state: FL

summary: QI Detention - FY25-26 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Southwest Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
2525 Ortiz Avenue
Fort Myers, Florida 33905
Review Date(s): September 9-12, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Nicos Antonakos, Office of Accountability and Program Support, Lead Reviewer (Standard 1
and Standard 5)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Interviews and
Standard 4)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Isaiah McGatha, Brevard Regional Juvenile Detention Center Assistant Superintendent,
(Standard 5)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Southwest Regional Juvenile Detention Center MQI Program Code: 1046
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Lee County / Circuit 20 Number of Beds: 50
Review Date(s): September 9-12, 2025 Lead Reviewer Code: 180
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 55
Lim ited R atings
1.07 In-S ervice Training
5.15 Fire D rills
Failed R atings
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 55
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
1 .1 0
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
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 *
F iv e -Y e a r R e s c re e n in g /R e n e w a l
S ta ff C o d e o f C o n d u c t
In c id e n t R e p o rtin g C C C *
R ig h t In te ra c tio n s (R I)
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts *
In -S e rv ic e T ra in in g
G rie v a n c e s
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n *
D a ta T re n d A n a ly s is
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
m u s t th e re fo re a c h ie v e 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
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
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
SSSSSS
SSS
g ra
d o
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
L im ite d
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
m o p e ra te s
s o w ill re s u lt
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 55
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 e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n
O rie n ta tio n
C la s s ific a tio n
N o tific a tio n o f J P O C irc u it G a n g R e p
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
R e le a s e
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
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
D a ily A c tiv ity S c h e d u le
E d u c a tio n a l A c c e s s *
C a re e r E d u c a tio 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
s . A p ro g ra m m u s t th e re fo re a c h ie v e 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
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
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
g ra m o p e ra te s
d o s o w ill re s u lt
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 55
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
3 .0 1 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 )
3 .0 2 L ic e n s e d M H /S A C lin ic a l S ta ff *
3 .0 3 N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
3 .0 4 M H /S A A d m is s io n S c re e n in g
3 .0 5 M H /S A A s s e s s m e n t/E v a lu a tio n
3 .0 6 M H /S A T re a tm e n t
3 .0 7 T re a tm e n t a n d D is c h a rg e P la n n in g
3 .0 8 S u ic id e P re v e n tio n P la n *
3 .0 9 S u ic id e P re v e n tio n S e rv ic e s *
3 .1 0 S e c u re O b s e rv a tio n *
3 .1 1 S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
3 .1 2 S u ic id e P re v e n tio n T ra in in g *
3 .1 3 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 *
3 .1 4 E m e rg e n c y C a re P la n *
3 .1 5 C ris is A s s e s s m e n ts *
3 .1 6 B a k e r a n d M a rc h m a n A c ts *
* T h e D e p a 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
b e 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 v e 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
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 ).
n tio n if a p ro
rs . F a ilu re to
g ra
d o
SSSSSSSSSSSSSSSS
m
s
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
o p e ra te s
o w ill re s u lt in
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 55
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
4 .1 9
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
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
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
D H A /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is 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 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 ic k C a ll P ro c e s s
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
O ff-S ite C a re /R e fe rra ls
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
M e d ic a tio n M a n a g e m e n t
P s y c h ia tric S e rv ic e s *
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
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
P re n a ta l C a re /E d u c a tio n
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
m u s t th e re fo re a c h ie v e 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
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
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
g ra m o p
d o s o w
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
e ra te s
ill re s u lt
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 55
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
b e lo w D
re s u lt in
e p a rtm
e p a rtm
a p ro g
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 *
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*
T e n -M in u te C h e c k s *
C e n s u s C o u n ts a n d T ra c k in g
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
K e y C o n tro l
V e h ic le s a n d M a in te n a n c e
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 *
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
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
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
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
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
E s c a p e D rills
F ire D rills
S e a rc h a n d C o n tra b a n d P ro c e d u re s
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
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 v e 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
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 ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
S a tis fa c to ry
L im ite d
S a tis fa c to ry
n tio n if a p ro g ra m o p e ra te
rs . F a ilu re to d o s o w ill
le
s
Program Overview
The Southwest Regional Juvenile Detention Center is a state-owned detention center, operated
by the Department, located in Fort Myers, Florida. The center serves youth in Lee, Hendry,
Glades, and Charlotte counties in Circuit 20. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Lee County School District. The
center’s management team includes the superintendent, two assistant superintendents, two
administrative assistants, nine juvenile justice detention officer supervisors (JJDOS), and forty-
four JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by a licensed
mental health counselor (LMHC) who serves as the designated mental health clinician authority
(DMHCA). In addition to the DMHCA, the center has one regional licensed supervisor, and the
center has three-licensed full-time therapists on-site. A licensed psychiatrist and a psychiatric
advanced practice registered nurse (APRN) provides psychiatric services for applicable youth
in the center. Clinical services provided by the center include mental health and substance
abuse evaluations, mental health treatment planning, individual, group and family therapy,
mental health crisis intervention services, on-site psychiatric services, and availability for
substance abuse services for youth with co-occurring disorders. Medical services are provided
by one medical doctor (MD) who serves as the designated health authority (DHA), one APRN,
six registered nurses (RN), and one licensed practical nurse (LPN). The medical clinic maintains
nursing coverage Monday through Sunday from 9:00 a.m. to 5:00 p.m. Food services are
provided by Department staff and include menus, meal planning, meal schedules, special diets,
nutritional analysis, daily allowance, food preparation, health certifications, food product
standards, sanitation, and cleaning. Staff are responsible for the custody and control of youth in
their care, providing youth supervision twenty-four hours a day, seven days a week. The center
has two living modules which are divided by male and female. There are thirty-seven security
cameras at the center, of which all were operational. A tour of the center was conducted during
the annual compliance review week. The center appeared clean and maintained. The center
and administration area were free of any unpleasant odors with the exception of the G-1
modular community bathroom, which was having plumbing issues, and a work order was
submitted for repair. The lobby and staff bathrooms were clean. There was no peeling or
scratched paint observed on the walls. The floors on both modules were in need of repair. There
was no insect infestation observed during the tour. There was some graffiti observed in several
youth dormitories during the tour. The assistant superintendent stated the center attempts to
paint over the graffiti once a week. Fencing appeared to be in good repair at the time of the
center walkthrough. At the time of the annual compliance review, the center had two vacancies,
which included one JJDO I and one maintenance mechanic.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 55
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures ensuring initial background screenings are
conducted for all newly hired staff, contracted providers, mentors, interns, and volunteers. The
Annual Affidavit of Compliance with Level 2 Screening Standards was submitted late, during the
annual compliance review, to the Department’s Background Screening Unit
(BSU)/Clearinghouse on September 12, 2025. The Annual Affidavit of Compliance with Level 2
Screening Standards for school district teachers was submitted to the BSU/Clearinghouse on
January 15, 2025. A review of the initial background screenings for eleven newly hired staff,
revealed the center received background screening results from the Department’s
BSU/Clearinghouse prior to each staff’s date of hire. There were nine new volunteers and four
contracted staff applicable for background screenings since the last annual compliance review.
All required documentation was reviewed prior to hire for each staff and volunteer. Each staff
and volunteer had a completed background screening prior to working with the center. None of
the reviewed staff were applicable for a break in service. None of the staff were applicable for a
background screening exemption. The center utilizes an ergometric pre-employment
assessment tool for all direct care applicants. Seven staff were applicable for being direct care
staff, and each record included a copy of the pre-employment assessment passing score, which
was maintained in accordance with policy. Four staff were not direct care staff and did not
require a pre-employment assessment. Reviewed documentation validated the center added all
applicable staff to the Clearinghouse Employee Roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all staff, volunteers, and contracted
providers with access to youth undergo a criminal history background rescreening every five
years from the initial date of employment. A review of the staff roster found the center had Five
staff and one contracted employee eligible for a five-year rescreening. Reviewed documentation
confirmed each applicable staff’s rescreening was completed and submitted to the Department’s
Background Screening Unit (BSU)/Clearinghouse within the required time frames. Additionally,
the contracted provider staff had an eligible rating in the Clearinghouse.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 55
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures to ensure staff adhere to the center’s code of
conduct. Staff are required to adhere to the code of conduct which prohibits any type of abuse,
profanity, threats, harassment, intimidation, horseplay, or personal relationships with youth. A
review of seven staff personnel records revealed each staff signed a code of conduct. The code
of conduct addressed officer professionalism, poor performance, negligence, insubordination,
conduct unbecoming of a public employee, and misconduct. A review of seven staff records
found four staff had code of conduct violations. One staff received a written reprimand, and
three staff received re-training. In each instance, management took immediate corrective action
to address conduct when staff violated policies and procedures. A review of seven staff records
found three staff received a certificate of commendation. Seven youth were interviewed, and
two youth stated they have never been stopped from reporting abuse at the center, and five
youth reported they never had to report abuse. All seven youth reported staff are respectful
when talking with them and to other youth. Five youth reported they have never heard staff use
profanity when speaking to them or other youth, and two youth reported they have heard
profanity used at least once or occasionally. All seven youth reported they have never been
threatened or heard staff threaten other youth. All seven interviewed youth indicated they feel
safe in the center. All seven youth reported they have never exchanged emails, telephone
numbers, or social media contact information with staff. Seven interviewed staff were able to
explain the process for allowing staff and youth to call the Florida Abuse Hotline or the
Department's Central Communication Center (CCC), to report suspected abuse. Two of the
seven interviewed staff indicated they have never observed a co-worker using profanity when
speaking to youth, and five staff indicated they have heard a staff using profanity occasionally.
Six of seven staff indicated they have never observed a co-worker using threats, intimidation, or
humiliation when interacting with the youth, one staff stated they heard threats only once in
response to what a youth said to staff. Interview information was shared with the center’s
administrative staff. Two staff reported working conditions at the center were fair, three staff
reported working conditions were good at the center, and two indicated the conditions at the
center were very good. An interview with the superintendent confirmed the purpose of the
employee code of conduct is to ensure staff communicate and interact with youth in a manner
which provides a role model of socially accepted behaviors, and staff behaviors are to be
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 55
respectful of others and reflect desired behaviors for youth. Physical abuse is prohibited by law
and a suspicion or knowledge of such is to be reported to both the Florida Abuse Hotline and
the Department’s Central Communication Center (CCC). If a youth is at least eighteen years of
age and not disabled, physical abuse is to be reported to the CCC only. Additionally, the youth
will be given the opportunity to file a police report. If a youth is at least eighteen years old and
has a disability, both the Florida Abuse Hotline and CCC shall be notified.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures to ensure when a reportable incident occurs, the
center notifies the Department’s Central Communications Center (CCC) within two hours of
becoming aware of the incident. The center had 116 reportable incidents during the annual
compliance review period. A review of eleven incidents showed all were reported to the CCC
within two hours of the incident or when staff became aware of the incident. Each of the incident
reports were documented in the center’s logbook. A review of the center’s internal
incident/grievance reports revealed there were no additional incidents which should have been
reported to the CCC. An interview with the superintendent indicated whenever a reportable
incident occurs, it will be reported to the CCC within two hours of staff learning or gaining
knowledge of the incident or event. Incidents are to be called in with the basic information such
as who, what, when, where, and how. If a youth is involved in the incident, a Department
identification number will be provided.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures pertaining to the use of the Right Interactions (RI)
model, in accordance with Florida Administrative Code. The center had a total of 224 RI
incidents since the last annual compliance review. A review of nine RI incident reports
confirmed each of the nine reviewed RI Reports were completed by the end of the staff’s
workday. Each of the reviewed reports contained statements from all the staff involved. None of
the incidents resulted in serious injury to the youth or staff or needed to be reported to the
Florida Abuse Hotline. All nine RI Reports were reviewed and processed by a supervisor or an
RI instructor. Each of the RI Reports confirmed a post-RI interview was conducted with the
youth by the center’s administration within thirty minutes after the incident. None of the youth
were applicable for a post-RI medical review. None of the incidents resulted in the use of
mechanical restraints. A review of internal incident/grievance reports and logbooks for the
compliance review period confirmed there were no additional RI incidents which did not have a
report. Each of the reviewed RI Reports were reviewed by the superintendent or designee within
seventy-two hours. The center’s RI rate during the annual compliance review period was 21.23,
which is higher than the statewide Detention RI rate of 12.59. Seven interviewed staff reported
the staff try to talk to youth prior to using RI or mechanical restraints. An interview with the
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superintendent indicated, in the event the use of physical or mechanical restraints are utilized,
all detention staff must complete a Physical and Mechanical Restraints log and conduct ten-
minute checks. Additionally, the superintendent and/or designee monitors RI incidents, reviews
the RI video footage within twenty-four hours, and all RI Reports are reviewed within seventy-
two hours from the incident.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures addressing the training and certification
requirements for all new staff. Phase One training consists of instructor-led and web-based
courses. Phase Two consists of 120 hours of academy instructor-led training. A review of seven
staff training records for pre-service training indicated each of the seven staff completed all
required trainings within 180-days of hire and the 120 hours of training at the academy. None of
the reviewed staff records qualified as returning direct care and state support staff who returned
less than one year from separation from the Department.
1.07 In-Service Training Limited Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures which require staff to complete twenty-four hours of
in-service training each calendar year after completion of pre-service certification training. The
policy requires supervisors to complete eight hours of supervisory training in addition to the
twenty-four hours of in-service training. The center provides in-service training to staff through a
combination of the Department’s Learning Management System (SkillPro) and instructor-led
classes. Seven staff training records were reviewed for in-service trainings, which included three
supervisory staff and four direct care staff. Five of the seven reviewed staff records confirmed
each staff completed the required twenty-four hours of the mandatory training topics which are
to be completed annually, and two staff were missing the Mental Health and Substance Abuse
training. In addition, one staff was missing Active Shooter Preparedness, Human Trafficking
Intervention, Information Security Awareness, Prison Rape Elimination Act (PREA), Sexual
Harassment, Trauma Responsive Practices, Infection Control training, Exposure Control Plan
training, annual Escape Prevention training, and Fire Prevention Plan/Disaster Procedures
trainings. The second staff was missing Active Shooter Preparedness, Human Trafficking
Intervention, Information Security Awareness, Mental Health and Substance Abuse,
Professionalism, Interpersonal Communication, and Ethics, Suicide Awareness and Prevention,
Trauma Responsive Practices, annual Escape Prevention training, and Fire Prevention
Plan/Disaster Procedures trainings. The policy requires supervisory staff to complete eight
hours of supervisory training annually. Three staff were applicable for a minimum of eight hours
of supervisory training, and each staff completed the required minimum hours. All trainings were
documented in SkillPro. Reviewed documentation confirmed the center has a licensed
registered nurse (RN) who provides in-service training annually for the education on girls’
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healthcare to all non-healthcare staff involved in the supervision or treatment of girls. Reviewed
training records found four of seven staff were missing education on girls’ healthcare. The
center has an annual in-service training calendar which is updated as changes occur. The in-
service training plan was approved by the Department’s assistant secretary for Detention
Services on December 2, 2024, and by the director of the Department’s Office of Talent,
Leadership, and Culture (TLC) on December 5, 2024. The superintendent stated there have
been no changes to the training plan. The superintendent has received management training
such as leadership development, certified public management (CPM) and the TLC’s tier one
and two management trainings.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures in place related to youth grievances to ensure each
youth has the right to grieve and ensure all youth are treated fairly, respectfully, without
discrimination, and their rights are protected. The grievance process is posted throughout each
living module and is explained to each youth during the admission and orientation process. The
center keeps blank grievance forms on the youth living modules which are available for youth
upon request. The center’s staff will then input the grievance into the Department’s Facility
Management System (FMS) within the Department’s Juvenile Justice Information System
(JJIS). The process includes an informal phase, formal phase, and the appeal phase. The
assistant superintendent stated the center had no documented grievances during the annual
compliance review period. An interview with the superintendent confirmed the center’s
grievance process, indicating the process has an informal and a formal phase. Additionally, the
superintendent indicated youth are provided with grievance forms to complete, and staff are to
submit the grievance in FMS, on behalf of the youth. Supervisors are to provide a response
within twenty-four hours, and the completed grievance form is to be provided to the
superintendent or designee. Seven youth were interviewed and four were able to explain the
grievance process, and three indicated they were not sure of the process. All seven youth
reported they had never filed a grievance. Seven staff were interviewed, and all staff were
knowledgeable and could explain the center’s grievance process.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures outlining the process of entering and sharing alerts.
The center’s practice is to appropriately enter, downgrade, or discontinue alerts in the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been previously identified prior to the youth’s admission. A review of seven youth
records confirmed alerts were documented in accordance with the center’s policy. The reviewed
youth were applicable for twenty-four separate alerts. Each reviewed youth record documented
alert types, and the name/title of staff removing/updating alerts. Each alert was documented in
the logbook. Documented alerts were accurately entered and matched the alerts in JJIS. All
applicable alerts were downgraded and removed by the medical staff and/or the mental health
staff, as applicable. A copy of the alerts are provided to the supervisors and detention staff at
the start of each shift, and the alerts are reviewed with staff during each shift briefing. A copy of
the alerts are maintained with the logbook and are accessible to all staff. Reviewed
documentation confirmed the alerts are discussed during shift briefings. In addition, alerts are
posted in the kitchen and kitchen staff have access to the alerts. A video observation of a shift
briefing meeting was conducted during the annual compliance review week. Video observation
confirmed alert sheets were distributed to staff during the shift briefing. There were no additional
alerts found which should have been entered into the alert system. An interview with the
superintendent confirmed the center’s practice for review and documentation of medical alerts.
Seven staff were interviewed and reported they are informed of security, safety, medical, and
mental health alerts which are specific to youth, through shift debriefings, the alert forms, JJIS,
the alert board, logbooks, and other types of communication. Each of the seven staff reported
management informs staff about issues within the center through shift debriefings, alerts,
logbooks, meetings, emails, as well as other forms of communication. Five of seven interviewed
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staff indicated the process for communicating information within the center is very good, one
indicated it was good, and one staff stated it was fair.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a practice in place regarding data trend analysis. The center uses internal report
cards, a visual analytics platform, the Juvenile Justice Information System (JJIS), and Vacancy
Reports to see which areas need improvement. All information and reports are shared with
supervisors. The center implements strategies to help with decreasing confinements, the
utilization of Right Interactions (RI), and Central Communication Center (CCC) incidents. Data is
shared with the center staff by email and during supervisors/department head meetings. The
data is collected from a visual analytics platform, Share Point, and JJIS, then the information is
forwarded to supervisors and instructors. Reviewed documents included Detention Vacancy
Rates from September 8, 2025, Detention Center Direct Care Gender Breakdown and twenty-
four hours or greater confinement reports from September 6, 2025, and incident reports from
September 8, 2025, which verified the center’s practice for sharing information with staff. The
center conducts weekly Detention Review meetings where information is provided to the
juvenile probation officers (JPOs), medical staff, mental health staff, and lead teachers. The
center shares information with providers and stakeholders on a quarterly basis. The information
is shared at meetings, as well as through email communication. The center utilizes the
Department’s visual analytics platform and JJIS to identify the areas which need improvement,
and the information is shared with the center’s administrative staff.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures to address youth admission into secure detention.
The center's policy requires the center to complete admissions electronically in the
Department's Juvenile Justice Information System (JJIS). During the annual compliance review
week, a total of seven youth records were reviewed. Each record contained an arrest
affidavit/custody order, a completed Detention Risk Assessment Instrument (DRAI), and a
completed Suicide Risk Screening Instrument (SRSI). A review of the documented admission
forms indicated a full-body search and/or electronic search was completed for all seven youth.
Reviewed documentation validated each youth was provided a meal, medical, mental health,
and substance abuse screenings. Four of seven records documented the youth was provided a
telephone call while three records documented the youth did not complete a call and did not
document whether the call was refused by the youth. An observation of an admission was
conducted during the annual compliance review week. Observations confirmed the center’s
admission procedures were followed, and the youth was provided lunch and a telephone call to
their parent/guardian.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
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The center has facility operating procedures stipulating the process for orienting each youth
within twenty-four hours of being admitted into detention. Youth orientation must include, both
verbal and written orientation to the center’s rules and regulations, grievance procedures, the
process for visitation and telephone calls, the availability and process for accessing medical,
mental health and substance abuse services, how to access the Florida Abuse Hotline and the
Department's Central Communications Center (CCC), expectations for behavior and related
consequences for failing to meet those expectations, possible new law violations for destruction
of property, youth rights, and Prison Rape Elimination Act (PREA) related information. A review
of seven youth records confirmed an orientation was completed for six youth within twenty-four
hours of admission, while one record did not document the completion of orientation nor the
youth’s acknowledgement of orientation topics discussed during admission. Observation of a
youth admission and orientation during the annual compliance review week validated the youth
was informed of all required orientation topics during the admission process. The youth received
a telephone call to their parent/guardian, was provided lunch, and viewed a video recording of
PREA-related information and guidelines. Seven youth were interviewed, and each confirmed
they were advised of the rules and regulations, daily schedule, education services, visitation,
abuse reporting, and the behavior management system during the admission process.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures requiring all youth admitted to the detention center
to be classified in order for the center to provide the highest level of safety and security. A
review of seven youth records indicated each youth’s classification process included a review of
information related to the youth’s history and status and included consideration of the youth’s
mental illness, intellectual/physical disabilities, history of violent and/or criminal behavior, gang
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affiliation, history of sexual offenses, the results of the Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) screening, medical concerns, suicide-risk, escape-risk, security
concerns, and history of human trafficking. The completed classification process documented
consideration of all the required topics prior to making room assignments, including the gender
of the youth, height, weight, age, and level of aggression. The center’s practice is to enter all
suspected gang affiliation alerts into the Department’s Juvenile Justice Information System
(JJIS) and notify the youth’s juvenile probation officer (JPO) by email. An interview with the
center’s superintendent indicated the JJIS alert system is utilized to document a single room
only youth classification for youth with a history of committing sexual offenses, a history of being
a victim of a sexual offense and/or abuse, or youth determined to be physically or sexually
aggressive. Any youth whose VSAB results indicate the youth is vulnerable to victimization
and/or sexually aggressive is placed on single room only status, and a single room only alert is
entered into JJIS.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures to address the screening process for youth newly
admitted into the center and to determine whether the youth is suspected or documented to be
a gang member or gang affiliated. The policy requires the center to share suspected gang
related information by email with the juvenile probation officer (JPO) designated as the circuit’s
gang representative. An email communication is sent to the JPO with pictures and
documentation of all suspected gang related activities. A review of seven youth case
management records found none were applicable for suspected gang affiliation. A review of the
alerts in the Department's Juvenile Justice Information System (JJIS) confirmed the center did
not have any youth documented as a suspected gang member during the annual compliance
review period. During the review period the center admitted two youth with documented gang
affiliation; however, one was a transfer from another detention center and the youth was
previously identified in 2023 for the gang alert, and the other was identified at another detention
center in March 2025, prior to having been transferred to this center. The center’s administrative
staff enter all suspected gang affiliation alerts into JJIS, when applicable. An informal interview
with the superintendent confirmed there is currently no gang liaison for the center; however, the
administration staff is responsible for sharing the gang related information to the JPO.
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2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures to address admissions and the storage of youth’s
personal property. The center’s policy requires all youth personal property to be inventoried and
returned upon release. A review of seven youth itemized Personal Property Receipt forms
showed each included the youth and staff signature and letter of acknowledgement regarding
unclaimed property. Two of the seven youth had personal items of value at the center which
were verified and secured in a clear tamper-proof property bag. During the annual compliance
review week an observation was made of the youth’s valuable property bags stored in the
secured property safe in the center’s master control office. A review of seven youth records
showed six youth signed their respective property receipts, which itemized each item of the
youth’s personal property brought to the center, including clothing, and a copy of the form was
maintained within the youth’s active record. One youth had been transferred from another
detention center and therefore did not have any property at this center. However, the
descriptions on the property receipts for the two youth with personal items of value did not
describe the items of value as “in the safe”, as required. The center maintains two logbooks for
documenting personal property received at each youth’s admission, which include the intake
property logbook and the property safe logbook. One logbook, maintained in the intake office, is
for documenting personal property received during the intake process where the youth’s
clothing and shoes are placed in personal property garment bags and stored in a secure room
which is used solely for storage of youth property. The property safe logbook is maintained in
the master control office and is used to record youth items of value which are stored in the
center’s property safes. The property safe logbook documents the youth’s name, Department
identification number (DJJID), the date the youth’s valuable property was placed in the safe,
with the signature/initials of the center administration staff placing the property in the safe. It is
the center’s practice, to update the log upon a youth’s discharge from the center to notate the
youth was released, the date of release, and the initials of the administration staff retrieving the
valuable property. The log is then highlighted in yellow across both entries to easily identify
those youth who have been released with their property. Observation of a youth admission was
made during the week of the annual compliance review which validated youth clothing was
received and logged, and the youth signed both the property receipt report and a letter of
acknowledgement pertaining to unclaimed property. An observation was conducted during the
annual compliance review week which validated the process of how youth property is secured
and documented at the center. The center has two drop-safes, and one is located in the intake
room and the other in master control. Both safes are under video surveillance and only
accessible to designated staff. A review of the Department's Central Communications Center
(CCC) incidents for the center confirmed no property related incidents were reported during the
annual compliance review period. An interview with the superintendent indicated all youths’
personal and valuable property is inventoried on the Juvenile Justice Information System (JJIS)
Property Receipt Report and signed by both the youth and admission staff. Valuable property is
placed in a clear tamper-proof bag and placed in a drop safe. The safe is always under video
surveillance, and at no time is anything with property to be done out of view of the camera. If
property is removed from the safe to a second location, the second location must be in camera
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view. The superintendent indicated only the center’s administrators have access to the valuable
property safes located in intake and the master control room. In the event any property is not
picked up within thirty days, and the youth or parent/guardian cannot be located, the property is
considered abandoned. Six of seven interviewed youth stated staff checked their personal
property and they signed a form to acknowledge their list of inventoried personal property was
correct. One youth had been transferred from another detention center; therefore, did not have
any property at this center.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures for releasing youth from secure detention. The
center’s policy requires each youth’s court order to be reviewed and verified prior to release.
Seven youth case management records were reviewed, and one was applicable for release
procedures. Two additional closed records were requested and reviewed for release. A review
of the three applicable closed youth records indicated the on-duty supervisor reviewed all
related paperwork and the youth’s identification was verified prior to release. One youth was
released to a parent/guardian and two were released to Department of Children and Families
(DCF) staff. A copy of the identification for each parent/guardian or DCF staff was present in
each of the records. None of the reviewed records were for youth with an endangered person
alert. Reviewed documentation confirmed the youth and parent/guardian or DCF staff were
reminded of future court dates, and all parties signed all applicable release forms. A review of
the Department's Juvenile Justice Information System (JJIS) confirmed each youth’s date of
admission and release correlated with the dates documented in the case record. During the
annual compliance review week, an observation of a release of a youth into the custody of DCF
was conducted. Copies of the DCF staff’s identification card were made and placed in the
record. The youth was retrieved, searched, and taken to the area for release processing. All
personal property was returned to the youth, the youth’s medications were provided to the DCF
staff, and signatures were obtained. The youth and the DCF staff signed the release
documentation, were reminded of the youth’s future court dates, and provided with a copy of the
youth’s court documentation.
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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.
The center has facility operating procedures requiring each youth's personal property to be
maintained securely and returned to the youth in a timely manner upon their release. The
center’s policy details procedures for the release of youth with prescription medications. Three
closed youth case management records were reviewed. All three closed youth records
confirmed the youth and parent/guardian signed the Property Receipt form upon release. Each
reviewed record contained a copy of the parent/guardian identification card confirming the youth
was released to the appropriate person. One of the three closed youth records was applicable
and supported the receipt of medication was signed by the person receiving the youth using the
Department’s Health Discharge Summary Transfer Note form. Reviewed documentation
confirmed both the youth and parent/guardian were reminded of any health or welfare issues
including any medical, mental health, and/or substance abuse needs during each of the three
releases. Observations of a youth property release during the annual compliance review week
confirmed the youth received their property and signed the Property Receipt form. The youth’s
assigned Department of Children and Families case worker, to whom the youth was released,
received the youth’s medication and signed the Department’s Health Discharge Summary
Transfer Note form.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures requiring Detention Reviews to be conducted
weekly for securely detained youth and to ensure proper management of youth and appropriate
sharing of information. Detention Review meetings are held at the center on Thursdays. During
the annual compliance review week, an observation of a Detention Review meeting was
conducted. All parties were present from all required departments and agencies. The meeting
included staff who were present in person, including the center’s medical and mental health staff
and transition services manager. Participating virtually were representatives from the local
school district, juvenile probation officers (JPOs), and the Department’s commitment manager.
During the Detention Review meeting the participants discussed each youth’s applicable
upcoming appointments, medical needs, court appearances, and behavioral changes while in
detention. A review of weekly documentation since the last annual compliance review in the
Department’s Facility Management System confirmed the required participants were in
attendance. Additionally, Detention Review records contained sign-in attendance sheets, youth
alerts, and Detention Review notes. Reviewed documentation validated Detention Review
meetings were held weekly at the center. An interview with the superintendent indicated the
weekly Detention Review meetings are typically conducted in the center’s conference room in
the secure area of the center.
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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 facility operating procedures requiring the establishment of a daily activity
schedule. The center’s policy requires the daily activity schedule to specify the days and times
of youth activities. The daily activity schedule was observed posted in the living areas during a
tour of the center. The activity schedule identified times for wake-up and personal hygiene,
mealtimes, visitation, physical and indoor recreation activities, and activities which promote
education and life skills. The daily schedule included bedtimes, groups, and open program time
including games and reading. Observations were made of youth engaged in various activities
throughout the annual compliance review week which included educational programming,
meals, youth searches, sick call, and recreation activities. Observed activities were in
adherence to the schedule. Seven interviewed youth confirmed the center has a daily activity
schedule which is followed. Seven interviewed staff all indicated the center’s daily activity
schedule is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center’s education services are directly supervised and administered by the Lee County
School District. Services operate on a year-round basis, providing the youth with 242 days of
education distributed over twelve months with a minimum of twenty-seven and one-half hours of
instruction each week. The annual academic calendar identifies the exact number of school
days and includes the provision of up to sixteen days of professional development/training for
the teaching staff. Upon inspection of the established academic calendar, it was noted the
calendar identified 226 days of direct instruction and sixteen days of professional development.
The center had an activity schedule, and this timetable was aligned with the daily academic
schedule. A video review of the center’s movement on three separate dates showed the youth
arrived and exited from the classes at the appropriate scheduled times and the videos showed
the classes were being conducted with minimal disruptions. Seven youth were interviewed and
asked if they thought the program was preparing them for their high school equivalency diploma
(GED), high school, vocational school, employment and/or college, and all seven agreed the
program was indeed preparing them. The seven youth were interviewed as to whether they
attended school Monday through Friday while at the center, and each youth stated they all
attend school Monday through Friday while at the center. Seven staff were interviewed
regarding whether there was minimal interference to the on-going classes. Five of the seven
interviewed staff stated there was minimal interference, whereas two staff stated there was
interference. The interviewed superintendent verified there was minimal interference to the
education instruction. The center had a deficiency for educational access which was identified
on December 12, 2024, and was corrected and closed on August 25, 2025. A review of logbook
entries from the date of the deficiency correction through the week of the annual compliance
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review was conducted. A review of the logbooks dated August 28, 2025, and September 4,
2025, showed the youth were three to ten minutes late to class. On August 28, 2025, there were
two instances which showed the youth had arrived to one class three minutes late and another
instance in which the youth had arrived five minutes late to class. A review of the logbook entry
for September 4, 2025, found youth arrived late to class three times. For one class the youth
arrived seven minutes late and for two classes the youth arrived ten minutes late to class. It was
noted two of the instances where youth arrived late to class were due to transitional issues from
lunch to the fourth period class.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has a process for the delivery of career education to students. This course of study
is categorized as a Type 1 Life Skills curriculum and is based upon the age of the youth as well
as their individual intellectual and educational abilities. This course classification, which stresses
soft skills, has activities which include learning and improvement of effective communication
skills as well as the focusing upon the development and enhancement of interpersonal and
decision-making skills. Seven youth were interviewed and asked to identify the classes they
were enrolled in, and all seven stated they were currently taking Math, Science, History and
Reading. Additionally, two of the seven responding youth stated they were enrolled in a Social
Studies class.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA), who is
responsible for the coordination and implementation of mental health and substance abuse
services. The DMHCA is a licensed clinical social worker (LCSW) and has an active license in
the State of Florida, with an expiration date of March 31, 2027. The DMHCA is a full-time staff
and scheduled to be on-site forty hours each week. The DMHCA is scheduled to be on-site
Tuesday through Saturday from 8:00 a.m. to 4:00 p.m. A review of the contract requirements
and the mental health sign-in logbook since the last annual compliance review confirmed the
DMHCA was on-site, as required. The DMHCA is available seven days a week, twenty-four
hours a day, by way of telephone for consultation. The center has a back-up DMHCA in the
event of scheduled leave and/or absences, who is one of the full-time clinical staff. The back-up
DMHCA is a licensed mental health counselor (LMHC), licensed in the State of Florida, with an
expiration date of March 31, 2027. An interview with the DMHCA indicated they met concerning
individual sessions, met with the psychiatrist for medication management, and coordinated
treatment plans and treatment plan updates. Additionally, clinical services are provided for youth
daily.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The clinical
supervisor ensures the licensed clinical staff are performing services based on their education,
training, and experience. The center has three licensed mental health staff contractual positions,
in addition to the designated mental health clinician authority (DMHCA). Copies of all licenses
were provided and are kept in a binder in the mental health office. A review of the licensed
clinicians’ credentials indicated two clinicians had an active license in the State of Florida for a
license mental health counselor (LMHC) with an expiration date of March 31, 2027. The third
clinician was a licensed clinical social worker (LCSW) with an active license in the State of
Florida expiring on March 31, 2027. The interviewed DMHCA stated all mental health staff are
licensed; therefore, a Chapter 397 license was not needed.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. All mental health
services are provided by licensed mental health professionals, and the center does not have
any non-licensed mental health clinical staff. Reviewed documentation indicated only the
licensed mental health counselors were facilitating all substance abuse treatment and groups. In
an informal interview, the designated mental health clinician authority (DMHCA) stated all
mental health staff are licensed; therefore, a Chapter 397 license was not needed. There were
no reported vacancies for clinical service staff during the annual compliance review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure the mental health and substance abuse
needs of youth are identified through a comprehensive screening process. The center’s policy
requires referrals to be made when youth are identified with mental health and/or substance
abuse needs or are identified as a possible suicide-risk in accordance with Florida
Administrative Code. A review of seven youth mental health and substance abuse records
indicated each youth was processed at the Juvenile Assessment Center (JAC). The juvenile
probation officer (JPO) conducts the intake process by completing the mental health, substance
abuse, and suicide risk screenings utilizing the Suicide Risk Screening Instrument (SRSI) and
the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) in the Department’s
Juvenile Justice Information System (JJIS). Seven records were reviewed, and the juvenile
justice detention officer (JJDO) reviewed each youth’s MAYSI-2 results, Face Sheet, and alerts
upon admission. The JJDO completed their assigned section of the SRSI for all seven youth. All
seven SRSIs were reviewed by a nurse and/or a mental health professional. Each of the SRSIs
had completed entries, which included an accurate referral selection in the “Screening Results”
sections. Six of the seven reviewed records had a positive “YES” response on the SRSI and
indicated youth were placed on suicide precautions and a mental health referral was completed,
which documented the youth’s need for an Assessment of Suicide Risk (ASR). Six of the seven
reviewed youth records were applicable for a suicide precaution placement based on an open or
closed suicide-risk alert in JJIS. Six of the seven reviewed SRSIs and MAYSI-2s indicated
further assessments were needed. Only three records were applicable for having all negative
responses on the MAYSI-2, and each were marked as “invalid” by the screener. Each of the six
applicable reviewed records indicated the superintendent or designee was notified of the
referrals made for assessments.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures for outlining the process to identify the mental
health and substance abuse needs of youth through a comprehensive screening. The center’s
policy requires the youth with identified needs be referred for a further in-depth mental health
and/or substance abuse evaluation. Seven reviewed youth records indicated two youth were
identified after admission and referred to the center’s provider. An additional two youth records
were requested from the designated mental health clinician authority (DMHCA). Three of the
four records evaluated had new Substance Abuse and Mental Health (SAMH) assessments.
One youth record had an updated SAMH assessment. Three of the four youth’s SAMH
assessments were completed by the youth’s thirty-first day. Reviewed documentation confirmed
one youth refused the SAMH assessment. All three applicable youth SAMH’s documented
treatment recommendations were made for all the diagnosed mental health or substance
related disorders. Seven reviewed youth records indicated none of the youth had a new or
updated comprehensive assessment (CA)/evaluation completed by a community provider.
Three additional youth records were provided and indicated the CA/evaluation was obtained
from a community provider and contained all the required elements including signature of the
license mental health professional (LMHP). The DMHCA explained youth initial screenings are
completed within twenty-four hours of entrance into the center and referrals for comprehensive
assessments are made.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures for mental health and substance abuse treatment
and discharge planning. The provider’s contract requires the superintendent and designated
mental health clinician authority (DMHCA), or mental health/substance abuse (MH/SA) clinical
staff to ensure the development and review of an initial and/or individualized treatment plan for
each youth receiving mental health/substance abuse treatment in the center. Seven youth
mental health and substance abuse records were reviewed, and only six were applicable for
mental health and substance abuse treatment services. All six applicable youth had a mental
health orientation held within fourteen days of admission. Only four of the six youth required a
treatment plan. The four applicable youth’s initial treatment plans were documented on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form and created within
seven days of the onset of treatment. Each initial treatment plan indicated the reason for referral
for treatment, the initial Diagnostic and Statistical Manual, Fifth Edition (DSM-5)
diagnosis/symptoms, treatment goals, methods of treatment including group or individual
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counseling, the medication the youth was prescribed at admission, and psychiatric services to
be delivered, including the frequency of services. The MH/SA professionals’ signatures and
youths’ signatures were present on all four initial treatment plans. All four youth were assigned
to a mini-treatment team whose members were involved with the development of the initial
treatment plan. Seven reviewed records indicated only three were applicable for having an
individualized treatment plan (ITP) developed for youth receiving MH/SA treatment in the center
by the thirty-first day after the youth’s admission. One youth had not yet been at the center long
enough to have an individualized plan developed. All three ITPs contained the DSM-5
diagnosis, treatment focused symptoms, treatment goals, and the youth’s strengths/needs. A
review of the documented ITPs indicated the three youth had prescribed psychotropic
medications listed at the time the plan was developed. All three plans had progress notes
documenting the youth received treatment services as stipulated in their treatment plans. ITP
documentation confirmed all three records contain the youths’, MH/SA professionals’, and
treatment team members’ signatures. None of the ITPs had applicable parent/guardian
signatures. A review of seven records indicated no youth were applicable for ITP reviews to be
completed every thirty-days. An additional three records were requested and reviewed. Two
youth had a total of three thirty-day periods requiring ITP reviews. The last applicable youth only
required one documented ITP review. Provided documentation confirmed clinical staff, the
youth, a licensed mental health professional, and treatment team members reviewed and
signed all three ITP reviews. None of the youth had an applicable parent/guardian signature on
the ITP review documentation. All three ITP reviews included treatment and services provided
by a licensed psychiatrist. None of the youth were alleged victims of a Prison Rape Elimination
Act (PREA) event needing additional services. A review of three closed records indicated all
three youth received a signed discharge plan documented on the Department’s Mental
Health/Substance Treatment Discharge Summary Form. All three closed records had
documentation indicating the completion date and the signature of the licensed mental health
professional. A copy of the discharge plan was provided to each youth, parent/guardian, and
juvenile probation officer (JPO). No additional documentation was present to be uploaded. The
interviewed designated mental health clinician authority (DMHCA) stated youth admitted into
secure detention for twenty-one days and not prescribed psychotropic medications, will not have
an ITP created unless requested by the youth. Only if the youth is prescribed psychotropic
medication upon admission, will have an ITP created prior to their thirtieth day in detention.
Treatment team meetings are conducted weekly on Tuesdays at 9:00 a.m. Video observation of
a recent treatment team meeting confirmed the meeting was held in the multi-purpose room.
Sign-in sheets obtained from the DMHCA confirmed the youth, mental health staff, nurse, and
additional treatment team members were present. The DMHCA interview stated the center’s
youth are provided mental health services. A youth’s ITP is reviewed once every thirty days.
Changes or updates are made as youths' objectives and goals are met or as they change.
Youth are a part of monthly treatment team meetings and information is gathered from collateral
sources.
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3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility operating procedures in place requiring mental health and substance
abuse treatment planning to focus on treatment provisions which reduce or alleviate youth’s
symptoms of mental disorder or substance abuse impairment and enable youth to function
adequately in the juvenile justice setting. Seven youth mental health and substance abuse
records were reviewed, and four were applicable for receiving mental health and substance
abuse treatment services. All four reviewed youth records included documentation the youth
required treatment, and each was assigned to a mini-treatment team which consisted of clinical
mental health staff, one staff from a different service area, the youth, and the youth’s
parent/guardian. Each reviewed youth record was applicable for treatment with individual
therapy, group, and/or supportive counseling sessions. All four records indicated the youth
received substance abuse group, individual, and/or supportive counseling sessions as indicated
on their active treatment plans. Reviewed records supported the four-youth had an Authority for
Evaluation and Treatment (AET), and three had proper consent forms for substance abuse
treatment and information release. One youth refused to give proper consent for mental health
treatment and to participate in services. Three youth were applicable and signed the required
release documents for receiving substance abuse treatment and the youth who refused
received supportive counseling services. Each youth’s record contained progress notes
documented on the Department’s Counseling/Therapy Progress Notes form. A review of the
center’s video footage for mental health groups confirmed licensed therapists conducted group
sessions with the youth on August 17, 2025, for both B-module and G-module. There were no
additional groups available to be viewed by video. A review of mental health/substance abuse
group sign-in sheets confirmed the “Healthy You” group was conducted according to the
schedule. Documentation verified mental health staff had adequate access to youth and had a
confidential space to provide treatment services. In addition, sign-in sheets validated mental
health groups were limited to ten or fewer youth. An interview with the designated mental health
clinician authority (DMHCA) confirmed if a youth is prescribed psychotropic medications, they
will see the psychiatrist for medication management within seven days of arrival to the center.
Additionally, the youth are engaged in treatment team meetings. The goals and objectives for
the treatment plan are determined by the youth and treatment team members. Youth receiving
substance abuse treatment have a substance abuse diagnosis and are engaged in substance
abuse treatment as part of their goals while in secure detention. The DMHCA added, the youth
have the option to refuse services. Mental health and substance abuse treatment services are
provided as weekly individual sessions, monthly treatment team meetings, and treatment
planning/updates every thirty days. Groups are held when detention staff are available. Seven
youth were interviewed regarding their rating of the center’s mental health and substance abuse
services. Five youth rated services as very good. Two youth stated they are not receiving
mental health and substance abuse services.
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3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures requiring a Suicide Prevention Plan. The plan
details the process to safely screen, refer, assess, monitor, and protect youth with elevated
suicide-risk in the least restrictive means possible. The policy requires the suicide prevention
procedures to be reviewed and signed by the designated mental health clinician authority
(DMHCA) and the superintendent. The plan elements include identification and assessment of
youth at-risk of suicide, staff training of at least six hours annually on suicide precautions, levels
of supervision, the referral process, communication, notification, documentation, immediate staff
response, and a review process. The center’s plan includes an established multidisciplinary
review process for every serious suicide attempt or serious self-inflicted injury and a mortality
review for a completed suicide which includes circumstances surrounding the event, center
procedures relevant to the incident, all relevant staff training, pertinent medical and mental
health services involving the victim, possible precipitating factors, and any recommendations for
policy changes as needed.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures requiring suicide prevention services. The Suicide
Prevention Plan outlines the process to safely screen, refer, assess, monitor, and protect youth
with an elevated risk of suicide in the least restrictive means possible. A review of seven youth
mental health and substance abuse records showed one youth was not applicable for having
been placed on precautionary observation (PO) at the time of admission and for documenting
the date the Assessment of Suicide Risk (ASR) was completed. The remaining six youth were
identified as at-risk based on the admission screenings. Each youth record contained
documentation to support the youth was placed on constant supervision prior to the completion
of the ASR. Four of the Suicide Precautions-Observation Logs were completed in their entirety
and indicated the mental health (MH) provider was involved. Two of the Suicide Precautions-
Observation Logs did not document safe housing requirements. None of the youth were
released from the center prior to receiving an ASR or released while on suicide precautions. All
the records indicated the staff documented a consultation with the designated mental health
clinician authority (DMHCA) or licensed mental health professional (LMHP) on the mental
health/substance abuse referral summary. All six reviewed records documented the
superintendent or designee was notified immediately of each youth’s suicide risk. A review of
the PO logs indicated the date and time of the referral and the date and time the youth was
placed on suicide precautions. Each of the ASRs were completed within twenty-four hours and
had documentation of a conference held by the superintendent and a licensed MH professional
regarding the youth’s level of supervision. All six youth required a Follow-Up ASR to be
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completed prior to the removal of youth from PO. A review of the center’s logbooks revealed the
starting and ending time of each youth’s precaution period was documented. PO logs indicated
all the youth were discontinued from one-to-one to constant supervision. Documentation
confirmed the discontinuation of close supervision according to the center’s Suicide Prevention
Plan. Each ASR was documented as completed by a licensed MH professional. A review of the
center’s logbook confirmed the changes to levels of supervision were documented. In addition,
a review of the Department's Juvenile Justice Information System (JJIS) confirmed the
appropriate youth alerts were entered into the system. The interview with the DMHCA explained
the ASR is conducted by the licensed staff and DMHCA. Youth follow-ups are conducted within
twenty-fours of referral. The center’s staff will contact the DMHCA by telephone if no BHP is
currently on-site. Mental health staff are notified face-to-face during business hours or by
telephone if a youth is potentially suicidal. According to the DMHCA, when a youth appears to
be acutely suicidal the BHP and/or DMHCA will conduct an ASR and place a youth on secure,
precautionary, or close observation if necessary. The DMHCA communicates by email and
face-to-face, while documenting on the ASR any revisions of a youth’s supervision level
changes with the superintendent/designee. Furthermore, if a youth is placed on PO due to a
potential suicide risk or suicide attempt, the mental health clinician notifies the youth's
parent/guardian and juvenile probation officer by telephone or email. An interview with seven
staff indicated if a youth is expressing suicidal thoughts the MH authority will be notified.
Additionally, all staff agreed the youth and rooms are searched for any sharp objects, staff must
document supervision and place the youth on constant sight and sound supervision. Four staff
stated they would place a youth in a locked room. Seven youth were interviewed about being
placed on suicide watch while at the center. Only one youth stated they were placed on PO and
staff observed them while on PO. The remaining six youth were not placed on PO while at the
center.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures regarding secure observation. The policy requires
youth placed on suicide precautions to remain under secure observation if less restrictive
methods are not effective. Seven youth records were reviewed, and only one record was
applicable for placement in secure observation. An additional two records were reviewed. Each
of the secure observation rooms were designated in writing. A review of the Department's
Juvenile Justice Information System (JJIS) indicated all three youth had a Health Status
Checklist completed prior to placement in secure observation. All three reviewed secure
observation logs were completed entirely. A new Assessment of Suicide Risk (ASR)/Follow-Up
ASR was completed within eight hours for two youth being placed into secure observation and
the youth’s parents/guardians were notified of the status changes. One youth’s ASR was not
completed within eight hours of secure observation placement. An informal interview with the
designated mental health clinician authority (DMHCA) indicated the ASR was not completed.
The staff member received a disciplinary action for the incomplete ASR. Documentation review
of the chronological note entered in JJIS by the DMHCA confirmed the ASR was missing on
August 12, 2025. On August 24, 2025, the ASR was completed and uploaded in JJIS. A review
of the center’s logbook confirmed the youth’s level of supervision changed from secure
observation to precautionary observation on August 10, 2025, at 9:43 a.m. Two reviewed ASRs
indicated the juvenile probation officer (JPO) was not notified of a youth’s potential suicide risk.
All three youth observation logs documented mental health (MH) staff provided support
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counseling services. Further review indicated each of the youth in secure observation had their
level reduced only after a conference with the superintendent and licensed MH professional.
Additionally, the youth’s discontinuation of secure observation and step-down to close
supervision documentation was confirmed after review of the center’s logbook and the youth’s
mental health record. An interview with the center’s superintendent indicated the center uses
secure observation for potentially suicidal youth.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures for the process to safely screen, refer, assess,
monitor, and protect youth with elevated suicide risk in the least restrictive means possible. A
review of seven youth mental health and substance abuse records verified six youth were
applicable for having been placed on suicide precautions. Five of the six youth had a Suicide
Precautions-Observation (PO) Log maintained in real time and each was maintained for the
duration the youth was on suicide precautions. One youth’s PO log was not maintained for the
entire duration the youth was on suicide precautions. The log had a gap for three of the twenty-
two hour duration the youth was on PO. The review of the PO logs for five youth found the staff
were documenting the youth’s behavior at thirty-minute intervals or less. None of the youth were
applicable for having warning signs documented on the PO logs. Each of the youth’s PO logs
included the signature of the mental health staff. Each of the five youth PO logs were signed by
the center’s shift supervisors and three logs documented safe housing requirements.
Observations of video footage for three random dates confirmed four youth on PO slept on a
portable bed in the module activity area. A review of video footage confirmed staff were always
present while the youth were on PO. A review of the close supervision logs indicated youth were
being supervised at five-minute intervals.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures to address suicide prevention training. The policy
requires all staff who work with youth be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions. A total of
seven in-service and seven pre-service staff training records were reviewed. Three staff training
records indicated the mental health and substance abuse training was not completed. One staff
training record was missing the required suicide training. A total of four suicide response kits are
located throughout the center. Two kits are located in sub-control, one is in medical, and one kit
is in master control. All suicide response kits include the rescue tool, wire cutters, and needle
nose pliers. Observations confirmed the suicide kits were co-located with the first-aid kits. A
review of the center’s drill logbook confirmed suicide drills were being completed quarterly on
each shift. Reviewed documentation confirmed, since the last annual compliance review,
suicide drills included the use of the suicide kits and were documented in the logbook with a
sign-in sheet to confirm staff participation. The mock mental health drills were in response to a
suicide attempt and/or incident of serious self-injury, were simulated, and did not include any
center youth. Staff who were not present during a quarterly drill did have the opportunity to
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review each drill scenario. Seven staff were interviewed and stated they knew the location of the
suicide response kits in master control, sub control, and medical. Four staff reported there is a
suicide response kit located in the shift supervisor’s office.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures regarding crisis intervention services and an
Emergency Services Plan. The policy requires the center’s staff to 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 center. The center maintains a Combined Emergency
Service Plan. Documentation and review of the Combined Emergency Service Plan confirmed
the notification and alert system, means of referral, including self-referral, communication, and
supervision were included.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures to address the Emergency Care Plan which
stipulates the response procedures for youth in crisis. The reviewed Emergency Care Plan
included all the required elements of immediate staff response, notifications, communication,
supervision, authorization to transport for emergency mental health or substance abuse
services, transport for emergency mental health evaluation and treatment under Chapter 394
Florida Statute, Baker Act, and the transport for emergency substance abuse assessment and
treatment under Chapter 397, Marchman Act. The Emergency Care Plan was located in the
mental health office, and was updated on July 18, 2025, and approved on August 8, 2025.
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.
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The center has facility operating procedures regarding Crisis Assessments. The policy requires
a detailed evaluation of a youth demonstrating acute psychological distress. Three youth
records were reviewed for a Crisis Assessment (CA). All three youth’s CAs documented a
reason for assessment and a Mental Status Examination and interview. The CAs consisted of
documentation for determination of danger to self/others, initial clinical impressions, supervision,
treatment recommendations, and follow-up evaluation recommendations. Two of the three
records did not have notifications to the parent/guardian for follow-up treatment. A review of the
mental health alerts in the Department's Juvenile Justice Information System (JJIS) confirmed
all three youth were placed on precautions after the completion of a CA. Two of the three youth
were identified by the direct care staff or clinical staff for having acute emotional or behavior
problems, or acute psychological distress, and were appropriately referred for an assessment.
The licensed mental health professional completed the CA immediately or within two hours for
emergencies, or within twenty-four hours based on the needs of all three youth. None of the
youth were applicable for being an alleged Prison Rape Elimination Act (PREA) victim receiving
mental health treatment services. The interviewed designated mental health clinician authority
(DMHCA) stated, in the past six months, the center had a total of four youth engage in, or
attempted to engage in, self-injurious behavior, and thirteen youth made suicidal
gestures/actions. The DMHCA stated the center had one youth still in the center who attempted
self-injurious behaviors.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures for Baker and Marchman Acts. The policy requires
youth who are believed to be an imminent danger to themselves or others because of mental
illness or substance abuse impairment require emergency mental health or substance abuse
services. Three youth records were reviewed, and all youth were applicable for having a Baker
Act documented. A review of precautionary observation (PO) log documentation for all three
applicable youth showed all were placed on one-to-one supervision. Each youth had a
completed mental health referral for a Mental Status Examination and was placed on suicide
precautions upon re-admission from Baker Act. Assessment of Suicide Risk documentation
confirmed all three youth’s supervision levels were maintained until youth were properly
transitioned to a lower level of supervision, after the completion of an assessment, and after a
conference between the licensed mental health staff and the superintendent or designee.
Discontinuation of the mental health alerts in the Department's Juvenile Justice Information
System (JJIS) were completed as required.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures to ensure clinical services are provided to all youth
in the center. The center retains a contract with VitalCore Health Strategies, LLC, who
subcontracts with an osteopathic physician (DO) to serve as the center's DHA. The DHA holds
an unrestricted, clear, and active license which meets all requirements for independent and
unsupervised practice in the State of Florida, which expires on March 31, 2026. The center
utilizes a part-time advanced practice registered nurse (APRN).) whose license expires July 21,
2026. The APRN has a signed Collaborative Practice Protocol in place with the DHA. A review
of the sign-in and sign-out logs during the annual compliance review period confirmed the DHA
was on-site for at least two hours each week, with a week defined as the seven days beginning
on Sunday and ending on Saturday, and is available twenty-four hours a day, seven days a
week for acute medical concerns, emergency care, and coordination of off-site care. The center
did not utilize telemedicine during the annual compliance review period. According to an
interview with the DHA, the role of the DHA includes both in-person clinical work and reviewing
protocols. The DHA performs Comprehensive Physical Assessments (CPAs), CPA updates,
and sick calls for each youth. The DHA reported being on call for in-person nursing when
evaluating youth for acute issues and chronic management. The DHA reviews and approves
protocols for certain acute situations. The DHA confirmed they are on-site at least once a week.
The DHA communicates with the program staff regarding youth medical needs. The DHA is
available to staff when not on-site by telephone. The DHA provides on-site clinical services. The
DHA reported all orders are made by nursing staff and must be signed by the DHA when they
are on-site. Off-site call orders are added to the sick call list and evaluated when the DHA is on-
site. Each youth has an intake performed within twenty-four hours to review chronic and acute
health issues, and each youth is evaluated within seven days by either the DHA or the ARNP. If
coverage is needed, the DHA would call their supervisor.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures for all health-related procedures and protocols
used. The designated health authority (DHA) reviewed, signed, and dated all medical Facility
Operating Procedures (FOPs) on October 23, 2025. The superintendent signed on November 1,
2024, and reviewed documentation confirmed each nurse reviewed, signed, and dated the FOP
cover page on October 23, 2024. Reviewed documentation showed FOPs for all health-related
procedures and treatment protocols were utilized at the center and signed on May 22, 2025.
The DHA and the psychiatrist reviewed and developed the FOPs related to psychiatric services
and psychotropic medication management. Reviewed documentation found all newly employed
healthcare personnel received a comprehensive clinical orientation to the Department's health
care policies and procedures, given by a registered nurse (RN), and the approval of treatment
protocols or standing procedures were written and authorized by the DHA.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures to ensure the completion of the Authority for
Evaluation and Treatment (AET) or Limited Consent for Evaluation and Treatment authorizing
specific treatment for youth in the custody of the Department. A review of seven youth Individual
Healthcare Records (IHCRs) revealed six had a valid Authority for Evaluation and Treatment
(AET), which was signed by the parent/guardian and a Department representative. One youth
had a Limited Consent for Evaluation and Treatment, which was signed by the judge, and a
representative from the Department of Children and Families (DCF). Reviewed documentation
found the center's practice is to have the youth provide consent for medical services once they
reach eighteen years of age. During an informal interview, the nurse reported all efforts are
made to obtain a valid AET once the youth enter the center. The nurse reported contacting the
assigned juvenile probation officer (JPO) to assist in obtaining the parent’s/guardian’s signature.
In the event the JPO is unable to obtain a signature from the parent/guardian, the
superintendent or designee will sign a Limited Consent for Evaluation.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures to ensure the parents/guardians are notified of
significant changes in the youth's condition and obtain consent when new medications and
treatments are prescribed. A review of seven youth Individual Healthcare Records (IHCR)
reflected one record contained documentation of parental notification for an over-the-counter
(OTC) medication beyond those covered by the Authority for Evaluation and Treatment (AET).
Consent was provided by the parent/guardian. Two youth had written notifications utilizing the
Department's Parental Notification of Health-Related Care form for new medications. Reviewed
documentation confirmed three of the seven youth were taking psychotropic medications at
admission. When applicable, attempted telephone contacts were documented in the progress
notes. One record was applicable for a newly prescribed medication, and there was
documentation of the parent/guardian contact in the progress note. The nurse provided a copy
of a parental notification for OTC medications, which was mailed during the annual compliance
review week. Reviewed documentation confirmed each of the seven reviewed IHCRs had
vaccination/immunizations records obtained and verified within thirty days of admission. An
informal interview with the nurse indicated parental notifications are to be made when starting
new medication, and the medical staff will contact the parent/guardian in order to ensure
parental notifications are made.
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4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures to ensure each youth receives a healthcare
admission screening utilizing the Department's Medical and Mental Health Admission Screening
form. A review of seven youth Individual Healthcare Records (IHCRs) found each contained a
Medical and Mental Health Admission Screening form completed on the date of the youth's
admission by the juvenile justice detention officer (JJDO) and it was reviewed by the licensed
nurse within twenty-four hours. Each screening form was completed in the Department's
Juvenile Justice Information System (JJIS). Reviewed documentation confirmed the designated
health authority (DHA) was notified of each youth's admission. One of the seven youth was
applicable for a healthcare admission rescreening. Reviewed documentation confirmed a
rescreening was completed by the JJDO and reviewed by the nurse within twenty-four hours of
the screening. Four youth’s IHCRs included documented verbal/written consent to receive a
qualitative urine pregnancy screening test. An interview with the center's nurse confirmed the
center's practice for completing an admission screening within the required timeframe.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the center. Each youth orientation included topics
addressing access to medical care, sick call, instances which constitute an emergency and
when to notify staff, the medication process and side-effect monitoring, the youth's right to
refuse care and how refusals are documented, what to do in the case of a sexual assault or
attempted sexual assault, the non-disciplinary role of the healthcare providers, and general
infection control/hygiene. Each reviewed IHCR included documentation to support the youth
received a general healthcare orientation within twenty-four hours of their admission to the
center, as documented on the Health Education Record form.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures to ensure the designated health authority (DHA) is
notified when youth admitted to the center require emergency care or routine notification. The
center's practice is to notify the DHA of the admission of any youth with a chronic medical
condition, psychotropic medication, or medical concern. A review of seven youth Individual
Healthcare Records (IHCRs) showed one was applicable for known or suspected chronic
conditions, three youth were currently taking psychotropic medication upon admission, and one
was taking medication. The youth records included a referral to the physician/advanced practice
registered nurse (APRN) and the youth were not identified as in need of emergency care upon
admission. The youth records included notification to the DHA documented in the chronological
progress notes within the required timeframe, and the psychiatrist was notified for each youth on
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psychotropic medication. During an interview, the nurse provided the timeframe and practice for
notifying the DHA when youth are admitted with a chronic condition or require emergency care.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures regarding the Health-Related History (HRH) form,
which indicates the HRH form shall be completed no later than seven days following the date of
the youth's admission. A review of seven Individual Healthcare Records (IHCRs) confirmed the
HRH was completed within seven calendar days of the youth's admission and was
updated/completed prior to the Comprehensive Physical Assessment (CPA), as evidenced by
signature and date. Reviewed documentation indicated a licensed nurse or practitioner
reviewed each HRH form. Each youth's HRH form was reviewed by the physician/advanced
practice registered nurse (APRN) and contained signatures and dates for the most current
admission. An interview with the clinical nurse manager stated the nurse is responsible for
completing the HRH, and the time frame for its completion is at intake.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures to ensure each youth in the center has completed a
Comprehensive Physical Assessment (CPA) upon their admission into the center. A review of
seven Individual Healthcare Records (IHCRs) was completed and all seven contained a current
CPA on file at the time of admission. Each CPA was completed or reviewed within seven days
of the youth's admission and signed by the designated health authority (DHA) or the advanced
practice registered nurse (APRN). Each CPA was completed in full to include the Medical
Grade, Tanner Stage, cardiovascular, body mass index, visual acuity field, and most recent
Tuberculosis Skin Test (TST). All sections of the CPAs were marked with an O or an X. A
review of each reviewed CPA found the DHA documented "asymptomatic/not clinically
significant" for sections nineteen through twenty-four for male and female youth, when
applicable. The center's policy and procedures for Tuberculosis (TB) control and screening
require the routine screening of all youth for latent and active TB and outline environmental
controls in the case of a youth with suspected active TB. Each of the reviewed records
documented a TST had been completed within the last year, and none of the reviewed youth
required further evaluation prior to entering the general population. All seven records had all
sections of the CPA completed or noted by the DHA or APRN as not being medically indicated.
The Department's Problem List was updated in each reviewed instance, as required. An
interview with the clinical nurse manager reported female youth do not routinely receive
gynecological exams.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures in place to ensure all youth entering the center are
clinically screened, evaluated, and treated, if necessary, for sexually transmitted infections
(STIs) and human immunodeficiency virus (HIV). A review of seven Individual Healthcare
Records (IHCRs) indicated six youth were clinically screened and evaluated for STIs. One youth
record indicated no screening was required. Four youth records included referrals, and testing
was ordered; and two were not applicable for a referral. There were no youth applicable for
being out of the Department's custody for thirty days or more who needed a rescreening during
the annual compliance review period. All seven reviewed records validated each youth was
offered counseling and testing for human immunodeficiency virus (HIV). Two of the seven youth
consented and received HIV testing, while five were not applicable. Each youth's HIV test
results were filed in the youth's hard copy record, and there was proof of the document.
Reviewed documentation confirmed pre-test/post-test counseling was documented on the
individual health education record and/or was in the youth's progress notes and the youth's
confidentiality was protected by not including the youth's HIV status or any other STI diagnosis
on the center's internal alert system. Seven interviewed youth reported they can request HIV
testing.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains a written policy and procedures to ensure all youth are able to make sick
call requests and have their complaints addressed through the sick call system. A review of
seven Individual Healthcare Records (IHCRs) reflected three youth were applicable for sick
calls. Each applicable youth's sick call was documented on the Sick Call Referral Log. The
nurse completed each sick call request in accordance with Florida Administrative Code. There
were no instances of a youth presenting with a similar sick call complaint three or more times.
None of the three applicable youth had complaints of severe pain staff were unfamiliar with
and/or the youth's medical condition could not be determined. There were three instances
where a licensed practical nurse (LPN) conducted a sick call, and it is reviewed by the clinical
nurse manager and documented on the form. Reviewed documentation reflected the Sick Call
Request forms were filed in the youth's IHCRs in reverse chronological order. All three youth
sick call forms were documented in accordance with Florida Administrative Code. All three
youth sick calls were documented on the Sick Call Index, and the dates correspond to the
completed Sick Call Request forms located in the IHCR. Postings throughout the center
indicated sick call takes place daily from 10:00 a.m. to 11:00 a.m. and 3:00 p.m. to 4:00 p.m.,
when youth are securely detained at the center; however, the clinical nurse manager indicated it
is typically the center's practice to provide a "flexible sick call" by responding to requests as
episodic care. The center has procedures in place for the shift supervisor to review all sick call
requests as soon as possible and within four hours after the request is submitted. During the
week of the annual compliance review, one sick call was observed. The youth was escorted to
the medical clinic by a direct care staff member. The youth's verbal consent was obtained prior
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to observation. The youth was observed in a private area with no other youth present to witness
or hear the examination. The medical staff was able to maintain privacy while the officer was
located by the door of the medical area. Seven youth were interviewed. Two youth reported it
takes two days to be seen once you make a sick call request, three youth reported they are
seen immediately, two reported never submitting a sick call request, and three additionally
reported the nurse conducts sick call within the required time frame. An interview with the
clinical nurse manager revealed the process for youth requesting to see a nurse and/or a
physician for health complaints. The youth can submit a sick call and be brought to medical for
the issue between 10:00 a.m. and 11:00 a.m. or between 3:00 p.m. and 4:00 p.m. The nurse
reported they routinely conduct sick calls; however, if conducted by the LPN on the weekend,
then the registered nurse (RN) will review the report the following Monday. The nurse reported
the DHA conducts sick calls when on-site. The nurse reported the process for referring youth to
the DHA/APRN when the youth have presented with repeated, similar sick call complaints. The
nurse reported the youth are placed on the report sheet to be seen during the next scheduled
time the DHA is on-site. Seven staff were interviewed and six reported the nurse conducts sick
calls, and one reported the doctor 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.
The center has facility operating procedures ensuring a comprehensive process for episodic
care, first aid treatment, and emergency care. The center utilizes an Episodic Care Report to
document episodic care and first-aid treatment. A review of seven Individual Healthcare
Records (IHCRs) revealed only one was applicable. An additional two records were requested.
All three-youth required on-site first aid or episodic care, with dates and times noted. Each
applicable youth received episodic care or first-aid from a licensed nurse. Each applicable IHCR
documented problem-oriented elements, which were used to capture pertinent information
pertaining to the nature of the youth's complaint, including identification of the subjective,
objective, assessment, and plan (SOAP) to address the complaint for each incident. All three
occurrences of episodic care required a referral for off-site care. A review of the Episodic Care
Log Report found all entries were completed. When applicable, a plan for follow-up care was
documented, and each youth was placed on the alert list, with parental notification documented.
The center maintains two automated external defibrillators (AEDs). The center's AEDs are
located in wall-mounted AED boxes in the medical clinic and master control. The AED batteries
and pads are checked by medical staff and an outside medical provider to confirm each is
operable. The AED procedures are stored with the AED, and each AED provides audible
instructions when utilized. Nursing staff check the AEDs weekly to ensure the AED is
operational and the checks are documented. A review of the center's AED tracking sheets
during the annual compliance review period validated the center's practice. The batteries in the
AEDs, which were last changed on April 23, 2025, were observed to be fully charged as
determined by the light on the front of each device showing green. The AED pads were last
changed on September 10, 2025, and expire March 28, 2026. There are six first-aid kits used
for transportation. An observation of three randomly selected first-aid kits was conducted. Each
first-aid kit was fully stocked with DHA-approved contents. Each first-aid kit contained a monthly
checklist log on the outside, confirming the nurse had checked all contents and none had
expired. A review of quarterly mock emergency drills conducted over the past twelve months
revealed the center's practice is to hold monthly emergency drills on each shift. The emergency
drills confirmed the drills were conducted at least once a month on each shift and documented
the use of life-saving techniques such as cardiopulmonary resuscitation (CPR) at least once
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during the review period. A video observation of a medical drill verified the drill was completed
as required. Observations confirmed emergency contact telephone numbers were posted out of
the view of the youth. Only healthcare staff and trained supervisory non-healthcare staff can
administer the epinephrine auto-injector for youth requiring administration, when indicated.
Reviewed documentation showed authorized direct care staff were trained on the administration
of the epinephrine auto-injector. A review of seven training records found five staff received the
required training on the center's Emergency Care Plan and two staff did not complete the
training. All seven staff were trained in first-aid, CPR, and AED. The nurse confirmed the
center's policy on the use, access, and inventory of Narcan. The nurse reported medical staff
and supervisors are the only staff with access. Narcan training is embedded within the
Department's Learning Management System (SkillPro) CPR course. The center's nurses are
responsible for conducting and simulating staff trainings on Narcan and its use with an
instructor-led class for the supervisors trained and approved for medication administration. An
observation of the medical cart found the center stores Narcan in a locked container inside the
medical cart. Reviewed documentation confirmed the nurse retains a weekly inventory of the
Narcan. Seven youth were interviewed, and six stated the medical care was good, and one
stated they had never received medical attention. Four youth reported the nurse gives
medication and three reported not taking medication.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures to provide timely referrals and coordination of
medical services for youth requiring off-site care. A review of seven youth Individual Healthcare
Records (IHCRs) found one youth was applicable; therefore, two additional IHCRs were
selected for review. Each applicable record included the Summary of Off-Site Care Consultation
Report form. Reviewed documentation, found each off-site non-emergent care incident was
documented on the Episodic Care Report. When applicable, parent/guardian notification was
documented. One youth was entered on the sick call log, as their off-site care was applicable for
discharge paperwork, and two were not applicable. Reviewed documentation confirmed the
designated health authority (DHA) reviewed and signed/initialed all follow-up appointment
documents. Reviewed documentation confirmed the referrals were tracked and the youth
received the appropriate follow-up care. An interview with the center's nurse confirmed the
center's practice for off-site care, referrals, and follow-up care.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures to ensure youth identified with chronic conditions
receive regularly scheduled evaluations and necessary follow-up care. Youth are screened
during the intake process for medical conditions warranting periodic evaluations and follow-up
care. A review of seven youth Individual Healthcare Records (IHCRs) found five youth were not
applicable and two youth were identified with a chronic medical condition; therefore, one
additional youth record was requested. All three youth were placed on the chronic list, and there
were no youth with a communicable disease during the annual compliance review period. One
youth was taking prescribed medication regularly, and two youth were undergoing treatment for
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a physical health problem. Each youth was classified with an appropriate Medical Grade. There
were no youth identified as being pregnant. There were no youth applicable for taking anti-
Tuberculosis medication. The Problem List for each youth was updated to indicate each youth's
chronic condition upon completion of the Comprehensive Physical Assessment (CPA). An
interview with the nurse in comparison to the center's Chronic List Report confirmed periodic
evaluations are tracked by medical staff. In addition, an interview with the designated health
authority (DHA) validated periodic evaluations are conducted every ninety days, or sooner if
indicated. Additionally, the DHA stated they would check with the clinical manager and review
records at each intake to ensure all youth with a chronic condition receive periodic evaluations
as required. An interview with the clinical nurse manager reported youth are seen as needed by
the DHA or the APRN and youth with chronic conditions are monitored.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures requiring medication to be stored, inventoried, and
provided in a safe and effective manner to youth. A review of seven Individual Healthcare
Records (IHCRs) confirmed four youth were taking medication at admission, and three were not
applicable. The prescription verification was included in the chronological progress note in the
IHCR/electronic medical record (EMR), or by utilizing the Prescription Medication Verification
Checklist form. Reviewed documentation confirmed the nursing staff notified the designated
health authority (DHA) of each admission on the youth's day of admission. All medications had
a current, valid order, and were administered pursuant to a current prescription. When current
medications were continued, discontinued, or changed, or new ones were ordered, the reviewed
records indicated the DHA placed an order on the Practitioner Order form, as required.
Reviewed documentation of prescription verifications, showed they were documented in the
chronological progress notes in the IHCR/electronic medical record (EMR). There were no youth
in restricted housing. All four applicable youth had over-the-counter (OTC) medications not
listed on the Authority for Evaluation and Treatment (AET) form, which were administered
according to approved protocols or the practitioner's order. The standard Department
Medication Administration Record (MAR) was used to document all medications and treatments.
The center utilizes the standard MAR/EMR to document all medication and treatment. The MAR
clearly indicated medication start and end dates. Each youth received either prescription
medications on a routine basis or OTC medications. There were no trained non-healthcare staff
assisting in the delivery of medication. Additionally, the nursing staff documented side effect
monitoring, at a minimum, weekly on the MAR. One youth's refusal was clearly documented on
reviewed MAR. Each MAR clearly documented the youth's name, Department identification
number (DDJID), date of birth, youth allergies, precautions, Medical Grade, medical alerts, and
current picture of the youth. Reviewed documentation reflected the staff documented weekly
side effect monitoring on the MAR, initialed each administered medication entry, and each
applicable youth documented their initials on the MAR. There were no standing orders for
psychotropic medications, emergency orders for psychotropic medications, or pro re nata (PRN)
orders for psychotropic medications. Observation of a medication administration was conducted
during the week of the annual compliance review, and no issues were identified. An interview
with the nurse revealed when a youth is admitted with medications, the nursing staff must verify
the youth's medication regimen. The nurse reported the youth’s parents/guardians bring the
medications into the center and speak with a nurse to review them. The center's practice is for
all youth taking medications to receive a medication monitoring/review every thirty days. An
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interview with the nurse confirmed the center's practice regarding medication management and
the center's disposal process. The nurse reported the type of MAR the program uses is the
standard Department MAR. The nurse was asked if non-healthcare staff provide medications,
and the nurse reported yes. The nurse reported the clinical nurse manager trains the
supervisors on how to administer medications. When asked how medications/prescriptions are
procured, it was reported the medications are ordered through a contracted pharmacy, and the
center rarely needs to go to the back-up community pharmacy to obtain medication. The nurse
indicated the center utilizes a chemical pharmaceutical drug disposal system to dispose of
expired medication in the presence of the consultant pharmacist. An interview with seven staff
regarding medication administration, reflected one staff reported they do assist in the
administration of medication, and six reported not giving medication to the youth. Seven youth
were interviewed, and four indicated the nurse administers their medication, while three
reported not taking medication.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility procedures ensuring psychiatric services include psychiatric evaluation,
psychiatric consultation, medication management, and medical supportive counseling for youth
with a diagnosed Diagnostic and Statistical Manual, Fifth Edition (DSM-5) mental disorder
and/or substance-related disorder. Each youth receiving psychotropic medication in the center
shall receive services as outlined in Florida Administrative Code. The psychiatrist's license
expiration date is March 31, 2026, and the psychiatric advanced practice registered nurse
(APRN) license expiration date is April 4, 2027. The center does not have a back-up
psychiatrist. A review of the contract indicated the center is approved to provide telemedicine
and telepsychiatry services. The interviewed designated mental health clinician authority
(DMHCA) reported meeting with the psychiatrist weekly to discuss youth receiving psychiatric
services. A review of seven Individual Healthcare Records (IHCRs) found three youth were
applicable for psychiatric services, and four were not applicable. All three youth entered the
center on psychotropic medication and received an initial diagnostic interview within fourteen
days of the youth's admission to the center. The initial diagnostic psychiatric interview included
a reason for the referral, history of any medical, mental health and substance abuse history, a
Mental Status Examination, DSM-5 diagnosis, and treatment recommendations specific to
mental health and /or substance abuse diagnoses. Reviewed documentation confirmed the
psychiatric interview documented the medication name, explanation of the need for medication,
frequency of medication management, and monitoring. A review of the Clinical Psychotropic
Progress Notes (CPPNs) revealed an in-depth psychiatric evaluation was conducted on all
referred youth within thirty days of admission. There were reasons and factors leading to the
referral documented for each applicable youth. The youth’s developmental history, medical
history including medical disorders, head trauma, prenatal exposure to alcohol/drug substance
abuse history, school history, social history, emotional development, peer relations, family
relationships, interest/talents, traumatic experiences, physical/ sexual abuse, neglect,
witnessing violence, and other forms of trauma were included in the evaluations. The CPPN
documents included mental health status and identification of individual family and or
environmental factors which may potentially influence or ameliorate the youth's difficulties. All
three youth came to the center with their medication, and no youth at the center were prescribed
any medication.
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4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center has facility operating procedures ensuring medical equipment classified as
medication or sharps are secured and inventoried using a routine perpetual inventory.
Additionally, procedures detailed the requirements for the storage and inventory of medication
and sharps and required all medication to be inaccessible to youth at the center. Observations
found all medical equipment classified as sharps were secured and inventoried using a routine
perpetual descending count, as each sharp was utilized and disposed of. All medications were
identified and secured in a locked area designated for the storage of medication. The
medication cart was clean and organized with stocked items separated from youth-specific
medication. All controlled substances had a perpetual inventory and were stored separately
from other medications. All medications were stored in a separate, secured area which was
inaccessible to the youth. Narcotics and other controlled medications were securely stored and
double-locked within the medication cart. Observations verified the oral medications were not
stored with injectable or topical medications. The center had no medication requiring
refrigeration during the annual compliance review week; however, the center has a refrigerator
which is used only for medication. Perpetual inventories with running balances are maintained
on all controlled substances, with a shift-to-shift inventory conducted. Weekly inventories are
conducted by the nurses every Thursday. An interview with the nurse reported only supervisors
are trained in the delivery and oversight of medication, and training is delivered by a registered
nurse (RN). A count with the RN of three controlled medications, three over-the-counter (OTC)
medications, and three sharps showed all counts matched the ending inventory numbers. The
nurse stated if there is a discrepancy regarding the inventory, they will notify the supervisor and
report the discrepancy to the Department’s Central Communications Center (CCC). The nurse
was able to explain the disposal process, stating the pharmacist comes in every month and
meds are destroyed using a chemical agent.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines The
comprehensive education plan shall include pre-service and in-service training for all staff.
Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures requiring the implementation of infection control
procedures including prevention, containment, treatment, and reporting requirements related to
infectious diseases, according to the Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. A
review of seven youth Individual Healthcare Records (IHCRs) was conducted. Reviewed
documentation indicated each youth received infection control training within seven days of
admission. The infection control training included hand-washing techniques, universal/standard
precautions, prevention/transmission of communicable diseases, vaccinations, and the Centers
for Disease Control and Prevention (CDC) guidelines for infection control. A review of the
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center's Exposure Control Plan/Infection Control Plan showed the plan was written in
accordance with OSHA guidelines to include risk assessment and methods of compliance. The
infection control procedure includes prevention, containment, treatment, and reporting
requirements related to infectious diseases, as outlined by OSHA and the CDC guidelines. The
plan addressed common childhood infectious diseases, self-limiting, episodic contagious
illnesses, viral and bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), blood-borne pathogens, other outbreaks or epidemics, and
outbreaks of pediculosis. In addition, the plan included Methicillin-Resistant Staphylococcus
Aureus (MRSA) food-borne illnesses and other antibiotic-resistant microorganisms, bioterrorism
agents, and chemical exposures in the workplace, and protocols for needlestick post-exposure
intervention and treatment. The center's post-exposure process for evaluating needle sticks
includes washing hands for two minutes, reporting the stick to the immediate supervisor,
documenting the circumstances, route of exposure, and the source individual and their status.
The center ensures Hepatitis B immunizations are available for staff, and staff have access to
protective equipment as needed. There were no reportable incidents for which the local county
health department, CDC, or the Department's Central Communications Center (CCC) was
notified relating to an infectious disease during the annual compliance review period. A review
of seven pre-service and seven in-service staff training records confirmed each staff completed
Exposure Control Plan/Infection Control Plan training. The interviewed nurse reported a copy of
the plan is accessible to staff and located in the medical clinic.
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 is 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 address the supervision of youth. During the
annual compliance review week, supervision of youth was observed each day of the review.
Youth and staff observations were conducted on the living modules, in classrooms, in the
cafeteria, in the booking area, during line movements, and during medication pass. Youth were
always in sight of at least one juvenile justice detention officer (JJDO). Detention staff always
maintained continuous sight and sound supervision of youth. Before movement of youth, each
JJDO would ask master control for permission to move to their destination and master control
would authorize all movement throughout the center. Observed interactions between youth and
staff demonstrated active supervision each day of the annual compliance review. Seven staff
were interviewed, and all seven staff reported they believe there is enough staff to provide
safety and security for youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures requiring a uniform behavior management system
(BMS) which offers a set of rewards, privileges, and consequences for behavior. The center has
a system of rewards, privileges, and consequences to motivate youth to meet and exceed the
center’s expectations. During a tour of the center postings of the BMS system were posted in all
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living areas which clearly specified appropriate and inappropriate behaviors, rules, and
expectations. A review of point sheets, and logbooks was conducted during the annual
compliance review week and confirmed youth were receiving their rewards and being held
accountable for their actions daily. The center prohibits the use of group punishment and there
were no instances of inappropriate use of restrictions or group punishment displayed during the
annual compliance review. Seven staff were interviewed, and all staff stated they had
knowledge of the BMS and were able to explain the system and believe the system is effective.
Each staff stated youth can earn rewards such as snacks, extra telephone calls, special visits,
access to the multi-purpose room, and a later bedtime. All seven staff stated they speak with the
youth to discuss the consequences being imposed and speak with youth about alternate
acceptable behaviors. Each staff stated youth have the ability to explain their behavior. Each
stated they receive feedback from their supervisors regarding the implementation of the BMS
during staff meetings, shift changes, through emails, and through one-on-one conversations on
a daily basis. Youth can drop a level and not earn points as a consequence for inappropriate
behavior. All seven staff stated they have never seen a co-worker take away meals, snacks,
clothing, education, or medical care from a youth because they were acting out. All seven staff
stated they have not observed any staff encouraging youth to beat up another youth. Seven
youth were interviewed, and six youth rated the BMS system as very good, and one youth rated
the BMS system as good. All seven interviewed youth had a general knowledge of how the
system works. Six youth reported staff use rewards the same, one youth reported they haven’t
been rewarded yet because they were recently admitted to the center. Six youth reported they
receive an orange jacket, canteen items, special visitation, access to the multi-purpose room,
extra snacks, and a later bedtime as rewards. Five of seven interviewed youth stated they were
not sent to their room as a punishment. Two youth stated they were sent to their room for being
disrespectful, not following directions, and arguing with other youth. The youth reported the door
to their rooms were shut and locked. Three youth reported they believe the consequences are
fair, four youth reported they never received consequences. Seven youth reported youth are not
allowed to punish other youth. Four of seven interviewed youth stated they have never received
consequences, three youth stated staff would drop a level or they would not earn points for
inappropriate behavior. Seven youth stated they never witnessed handcuffs or restraints being
used to prevent a youth from harming themselves or others. The superintendent was
interviewed and reported the center has a BMS which enhances safety and security as it relates
to youth’s behavior and promotes the health and well-being of youth by providing an
environment which fosters social, emotional, intellectual, and physical development.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks to ensure ten-minute
checks are conducted when youth are in their rooms for sleeping purposes, shift change, and
confinement. The observations by a staff member assigned to monitor a youth shall occur at
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intervals not to exceed ten-minutes throughout the youth’s stay in their room and/or sleeping
areas. Visual checks must be made of the youth’s condition, such as outward appearance,
behavior, and position in the room. When conducting room checks, staff must pause at each
room door and look inside the room to ensure there are no issues with the youth. There are
thirty-seven security cameras at the center, of which all were operational at the time of the
annual compliance review. The center utilizes Visual Observation Reports (VORs), which are
written reports, to document room checks. A review of ten-minute check log samples for each
month since the last annual compliance review, reflected checks were consistently conducted at
intervals of no more than ten-minutes. There were computer issues during the month of January
2025 with the local drive, and some VOR documentation was unrecoverable. A review of the
documentation and surveillance coverage was conducted for nine randomly selected dates
during the thirty days prior to the review, across two shifts, and on two different youth modules.
The review confirmed the ten-minute checks were being conducted at intervals of ten-minutes
or less with the exception of three checks which were conducted two to eleven minutes late.
Seven staff were interviewed, and each staff stated checks are conducted every ten-minutes or
less. An interview with the superintendent reported anytime a youth is placed in their room, staff
are assigned to monitor the youth at intervals not to exceed ten-minutes and a VOR is used to
document the checks.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures to ensure staff always know the exact number and
location of all youth under their supervision. During the annual compliance review a headcount
throughout the center was observed. Master control called for the headcount, and each living
module had a juvenile justice detention officer (JJDO) respond with the headcount for the
module. Master control verified the headcount and cleared the count and documented the
findings in the master control logbook. A review of the master control logbooks confirmed the
census counts of youth are written at the beginning and at the end of each shift. Counts are
conducted and documented, at a minimum, one additional time randomly during each shift.
Counts were documented following emergencies, disturbances, and drills. Census counts were
documented upon any change in population. Living module counts were recorded in their
assigned module logbooks. Seven staff were interviewed and reported youth counts are
conducted at the beginning and the end of shift. In addition, six staff reported head counts are
conducted before/after school and before/after meals. Seven interviewed staff stated
emergency counts are conducted when a youth is believed to be missing, when visibility is
hindered, and after a major disturbance.
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5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures regarding logbooks. The center maintains separate
logbooks for master control, each module, for visitors, and for each vehicle. A review of
logbooks since the last annual compliance review revealed logbooks were bound with
numbered pages and displayed the date at the top of each page. All entries included the times
of the events in a.m./p.m. format and were not displayed in military time, the name of the staff
and youth involved were displayed, a brief description of the events, and the initials of the staff
making the entries. All entries impacting the safety and security of the center, including
medical/special needs and mental health alerts were highlighted. All errors were struck through
with a single line and had void written after the error followed by the staff’s initials. Reviewed
master control logbooks included emergency situations, incidents, fire and escape drills,
population counts at the beginning and end of each shift, group movements, admissions and
releases, presence of law enforcement, and name of youth placed in confinement, including the
time confinement began and the time confinement ended, name of youth placed on
precautionary/secure observation, including the time precautionary/secure observation began
and the time precautionary/secure observation was discontinued. The master control and living
unit logbooks for the past nine months were reviewed. The juvenile justice detention officer
supervisors (JJDOS) reviewed 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 superintendent or designee reviewed the logbooks on a weekly basis. The juvenile
justice detention officer (JJDO) assigned to the modules reviewed the logbooks upon accepting
the shift. An interview with the superintendent confirmed supervisors are required to document
their reviews and security checks in the center’s logbooks at a minimum of two times during
their shift. The superintendent or designee is required to document their review and security
checks at a minimum of once a week on each shift.
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5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures regarding key control, issuance of keys to staff,
inventory and tracking, key restrictions, storage, missing or lost keys, and reporting and
replacement of damaged keys. A review of the key inventory confirmed the key rings on the
inventory matched the actual key rings in use. Staff keys are secured in master control and are
issued to staff during shift change. Emergency keys are secured in master control and only the
superintendent and assistant superintendent have access. All center keys were maintained on a
tamper-resistant ring and color coded in accordance with policy. The master key inventory
included the ring number, number of keys on each ring, capability of each key, and to whom the
key ring was issued to. The issuance of keys and key ring numbers were documented on each
shift report. Additionally, key logs included the date and time of issue, the name of the staff, and
the time the key ring was returned. Based on observations during the annual compliance review
week, staff carried their center issued keys on them at all times, did not allow youth to handle
keys, and did not remove keys from the center without the approval of the superintendent. The
key box was not easily accessible when locked and would not be opened without a key. Three
staff were informally interviewed about their keys, and all knew the number of keys on their ring
and the function of each key in their possession. An informal interview with the master control
operator revealed all staff give a set of personal keys as collateral for issuance of a chit or
center keys. Seven interviewed staff stated restricted keys include medical, youth property area,
medical records, case management records, and kitchen. Seven staff were interviewed and
reported staff and visitors’ personal keys are securely stored in master control before going to
the secure floor. All seven staff reported youth do not have access to keys and they notify
master control and conduct a center-wide search if keys go missing. The superintendent was
interviewed and reported 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 procedures and operation of
Department owned vehicles. Observations during the annual compliance review week
confirmed each of the seven vehicles used to transport youth underwent an annual vehicle
inspection by a certified mechanic. A review of documentation confirmed maintenance staff
were conducting visual checks of all transport vehicles on a monthly basis and checking the
tires, batteries, windows, mirrors, and the inspections were documented on the mandatory
inspection form, and a copy of the form was maintained by the maintenance staff. All vehicles
on site at the time of the annual compliance review had the appropriate number of seatbelts, a
seatbelt cutter, a window punch, a fire extinguisher, and a first-aid kit with items approved by the
designated health authority. Two vans were in the shop for repairs during the time of the annual
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compliance review. Logbook documentation for all vans was reviewed during the annual
compliance review, and all logbooks included the acknowledgement of the van being searched
before the trip, the destination, the number of youth and staff names, the name of the officer
riding in the back of the van, time the transport began, and the time the transport ended. During
the annual compliance review, a transport of youth was unable to be observed due to court
transports departing before the review team reported to the center each day. There were no
additional transports completed during the annual compliance review week. When not in use, all
vans were secured at the time of the annual compliance review. Seven youth were interviewed,
and all reported they felt staff are driving safely during transports. Seven youth stated they have
never seen anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures addressing tool inventory and management, youth
access to tools, and use of tools and cleaning items. An inspection of the tool room and kitchen
determined the tools were secured when not in use. No tools were missing on the inventory and
all tools were listed on the inventory. Kitchen staff conducted itemized inventory of all
equipment, including knives. An informal interview with the maintenance staff confirmed all
service vendors are always accompanied by designated center staff. The center does not allow
youth to use tools, including kitchen tools, and medical equipment. Youth are allowed to use
cleaning items such as mops, brooms, and other common household items, under direct staff
supervision. An informal interview with maintenance and kitchen staff determined when a tool is
damaged or missing the practice is to inform the superintendent immediately, secure the broken
tool, and begin a search for the missing tool. During the annual compliance review week, a
sample of ten tools from the kitchen and maintenance were reviewed. All ten tools were
secured, had marked for easy identification, accurately inventoried, and the inventories were
signed by the superintendent/designee. The superintendent was interviewed and reported only
maintenance and administration staff have access to center tools. Seven interviewed staff
reported if a tool is damaged or missing, they would notify a supervisor, administration, and
maintenance. Seven staff were interviewed, and all reported youth are only allowed to use mops
and brooms. Seven youth were interviewed, and five youth reported they are only allowed to
use mops and brooms, and two youth reported they don’t use any tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
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,
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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 address the inventory of flammable, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
the laundry room and maintenance room with limited access. Safety Data Sheet (SDS)
logbooks are located at the locations where the chemicals are stored. Inventories of flammable,
toxic, caustic, and poisonous items are maintained by the maintenance mechanic and the
administration. The inventories were compared to the items on-site and were found to be
accurate and complete. During the annual compliance review week five chemicals were
reviewed, and all counts were accurate with no discrepancies and all SDS’s were present for
each item. Seven youth were interviewed, and five reported they clean with a cleaning agent;
however, staff spray the cleaning agent and youth wipe it off. Two youth stated they do not use
any cleaning agents. All seven interviewed youth reported they do not have access to
flammable, toxic, caustic, or poisonous items. Seven staff were interviewed, and all stated youth
are not allowed to clean with toxic, caustic, or poisonous items.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures addressing the proper use, storage, and disposal of
all flammable, toxic, caustic, and poisonous items. There have been no instances of a chemical
spill since the last annual compliance review. All items requiring disposal are transported by
authorized staff to a local hazardous waste authority. The kitchen has a container for grease
designated for disposal. An informal interview was conducted with the maintenance staff and
superintendent, and both advised chemicals are either used or picked up by a vendor for proper
disposal.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures to address requirements for behavioral
confinement for less than twenty-four hours. The center had 182 confinements lasting less than
twenty-four hours since the last annual compliance review. The center documents confinements
in the Facility Management System (FMS). Fifteen confinements were reviewed. Documentation
indicated all youth rights were afforded in each instance including three meals a day, access to
mental healthcare as requested, daily shower, clean clothing, and bedding. An informal
interview with several teachers verified education materials are provided to youth in confinement
dependent on their risk level for safety and security to include worksheets or books. All youth
were afforded the right to grieve a confinement placement. Review of FMS indicated the
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supervisor approved all confinements, staff only placed one youth in a room, the room was
searched, and the search was documented in FMS. All reviewed documentation of confinement
logs indicated the youth in confinement were supervised by staff. During the first hour, five-
minute checks were conducted for all fifteen confinements and then every ten minutes after the
first hour. The reason for confinement was explained to each youth, and the supervisor on duty
conducted reviews within one hour of the youth being placed in confinement. All reports were
completed by the staff, supervisors conducted additional reviews with the youth at the required
minimum of three hours, and youth were continually counseled by the supervisors and staff.
Superintendent reviews were completed within the required forty-eight hour timeframe. During a
tour of the center the plexiglass windows appeared to be in good condition in the living modules,
and cameras were free of obstruction allowing visual observations of youth. The superintendent
was interviewed, and stated confinements are tracked by a supervisor and observation reports.
The superintendent confirmed checks should be completed every five minutes for the first hour
and every ten minutes after the first hour. Seven interviewed staff stated an incident report must
be completed, and they conduct ten-minute checks on the youth while in confinement. Six of the
seven interviewed staff stated they must search the confinement room prior to placing a youth in
confinement.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures to manage various emergencies and disaster
events. The center’s Continuity of Operations Plan (COOP) was approved by the regional
director. Reviewed documentation showed there were two COOP drills conducted during the
annual compliance review period. Documentation confirmed the center conducted a hurricane
drill on May 21, 2025, prior to the beginning of hurricane season, and on August 20, 2025. Each
reviewed drill had documentation containing the type of drill, time and date, participants, a brief
scenario, findings, recommendations, critique forms, and emails used to document the drills.
Additionally, drills are reviewed during monthly management meetings and during shift briefings.
An interview with the superintendent confirmed a minimum of two annual COOP drills are to be
conducted, and at least one drill shall be completed prior to the beginning of hurricane season.
Additional drills may be conducted to ensure the center maintains readiness to respond to an
emergency or disaster. Deficiencies identified during this process are reported to the
superintendent and designated staff must ensure timely corrective actions.
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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 regarding implementing and maintaining an Escape
Prevention Plan. The center’s policy requires the center to conduct escape drills at least
quarterly. A review of the center’s Escape Prevention Plan confirmed it included the
Department’s established policies and procedures regarding escapes. A review of the center’s
drill documentation confirmed escape drills were conducted monthly during the annual
compliance review period. The center completed escape drills on January 1, February 12,
March 8, April 2, May 21, June 11, July 15, and August 3, 2025. The Emergency Drill Reporting
form included scenarios, a synopsis of the incident, start and end date, time of drill, detailed
information of problems and concerns during the drill, and a staff sign-in attendance roster. A
review of logbooks revealed each mock escape drill was documented in the logbooks, as
required. A review of seven staff training records confirmed five staff were trained in escape
prevention annually and two staff did not receive the training. Seven staff were interviewed, and
staff reported they participated in fire, weather, major disturbance, chemical spills flooding,
hostage situation, terrorism, bomb threat, and escape drills during the annual compliance review
period.
5.15 Fire Drills Limited Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has facility operating procedures regarding fire drills. The fire prevention procedures
have been approved by the Division of State Fire Marshal, and an annual inspection was
completed. The center maintains a Fire Prevention Plan and a Disaster Preparedness Plan
approved by the local fire department. A review of the center’s monthly drills indicated drills
were documented in the master control logbooks. Reviewed documentation supported the
center was conducting fire drills monthly on the first shift, and drills were documented on the fire
drill report; however, the center’s second shift was missing four out of eight required fire drills.
An observation of a fire drill was conducted during the annual compliance review week. Staff,
youth, and visitors evacuated the building and completed the drill as required. Reviewed
documentation confirmed fire extinguishers were inspected annually. Seven interviewed staff
reported participating in a fire drill at least once every month. Seven interviewed youth stated
they were instructed on what to do in the case of a fire.
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
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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 regarding searches and contraband procedures.
During the annual compliance review, observations of searches were conducted. Before a youth
was released, staff wore gloves to search the youth. Additionally, during contraband room
searches staff wore gloves. Since the last annual compliance review, there were no full body
searches conducted by the center outside of the initial full body search at admission. Full body
search procedures observed during the intake process showed policy was followed by having
two staff of the same gender present, gloves being worn, and the search was conducted
individually, and not in a group setting. All visitors entering the center were searched
electronically, all bags, cases, and jacket pockets were searched, and all personal keys were
collected by master control prohibiting them from entering the secure area. Room searches are
completed upon releasing a youth. Room searches were conducted on each awake shift. A
review of room searches was conducted for one day each month during the annual compliance
review period and confirmed the awake shift completed and documented room searches. All
visitors entering the center are required to sign a contraband attestation statement. A review of
seven newly hired staff training records was conducted, and all seven records contained a
signed contraband attestation. A review of the Department’s Central Communications Center
(CCC) reports during the annual compliance review period found there were two instances of
contraband found at the center. The two instances of contraband entering the center were
reviewed and logbook documentation confirmed the center documented the confiscation of
contraband, informed administration, and contacted the CCC. A review of the Facility
Management System (FMS) confirmed all incident reports regarding contraband were entered
into the system. Confiscated items were handed to the on-duty supervisor and law enforcement
was contacted for the illegal contraband entering the center. Shift supervisors documented the
chain of custody of confiscated items. The superintendent was interviewed and confirmed
contraband is confiscated, law enforcement is notified, a search of the youth living unit is
conducted, a search of the youth is conducted, a video review is completed, and the CCC is
notified.
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source: DJJ

program_name_raw: Southwest Florida Regional Juvenile Detention Center

rule: Indicator 1.07

excerpt: In-Service Training

rule: Indicator 5.15

excerpt: Fire Drills