fa c to ry
E s c a p e D rills S a tis fa c to ry
F ire D rills S a tis fa c to ry
S e a rc h a n d C o n tra b a n d P ro c e d u re s S a tis fa c to ry
rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to
s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
Program Overview
The Okaloosa Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Crestview, Florida. The center serves youth in Okaloosa and
Walton counties in Circuit 1. The center is co-located with a Juvenile Assessment Center (JAC),
which is operated by a contracted provider. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
thirty-five bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Okaloosa County School Board.
The center’s management team includes the superintendent, two assistant superintendents,
one staff assistant, seven juvenile justice detention officer (JJDO) supervisors, thirty-six JJDOs,
one food service director, and three food support workers. Mental health and healthcare
services are provided through the contracted provider, VitalCore Health Strategies, LLC. Mental
health services are provided by one designated mental health clinician authority (DMHCA) and
one licensed mental health professional. Clinical services provided by the center include mental
health and substance abuse evaluations, mental health treatment planning, individual, group
and family therapy, mental health crisis intervention services, on-site psychiatric services, and
availability for substance abuse services for youth with co-occurring disorders. Medical services
are provided by one designated health authority (DHA), one advanced practice registered nurse
(APRN), and four registered nurses (RNs). The medical clinic maintains nursing coverage seven
days a week, from 7:15 a.m. to 7:15 p.m., Monday through Friday, and from 7:00 a.m. to 5:00
p.m., on weekends. Food services are provided by Department staff and include menus, meal
planning, meal schedules, special diets, nutritional analysis, daily allowance, food preparation,
health certifications, food product standards, sanitation, and cleaning. Staff are responsible for
the custody and control of youth in their care, providing youth supervision twenty-four hours a
day, seven days a week. The center has three living modules which are divided by male and
female. There are seventy-two security cameras at the center; one was found to be non-
operational, but it is located outside and does not monitor youth areas. The center has several
areas, largely living modules, which need to be painted; there are also a few rooms with graffiti,
however, the center is unable to purchase paint. Work orders were submitted by the program.
At the time of the annual compliance review, the center had fourteen vacancies including twelve
JJDOs, one administrative assistance, and one maintenance mechanic.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPs) outlining the process of background
screening for all new staff, volunteers, and contracted staff. There were eleven staff hired at the
center since the last annual compliance review. All staff reviewed had a background screening
completed prior to their hire date. A criminal history report was reviewed for each of the staff
reviewed. None of the hired required an exemption prior to working with youth. All staff had a
pre-employment assessment tool administered. In addition, a passing score was found and
documented within the staff record. None of the newly hired staff were contracted providers;
therefore, they were not eligible for inclusion on the Clearinghouse roster. The center has one
volunteer and one intern, each of whom completed a background screening and criminal history
check prior to having contact with youth or accessing confidential youth records. The center has
a policy and procedures for volunteers, mentors, and interns who work with the youth less than
ten hours a month requiring sight and sound supervision. The center had an Annual Affidavit of
Compliance with Level 2 Screening Standards signed on December 30, 2024. The school board
had an Annual Affidavit of Compliance with Level 2 Screening Standards signed on January 28,
2025.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures (FOPs) outlining the process of five-year
background rescreening for staff. One staff was applicable and reviewed for five-year
rescreening. The staff had the five-year rescreening completed every five years, calculated from
the agency hire date, as required. The center did not have any contracted provider staff who
required a rescreening.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 56
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 (FOPs) outlining the guidelines of staff code of
conduct. Six staff records were reviewed for code of conduct. All six staff had a signed code of
conduct, as required. Of these six, three staff had documented disciplinary actions related to
code of conduct violations; in each instance, management issued an oral reprimand. The
remaining three staff were reviewed for commendations. All three were nominated for Employee
of the Month at the regional level, although none were selected for the award.
Five youth were interviewed. When asked if they had ever been stopped from reporting abuse
to the abuse hotline, one youth reported never being prevented from making the call and the
remining four reported never needed to report abuse. When asked if staff are respectful when
talking with them or other youth, three youth reported staff generally speak to them and others
with respect, while two youth stated staff were not respectful and provided specific examples
and the names of the staff involved. When asked how often they heard staff use profanity when
speaking to youth, one youth reported never, one reported occasionally, and three reported
often. In response to how often staff threatened youth, four youth stated never and one youth
reported it occurred once. When asked if they feel safe at the center; four youth reported feeling
safe at the center, while one youth said they did not feel safe. The youth explained the reason
and was offered the opportunity to contact the Florida Abuse Hotline. The youth made the call
with the assistance of detention staff. All five youth reported they had never exchanged emails,
phone numbers, or social media information with staff. Five staff were interviewed. Each staff
was asked to explain the process for allowing staff and youth to call the Florida Abuse Hotline or
the Department’s Central Communication Center to report suspected abuse. All five staff stated
the process involves notifying a supervisor and allowing the youth to make the call. One staff
added the superintendent is also notified. When asked how often they had observed a coworker
using profanity when speaking to youth, two staff reported never and three reported
occasionally, noting such incidents typically occurred during stressful situations but were not
directed at youth. All five interviewed staff stated they have never observed a coworker using
threats, intimidation, or humiliation toward youth. Regarding working conditions over the past
year, three staff described them as fair and two as good. The information obtained during the
interviews was shared with center leadership. Shift supervisors were instructed to review FOPs
for Staff Code of Conduct and Abuse-Free Environment during daily shift briefings for the next
five days. Sign-in sheets were provided for documentation and reviewed prior to MQI staff
leaving the center. An interview with the superintendent revealed employees of the state are
expected to perform their specific duties and conduct themselves in a manner which fosters the
achievement of the Department's purpose and goals. Actions taken if physical abuse, threats or
profanity towards the youth are used are; abuse phone call, internal investigation, law
enforcement investigation, no client contact, corrective action, termination, and suspension.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures (FOPs) outlining the process of contacting the
Department’s Central Communications Center (CCC). The center had fifty-eight total incidents
reported to the CCC since the last annual compliance review. Six CCC incidents were reviewed.
All incidents reviewed were reported within a two-hour timeframe. All six reviewed incidents
were found documented in the center’s logbook. There were no indications of any additional
internal incidents or grievances which should have been reported to the CCC. An interview with
the superintendent revealed the CCC is called within two hours of said incident or two hours of
gaining knowledge of an incident. All staff can report and contact the Florida Abuse hotline.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures (FOPs) outlining the staff’s use of physical
intervention techniques. There was a total of 182 Right Interactions (RI) incidents reported at
the center since the last annual compliance review. A sample of nine RI reports were reviewed,
and three contained exceptions. Although all nine reports included statements from the involved
staff, three reports were completed after the end of the respective staff’s work shifts.
Additionally, one report was reviewed by the superintendent or designee outside the required
seventy-two-hour timeframe. None of the reviewed RI reports resulted in serious injury to either
youth or staff; therefore, notification to the Department’s Central Communications Center (CCC)
was not required. Similarly, none of the incidents involved allegations of abuse by the youth, so
a report to the Florida Abuse Hotline was not necessary. Each of the nine RI reports were
reviewed by a supervisor or RI instructor and included a post-incident interview with the youth
conducted by an administrator or designee within thirty minutes of the incident. No medical
reviews were required, and none of the reports involved the use of mechanical restraints. A
review of internal incident reports, grievances, and logbooks revealed no additional RI incidents
were undocumented. The center’s RI rate during the previous quarter was 36.68, which is
above the statewide Detention RI rate of 13.49.
Five staff were interviewed, all of whom reported they attempt to de-escalate situations by
speaking with youth before initiating any form of physical intervention. Additionally, five staff
were specifically asked whether they attempt verbal de-escalation prior to using Physical Action
Response (PAR) or mechanical restraints; all affirmed this practice. The superintendent
demonstrated a clear understanding of the processes in place for tracking and monitoring RI
incidents. Physical and mechanical restraints are tracked through an inventory log and
monitored by staff accountability. PAR incidents are reviewed daily in the Facility Management
System (FMS) by the superintendent or designee, with the goal of monitoring incident trends
and providing feedback aimed at reducing future occurrences.
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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 (FOPs) outlining the training requirements for all
new staff. A review of five staff training records was conducted to assess compliance with pre-
service and certification requirements. All staff had successfully completed the required pre-
service training and certification within 180 days of hire, including the mandated 120 hours of
academy training. Additionally, each staff completed the new staff orientation within thirty days
of hire. None of the five staff reviewed were returning direct care or state support staff who had
separated from employment within the past year. All applicable pre-service trainings were found
documented in the Department’s Learning Management System (SkillPro).
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 (FOPs) outlining the annual training requirements
for staff. A total of five staff training records were reviewed to assess compliance with annual in-
service training requirements. All staff had completed the mandatory training topics and met the
minimum requirement of twenty-four hours of annual in-service training. Additionally, the records
of two supervisory staff were reviewed. Each supervisor completed at least eight hours of
training in coaching, leadership, and/or personal accountability within the calendar year. All
applicable in-service training was documented in the Department’s Learning Management
System (SkillPro). Documentation confirmed in-service education on girls’ healthcare was
provided and delivered by a registered nurse (RN). This training included monitoring,
observation, and emergency care related to pregnant youth. The center maintains an annual in-
service training calendar, which is updated as needed. The calendar was reviewed and found to
be approved by the superintendent, the assistant secretary for Detention, and the director of the
Department’s Office of Talent, Leadership, and Culture. During an interview, the superintendent
identified the supervisors receive management training through the leadership academy and the
superintendent is aware of the annual in-service training requirements for staff.
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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 (FOP) for grievances, which ensures each youth
has the right to file a grievance and be treated fairly, respectfully, and without discrimination.
This procedure is designed to protect the rights of youth and promote equitable treatment.
Grievance forms are readily available in all youth housing areas throughout the facility. During
the annual compliance review period, there were no grievances filed. Five youth were
interviewed as a part of the review. Four of the five were able to explain the grievance process.
The remaining youth reported not knowing the process, explaining they had never needed to
submit a grievance. Two youth described the grievance process as fair, one rated it as good,
and the other two had not used the process. Additionally, five staff were interviewed, all of
whom reported they were familiar with the grievance process and were able to clearly articulate
the steps involved. In an interview with the superintendent, the grievance process was
explained in detail. Initially, the Juvenile Justice Detention Officer (JJDO) works to resolve the
youth’s grievance. If the youth is not satisfied with the proposed solution, they may escalate the
grievance to the Juvenile Justice Detention Officer Supervisor (JJDOS) within two hours. The
JJDOS is then required to respond within twenty-four hours. If the youth remains unsatisfied, the
grievance can be further escalated to the superintendent or assistant superintendent, who must
review and respond with a final resolution within seventy-two hours, excluding weekends and
holidays. Grievance forms are kept in the assistant superintendent’s office and are retained for a
period of one year.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
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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 (FOPs) outlining the process of entering and
sharing alerts. A review of five youth with alerts entered into the Department’s Juvenile Justice
Information System (JJIS) resulted in a total of sixteen alerts examined. All applicable alerts had
been appropriately updated or removed by designated center staff. Additionally, each relevant
alert was documented in either the center’s logbook and/or shift report, as required. The center
utilizes the JJIS alert roster to effectively communicate youth alert information to staff. A review
of shift reports confirmed alerts are regularly reviewed by supervisors, administrators, and staff.
Although a shift briefing was not observed during the on-site annual compliance review, informal
interviews with staff confirmed alert information is routinely shared during shift briefings and
documented accordingly in logbooks and reports. No additional alerts requiring entry into JJIS
were identified during the on-site visit, consistent with the center’s procedures.
Interviews were conducted with five staff. When asked how they are informed of youth-specific
alerts, all five reported receiving this information during shift briefings. Additionally, three
referenced the use of alert forms, one mentioned email, and one noted they personally carry the
information. Regarding how management communicates center-related issues, all five staff
again cited shift briefings, with one also mentioning the use of email. When asked about the
effectiveness of the alert communication process, one staff member rated it as good, while the
remaining four rated it as very good. An interview with the superintendent confirmed medical
alerts are reviewed by medical personnel to ensure proper entry and tracking within the system.
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
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with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
Data trend analysis is conducted bi-weekly during the North Region Detention Services call.
These meetings focus on key operational goals, including maintaining staff vacancies below
fifteen percent, reducing youth-on-youth altercations, and minimizing incidents involving suicidal
ideations or gestures among youth. Each center is responsible for monitoring the hiring process
to ensure both efficiency and effectiveness. Particular care and caution must be taken when
addressing suicide-related concerns, with the ultimate objective being prevention. Reducing
interpersonal incidents between youth also remains a high priority. Information related to these
goals and trends is shared regularly across multiple platforms, including bi-annual all-staff
meetings, monthly supervisor meetings, and daily shift briefings. A review of meeting agendas,
minutes, sign-in sheets, and shift briefing documentation confirms these communication
practices are consistently followed. In addition to internal communication, the center
collaborates with local probation officers during detention reviews and engages with the school
principal as needed. This practice is supported by Detention Review notes and email
correspondence. The center continually reviews data, identifies trends, and implements
corrective strategies to improve outcomes and support a safe, effective detention environment.
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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.
Five youth records were reviewed for admission requirements. Each youth record contained a
completed Admission Wizard which notated a review was made for each youth’s arrest affidavit
or custody order, Detention Risk Assessment Instrument (DRAI), and Suicide Risk Screening
Instrument (SRSI). Documentation was also notated in each record of a full body search
completed, youth telephone call or attempted call made to the parent/guardian, a meal provided
to each youth, and a medical, mental health and substance abuse screening completed An
observation of an admission was unable to be completed due to the center having had no
admissions during the time the annual compliance review was taking place.
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
Five youth records were reviewed for orientation requirements. There was evidence in each
record the youth signed the orientation acknowledgement form to document all required topics
were discussed at orientation. Copies of the forms were maintained in the youth records.
Orientation was completed on the day of each youth’s admission to the center. An observation
of an admission was unable to be completed, the center had no admissions during the time the
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annual compliance.: however, observation found there center did have the Prison Rape
Elimination Act video system in place to show during admissions. Four of five interviewed youth
confirmed the center staff discussed with: them facility rules and expectations at the time of their
admission and one of five stated they did not.
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.
Five youth records were reviewed for classification requirements. All five contained evidence
classification for each youth included consideration for mental illness, intellectual and physical
disabilities, history of violent behavior, criminal behavior, sexual history, vulnerability to
victimization, medical, suicide risk, escape, security, and history of human trafficking. Four of
five records documented the youth’s gang affiliation. One exception found indicated the youth
had an open alert for Gang Member Documented, but the box notating gang affiliation was not
marked on the youth’s Admission Wizard. Each youth was assigned to a room based on their
completed classification and included all required topics. An interview with the center’s
administration confirm released documentation for a review for special alerts is captured on the
Admission Wizard for all youth being admitted. Staff review the alerts and Juvenile Justice
Information System (JJIS) facesheet for things such as history of human trafficking, gang
information security issues, and past criminal history. All required topics are considered prior to
youth room assignments being made. The detention superintendent stated youth are assigned
to a room based off their classification. Youth are re-classified if changes in behavior or status
are observed and documented.
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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.”
Five youth records were reviewed for gang notification requirements. None of the five youth
reviewed were applicable for requiring notification. According to the superintendent, the center’s
captain is currently serving as the gang representative for the detention center. In addition, it
was reported Circuit One Probation has no current gang liaison representative identified. Center
administration confirmed the center has had no youth, for the scope of the annual compliance
review, who they have found to be suspected of gang activity, thus requiring notification to the
Circuit One office for notification requirements. The center’s captain stated in an informal
interview, in the event a youth were to enter the facility and the detention staff determined they
suspected the youth of being a gang member, they would take photographs of the youth and
evidence, and provide documentation to send through email to the youth’s assigned juvenile
probation officer. In addition, the center has a written facility operating procedures which
outlines the process for notification of any suspected gang activity.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
Personal properties for youth are maintained in the intake area of the detention center. The
personal properties for youth, which are not considered valuables, are placed in a mesh bag
along with the property sheet form. These bags are secured in a closet in the intake room area.
Valuables are maintained in a drop safe with limited key access assigned. The drop safe is
under video surveillance. The safe has a valuables logbook sitting on top with documentation as
to the property itself, youth name, name of staff securing the valuable items, and time in and out
of the safe. A sample of five youth personal property and three youth valuable properties were
reviewed for admission and stage of property requirements for youth.
All youth properties reviewed in the sample collected contained a completed Property Receipt
Form outlining the items collected. All but one record reviewed had a letter of acknowledgement
regarding unclaimed property signed by the youth. For the one exception, the letter was in the
record but was not signed by the youth. All valuables reviewed in the sample size were
documented in the valuables logbook and were in the tamper proof property bag in the safe as
required. One of the three valuables’ bags did not have the youth’s Department of Juvenile
Justice Identification number written on the bag. For the five youth with personal property
located in the property closet, there was one of the five which did not have a copy of the
Property Receipt Form in the mesh bag. The center administration made a copy of the proper
form and corrected the issues while on-site for the annual compliance review week.
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An observation of an admission was unable to be completed due to the center having had no
admissions during the time the annual compliance review was taking place. A review of the
Department’s Central Communication Center (CCC) reports for the scope of the annual
compliance review found none were applicable for incidents involving youth property valued
over fifty dollars.
Five youth were interviewed. All five confirmed when they arrived at the detention center, the
staff checked their personal property and had them sign a form stating the personal property
was correct. The superintendent was interviewed and stated the juvenile justice detention officer
supervisor (JJDOS) or higher ensures youth's personal property is stored. Admitting JJDO and
JJDOS conduct safe drops together and document in the safe logbook. Youth's personal
property is stored in a bag with a property sheet documenting all of youth's property. Property is
stored behind a locked room which is under video surveillance and where only JJDOS or higher
have access. Valuable items are stored in a safe which is also under video surveillance. Other
youth personal property is stored in a bag with a property sheet documenting all of youth's
property. The superintendent or designee ensures all money and properties are counted and
inventoried. A money order is sent to the regional office which is forwarded to detention
headquarters. Any property not picked up within thirty days is considered abandoned.
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.
Three youth closed records were selected and reviewed for release requirements. For each
record, there was evidence the on-duty supervisor reviewed all paperwork prior to releasing the
youth, which included a review of any court requirements and verification of the youth’s
identification and identification of the parent/guardian responsible for taking the youth. None of
the youth reviewed were applicable for having an Endangered Person Alert. Documentation
indicated each youth was reminded of any future court dates as required. Two of three records
had evidence all required parties signed the applicable release forms. For the one remaining
record, there was no signature on the Release Wizard from the detention staff. Each youth’s
date of admission and date of release correlated with the dates indicated in the Juvenile Justice
Information System (JJIS) as required. A release was observed during the annual compliance
review week. Detention release forms were observed being completed on a computer by the
releasing officer on the Detention Release Wizard. The youth had no prescribed medications, as
observed being verified by the detention officer releasing the youth to the custody of a receiving
commitment program and their staff. The youth was also verified as not being on any special
precautions or special observation status. A copy of the receiving party’s photograph
identification was made by detention staff.
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2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
Three youth closed records were selected and reviewed for release requirements related to the
release of youth personal property, medications, and aftercare instructions. Two of the three
had evidence the youth and parent/guardian signed the receipt of property form upon the
release. For the remaining record, there was not a signature from the parent/guardian on the
form. All three youth records had documentation verifying the youth was released to an
approved person with a copy of their identification attached to the closed records. None of the
three youth were applicable for being on medications. There was evidence in each record the
releasing officer reminded the person to whom the youth is being released of any health or
welfare issues, including medical, mental health, and/or substance abuse needs, or pending
appointments. The superintendent was interviewed and stated the center has not had any
incidents of having youth property for over thirty days once they were released from the facility.
A release was observed during the annual compliance review week. Detention release forms
were observed being completed on a computer by the releasing officer on the Detention
Release Wizard. The youth had no prescribed medications, as observed being verified by the
detention officer releasing the youth to the custody of a receiving commitment program and their
staff. The youth was also verified as not being on any special precautions or special observation
status. A copy of the receiving party’s photograph identification was made by detention staff.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center conducts weekly detention reviews for youth on Tuesdays. Observations of the
detention reviews being held were made during the annual compliance review week.
Participants included the detention administration, a representative from education, medical,
and mental health. In addition, the Department’s commitment manager was also present
electronically via Teams. Signature forms were passed around for staff, along with each youth
active Juvenile Justice Information System (JJIS) alerts. Each youth status in the detention
center was discussed, along with their number of total days in detention, future court dates, alert
information, and any changes in their status. Participants were given opportunities to provide
input regarding the youth. Documentation of previous detention reviews is maintained
electronically in SharePoint. A review of the documentation found the reviews are conducted
weekly as required. One day each month was reviewed for the scope of the annual compliance
review. There was documentation all participants attended as required with only two exceptions
identified: two months had no documented participation from education present according to the
signature form. Telephone contact was made with the local area Department commitment
manager who confirmed the center conducts their detention review meetings weekly as
required.
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2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has a daily activity schedule which is posted in all living areas as well as the
cafeteria. Observations during the annual compliance review week revealed the staff and youth
all adhering to the daily schedule. Youth were seen participating in meal times and educational
classes. The posted daily schedule included scheduled times for youth visitation, recreation and
physical activities, indoor and outdoor activities, groups, bed times, and meal times, as well as
wake up and personal hygiene. Five interviewed staff all confirmed the center’s daily activity
schedule is followed as required. Five interviewed youth confirmed the center has an activity
schedule which is followed daily.
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 program is directly managed and supervised by the Okaloosa County
School Board. It is required to operate on a year-round basis providing the youth with a
minimum of twenty-five hours of weekly instruction. The center has an activity schedule which
reflects the educational schedule and times, which coincides with the daily activity schedule t.
Each schedule shows the youth are receiving the required twenty-five hours of educational
services per week. Three days of video was reviewed which confirmed classes were conducted
with minimal interference, and youth were in class in accordance with the schedule. A review of
the program’s logbooks for one day each month of the annual compliance review period found
youth attended school as scheduled. Youth interviews confirmed youth attend school Monday
through Friday and arrived and left during the correct times. Staff and superintendent interviews
confirmed minimal interference in education.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
Under the supervision of the Okaloosa County School Board, youth are provided an appropriate
career education curriculum based upon their age and assessed intellectual and educational
abilities. The center has established facility operating procedures to deliver career education to
youth, offering a Type 1 program which includes communication, interpersonal, and decision-
making skills. The center utilizes the career education program Xello to provide assessments
and various career learning opportunities. Youth attend a College and Career Planning class
daily. All five interviewed youth confirmed participating in various courses while enrolled at the
center, which incorporates career education.
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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 utilized the regional supervisor for VitalCore, licensed expiration of March 31, 2027,
as the designated mental health clinician authority (DMHCA) until the full-time DMHCA was
hired. The regional supervisor was on-site for approximately twenty hours per week. One other
licensed staff, licensed expiration of March 31, 2027 was on site for forty hours, to ensure
appropriate coordination and implementation of mental health and substance abuse services
were taking place. A new full-time DMHCA, a licensed clinical social worker, was hired on
November 18, 2024, whose licensed expiration is March 31, 2027. Copies of the DMHCA’s
agreement and position were reviewed along with the contract requirements, which contain the
requirements/ job description of the DMHCA and confirm weekly hours of coverage as specified
in the contract were met. The interviewed DMHCA stated each youth who enters the center is
screened and evaluated by a mental health counselor within twenty-four hours to determine if
mental health/substance abuse services are warranted. Youth who are prescribed psychotropic
medications are scheduled for initial evaluation with the psychiatrist within fourteen days of
arrival and every thirty days thereafter. Youth who are receiving mental health services are seen
weekly by mental health staff. Communication between the DMHCA and detention staff happen
daily and as needed.
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 clinical supervisor ensures the licensed clinical staff working under their supervision are
performing services they are qualified to provide based on education, training and experiences.
The center has one additional licensed mental health professional. The license was reviewed,
which indicated the licensed mental health professional has a valied and active license with an
expiration date of March 21, 2027, per the Florida Department of Health. Copies of all licenses
were available within the health administration office at the center.
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.
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The center has one non-licensed clinical staff working under the supervision of the designated
mental health clinician authority (DMHCA) as of June 9, 2025. The DMHCA ensures the non-
licensed staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience. A review of the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Supervision Log, the DMHCA provided weekly face-to-face supervision weekly as required. The
center does not have a Chapter 397 license, and all substance abuse services were provided by
a licensed qualified professional. The DMHCA was vacant from August 9, 2024 to November
18, 2024. During the timeframe, the vacancy was covered by the regional supervisor for
VitalCore. The non-licensed mental health clinical staff does not hold a master’s-level degree.
The non-licensed mental health clinical staff does hold a bachelor’s degree but has not yet
completed the two years of clinical experience. The non-licensed mental health clinical staff is
currently enrolled in a graduate degree program and is currently obtaining clinical experience as
an intern at the center. An email was provided, showing approval by the Office of Health
Services (OHS). The required fifty-two hours of pre-service training was completed, along with
the twenty hours required to complete Assessments of Suicide Risk (ASRs).
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.
Five youth records were reviewed for mental health and substance abuse admission screening.
All five records had a Suicide Risk Screening Instrument (SRSI) and Massachusetts Youth
Screening Instrument (MAYSI-2) completed upon intake and reviewed by detention staff. Both
screening instruments were completed in the Department’s Juvenile Justice Information System
(JJIS). All five youth records indicated a nurse and/or mental health staff completed the required
sections of the SRSI, which included an accurate referral selection in the “screening results”
section. Each of the five youth had a positive response on the SRSI, resulting in each of the five
youth being placed on suicide precautions and a mental health referral was completed. Each of
the five youth’s SRSI screenings included a positive response when youth have any open or
closed suicide risk alerts in JJIS. Each of the five youth records indicated a need for further
assessment, which had a follow-up referral and notification made to the
superintendent/designee. Each of the youth’s MAYSI-2 results indicated an elevated suicide risk
subscale, resulting in the youth being placed on suicide precautions. Each of the five youth
required a comprehensive assessment, of which a referral to the mental healthcare staff was
made.
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.
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Five youth records were applicable for mental health and substance abuse evaluations. Four of
the five youth were identified as in need of a mental health and substance abuse evaluation
after admission and was referred to the center provider. One youth had not been at the center to
have had the evaluation completed. Each applicable youth received new evaluations, being
completed prior to the youth’s thirty-first day after admission. Each of the four evaluations
included treatment recommendations which corresponded to all diagnosed mental health or
substance-related disorders. None of the evaluations were completed by a community provider.
The designated mental health clinician authority (DMHCA) interview results were reviewed. The
DMHCA stated if a detained youth who was referred for a Comprehensive Assessment by the
juvenile assessment center (JAC) or the juvenile probation officer (JPO) has not received an
assessment by the community-based service provider within thirty days of screening, the
detention center’s mental health provider shall administer a comprehensive mental health
evaluation to the youth prior to the thirty-first day in the detention center.
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.
Five youth mental health records were reviewed for treatment and discharge planning. Four of
the five records indicated the mental health orientation was held within fourteen days of
admissions, with the one remaining youth not having been at the detention center for fourteen
days at the time of the review. The four applicable youth required a treatment plan. Each of the
four youth with treatment plans, had an initial treatment plan in place within seven days of onset
treatment. All four initial treatment plans were developed on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form and each of the four plans contained the required
information. Three of the four youth mental health records included documentation of the
individualized treatment plan. The remaining youth had not been in the center for thirty days at
the time of the review to have the treatment plan completed. Each of the three applicable
individualized treatment plans were developed for youth receiving mental health and/or
substance abuse treatment in the center by the thirty-first day of the youth’s admission. Each
individualized treatment plan included the following elements: Diagnostic and Statistical Manual
of Mental Disorders V (DSM-V) diagnosis, symptoms which are treatment focused, treatment
goals which include mental health services and/or substance abuse services, and strengths and
needs. One youth was applicable for psychiatric services, which included psychotropic
medication and frequency of monitoring, along with the psychotropic medications which
matched the initial treatment plan. Each of the three applicable mental health records included
progress notes which validated the youth was receiving treatment services as stipulated on the
treatment plan. Each reviewed individualized treatment plan included dates and signatures of
the following participants: youth, mental health and substance abuse professionals, and
treatment team members. Each of the three individualized treatment plans had notation the
parents were contacted by phone to participate. Two of the three applicable youth with
individual treatment plans were applicable for thirty-day plan reviews. An additional record was
requested and provided to review. Each of the three records had plan reviews completed every
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thirty days, as required. Each applicable record had modifications which were documented on
the review form and clearly identified as such. Each of the three applicable youth mental health
records reviewed indicated all individualized treatment plan reviews were signed by the
following participants: clinical staff, youth, licensed mental health professionals, treatment team
members, and parents. None of the youth treatment plans reviewed were applicable for
treatment or services provided by a licensed psychiatrist. None of the youth mental health
records reviewed were applicable for an alleged victim of a Prison Rape Elimination Act (PREA)
event. Three closed youth mental health records were reviewed. All three records included
discharge plans documented on the Department’s Mental Health and Substance Abuse
Treatment Discharge Summary, which were all completed upon the youth’s discharge. A copy
of the discharge summary was provided to the youth, parent/guardian, and juvenile probation
officer (JPO) for all three youth. The electronic health record was completed upon the day of
service for all three youth. Documentation was signed by the licensed mental health
professional, and all uploads were completed within fourteen days.
A mini-treatment team meeting was observed by a regional monitor. During the treatment team,
all youth are reviewed to include their alerts, status, services to provide, concerns and
psychiatry needs. Detention, medical and mental health staff are in attendance of the mini-
treatment team. The DMHCA interview results were reviewed, stating all services are reviewed
at a minimal once a week at management meetings. The facility operating procedures (FOPs)
are reviewed annually, at a minimum. An initial treatment plan is developed seven days from the
date the youth was evaluated by psychiatry. An individualized treatment plan is developed
based on the assessment by the thirty-first day the youth has been in secure detention. A
review of individualized treatment, substance abuse or integrated mental health/substance
abuse treatment plans must be conducted every thirty days while a youth is in secure detention.
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.
Five youth mental health records were reviewed for mental health and substance abuse
treatment. Four of the five youth required treatment. Each of the four applicable youth were
assigned to a mini-treatment team. A review of documentation revealed mini-treatment teams
consisted of mental health staff, one staff from a different service area, youth, and
parents/guardians, if possible. Each of the four applicable youth were required and received
mental health treatment. All four treatment plans included individual therapy and group therapy.
Each youth had proper consent for treatment. Each of the five youth had the proper consent for
substance abuse treatment although none of the youth required substance abuse treatment. All
reviewed treatment notes were documented on the Department’s Counseling/Therapy Progress
Notes and included all required elements. Three groups were observed on video review with no
issues noted. Each of the three groups observed were documented in clinical notes. A review of
clinical notes confirmed group therapy was limited to ten or fewer youth with mental health
diagnoses for mental health treatment groups and all mental health staff had adequate access
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to youth and confidential space to provide treatment services. The program has not conducted
group therapy for substance abuse; therefore, it could not be verified if substance abuse groups
were limited to fifteen or fewer youth.
Five youth were interviewed regarding mental health and substance abuse services. Two of the
youth interviewed rated the services as fair and three youth rated the services as good. Two
youth stated the licensed mental health clinician doesn’t seem to be interested in youth issues.
The designated mental health clinician authority (DMHCA) interview verified the center provides
psychiatry services, mental health services, and substance abuse services.
3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written suicide prevention plan detailing suicide prevention procedures which
were reviewed and signed by the designated mental health clinician authority (DMCHA) and
superintendent annually. The plan included identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referrals, communication,
notifications, documentation, immediate staff response, and the review process as referenced.
The center has an established plan for every serious suicide attempt or serious self-inflicted
injury, and mortality review for a completed suicide. The multidisciplinary review process
includes circumstances surrounding the event, center procedures relevant to the incident, all
relevant training received by involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations.
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).
Five youth were reviewed for suicide prevention services. Each of the five youth were admitted
to the center and placed on precautionary observation (PO). The start date and time of the
youth being placed on PO matched the Department’s Juvenile Justice Information System
(JJIS) alert date and time. All five youth had a suicide risk assessment referral which matched
the date and time of the JJIS alert and placement on PO. Each Assessment of Suicide Risk
(ASR) was completed on the Department’s ASR forms for all five youth. All youth were on
constant supervision prior to the ASR being completed. All five youth had PO logs completed in
their entirety for the full time they were on PO. A qualified mental health professional was
involved for all five youth. None of the youth reviewed were released prior to receiving an ASR
or released while on suicide precautions. All five records indicated the staff documented a
consultation with the designated mental health clinician authority (DMHCA) or licensed mental
health professional on the mental health/substance abuse referral summary. All five records
indicated the superintendent or designee was notified immediately of suicide risk. Each of the
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five youth were placed on PO within thirty minutes of the referral being placed. Each of the five
youth had an ASR completed within twenty-four hours of being placed on precautionary
observation. Each record indicated a follow-up ASR was conducted prior to being removed from
PO. All five records included documentation a conference was held by the superintendent and
licensed mental health professional to reduce the level of supervision and the discontinuation of
close supervision was documented in accordance with the center’s suicide prevention plan. The
ASR for all five youth was completed by a licensed mental health professional and contained
results of the assessment, including recommendations for supervision and follow-up.
Documentation reviewed found evidence in the center’s logbooks and on the ASR indicating
administration or supervisory staff provided specific instructions related to the suicide risk
assessment findings and decisions. All five youth had alerts entered and subsequently
removed, following the youth being removed from PO. Logbook entries revealed proper start
and end times of PO for each of the five youth.
The interviewed DMHCA stated mental health staff are responsible for conducting suicide risk
screenings. The ASR, Suicide Risk Screening Instrument (SRSI), and the Massachusetts Youth
Screening Instrument (MAYSI-2) are used to determine suicide risk factors, with referrals being
responded to by mental health staff within twenty-four hours. Mental health staff are notified of
referrals by email, phone calls, and in-person notifications. The center has a licensed clinician
on call twenty-four hours a day, 365 days a year. Five staff were interviewed about staff
responsibilities if a youth expresses suicidal thoughts. Each of the staff stated they would notify
mental health and the supervisor. Two staff stated the youth would be placed on constant sight
and sound supervision. Five youth were interviewed. Two of the five youth stated they have
been placed on suicide watch while at the center and staff watched them all the time while on
precautions.
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.
Five youth mental health records were reviewed for secured observation documentation. None
of the files were applicable for secure observation. Additional files were requested, with two files
being provided as the only secure observations during the annual compliance review period. A
review of the two applicable files indicated the youth’s placement in secure observation was
authorized by the superintendent and designated mental health clinician authority (DMHCA),
and the secure room designation was completed in writing. A review of both records showed the
Department’s Health Status Checklist, Department’s Suicide Precautions Observation Logs, and
follow-up Assessment for Suicide Risk (ASR) were all completed. Each record indicated the
parent/guardian and juvenile probation officer (JPO) was notified of the youth’s potential suicide
risk as indicated by an ASR. Neither of the two youth were in secure observation beyond
twenty-four hours. There was documentation the mental health staff provided supportive
counseling services during secure observation status for both youth records reviewed. The
observation logs documented supervision for the full time both youth were in secured
observation. The level of supervision was reduced after a conference between the
superintendent and the licensed mental health professional was completed, and the
discontinuation was documented in the center’s logbook.
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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.
Five youth mental health records were reviewed for Suicide Precaution Observations (PO)
Logs. All five records included documentation the PO logs were maintained for the duration the
youth was on suicide precaution, and the appropriate level of supervision and observations of
the youth’s behavior was documented in real-time, not exceeding thirty-minute intervals. None
of the youth displayed warning signs. The PO logs were reviewed and signed by each shift
supervisor and mental health clinical staff. All PO logs documented safe housing requirements.
Three incidents of precautionary observations were able to be reviewed by video review. Each
of the three incidents showed staff providing proper supervision of the youth along with proper
documentation.
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.
Five pre-service and five in-service training records were reviewed, indicating each staff have
completed all required pre-service and in-service suicide awareness training. A review of
training documentation revealed suicide drills were conducted no less than quarterly for each
shift. The center has two suicide response kits, each containing the knife-for-life, wire cutters
and needle nose pliers. The kits are co-located with the first-aid kits in master control and the
medical office. Video review was conducted, showing a suicide drill being simulated with staff
appearing to show up to the drill with the appropriate kits. A review of the drill documentation
and staff rosters show the center has conducted mock suicide drills, to include all staff who
come into contact with the youth, including kitchen and maintenance staff. All mock suicide drills
were in response to a suicide attempt and/or an incident of serious self-injury, and youth were
not used in drill simulation related to mental health care. The center provided semi-annual
training on emergency response procedures to include mock training in emergency response to
a suicide attempt or incident of serious self-inflicted injury. All staff who were not present during
a quarterly drill had an opportunity to review each drill scenario as evidenced by sign-in sheets.
Five staff were interviewed regarding suicide kits in the center, of which each stated the suicide
response 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.
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The center has a combined emergency services plan which included a notification and alert
system, means of referral, including self-referral, communication, supervision, and
documentation and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center’s emergency care plan was reviewed. The emergency care plan contained
information regarding immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health or substance abuse services, transport
for emergency mental health evaluation and treatment for Baker Acts, transport for emergency
substance abuse assessment and treatment for Marchman Acts, documentation, training, and
review. The plan was approved on May 30, 2025, and is located in the facility operations book.
The plan is accessible to all staff.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
Five youth mental health records were reviewed for crisis assessments. None of the five youth
were applicable. A request was made for additional files. The center provided three additional
files for review. All three youth mental health records included documentation for the reason for
assessment, Mental Status Examination and interview, determination of danger to self/others,
initial clinical impressions, supervision recommendations, treatment recommendations,
recommendations for follow-up or further evaluation, and notification to parent/guardian for
follow-up treatment. One youth was applicable for a mental health alert being placed into the
Department’s Juvenile Justice Information System (JJIS) for being placed on precautions upon
the completion of the crisis assessment, which was completed as required. None of the youth
were applicable for acute emotional or behavioral problems. Each of the three records indicated
the crisis assessments were conducted by a licensed mental health professional and were
conducted immediately or within twenty-four hours based upon the needs of both youths. None
of the three records reviewed were applicable for the youth being an alleged victim in a Prison
Rape Elimination Act (PREA) event.
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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.
Five youth mental health records were reviewed for Baker and Marchman Acts. None of the five
youth were applicable. A request was made for additional files, to which the center provided one
additional file. The center had no other applicable youth during the annual compliance review
period. A review of the one applicable record showed the center opened a suicide risk alert
while the youth was pending off-site transport, and the youth was placed on one-to-one
supervision. The supervision was documented on the Precautionary Observation (PO) Log until
the youth’s release. Documentation showed the youth was placed on suicide precautions upon
re-admission from the Baker Act, with a referral being completed for a Mental Status
Examination (MSE). The MSE was completed by a licensed mental health professional.
Constant supervision was maintained on the youth until an appropriate assessment was
conducted and the mental health staff conferred with the superintendent or designee, at which
point the youth was properly transitioned to a lower level of supervision. A review of the
Department’s Juvenile Justice Information System (JJIS) revealed the suicide risk alert was
discontinued based upon an assessment of suicide risk.
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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’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD), specializing in family medicine. The DHA license is unrestricted and meets
all requirements for independent and unsupervised practice in the state of Florida. The DHA’s
licensure expires on January 31, 2026. The center utilizes an advanced practice registered
nurse (APRN). Visual observation confirmed the collaborative practice protocol is in place. The
center does not utilize a physician assistant (PA). Documentation review confirmed the DHA
has been on-site at least once a week as contractually required. The center does not utilize a
back-up DHA. The specific duties of the DHA consist of being responsible for providing medical
care, being on-site one time per week, being available for consultation by phone, assisting in
development of policy and procedures, as well to providing medical oversight. Tele-medicine
was not utilized during the scope of the annual compliance review period.
The DHA was interviewed and stated their role was performing Comprehensive Physical
Assessment’s (CPAs), conducting periodic evaluations, sick call, emergency room follow-up,
procedure development, and collaborating with nursing for patient care plans. The DHA
reported being on-site once per week. The DHA reported communicating with the program staff
regarding medical needs while on-site or by telephone, as well as being on-call if not on-site.
The DHA further reported providing on-site services along with having an advanced practiced
registered nurse (APRN). Medical maintains a communications folder which is checked daily by
nursing and once weekly by the DHA while on-site to help ensure all off-site care findings,
instructions, or information is reviewed. The DHA reported meeting with medical staff once
weekly while on site as the formalized practice in place to review medical issues. If there is a
need for coverage due to vacation or scheduled absences, the clinic manager will be notified
who reports and arranges coverage.
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 utilizes facility operating procedures (FOPs) for all healthcare protocols, policies, and
procedures. During the annual compliance review period, documentation review confirmed the
designated health authority (DHA) signed the FOPs August 28, 2024, the superintendent signed
on August 28, 2024, and the psychiatrist signed on August 28, 2024. Documentation review
also noted nursing and other medical staff documented review of the center’s protocols on
August 27- 28, 2024.There were no new policies or changes made during the annual
compliance review period. An annual review of medical policies, procedures, and protocols were
conducted as required and signed off on August 28, 2024. Documentation review and visual
observation confirmed the center’s FOPs and treatment protocols are being utilized. There was
no newly hired healthcare personnel hired during the scope of the annual compliance review
period.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center maintains facility operating procedures (FOPs) addressing Authority for Evaluation
and Treatment (AET) or a Limited Consent for Evaluation and Treatment (LCET). Five youth
Individual Healthcare Records (IHCRs) were reviewed for requirements. Four of the five IHCRs
contained a filed AET. Each of the AETs were signed by appropriate parties, was obtained prior
to providing medical services, and was valid. The remaining youth was involved with the
Department of Children and Families and the IHCR contained an LCET, with documented
authorization from the courts for treatment procedures. The nurse was interviewed and reported
the juvenile probation officer (JPO) is responsible for ensuring the AET is signed and dated by
the parent or legal guardian and then forwarded to the location the youth is in custody. If the
parent or legal guardian is unavailable during the detention screening, the assigned JPO shall
schedule an intake conference as soon as possible to complete the AET. If eighteen or older,
the youth will provide consent at the point of contact of healthcare services and said consent will
be documented in the youth's healthcare record.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains facility operating procedures (FOPs) addressing parental
notification/consent. Five youth Individual Healthcare Records (IHCRs) were reviewed for
inclusion of parental notification/consent requirements. Three of five IHCRs contained
documentation of parental notification for over-the-counter medication (OTC) beyond those
covered by the Authorization for Evaluation and Treatment (AET). Each of the three IHCRs
contained evidence written notification was sent using the Department’s Parental Notification of
Related Healthcare form. Three of the five youth were taking psychotropic medications at
admission. No new medications were ordered for any of the youth. All five IHCRs included
documentation confirming vaccinations were verified within thirty days of admission. No youth
required consent for obtaining vaccinations. None of the five reviewed youth were applicable for
obtaining Religious Exemption from Immunization.
The nurse was interviewed and was able to transcribe the FOPs for what situations require
parental notifications, as well as the procedures for a youth requiring emergency medical
services. The nurse further stated medical staff attempts parental notification immediately after
qualifying event occurs. For the prescriber of any psychotropic medication, a copy of the Clinical
Psychotropic Progress Note (CPPN) shall be sent to the parent/guardian at the address on
record. Telephone consent must be attempted and witnessed on the completed CPPN and must
include a discussion of the information contained. Vaccinations are provided by the local health
department. Immunization records are obtained through Florida Shots during youth's admission
process at medical. The timeframe for reviewing records is twenty-four hours. 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 provided by the
Health Department, have it signed and authorized there, and then submit this to the center.
Copies of the exemption will be filed in the youth’s IHCR and uploaded to the youth’s electronic
medical record (EMR).
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4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains facility operating procedures (FOPs) addressing healthcare admission
screening and rescreening. Documentation review confirmed each Individual Healthcare
Records (IHCR) contained a medical and mental health admission screening completed on the
Department’s Facility Entry Physical Health Screening (FEPHS) form on the date of admission.
Each screening was completed by a juvenile justice detention officer (JJDO) and the screening
results were reviewed with the youth by a licensed nurse within twenty-four hours. Notification to
the designated health authority was made (DHA) for three of the five applicable youth and
documented in the youth’s IHCR. None of the reviewed youth had a change in physical custody
since arrival to the center, and it was reported there have been no youth who have had a
change in physical custody during the annual compliance review period. One of five applicable
youth received a qualitative urine pregnancy screening test with confirmed documentation of
consent within chronological notes.
The center’s nurse was interviewed and reported 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. Newly admitted youth will have admission packets placed in the basket at medical clinic
door. The center’s roster is also reviewed daily for newly admitted youth. Assessment
screenings are completed by assessment center screeners. If admission screenings are
completed by direct care staff, nursing staff will sign and date the bottom of each page of the
admission screening form. A FEPHS rescreening is to be completed each time the physical
custody of the youth changes and they are subsequently returned or re-admitted to the center.
A change in physical custody within secured detention requires a complete rescreening by the
receiving center whenever they are moved from one to the other with an anticipated stay of
twenty-four hours or more but 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 maintains facility operating procedures (FOPs) addressing youth orientation to
healthcare services/health education. Documentation review confirmed the center’s FOPs
include all of the required elements such as access to medical care, sick call, what constitutes
an emergency and when to notify staff, medication process including side effects monitoring, the
right to refuse care, what to do in the case of a sexual assault or attempted sexual assault, non-
disciplinary role of the health care provider, and general infection control/hygiene. Five youth
individual healthcare records were reviewed for inclusion of healthcare orientation. Each record
contained evidence youth received general healthcare orientation, and the topics were
documented on the appropriate Health Education form. Each youth with a documented chronic
condition was educated on their medical condition.
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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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for designated health
authority (DHA) admission notification. Four of the five youth were admitted to the center with
known chronic conditions in which a referral was made to the designated health authority
(DHA). None of the applicable youth were identified as in need of emergency care upon
admission. Each of the four applicable youth IHCRs contained evidence within the chronological
progress notes the DHA was notified. Three of five youth were currently taking psychotropic
medications upon admission and documentation confirmed the psychiatrist was notified. The
nurse was interviewed and reported the DHA is notified within twenty-four hours of youth being
admitted into facility. Medical staff, during working hours, and non-health-care staff, after hours,
are responsible for notifying the DHA. All notifications shall be documented on the admission
progress note of the IHCR in the electronic medical record (EMR) by the licensed medical staff.
If notification is made by non-healthcare after hours, the report of Health Care by Non-Health
Care staff form shall be used and placed in the youth’s IHCR and uploaded to the EMR
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.
Five youth Individual Healthcare records (IHCRs) were reviewed for Health Related History
(HRH) completion. Each of the five IHCRs contained an HRH which was updated/completed
within seven calendar days of admission. Each HRH was updated/completed prior to the
Comprehensive Physical Assessment (CPA) or focused evaluation as evidenced by signature
and date. Each HRH was completed by a licensed nurse or practitioner. Each HRH was
reviewed by the DHA or APRN as evidenced by documentation on the focused note and
admission documentation. Review of each HRH confirmed signatures and dates are for the
most current admission. The nurse was interviewed and reported the HRH shall be completed
or reviewed by nursing staff through interview with the youth no later than seven calendar days
of youth's admission into facility.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for Comprehensive Physical
Assessment (CPA) and Tuberculosis Screening (TB) completion. Each of the five youth’s CPA
were completed on the required Department form. Each youth had a current CPA on file at the
time of admission. Four of the five CPAs were completed by the designated health authority
(DHA), and the remaining CPA was completed by the advanced practice registered nurse
(APRN). Each of the five CPAs had a documented medical grade with no missing or incomplete
information and each were current with no changes to the youth’s medical condition.
Documentation review confirmed each of the five current CPAs were signed off as reviewed by
the DHA or APRN. Documentation review also confirmed a focus evaluation was completed
with each readmission as a current CPA was utilized for each of the five youth. All sections of
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each CPA were marked with an X or an O. Four of the five youth refused to participate in the
genital examination and a signed refusal form was found in each youth IHCR. The remaining
youth was female the DHA deferred the genital exam. None of the youth’s problem list required
updating. Each of the five IHCRs contained evidence a TB skin test was administered within the
past year and the results of each TB skin test documented on the CPA matched the Infectious
and Communicable Disease (ICD) form. The center had facility operating procedures for both
refusal of any part of the exam and TB screening and rescreening processes.
The nurse was interviewed and reported if a CPA has not been performed, is not current, or
there are changes to the condition of the health of the youth, the youth shall have a CPA as
soon as possible, but no longer than within seven calendar days of admission. The nurse further
reported all youth should have on file in the Department’s Electronic Medical Record (EMR) and
IHRC one verified tuberculin skin test (TST) skin test result within the past year, measured and
documented in millimeters (unless skin testing is medically contraindicated). This documentation
may come from prior records, including private health care practitioners, county health
departments, or from prior TST administered in the Department’s detention centers or
residential commitment programs. If no record of a prior TST result within the past twelve
months is located or identified after a youth enters a detention center, and the youth’s juvenile
probation officer (JPO) has made a reasonable attempt to obtain test results from outside
providers, the TST will be administered. The nurse also reported gynecological exams are not
routinely completed for female youth.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. Two of the
five youth were eligible for STI and HIV screening. A request for an additional applicable record
was made and provided. Each of the three applicable youth reported being sexually active and
were screened and evaluated for STI’s. Each screening tool were reviewed by the designated
health authority (DHA) or advance practice registered nurse (APRN) as each tool required
further evaluation and referral. Each of the referrals were documented on the required STI form.
Testing for each applicable youth was ordered with results documented on the Infectious and
Communicable Disease (ICD) form and filed in the appropriate section of the IHCRs. A
gynecological exam was not ordered for any of the applicable youth and none of the sexually
active youth were out of the Department’s physical custody. Documentation review confirmed
each of the applicable youth were offered counseling and received HIV testing. Each applicable
IHCR contained evidence of documented youth consent. HIV testing for each applicable youth
was completed within thirty days of the request, the results were filed within the youth’s IHCR,
and there is documented proof the results were reviewed by the DHA and pre and post-test
counseling was administered. Confidentiality of each youth was maintained and protected. Five
youth were interviewed, and each youth reported they can ask for an HIV and/or acquired
immunodeficiency syndrome test. The interviewed nurse confirmed the procedures for
screenings, rescreenings, referrals, tests, counseling, and documentation requirements for STI
and HIV testing.
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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.
Five youth Individual Healthcare Records (IHCR) were reviewed for sick call process
requirements. Two of the five IHCRs were eligible for a sick call process. A request for an
additional applicable record was requested and provided. All three youth’s sick calls were
documented on the Sick Call Referral Log. None of the youth presented with a similar sick call
complaint three or more times within a two-week period or were due to severe pain in which
staff were unfamiliar treated as an emergency. All three youth completed a sick call on the Sick
Call Request form. Documentation review in each IHCR confirmed nursing completed the Sick
Call Request form. There was no evidence in any IHRC indicating youth’s sick calls was
conducted by a licensed practical nurse (LPN). Each applicable youth’s sick calls request form
was filed in the youth’s IHCR in reverse chronological order. According to documentation
review, none of the applicable youth reviewed were in restricted housing. All three applicable
youth’s sick call forms were documented in accordance with the appropriate Health Services
rule. Each of the three applicable youth’s sick calls were documented on the Sick Call Index and
dates listed on the sick call forms corresponded with the dates of the sick call index.
Documentation review and informal interviews confirmed sick call is conducted daily and youth
are seen within at least twenty-four hours of submitting a sick call request. The center does
maintain approved protocols for both registered nurses (RNs) and LPNs. Documentation review
and informal interviews confirmed sick call is conducted Monday through Friday at 11:00 a.m.
and 5:00 p.m., and on Saturday and Sunday at 10:00 a.m. Sick call hours are posted in the
medical station. Only a licensed nurse completes sick call requests. When there is not a
licensed nurse on-site, the center has procedures whereby the shift supervisor reviews all the
sick call request as soon as possible and within four hours after the request is submitted. The
center maintains a policy and procedures for room restrictions/confinement in which youth in
restricted housing shall be afforded access to healthcare at equal or greater intervals of youth in
regular housing. An observation of sick call was unable to be viewed due to none being
conducted during the annual compliance review.
The nurse was interviewed and reported the process for a youth to request to see a nurse
and/or physician for health complaints and verified sick call days and times which are conducted
in the medical clinic. In situations where medical care is needed but could wait until the next
available scheduled sick call time, staff may submit through electronic means a request to be
seen by the medical provider. Youth also have access to place a paper request. All licensed
medical staff conduct sick call. If an LPN conducts sick call or episodic care, this must be
reviewed daily (either telephonically or in person) with someone at the level of a RN or above on
the day of the occurrence. The nurse verified there are designated health authority (DHA)
approved protocols. Youth presenting with similar sick call complaints three or more times within
a two-week period require a referral to the DHA or advance practice registered nurse (APRN).
These youth will be placed on the list for the provider to evaluate. For youth in restricted housing
of any kind, the supervisor on each shift will question the youth about medical related issues,
document such questioning on the shift report daily, and input any non-emergent request in the
Department’s Electronic Medical Record, which then the nurse will make daily visits for
evaluations. Five youth were interviewed. Two of five youth reported they were seen within one
day of submitting a sick call request, one reported being seen within two days, one reported
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being seen more than three days of submitting a sick call request, and the remaining youth
reported never requesting a sick call. Three of the five youth reported the nurse conducts sick
call, one reported never being seen, and the remaining youth reported not having had a sick call
request. The center’s administration was made aware of youth responses to interview
questions. Five staff were interviewed, and each staff reported the nurse reviews and conducts
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for episodic/first aid/emergency
care requirements. Three out of five youth required on-site first-aid or episodic care. All three-
youth received episodic care or first-aid by a licensed healthcare staff and was documented in
subjective, objective, assessment, and plan (SOAP) format. None of the applicable youth
received episodic or first-aid care by a non-healthcare staff. Documentation review confirmed
each of the three youth complaints were document with findings of person rendering care as
well as documented treatment rendered. None of the applicable youth required a referral to off-
site care. Education/ instruction was documented in each of the applicable youth’s IHCRs
Documentation review confirmed the Episodic/First-Aid Care Log contained entry of each
applicable youth’s episodic/first-aid care. None of the applicable youth required a plan for follow-
up care nor applicable for to be placed on alert list. The are a total of thirteen first-aid kits
located throughout the center. First aid kits are in master control, each of the four living module,
kitchen, intake, administration, and one in each of five transport vehicles. Visual inspection of a
sample of three first-aid kits was conducted to ensure the kits were fully stocked with approved
contents. Each sampled first-aid kit contained designated health authority (DHA) approved
content. The center’s process of ensuring content is maintained and stored in accordance with
guidelines includes the DHA reviewing the supply list. Kits are checked monthly by nursing and
documented on the monthly first-aid check log. Documentation review confirmed the kits were
monitored as required. There is a total of two automated external defibrillators (AED) units at the
center. One is in the medical clinic hallway, and the other in administration area. AED
procedures are co-located with each AED. Both are inspected monthly by nursing staff.
Documentation review confirmed the AEDs are monitored as required. Expiration date
inspection and self-test was conducted in the presence of nursing staff during the annual
compliance review with no issues. The AED battery expiration dates is December 26, 2026. The
AED batteries were last changed January 11, 2023. The expiration date of the AED pads are
February 28, 2027, and the AED pads were last changed on October 23, 2024. Emergency
drills were conducted monthly on each shift, in which a simulated episodic care event occurred
calling for the immediate use of first-aid, AED and or cardiopulmonary resuscitation (CPR)
techniques and the initiation of emergency procedures. The center maintains documentation of
emergency drills conducted. A list of emergency numbers, which included the number to Poison
Information Center, was posted and accessible to licensed and unlicensed staff. The numbers
were not accessible to any youth. All authorized direct care staff were appropriately trained by a
registered nurse on the administration of an epinephrin auto-injector. Five staff records were
reviewed which showed training requirements were met regarding episodic care, first-aid, and
emergency care. The center’s policy on the use, access, and inventory of Narcan indicates
Narcan must be inventoried by a licensed nurse weekly. Narcan is administered when indicated
and the individual must be monitored for symptoms of overdose. Narcan is stored in the
medication cart and is accessible to the registered nurse and nonhealthcare supervisory staff.
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Each staff with access to Narcan has been trained on when and how to use it. Training sign-in
logs were reviewed to ensure compliance.
The interviewed nurse confirmed number and locations of first aid kits in the center, as well as
the AED information. The nurse was versed in the policy for youth who are provided on-site
episodic care, both by medical staff and/or non-healthcare staff. The nurse further reported
youth are tracked utilizing a monthly calendar which is kept with all other monthly logs.
Emergency drills including CPR techniques must be practiced on a regular basis and at least
once per quarter or once per shift, per year. The drill should be announced and unannounced
and simulate an episodic care event calling for immediate first aid and/or administration of CPR
techniques along with the initiation of the emergency procedures to follow when a life-
threatening emergency does occur. Five youth were interviewed. Two of five youth stated they
would rate the medical care at the center as very good, with one youth rating it good, one youth
rating it as fair and the remaining youth reporting it as very poor. The center’s administration
was made aware of interview results. Five staff were interviewed and each of the five staff
reported they can call 9-1-1 if necessary.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center maintains facility operating procedures (FOPs) addressing off-site care and referrals.
Five youth Individual Healthcare Records (IHCR) were reviewed for off-site care/referrals. One
of five youth IHCRs was applicable for offsite care and referrals. A request for two addition
IHCRs was made and provided. Each of the applicable youth required off-site care, which 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 notifications
were made for each of the applicable youth and documented in the IHCR. Each IHCR contained
discharge documents, and the designated health authority (DHA) reviewed the discharge
findings, instructions, and information, as evidenced by signature. Each applicable youth
received non-emergent off-site care and did not require follow-up testing, referrals, or
appointments. The nurse was interviewed and reported youth who receive off-site care are
tracked utilizing a monthly calendar which is kept with all other monthly logs. The DHA is
contact upon youth's return to facility and discharge instructions/orders are discussed. Off-site
records are placed in the DHA's folder for review and signature. Monthly calendar/tracking
board is located in medical.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains facility operating procedures (FOPs) addressing chronic conditions and
periodic evaluations. Five youth Individual Healthcare Records (IHCR) were reviewed for
chronic conditions and periodic evaluation. Three of five youth were identified on the
Medical/Mental Health Screening form for having a chronic condition. Neither of the applicable
youth had a communicable disease nor were taking prescribed medication on an on-going basis
for any reason. Three of the youth were undergoing treatment for a physical health condition.
Three of the applicable youth were classified with a Medical Grade of between two and four.
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None of the youth were identified as pregnant. One of the three applicable youth had a periodic
evaluation which was documented and found in the progress notes. The two remaining
applicable youth had not been at the center long enough to have evaluations conducted as
required. None of the youth were taking anti-tuberculosis (TB) medications, needed a periodic
evaluations conducted prior to renewing an expired medication prescription, or required an off-
site care evaluation. There was no evidence of any lapse in care or periodic evaluations for
either of the applicable youth. The Department’s Problem List was updated in accordance with
Administrative Rule for the three applicable youth. The designated health authority (DHA) was
interviewed and reported periodic evaluations are done within ninety days or less and are
maintained on a list. The DHA also reported reviewing the maintained list of youth with chronic
conditions and discussing care plans with nursing and working together to ensure all youth are
seen and treated as needed. The nurse was interviewed and reported youth with chronic
medical conditions are tracked on a white board located in medical. The clinic manager also
performs weekly review of medical charts.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for medication management
requirements. Four of the five youth were taking medication at admission and the medication
was verified prior to being admitted into the center. For each of the applicable youth,
prescription verification was completed utilizing the Department’s Prescription Mediation
Verification Checklist form and the designated health authority (DHA) and psychiatrist were
contacted to obtain an order to continue the medications. The prescription verifications were
noted in the progress notes, IHCR, and Electronic Medical Record (EMR). Medications for all
applicable youth had a current valid order and all continued medications were placed on the
Practitioner Order Form. None of the applicable youth reviewed were in restricted housing
during medication administration hours. Two of the four applicable youth were given over-the-
counter (OTC) medications which were not listed on the Authority for Evaluation and Treatment
(AET) form and administered according to approved protocols or orders. Each of the four youth
utilized a standard Department Medication Administration Record (MAR) in the EMR which
contained a clearly indicated start and stop date. None of the applicable youth received
medications from a trained non-healthcare staff after hours when a licensed staff was not on-
site. No lapses or errors in medication administration was noted. Side effect monitoring was
documented weekly on each applicable MAR. There were no instances of youth refusal of
medication. Each applicable MAR contained all the required elements such as youth’s name,
Department identification number (DJJID), date of birth, youth allergies, precautions, Medical
Grade, medical alerts, and current picture of youth. Staff initialed each administered medication
entry and youth initialed each provided medication entry. No youth required parenteral
medications. Documentation review and visual inspection confirmed there were no standing
orders for psychotropic medications, emergency treatment orders for psychotropic medication,
or any orders pro re nata (PRN) psychotropic medications. An observation of medication
administration was conducted during the annual compliance review with youth consent. The
designated youth was escorted to the medical station by direct care staff. The youth individually
approached the licensed medical staff administering the medication. The licensed medical staff
identified themselves and informed the youth why they were there. The same licensed medical
staff preparing the medication also administered the medication. The youth’s allergy status was
verified. Prescription medications were not pre-poured from original packaging. After
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administration, licensed medical staff verified medications were ingested and the youth and
licensed medical staff each initialed the MAR. All designated non-health-care staff identified to
administer medications were trained by the registered nurse (RN) on December 24, 2024. The
center’s disposal process of medications dictates medications in need of destruction are
identified by the appropriate health care professions. Identified medications are destroyed using
RX destroyer. Medications are documented on disposal log. Controlled substances are
destroyed by the pharmacist.
The interviewed nurse was able to relay the procedures and policy on how to verify medication
at admission, non-healthcare verifying medication at admission, and where information is
documented. The nurse further reported the electronic and the standard Department MAR is
used, and non-healthcare staff do provide medications, who are trained by the clinic manager
on how to administer medications. The approved list of staff is kept in the front of the MAR book.
The nurse verified medications are administered daily at 8:00 a.m., 12:00 p.m., 5:00 p.m., and
8:00 p.m., but may vary based on prescriber’s instruction. Medications are verified and ordered
from Diamond pharmacy, but a backup pharmacy will be utilized if necessary, with ninety-eight
percent coming from usual pharmacy and two percent from backup. The center does utilize a
psychiatrist who completes off-site tele-psychiatry visits weekly for one-on-one counseling and
medication management. No separate fees are generated for each youth. Five youth were
interviewed. Four of the five youth reported nursing staff administers medications. The
remaining youth reported not taking medications. Five staff were interviewed. Two of the five
staff reported administering medications to youth. The remaining staff reported they have not
administered medications to youth.
4.16 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
Five youth records were reviewed for psychiatric services. Three five were applicable for
psychiatric services. Each of the three applicable youth were admitted to the center on
psychotropic medications. The initial diagnostic interview for each youth who was admitted to
the center was completed within fourteen days of admission. All initial diagnostic interviews
contained the reason for referral, history, Mental Status Examination, diagnosis, treatment
recommendations, and prescribed medications. Each record contained the explanation of the
need of the psychotropic medication and the frequency of the medication management. In each
record, an in-depth psychiatric evaluation was completed within thirty days of admission. The in-
depth psychiatric evaluation in each record included the reason and factors leading to the
referral, history, history of psychiatric illness, psychotropic medication management, mental
health treatment and or substance abuse treatment, Mental Status Examination, identification of
individual, family and or environmental factors which may potentially account for, influence, or
amelioration of difficulties, diagnostic formulation, treatment recommendation and interventions,
prescribed medications and frequency of medication management, and the explanation of the
need for psychotropic medications related to youth’s diagnosis, target symptoms, potential side
effects, risk, and benefits of taking medications. Documentation review also confirmed each of
the three applicable in-depth psychiatric evaluation contained the most recent applicable
therapeutic serum levels and signature of the practitioner conducting the evaluation. None of the
applicable youth were prescribed new medication or had any changes made to existing
medications. Page three of the Clinical Psychotropic Progress Note (CPPN) was completed and
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the CPPN was clearly identified. Each applicable youth record contained all the required
information when psychotropic medications are prescribed, dispensed, or administered by the
psychiatrist, including identifying data, diagnosis, target symptoms, evaluation and description of
effects of prescribed medication on target symptoms, medication name, dosage and quantity,
ordered dosage, frequency and route of administration, reasons for changes in medications or
dosages, side effects, youth’s adherence to medication regime, height, weight, weight, blood
pressure, most recent serum drug levels or laboratory findings, whether telephone contact with
youth or guardian to discuss medication, signature of psychiatrist, and date of signature. The
psychiatrist and nursing staff documented monitoring for Tardive Dyskinesia monthly on the
CPPN in each of the applicable youth records. Each record contained an appropriate
Authorization for Evaluation and Treatment (AET). No youth was prescribed new medications,
medication discontinued, or significant change in dosage. One of the three applicable youth
required consent provisions of psychotropic medication while under the care of the Department
of Children and Families (DCF). The youth mental health record included a consent for
psychotropic medication for youth under the care of DCF. No youth was over the age of
eighteen. The center utilizes tele-psychiatry. The standard of psychiatric care delivered through
tele-psychiatry was the same as rendered in person for each youth. Tele-psychiatry was utilized
only for youth who agreed to participate, and proper consent was obtained for each youth. The
center has a psychiatrist who is board certified in Child and Adolescent Psychiatry with a license
expiration date of March 31, 2026. The center does not utilize an advanced practice registered
nurse (APRN). The back-up psychiatrist is licensed under chapter 458 with a license expiration
date of January 31, 2027. The back-up psychiatrist maintains equal education of the
psychiatrist. The designated mental health clinician authority (DMHCA) was interviewed and
reported psychiatric services, mental health services, and substance abuse services are being
provided at the center and meets with the psychiatrist at least once a week.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains facility operating procedures (FOPs) addressing medication/sharps
inventory and storage. Medical equipment classified as sharps were secured and inventoried
utilizing a routine perpetual inventory with a 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 found to be clean and organized with stock items
separate from youth-specific medications. Narcotics and other controlled medications were
stored behind two locks. No oral medications were stored with topical medications. Medications
required refrigeration were stored in a secured refrigerator which is used for medication only.
There was evidence of perpetual and weekly inventory of all sharps and stock over-the-counter
(OTC) medications being conducted. For controlled substances, a perpetual shift-to-shift
inventory count was conducted and documented on the youth’s individualized Controlled
Medication Inventory Record. Non-healthcare staff were trained in the delivery and oversight of
medication self-administration when nursing staff are not on-site. Training was delivered by a
registered nurse. A sample of three controlled medications were reviewed and counts of the
items matched the ending inventory numbers. A sample of three OTCs medications were
reviewed and counts of the items, with two matching the ending inventory numbers and one
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which did not match the ending inventory numbers. The observed OTC Ibuprofen had an end
inventory count of forty-two on the inventory and the actual count observed was forty-four. The
nursing manager was able to rectify the discrepancy when identified. A sample of three sharps
were reviewed and counts of the items matched the ending inventory numbers. The procedure
for reporting inventory discrepancies states any medication inventory discrepancy shall require
notification to the superintendent and the Department’s Central Communications Center (CCC).
The nurse was interviewed and reported a registered nurse (RN) shall be responsible for the
disposal of medications in conjunction with the pharmacy consultant. Controlled and non-
controlled medications for disposal shall be inventoried prior to disposal and disposed in the
presence of the pharmacy consultant. Controlled and non-controlled medications must be
disposed of by utilizing the drug enforcement administration (DEA) approved drug buster
disposal system and in accordance with state board of pharmacy and DEA disposal plan.
Documentation of the disposal of all medication shall be maintained. All controlled substances
will be double locked, with daily perpetual inventories and running balances maintained.
If a controlled substance is administered to a youth as ordered through a prescription, the
number of pills, tablets or dosages remaining after each administered dosage must be
documented on the youth’s individualized Department controlled medication Inventory form.
Additionally, the administration of the medication will be documented on the Department’s
Medication Administration Record (MAR) in the Department’s Electronic Medical Record (EMR).
Shift-to-shift witnessed inventory counting of controlled substances shall also be maintained.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for infection control, exposure
control, and education requirements. Documentation review confirmed each youth received
infection control training on admission, to include hand-washing techniques, universal/standard
precautions, prevention/transmission of communicable disease, vaccinations, and the Center for
Disease Control (CDC) and Prevention guidelines for infection control. The Exposure Control
Plan was written in accordance with Occupational Safety and Health Administration (OSHA) and
included a risk assessment listing all job classifications in which staff and/or some staff have the
potential for occupational exposure, and tasks or procedures which would cause staff in job
classifications to have an occupational exposure. The center’s Exposure Control Plan includes a
method of compliance which includes infection control practices and the required engineering
and work practice controls. The center’s infection control procedures in place included
prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to OSHA and the CDC guidelines. Infection control procedures included all required
elements such as for common infectious diseases of childhood, self-limiting episodic contagious
illnesses, viral or bacterial infections, Tuberculosis, Hepatitis A, B, C, human immunodeficiency
virus (HIV), other outbreaks or epidemics caused by any other infectious agent, outbreaks of
pediculosis and or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA), food-borne
illnesses, bio-terrorist agents, and chemical exposure in the workplace. The center’s process for
needle stick post exposure evaluation dictates post exposure follow-up is required when an
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employee incurs an exposure incident. It must be reported to the immediate supervisor. All staff
who incur an exposure incident will be offered post exposure evaluation and follow-up in
accordance with OSHA standards. Hepatitis B immunizations are made available for staff. All
staff have access to protective equipment. An informal interview was conducted with the nursing
manager, and it was reported there were no instance in which infectious diseases and sexually
transmitted infections needed to be reported to the local health department. There were no
instances which required reporting to the Department’s Central Communications Center (CCC).
There were not three or more cases of reportable infectious diseases which needed to be
reported to the local health department and/or CDC. The nursing manager also reported the
superintendent maintains a separate file containing all documents for youth and staff who have
experienced facility/occupational exposure for a ten-year period as required. Five staff in-service
and five pre-service training records were reviewed. Documentation review confirmed each of
the five staff received pre-service or in-service training on the center’s specific Exposure Control
Plan.
The nurse was interviewed and reported a copy of the exposure control plan is available.
Infection control training is provided by the clinical manager, and infection control training is
provided to youth at each admission to the center and during nursing intake. The center’s
provider medical staff shall conduct training regarding the site-specific Exposure Control Plan, to
include the prevention of transmission of blood-borne pathogens within ninety days of hiring of
staff and annually thereafter. A record of the training shall be kept in the staff personnel record.
The nurse also reported immunizations are a routinely used service of the local county health
department.
4.19 Prenatal Care/Education [Contract Provider] Non-Applicable
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 not had any pregnant youth throughout the annual compliance review period;
therefore, this indicator will be rated non-applicable.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures to ensure youth are actively supervised by staff.
During the annual compliance review, youth supervision was observed each day. Facility staff
were adhering to the daily activity schedule and were observed maintaining continuous sight
supervision of all youth in their assigned area, during education, transportation, and line
movements. The center staff were interacting appropriately with youth. All movements were
authorized by master control prior to the youth being moved. Review of the center’s logbooks
during the annual compliance review period confirmed all movements were logged and counts
were conducted consistently. Each day of the annual compliance review week, the center had
adequate staff to meet the required staff-to-youth ratio.
Five staff were interviewed, and four stated there was enough staff to provide adequate
supervision. One stated there was not enough staff, and it would be better if people would stop
calling out. Three of the five interviewed staff stated a co-worker may use profanity occasionally
when speaking with a youth, but none have ever observed a co-worker using threats,
intimidation, or humiliation when interacting with a youth. The Department’s Learning
Management System (SkillPro) validated all direct care staff completed the Safety, Security,
and Supervision of Youth annual training.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
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The center has facility operating procedures (FOPs) detailing the behavior management system
(BMS) to ensure the safety and security of youth and staff. During a walkthrough of the center,
BMS posters were observed throughout the building accessible to youth.. Five youth records
were reviewed and found evidence each youth signed an orientation form indicating they have
been informed of the BMS. According to the center’s superintendent, the new level boards have
not been sent yet. The program is using a board in the G module and a level sheet was
developed for all youth which is being used in the B module. A review of logbooks found
documentation showing youth levels were notated and highlighted. The new BMS includes
rewards for positive behavior and consequences for inappropriate behavior. The youth were
observed in classes each day during the annual compliance review week, adhering to the daily
schedule. An informal interview with the assistant superintendent revealed canteen is
disseminated to applicable youth on Mondays. Level sheets and level boards observed to show
different youth levels maintained and documented daily. A review of documentation did not find
any instances of inappropriate use of restrictions or group punishment. Five youth were
interviewed regarding the center’s BMS. When asked to rate the BMS, one youth rated it very
poor, two rated it poor, one rated it fair, and one rated it good. All five youth were able to explain
the differences between each level of the BMS and how to progress from one level to the next.
When asked about rewards at the center, one youth reported no rewards are given, one stated
dessert is offered on weekends, and three reported they receive canteen. Regarding
consistency in the use of rewards by staff, one youth said staff do not use rewards consistently,
one said some staff do, and three reported staff use rewards consistently. All five youth stated
they are not allowed to punish other youth. When asked if they had ever been sent to their room
as a form of punishment, one youth said no, while four said yes and reported the door was shut
and locked. In terms of fairness of consequences, one youth reported never receiving
consequences, while the remaining four stated the consequences they received were fair. When
asked whether vital needs such as meals, snacks, sleep, clothing, bedding, medical care, or
school were ever withheld as a consequence, one youth stated they had never received
consequences and four reported none of these essential items had ever been taken away. All
five youth confirmed handcuffs or leg irons are not used to control behavior or prevent harm to
self or others. Five interviewed staff were able to explain the BMS and provided examples of
rewards used within the system. Each staff member reported the BMS is effective in managing
youth behavior. All staff indicated they engage in conversations with youth to explain the
consequences being imposed and youth are given the opportunity to explain their behavior.
Staff also reported they discuss alternative, acceptable behaviors with the youth as part of the
intervention process. All five staff were able to describe how supervisors provide feedback on
the implementation of the BMS. When asked how often this feedback occurs, two staff reported
receiving it daily, while three stated it is provided as needed. All staff confirmed only levels or
points may be taken away as consequences and they had never witnessed a co-worker deprive
a youth of meals, snacks, clothing, education, or medical care due to behavioral issues.
Additionally, all five staff reported they had never observed any staff encouraging youth to
physically harm another youth. The superintendent was interviewed and stated the center uses
a uniform BMS with predictable awards, privileges, and consequences for behavior. It is a three-
level system which tracks youth behavior. Regardless of the level, all youth receive their basic
rights.
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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 maintains facility operating procedures (FOPs) requiring ten-minute checks to be
conducted when youth are in their rooms. The center has seventy-two surveillance cameras,
with seventy-one operational during the week of the annual compliance review. One
surveillance camera is inoperable; this camera is located outside of the secure building and
does not supervise youth. A work order for this camera has been submitted. The surveillance
cameras have a thirty-day recording capacity. An electronic wand system is used in the center
to document and collect data of the ten-minute visual checks. Staff tap an electronic wand on
the check point sensors on the outside of each youth’s assigned sleeping room door, and the
data is downloaded as wand reports. The electronic wand system has been out for repair, when
this occurs the staff are utilizing hardcopy Visual Observation Reports (VORs). Supervisors and
administration are also conducting random video reviews of ten-minute checks each week and
these reviews are then documented in the SharePoint system. The center is currently running
two, twelve-hour shifts. A review of six samples of video and their corresponding wand
reports/VORs from each living module revealed staff conducted ten-minute checks as required.
Staff were observed looking into the windows of each sleeping room before tapping the wand to
the check point sensor or documenting on the VOR. After a review of logs and SharePoint
system documentation, an hour’s worth of checks each month, on C shift for the past twelve
months, no checks were later than ten minutes apart. Five staff were interviewed, and each
indicated room checks are conducted every ten minutes when a non-suicidal youth is placed in
their room. The superintendent interview confirmed when a youth is placed in a room, whether
for sleeping or other reasons, staff shall conduct visual observations to ensure safety and
security and notate those checks on the VOR or by utilizing an electronic wand system. Visual
observation intervals should be varied but must not exceed ten minutes between checks.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures (FOPs) addressing census, counts, and
tracking, which requires staff to know the exact number and location of all youth under their
supervision at all times. Census counts are documented upon any change of population. Living
module counts are recorded in their assigned module logbooks. Observations and a review of
the master control logbooks one full day for twelve months confirmed the census counts of
youth are written at the beginning and at the end of each shift, following any emergency, prior to
and following group, population change, randomly, head counts, and at youth movements. Five
staff were interviewed and all indicated youth counts are conducted at the beginning of shift and
four stated they are also conducted at the end of the shift. Three staff indicated counts are
conducted mid-shift. All interviewed staff stated emergency counts were conducted if a youth is
believed to be missing, when visibility is hindered such as an electrical outage, after codes, and
if there is bad weather.
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 to ensure the census, counts, and tracking of all
youth are always maintained. The center has separate logbooks for master control and each
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living module, visitors, and vehicles. A review of eleven logbooks found they were bound with
numbered pages, numbered at the top of the page. Six living module logbooks had loose or torn
covers, but all pages were accounted for. All entries in the logbooks were legible and written in
ink with no erasures or whiteout areas. Some corrections were made with only a strike through
or changed by writing over information instead of a strike through, writing “VOID”, and then staff
initials per policy. Entries included the date and time of the event, name of the staff and youth
involved, a brief description of the event, and initials of the person making the entry.
Observations during the annual compliance review week showed there was no youth movement
until master control confirmed the count. Documentation in master logbooks included
highlighted entries for special needs, mental health alerts, the opening and closing populations,
incidents, and emergency situations including drills, as well as admissions and releases, line
movements, searches, and the presence of law enforcement. Names of youth placed in
confinement were documented, including the time confinement began and ended, and calls to
the Florida Abuse Hotline and the Department’s Central Communications Center (CCC) were
documented in the master control logbooks. The master control and living module logbooks for
the months since the last annual compliance review were examined. The juvenile justice
detention officer supervisor (JJDOS) reviews the logbooks each shift, including the master
control logbook, when accepting the shift, to document they are aware of current relevant
situations in the center. The juvenile justice detention officers (JJDO) assigned to each living
module review the module logbook upon accepting the shift. Administrator logbook reviews
were inconsistent and averaged one every three weeks. Also, per policy, administrator reviews
need to be highlighted yellow. The superintendent was interviewed and stated they review all
logbooks at a minimum of weekly and review the entries for the last seventy-two hours. The
review documentation is highlighted in yellow marker. A supervisor must review the master
control logbook, going back seventy-two hours, and document their presence in the living area
logbooks every shift.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures describing the center’s key control, issuance of
keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys, and reporting
and replacement of damaged keys. Missing or lost keys must be documented, and the juvenile
justice detention officer supervisor (JJDOS) must be notified immediately; a Department’s
Central Communications Center (CCC) report is generated if any key is not found or located. An
incident report is completed if any key is damaged, and the key is replaced by the maintenance
staff. An observation during the week of annual compliance review and an informal interview
with the center’s master control staff revealed the facility keys are stored on a tamper-resistant
key ring which prohibits the removal of keys and is color coded specific to the position to which
the keys are assigned. These keys are kept in a box in master control secured by a padlock.
When detention staff enter the center, their personal keys are to be secured in lockers on the
non-secure side of the center prior to being issued a key set by the master control operator.
Visitors and contracted staff turn in personal keys to master control. In addition, observations
during the week of annual compliance review and an informal interview with the master control
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staff and superintendent validated youth have no access to facility keys. 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 administration
area which staff can access. A review of the key control logs and observation of distribution and
collection of keys confirmed the issuance of keys and key rings were documented on the key
control logs on each shift with the date and time of issue, name of person receiving the key ring,
and the time each was returned. Issued key sets are also documented on the daily shift reports
in SharePoint. Staff were observed always carrying the facility keys on their person during the
week of the annual compliance review and youth did not have access to facility keys. A review
of the master key control inventory confirmed the inventory report matched the actual key rings
in use. There were no reported incidents of lost keys during the annual compliance review
period. The 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. Five staff were interviewed and stated the restricted keys are for medical or mental health
records, supervisors, administration, and maintenance personnel. Each staff reported they knew
the key control process. An interview with the superintendent revealed permanent keys are not
issued to any staff.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures for transportation, operation, and maintenance of
each vehicle, which is used to transport youth. The center’s maintenance mechanic is
responsible for the weekly and monthly vehicle inspections; however, this position has been
vacant, and the assistant superintendents are sharing these job responsibilities. The staff using
vans for transport complete the vehicle checks daily to ensure all vehicles are equipped and
readily available to drive. The center has a total of seven vehicles used to transport youth, one
van assigned as a maintenance van, one van currently awaiting surplus and not in use, and one
Nissan car for staff use. Each vehicle had an annual safety inspection conducted by a certified
automobile mechanic. Observation of five vehicles verified each was locked when not in use. All
five vehicles have the appropriate number of seat belts, a seat belt cutter, a window punch, up-
to-date fire extinguishers, and a first-aid kit with approved items by the designated health
authority (DHA). One vehicle was off-site (shop) during the annual compliance review. A binder
is maintained for each vehicle which contains the vehicle mileage log, vehicle inspection log,
vehicle oil change log, automobile accident reporting form, driving directions and maps,
AmeriSys information, gas card, vehicle registration, and vehicle policies. Mechanical restraint
keys are kept on the vehicles’ tamper resistant key rings. Weekly visual vehicle inspection
checks are conducted on all vehicles as required and documented on the preventive
maintenance check sheets. Prior to each transport, a pre-trip vehicle inspection is conducted by
staff and documented in the vehicle logbook and vehicle inspection log. Observation of one
male youth transported to a doctor’s appointment conducted by two officers during the annual
compliance review week and the transporting staff were observed following all required
transportation procedures prior to and after transport. Staff are given a mobile telephone to take
with them on the transport. The assigned mobile phones are kept in master control. All vehicle
logbooks indicated each vehicle was searched for contraband prior to use and again upon
return. The number of youth transported and the destination with date and time were
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documented for each trip. Five youth were interviewed regarding safety while being transported
in center vehicles and each youth indicated they feel staff drive safely during transports and
none of the youth ever observed anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures detailing the requirements for tool inventory and
management. A perpetual tool inventory list is maintained by the center and inventoried monthly
by the maintenance mechanic; however, this position has been vacant, and the assistance
superintendents are sharing these job responsibilities. A review of ten tools was completed. All
tools are stored in a locked area when not in use. Tools are maintained on a locked toolbox and
are identified with an engraved number on each tool which coincides to the tool inventory sheet.
One wrench was missing during the annual compliance inventory review, but it was found in the
wrong drawer and corrected on site. Further observations indicated there were no other missing
or damaged tools. All tools are checked out on a tracking form prior to use and checked in after
they are returned. An itemized inventory of kitchen equipment and tools is also maintained. All
items are inventoried daily upon kitchen staff reporting for duty. The kitchen knives and other
hazardous kitchen sharps are stored in a locked cabinet and are inventoried three times a day.
No service vendors were observed during the week of the annual compliance review. An
informal interview with the assistant superintendent indicated all service vendors are identified
prior to entering the secure area of the center and are accompanied at all times. Youth are
removed from the area being serviced and are not allowed to re-enter the area until it has been
searched and cleared by center staff. The vendor checks for all their tools to ensure they leave
with the tools they entered with into the center. An interview with five staff found four were able
to explain the process when there are missing or damaged tools, and one staff was not entirely
sure because this was a maintenance thing. During an interview with the superintendent, it was
confirmed only the administration staff and maintenance staff have access to the maintenance
Class A tools. All inspections and inventories are uploaded into SharePoint and the
superintendent or designee review them. The center maintains a written policy and procedures
prohibiting youth from having access to any tools, including kitchen and/or medical equipment.
Youth are allowed to use cleaning items such as mops, brooms, and scrub brushes when
completing general cleaning. Youth are under staff supervision when these items are in use.
Five interviewed youth indicated they only use mops, brooms, and scrub brushes. All five youth
stated they do use cleaning agents, but they are not allowed to handle the cleaning agents. The
staff handles the cleaning agents such as spraying a table and then the youth can wipe it down.
Five interviewed staff stated youth are allowed to use mops, brooms, and dust pans. The five
interviewed staff reported youth are not allowed to handle substances which are toxic,
flammable, and poisonous. An interview with the superintendent revealed the facility
maintenance mechanic and administration staff have access to facility Class A tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
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items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has facility operating procedures to ensure the proper inventory of flammable, toxic,
caustic, and poisonous items. All items are inventoried and securely stored. All items observed
had a Safety Data Sheet (SDS) on record for each chemical. Five chemical items were
reviewed on-site during the week of annual compliance review for which the center maintained a
corresponding SDS, with complete and accurate inventories. Flammable, toxic, caustic, and
poisonous items were observed to be stored securely in areas inaccessible to youth. The center
maintains a written policy and procedures to ensure limited access to flammable, toxic, caustic,
and poisonous items. These items can only be used by authorized staff. Youth are not permitted
to use or handle hazardous chemicals. No toxic materials were observed at the center in any
place accessible to youth during the week of annual compliance review. An interview with five
youth found they do not have access to flammable, toxic, caustic, and/or poisonous items. Five
interviewed staff stated youth are not allowed to clean with substances which are toxic,
flammable, or poisonous.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) addressing proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. The assistant superintendent
reported in the event a chemical is to be disposed of, it is done so accordance with the Safety
Data Sheets (SDS) requirements. The center’s assistant superintendent and food service
director (FSD) also reported the center does not utilize grease for cooking and all kitchen liquid
waste is disposed of in the kitchen drain. Medical sharps and waste are disposed of through a
contracted medical waste disposal company. No disposal of chemicals could be observed
during the annual compliance review week. The superintendent and assistant superintendents
reported the center has not experienced any chemical spills or leaks during the annual
compliance review period.
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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 (FOPs) ensuring confinement under twenty-four
hours are used as an immediate, short-term response to incidents which affect physical safety
of youth or others. The center utilizes the youth’s assigned sleeping room for confinement. The
center had 332 instances of confinement under twenty-four hours during the annual compliance
review period, with the average confinement time of a little over seven hours. Fifteen of the 332
confinements were reviewed. All confinement reports confirmed rooms were searched prior to
youth being placed in confinement, all non-fixed items were removed from the room. All fifteen
confinement reports documented approval by a juvenile justice detention officer supervisor
(JJDOS). All youth had access to mental health and education, as needed, and six out of the
fifteen youth in confinement during shower time were all given the opportunity to shower and
given clean clothes. All youth were notified they could grieve the situation of being placed in
confinement. Two of the fifteen youth in confinement did not receive educational materials, one
youth was on Secure Observation and the other one had graduated. Thirteen of the fifteen
confinement reports were completed before the end of shift. Documentation showed five-minute
checks were conducted for the first hour for each confinement. Each reviewed report indicated a
juvenile justice detention officer supervisor (JJDOS) conducted an initial confinement review
with the youth within two hours from the incident. In fourteen of the fifteen confinement reports
reviewed, a juvenile justice detention officer supervisor (JJDOS) evaluated youth every three
hours; however, eight of the fifteen supervisory reviews did not include documentation of the
conversation with the youth and continued reason for confinement. Each report indicated the
youth were released from confinement within twenty-four hours. Each of the fifteen confinement
reports indicated the superintendent or designee reviewed the confinement report within forty-
eight hours except for one incident, the review was six days later. There were no pregnant youth
confined during the annual compliance review period.
Five youth were interviewed, and four of the five were placed in confinement for fighting. Five
youth were interviewed and stated basic rights were not taken away as a consequence of being
placed in confinement. Five staff were interviewed, three reported when a youth is placed in
confinement staff must search the room first, three stated a confinement report must be
completed, and four agreed ten-minute checks must be documented. All five interviewed staff
stated educational materials are provided when a youth is temporarily placed in confinement.
The superintendent interview confirmed confinements are reviewed to determine if they were
appropriate for the infraction.
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.
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Office of Accountability and Program Support Page 53 of 56
The center has facility operating procedures (FOPs) addressing confinement over twenty–four
hours. A review of the Department’s Juvenile Justice Information System (JJIS) revealed the
center had no confinements over twenty-four hours during the annual compliance review period.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures (FOPs) and a Continuity of Operations Planning
(COOP) to manage various emergencies and disaster events. One required drill during the
annual compliance review period was conducted. Documentation confirmed the center
conducted a hurricane drill on April 30, 2025. The next required drill is to be conducted in the
next quarter per policy. A training roster was completed and signed off by the center’s major. A
“North Region Emergency Checklist for COOP Drills” ensured the following had been
completed: activate phone tree, emergency log, account and ensure satellite and cell phones
are charged/working, radios are charged and working, communicate information to potential
impact areas, review facility population to determine if some youth are eligible for home
detention, inventory of mechanical restraints, vehicle conditions, all emergency equipment is in
vans, first-aid kits are checked thoroughly, ensure vehicles have a full tank of gas, ten day
supply of medications, maps, Juvenile Justice Information System census, picture of each
youth, parents/guardians have been notified, check generator and fuel and make sure running
properly, check area for debris, food services has a fourteen day supply of food, ensure Sally
Port is in working order, and email the regional office with status reports. Email communications
were included in the documentation. The drill was also uploaded into SharePoint. Five staff
were interviewed regarding the type of drills in which they had participated over the previous
twelve months, and only one of the five staff reported having participated in weather drills.
Superintendent interview reports COOP is set in place for environmental emergencies and are
conducted two times per year.
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 (FOPs) to address escape drills and escape
prevention. The policy requires the center to conduct escape drills at least quarterly. Each of the
twelve required drills during the annual compliance review period were conducted on all shifts.
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 supervisory staff and the staff
coordinating the drill. Recommendations and critiques of the drills were included in each report.
A review of logbooks revealed each escape drill was documented in the logbook, as required.
All documentation was also uploaded into SharePoint and signed off by the superintendent or
designee. The Department’s Learning Management System (SkillPro) validated all direct care
staff have completed annual training in escape prevention. Five staff were interviewed. Four of
the five interviewed staff indicated they had participated in an escape drill in the past twelve
months. Superintendent interview confirms escape drills are conducted quarterly.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 56
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention plan, and evacuation plan addressing fire
prevention and safety in the center. The center has evacuation egress plans posted throughout
the center. Each egress plan defined the primary and secondary exit route and the locations of
emergency equipment such as fire extinguishers and first-aid kits. The center’s disaster plan,
fire prevention, and evacuation plan were reviewed and approved by the local fire marshal.
Reviewed documentation also revealed the center fire extinguishers are inspected annually.
Thirty-six reviewed drills verified the center conducts fire drills each month, on each shift, during
different times. Drills are also reviewed during shift briefings. All documentation is uploaded into
SharePoint and signed off by the superintendent or designee. Five youth were interviewed and
three stated they have been instructed on what to do in case of a fire. Five staff were
interviewed and each stated fire drills take place at least monthly. Superintendent interview
reports fire drills are conducted monthly.
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 (FOPs) for search and contraband procedures.
Strip searches shall be conducted during admission, if there is a reasonable suspicion a youth is
harboring contraband, and when deemed appropriate by the shift supervisor. All searches are to
be documented in the logbook. Staff will wear gloves during all searches. Electronic searches
are conducted on all staff and visitors entering the secure floor. All shoes, clear bags, jacket
pockets, and other items were also searched. All personal keys, personal cell phones, and other
contraband items were prohibited from entering the secure area. Clear bags are utilized
throughout the facility. Prior to admission, all youth are searched for contraband by electric
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Office of Accountability and Program Support Page 55 of 56
wand and strip searches, verified electronically using the Admission Wizard. No youth were
admitted during the annual compliance week; therefore, an observation was not able to be
completed.. A frisk search prior to a transport was observed during the annual compliance
review week. The staff completing the searches were of the same gender and wearing gloves.
The superintendent stated room searches are conducted upon a youth’s release, prior to new
youth being placed in a room, and searched for contraband on each awake shift. A sampling of
one day from each month during the annual compliance review period indicated room searches
were completed during each awake shift. Observations were completed daily during the annual
compliance review week of searches being completed on all staff and visitors prior to entering
the secure area of the center. The center utilizes a binder with Attestation Forms filed by direct
care staff, support staff, contracted staff, and visitors. There were no instances which may have
compromised the safety and security of the center throughout the annual compliance review
week. There has been one incident of contraband reported during the annual compliance review
period. The contraband was confiscated and secured and the Department’s Central
Communications Center (CCC) was notified of the discovery and confiscation. Law enforcement
was not notified due to the contraband not being illegal. After video review, the staff who gave
the youth the contraband was identified and put on “No Youth Contact,” with the staff resigning
the following day. Notifications were completed as required. The superintendent’s interview
confirmed staff wear gloves when conducting a frisk or room search. Staff shall prepare youth
prior to the initial frisk search or any strip search by explaining the purpose and procedure of the
search while assuring the youth of his/her safety. All searches shall be in compliance with the
Right Interactions (RI) curriculum and policy.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 56

report_type: QI Detention