state: FL

facility_name: Broward Youth Treatment Center

summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Broward Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
222 NW 22nd Avenue
Fort Lauderdale, Florida 33311
Review Date(s): January 13-16, 2026
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:
Shakela Minns, Office of Accountability and Program Support, Lead Reviewer (Standard1)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Interviews)
Amari Exalien, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Alphonza Gates, Detention Services, Government Operations Consultant (Standard 5)
Peter Keelan, Office of Education, Southeast Education Coordinator (Standard 2)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Samuel Sainval, Collier Detention, Superintendent (Standard 5)
Program Name: Broward Regional Juvenile Detention Center MQI Program Code: 206
Provider Name: State Operated Contract Number: N/A
Location: Broward County / Circuit 17 Number of Beds: 95
Review Date(s): January 13-16, 2026 Lead Reviewer Code: 159
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
This monitoring report reflects the Department’s assessment of program compliance with applicable standards during the established review period. Monitoring reports represent a
snapshot of program operations and documentation at the time the review was conducted. When areas of limited or failed compliance are identified, the Department works with the
provider through established processes to address those issues and ensure corrective actions are implemented as outlined in FDJJ 2000. Follow-up monitoring, verification activities, and
corrective action processes are used to confirm identified deficiencies are addressed and programs return to compliance with applicable standards.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting (CCC) * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Youth Management
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Representative Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 58
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Evaluation Satisfactory
3.06 Treatment and Discharge Planning Satisfactory
3.07 MH/SA Treatment Satisfactory
3.08 Suicide Prevention Plan * Satisfactory
3.09 Suicide Prevention Services * Satisfactory
3.10 Secure Observation* Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 58
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Psychiatric Services* Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control/Education Satisfactory
4.19 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 58
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth* Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58
Program Overview
The Broward Regional Juvenile Detention Center is a state-owned detention center, operated
by the Department, located in Fort Lauderdale, Florida. The center serves youth in Broward
County in Circuit 17. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the ninety-five-bed center.
Youth are provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Broward County School District. The center’s
management team includes the superintendent, three assistant superintendents, one
administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, and fifty-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 designated
mental health clinician authority (DMHCA), as well as one psychiatrist, three licensed mental
health counselors (LMHC), two licensed clinical social workers (LCSW), and one licensed
marriage and license family therapist (LMFT). Clinical services provided by the center include
mental health and substance abuse evaluations, mental health treatment planning, individual,
group and family therapy, mental health crisis intervention services, on-site psychiatric services,
and availability for substance abuse services for youth with co-occurring disorders. Medical
services are provided by one designated health authority (DHA), one advanced practice
registered nurse (APRN), one registered nurse (RN) serving as the clinical manager, six RNs,
and one medical clerk. The medical clinic maintains nursing coverage seven days a week, from
7:00 a.m. to 8:00 p.m., and on weekends, 7:30 a.m. to 5:30 p.m. Food services are provided by
Department staff and include menus, meal planning, meal schedules, special diets, nutritional
analysis, daily allowance, food preparation, health certifications, food product standards,
sanitation, and cleaning. Staff are responsible for the custody and control of youth in their care,
providing youth supervision twenty-four hours a day, seven days a week. The center has four
living modules which are divided by male and female. There are ninety-six security cameras at
the center, of which sixty-five were operational. The center was able to provide open work order
documentation to confirm pending repairs for the cameras. A tour of the center was conducted
during the annual compliance review week and observations found it to be clean, the exterior
was free from debris, the grass was manicured, and the center was free from insect infestation.
The observed lobby area was clean and had no broken furniture. Common areas, living
modules, bathrooms, and kitchen and dining areas were observed to be clean; however, two of
the four living modules bathroom shower stalls appeared to be rusting due to the water. In
addition, the Plexiglass located on the doors inside of the modules contained graffiti. The center
is an older center and is currently awaiting renovations. At the time of the annual compliance
review, the center had eleven vacancies, which included one JJDO supervisor, five JJDO IIs,
four JJDO Is, and one maintenance manager. At the time of the annual compliance review, the
center was utilizing maintenance staff from other centers.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58
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 on all newly hired staff, contracted providers, grant recipient staff, mentors, interns,
and volunteers. The Annual Affidavit of Compliance with Level 2 Screening Standards was
submitted January 10, 2026. The Annual Affidavit of Compliance with Level 2 Screening
Standards for school district teachers was submitted to the BSU/Clearinghouse on January 9,
2026. A review of the initial background screenings for seventeen newly hired staff, nine
contracted staff, and five volunteers found the center received background screening results
from the Department’s Background Screening Unit (BSU)/Clearinghouse prior to each staff’s
hire date. Reviewed documentation validated a criminal history report was reviewed for each
staff, contracted staff, and volunteer prior to being hired. None of the staff, contracted staff, or
volunteers were applicable for an exemption. The center utilizes a pre-employment assessment
tool for all direct care applicants. Fourteen applicants were applicable for being direct care, and
a passing score was documented in each applicant’s record. Reviewed documentation
confirmed the contracted providers added each 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 which outlines the process for five-year background
rescreening. A background rescreening is required for all staff, grant recipient staff, mentors,
interns, and volunteers every five years, which begins from the initial date of employment. A
review of the staff roster found the center had thirteen staff eligible for a five-year rescreening
since the last annual compliance review. Reviewed documentation confirmed each staff’s
rescreening was completed and submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse within the required time frame. None of the contracted staff or volunteers
were applicable for a five-year rescreening during the annual compliance review period.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58
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 outlining the staff code of conduct. Staff are
required to adhere to the code of conduct which prohibits any type of abuse, profanity, threats,
harassment, intimidation, horseplay, or personal relationships with youth. Six staff personnel
records were reviewed, and each record contained a signed code of conduct form. Three staff
records documented disciplinary actions for a violation of the code of conduct with management
implementing an oral and written reprimand. Three personnel records were reviewed for
commendations. All three staff were nominated and received employee of the month. Nine
youth were interviewed. One of nine youth reported never being stopped from reporting abuse
to the Florida Abuse Hotline, and eight youth reported they never had to report abuse. Each
youth reported staff were respectful when talking to youth. Each youth stated they never heard
staff use profanity when speaking to the youth. All nine-youth reported they have never heard
staff threatening youth and they felt safe at the center. Each youth reported they have never
exchanged emails, telephone numbers, or social media information with staff. Nine staff were
interviewed, and each staff was able to explain the process for allowing youth to call the Florida
Abuse Hotline or the Department’s Central Communications Center (CCC) to report suspected
abuse. Each staff reported never hearing staff use profanity when speaking to youth. Each
interviewed staff reported never hearing a co-worker use threats, intimidation, and/or humiliation
when interacting with youth. Five of the nine staff stated the working conditions at the center
were good. One staff stated the conditions were very good. Three staff stated the center’s
working conditions were fair. An interview with the superintendent confirmed staff must act in a
professional manner with youth and peers. The superintendent further stated staff are expected
to be role models for the youth.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58
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 214 incidents reported to the CCC during the
annual compliance review period. Ten incidents were reviewed. All ten incidents were reported
within the two-hour reporting time frame. Each incident was documented in the center’s CCC
logbook. A review of the center’s internal incident/grievance reports found there were no
additional incidents which should have been reported to the CCC. The superintendent indicated
all reportable incidents must be called into the CCC within two hours of the incident or two hours
after gaining knowledge of the incident.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures pertaining to the use of the Right Interactions (RI)
model, in accordance with Florida Administrative Code. The center had a total of 635 RI
incidents during the annual compliance review period. A review of nine RI Reports found eight
of the nine reviewed RI Reports were completed by the end of the staff’s workday. One report
required several staff statements; however, one staff did not complete their report. This
information was shared with the administration staff during the annual compliance review week.
None of the incidents resulted in serious injury to the youth or staff, required the use of
mechanical restraints, or needed to be reported to the Florida Abuse Hotline. All nine RI Reports
were reviewed by a Right Interactions (RI) certified instructor, and superintendent or designee.
Each report documented a post-RI interview which was conducted with the youth within the
required timeframe with a supervisor or designee. None of the RI Reports indicated the need for
an RI medical review. A review of internal incident reports and logbooks indicated there were no
additional RI incidents which should have been reported. The center’s RI rate during the
previous quarter was 32.69, which is above the statewide Detention RI rate of 12.59. Nine staff
were interviewed and reported staff try to talk to youth prior to using RI or mechanical restraints.
The superintendent was interviewed and indicated RI incidents are reviewed through video
footage by the superintendent and/or designee. The superintendent and/or designee reviews RI
Reports.
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 newly hired detention staff. The center’s policy requires two phases of training
and consists of 120 hours of workplace training during the first phase. In the second phase, staff
complete 120 hours of academy instructor-led training. A review of nine staff training records for
pre-service training was completed . Four of the nine staff completed the pre-service
requirements, new staff orientations, and 120 hours of academy training within 180 days of hire.
Four staff were still within 180 days of hire. One staff qualified as a returning direct care staff
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58
who returned less than one year from separation from the Department. Review documentation
found the staff completed the required trainings in accordance with the Department’s policy.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures which require staff to complete twenty-four hours of
in-service training each calendar year after completion of pre-service certification training. The
policy requires supervisors to complete eight additional hours of supervisory training annually.
The center provides in-service training to staff through a combination of the Department’s
Learning Management System (SkillPro) and instructor-led classes. Nine staff training records
were reviewed for in-service trainings including six direct care staff and three supervisory staff.
Nine staff training records reflected staff completed the mandatory training topics. Three staff
were applicable for a minimum of eight hours of supervisory training. Each staff completed the
required eight hours of supervisory training. Additionally, the licensed nurse provided in-service
education on girls’ healthcare and emergency care of pregnant youth to all of the non-
healthcare staff involved in the supervision or treatment of girls. All trainings were entered into
SkillPro. Reviewed documentation confirmed the center maintains an updated annual in-service
training calendar approved by the center’s superintendent, assistant secretary of the OFfie of
Detention services, and the director of the Department’s Office of Talent, Leadership, and
Culture. A formal interview with the superintendent confirmed the center’s practice.
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 consists of informal, formal
and an appeal phase. The center keeps blank grievance forms on the living modules which are
available for youth, upon request. The center’s staff will then enter the grievance into the
Department’s Facility Management System (FMS) in the Department’s Juvenile Justice
Information System (JJIS). The informal phase is completed by detention staff whereby the
youth and staff attempt to resolve the youth’s complaint. If the staff is unable to resolve the
issue, the written grievance will be submitted to the supervisor, beginning the formal grievance
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58
process. The written grievance requires a response from the juvenile justice detention officer
supervisor (JJDOS) by the end of the shift if possible or within twenty-four hours. Next, the
appeal phase requires a response from the superintendent or designee. The superintendent will
have seventy-two hours to completed the corrective action deemed necessary. An interview
with the superintendent confirmed the three phases to the grievance process. An interview with
the assistant superintendent in comparison to the FMS confirmed the center has not had any
grievances since the last annual compliance review. Nine youth were interviewed and knew the
process for submitting a grievance. Each youth indicated they have never filed a grievance.
Nine staff were interviewed, and each staff was knowledgeable and was able to explain the
grievance process and procedures.
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) by the appropriate staff member on
the date each was identified and no longer applicable. A review of nine youth records confirmed
alerts were documented in accordance with the center’s policy. The reviewed youth were
applicable for twenty-two separate alerts to be entered by the center. A review of youth records,
the master control logbook, and the JJIS alert list found the center is documenting and sharing
alert information, as required. An informal interview with the assistant superintendent indicated
staff are given updated alerts daily during shift briefings. Reviewed documentation indicated
alerts were discussed during shift briefings. A printed copy of the alert report is provided to the
supervisory staff on each shift daily, and alerts are reviewed with all staff during each shift
briefing. Observations of a shift briefing during the annual compliance review week confirmed
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58
the center’s practice. Nine interviewed staff reported being made aware of alerts during shift
briefings, by reviewing logbooks, and on the alert report.
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. An informal interview with the
assistant superintendent in comparison to reviewed documentation found the center captures
data daily through various reports and changes are made as needed. The assistant
superintendent indicated the center’s practice regarding data trend analysis is to review incident
reports, confinements, Right Interactions model (RI) Reports, the Department’s Central
Communications Center (CCC) reports, staff retention reports, vacancies, and maintenance
issues. The center conducts monthly supervisor meetings and shift briefings to ensure all staff
are made aware of imperative information regarding the center. The assistant superintendent
indicated the center shares information with providers and stakeholders during quarterly
advisory board meetings, and the last meeting was held on November 26, 2025. The
superintendent or designee participates in Department head meetings and weekly
superintendent meetings. The assistant superintendent reported the center retrieves the data
collected and uses the data to help improve staff morale.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 58
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 which address youth admissions into secure
detention. The 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 nine 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 nine youth and
each was provided medical, mental health, and substance abuse screenings. Eight of the nine
reviewed records documented the youth were provided with a meal at admission; however, one
record did not indicate whether the youth received or refused a meal. Six of nine reviewed
records documented the youth completed a telephone call. Two of the remaining three records
documented the youth did not complete a call at admission, which was reasonable as the
admissions occurred at 3:32 a.m. and 3:42 a.m. One reviewed record documented the youth
was admitted at 1:06 p.m. and had no call completed, and documentation did not indicate a 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;
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8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures which stipulate the process for orienting each youth
within twenty-four hours of admission into detention. Youth orientation is to include both verbal
and written orientation to the center’s rules and regulations, grievance procedures, 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/Department's Central
Communications Center (CCC), behavioral expectations 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 nine youth case
management records confirmed an orientation was completed for each youth within twenty-four
hours of admission, as required. 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. Nine youth were interviewed, and each confirmed they were advised of the rules
and regulations. Each youth confirmed they were provided information about the 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 nine youth records indicated each youth’s classification process included a review of
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information related to the youth’s history, status, and consideration of the youth’s mental illness,
intellectual/physical disabilities, history of violent and/or criminal behavior, gang affiliation,
history of sexual offenses, the results of the Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) screening, medical concerns, risk of suicide or escape, and history
of human trafficking. The completed classification process documented consideration of all the
required topics prior to making room assignments, including the gender of the youth, height,
weight, age, and level of aggression. An interview with the center’s superintendent indicated the
youth are assigned to a room based upon their classification and are reclassified if there are any
changes in the youth’s behavior or status. Youth with prior victimization are not to be placed in a
room with any other youth, and if a youth is suicidal, they will be placed on the dayroom floor
until assessed by mental health staff.
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 newly
admitted youth to determine whether the youth is suspected or confirmed to be a gang member
or gang affiliate. The policy requires the center to share suspected gang related information by
email with the circuit gang representative. An email communication, including a photograph of
the youth, is sent to the juvenile probation officer (JPO) serving as the circuit gang liaison. The
liaison then sends the information to the Broward County Multi-Agency Gang Task Force at the
Broward County Sheriff's Office indicating the criteria met by the youth which meets the
statutory definitions for possible gang membership or association. A review of nine youth case
management records found none were applicable for suspected gang affiliation; therefore, three
additional records applicable for gang involvement were requested. Each of the three applicable
records documented a referral for suspected gang involvement, including pictures, copies of
written statements, drawings, graffiti, and a description of any displayed gang signs, was shared
by email with the circuit’s gang liaison. An informal interview with the superintendent confirmed
the center’s gang liaison is currently on medical leave; however, an assistant superintendent is
temporarily responsible for sharing the gang related information with the JPO.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures to 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 nine youth records validated each youth signed their
respective property receipts which listed each item of the youth’s personal property brought to
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the center, including clothing, and a copy of the form was maintained within the youth’s active
record. Staff signed each property receipt, and each youth signed a letter of acknowledgement
regarding unclaimed property, which was included in each record. Three of the nine 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 supervisor’s office.
The center maintains bound logbooks for property received at each youth’s admission. The
intake property logbook is for documenting personal property received during the intake
process. 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 supervisor’s office. The logbook is used to record youth valuable
personal property which is stored in the center’s securely locked property file cabinets, which
are referred to as the drop safe. The property safe logbook documents the youth’s name,
Department identification number (DJJID), the date and time the valuable property was placed
in the safe, and the name 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 and time of release, and the name of the administration staff
retrieving the valuable property. An observation of a youth’s admission during the week of the
annual compliance review 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.
Both property storage areas 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 out of view of the camera. The superintendent indicated
only the center’s administrators have access to the valuable property safes located in intake and
the supervisor’s office. 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. Nine
interviewed youth stated staff checked their personal property and they signed a form to
acknowledge their list of inventoried personal property was correct.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures for releasing youth from secure detention. The
center’s policy requires each youth’s court order to be reviewed and verified prior to release.
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Nine youth case management records were reviewed, and none were applicable for release
procedures. Three 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. Two youth were
released to a parent/guardian, and one youth was released to Department staff for transport to a
residential commitment program. A copy of the identification for each parent/guardian or
Department staff was present in each of the records. None of the reviewed records were for
youth with an endangered person alert. When applicable, the youth, parent/guardian, or
Department staff were reminded of future court dates and appointments. None of the three
youth had any medication while in the center. 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
their parent/guardian was conducted. Copies of the parent’s/guardian’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, and signatures were
obtained. The youth and the parent/guardian signed the release documentation, were reminded
of the youth’s future court dates, and provided with a copy of the youth’s court documentation.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures requiring each youth's personal property to be
maintained securely and returned to the youth in a timely manner upon their release. The
center’s policy also details procedures for the release of youth with prescription medication.
Three closed youth case management records were reviewed. All three closed youth records
confirmed the youth and parent/guardian or Department staff taking custody of the youth signed
the Property Receipt form upon release. Each reviewed record contained a copy of the
parent/guardian or Department staff identification card confirming the youth was released to the
appropriate person. None of the three reviewed closed youth records were applicable for receipt
of medication at release. 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 when applicable. 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 released youth did not have any medication at the
center.
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
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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
was conducted virtually. The meeting included the center’s medical and mental health staff,
representatives from education, juvenile probation officers (JPOs) from each of the circuit’s
probation units, the court assigned JPO, the Department’s commitment manager, the circuit’s
assistant chief probation officer, and from Broward County’s Community Based Care lead
agency, ChildNet. During the Detention Review meeting the participants discussed each youth’s
applicable upcoming appointments, medical needs, court appearances, participation in mental
health and educational services, and relevant behavioral changes while in detention.
Documentation of Detention Review meetings occurring since the last annual compliance
review confirmed the required participants were consistently in attendance. Reviewed
documentation validated Detention Review meetings were held weekly at the center. An
informal interview with the assistant superintendent indicated the weekly virtual Detention
Review meetings are typically conducted in an administrative office in the secure area of the
center.
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, cleaning of the living modules,
volunteer programming, and activities which promote education and life skills. The daily
schedule identified bedtimes, and times for short group sessions. Observations were made of
youth engaged in various activities throughout the annual compliance review week which
included educational programming, meals, youth searches, and recreation activities. Observed
activities were in adherence to the schedule. Nine interviewed youth confirmed the center has a
daily activity schedule which is followed. Nine 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.
Education services in the center are administered by the Broward County School District.
School operates on a year-round basis distributed over twelve months with 240 instruction days
or a minimum of twenty-five hours of weekly instruction. The center maintains an activity
schedule which reflects the scheduled education times. Three random days of video footage
were reviewed for educational access. Observations found all academic classes were being
conducted within the living modules. The teachers navigated from class-to-class and the youth
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remain in their assigned living module. Youth arrived and were dismissed from the classes at
the appropriate scheduled times. A review of logbooks from March 2025 to January 2026
validated the center ensured all youth were present for school at the required times; however,
reviewed documentation reflected eight instances, in which teachers arrived late or left earlier
than the scheduled end time causing classes to start three to nine minutes late and departure
five to seven minutes earlier. Nine youth were interviewed, and each stated the center was
preparing them for a high school equivalency diploma (GED), high school, vocational school,
and/or college. Nine youth reported attending school Monday through Friday. Nine interviewed
staff stated classes are conducted with minimal interference or interruption. An interview with
the superintendent confirmed there was minimal interference to the education instruction.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center provides career education programming which meets the requirements of a Type 1
program and incorporates soft skills, interpersonal, and decision-making skills, as well as life
skills and activities through the personal career and social development class. Nine youth were
interviewed and asked to identify the classes they were enrolled in. Nine stated they were
currently taking math, science, history, social studies, and reading. Seven youth reported they
were enrolled in life skills. Eight youth reported they participated in career choice classes.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures ensuring a single licensed mental health
professional serves as the designated mental health clinician authority (DMHCA) to oversee
appropriate coordination and implementation of mental health and substance abuse services.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The DMHCA is a
licensed clinical social worker (LCSW) with a clear and active license in the State of Florida,
with an expiration date of March 31, 2027. The DMHCA is a full-time staff and scheduled to be
on-site weekly, for enough time to ensure appropriate coordination and implementation of
mental health and substance abuse services were taking place. A review of the mental health
sign-in logbook 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. The back-up DMHCA was not
utilized during the annual compliance review period. The DMHCA indicated their responsibilities
include maintaining consistent and ongoing communication with all clinical staff and each
youth’s juvenile probation officer (JPO). The DMHCA ensures all evaluations and assessments
are uploaded into the Department’s Juvenile Justice Information System (JJIS) within thirty one
days of the youth being in the center. In the event the youth does not have an assessment or
evaluation in JJIS, the DMHCA coordinates with the JPO to obtain one. The DMHCA indicated
they communicate with the center's staff and mental health staff daily and consistently to
address any mental health or substance abuse needs and outstanding issues or processes
concerning youth.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The center requires
mental health and substance abuse services to be provided by individuals with appropriate
qualifications. The clinical supervisor ensures the licensed clinical staff working under their
supervision perform services they are qualified to provide based on education, training, and
experience. A review of the licensed clinicians’ credentials confirmed three licensed mental
health counselors (LMHCs), two licensed clinical social workers (LCSWs), and one licensed
marriage and family therapist (LMFT) all had an active license in the State of Florida, with an
expiration date of March 31, 2027.
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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, ensuring mental
health and substance abuse services are provided to all applicable youth in the center. The
center does not have a Chapter 397 license with the Department of Children and Families. All
mental health services are provided by licensed mental health professionals, and the center
does not have any non-licensed mental health clinical staff. Reviewed documentation confirmed
only the licensed mental health counselors were facilitating all substance abuse treatment and
groups.
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 ensuring 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 nine youth mental health and substance abuse records
confirmed initial screening documents were completed by a probation officer/screener. Each
screening document was reviewed by detention staff. Reviewed documentation confirmed the
Suicide Risk Screening Instruments (SRSI) and the Massachusetts Youth Screening
Instruments, Second Version (MAYSI-2) were completed during intake in the Department’s
Juvenile Justice Information System (JJIS). The nurse completed the required section of the
SRSI for each screening and completed entries included the accurate referral selections in the
“Screening Results” section. Five of nine reviewed screenings confirmed each youth had
positive “YES” responses on the SRSI and 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). Each SRSI screening including a “YES” response had a suicide risk alert
entered into JJIS. None were applicable for all negative responses resulting in an “invalid”
screening. Six reviewed screenings indicated a need for further assessment and the referrals
were made. Each assessment confirmed the superintendent was notified. One of the MAYSI-2
screenings indicated an elevated suicide risk subscale and the youth was referred as required.
Four MAYSI-2s indicated the need for a comprehensive assessment and confirmed the
screener referred the youth to mental health clinical staff for a comprehensive
assessment/Society for Adolescent Health and Medicine (SAMH) assessment within the
detention center.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures regarding the process to identify the mental health
and substance abuse needs of youth through comprehensive screening. The center’s policy
requires the youth with identified needs to be referred for a further mental health and/or
substance abuse evaluation. A review of nine youth records indicated only four youth were
identified upon admission and three youth after admission as in need of a new or updated
comprehensive evaluation. Six youth were applicable for a new Society for Adolescent Health
and Medicine (SAMH) assessment completed by center staff and each assessment’s treatment
recommendations were made and corresponded with diagnosed mental health or substance-
related disorders. The comprehensive mental health and substance abuse evaluation consists
of the SAMH assessment, which was completed in the Department’s Office of Health Services
(OHS) electronic medical record (EMR). One youth record was applicable for having an updated
comprehensive evaluation due to a referral from the juvenile probation officer (JPO). No youth
were applicable for having an evaluation completed by a community provider. An interview with
the designated mental health clinician authority (DMHCA) confirmed as part of the intake and
assessment process, the DMHCA will search the Department’s Juvenile Justice Information
System (JJIS) to determine whether a comprehensive evaluation has been uploaded for the
youth. If a comprehensive evaluation is not found in JJIS, the JPO will be contacted to
determine if one was completed. If the youth does not have a comprehensive evaluation, or the
JPO does not respond, a SAMH will be completed by the thirty-first day and entered into the
EMR.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
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 and substance abuse clinical staff
to ensure the development and review of an initial and/or individualized treatment plan for each
youth receiving mental health and substance abuse treatment in the center. A review of nine
youth mental health and substance abuse records indicated five were applicable for mental
health and substance abuse treatment services, while four youth received supportive services
as needed. Each of the nine youth received a mental health orientation which was completed
within fourteen days of admission. Five of the nine youth records required an initial treatment
plan. A review of documentation showed the initial treatment plans were in place within seven
days of the onset of treatment, and each plan was developed on the Department’s Initial Mental
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Health/Substance Abuse Treatment Plan form. Two initial treatment plans were applicable and
listed the psychotropic medications the youth was prescribed at the time of the treatment plan.
Each record included progress notes which validated the youth was receiving treatment
services as indicated on their treatment plan. Each applicable plan documented the reason for
referral for treatment, initial Diagnostic and Statistical Manual, Fifth Edition (DSM-5)
diagnosis/symptoms, initial treatment methods including counseling and frequency, initial
treatment goals, applicable psychotropic medication and frequency of monitoring, the
medication the youth was admitted with the initial treatment plan, mental health/substance
abuse professional’s signature, and youth’s signature. Documentation confirmed the mini-
treatment team members involved in development of the initial treatment plan were present.
Five of the nine youth records required an individualized treatment plan. The individualized
treatment plans were developed for youth receiving mental health and/or substance abuse
treatment in the center by the thirty-first day of the youth’s admission. The plan included the
DSM-5 diagnosis, symptoms which were treatment-focused, treatment goals including mental
health services if the youth had a mental illness, and substance abuse services if the youth had
a substance-related diagnosis, and the youth’s strengths and needs. The individualized
treatment plans were signed and dated by the youth, the mental health/substance abuse
professionals, treatment team members, and the parent/guardian. Three of the five youth were
applicable for one thirty-day period requiring individual treatment plan reviews. One youth was
still within the treatment plan review period, and the other youth had five thirty-day periods of
treatment plan reviews. Each individualized treatment plan was reviewed every thirty days by
the treatment team and modifications were documented on the review form and clearly
identified as such. Reviewed documentation indicated the individualized treatment plan reviews
were signed and dated by the clinical staff, youth, licensed mental health professional, treatment
team members, and the parent/guardian. The treatment plans included treatment and services
provided by a licensed psychiatrist. None of the youth were an alleged victim of a Prison Rape
Elimination Act (PREA) event. Three records were reviewed for discharge summaries. Each of
the three reviewed mental health and substance abuse treatment discharge summaries were
documented on the Department’s Mental Health and Substance Abuse Treatment Discharge
Summary form upon the youth’s discharge. A copy of the treatment discharge summaries were
provided to each youth, parent/guardian, and juvenile probation officer (JPO). Each discharge
summary included the completion day of service, signature of the licensed mental health
professional, and additional documentation was completed and uploaded within fourteen days.
During the annual compliance review week, a mini treatment team meeting was observed. In
attendance were the youth, a juvenile justice detention officer, two mental health staff, medical
staff, and education staff. The parent/guardian was contacted by telephone. At the time of the
mini treatment team meeting, the youth’s education goals, behavior, and medication were
discussed. An interview was conducted with the DMHCA, and it was revealed once the youth is
open and receptive to engaging in services, mental health staff are responsible for tracking the
youth by using a caseload tool to ensure services are provided. The DMHCA reviews the
caseloads with mental health staff and will meet with the youth to review the comprehensive
evaluation. The information gathered is utilized for developing the youth's individualized
treatment plan. Once a treatment plan is completed, mental health staff will ensure the youth
are seen at least once a week to address and review treatment plan needs and work on their
identified goals and objectives. The youth’s progress will be monitored through attendance of
treatment team and treatment plan reviews will be conducted at least every thirty days. The
DMHCA confirmed mental health staff meets with administration informally daily, and formally
twice a week during department head and treatment team meetings.
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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 ensuring mental health and substance abuse
treatment planning focuses on treatment provisions to reduce symptoms of mental disorder or
substance abuse impairment and enable youth to function adequately in the juvenile justice
setting. A review of nine youth mental health and substance abuse records found five youth
required treatment and the remaining four youth received supportive services as needed. Each
youth was assigned to a mini-treatment team consisting of a mental health staff, a staff from a
different service area, youth, and the youth’s parent/guardian if possible. Each of the applicable
youth received individual, group, or family counseling provided according to frequencies
required by their plans. The reviewed plans included individual, group, and or family therapy
prescribed at least weekly. Reviewed documentation confirmed each youth had an Authority for
Evaluation and Treatment (AET). All five youth were applicable for substance abuse services,
and the proper consent for substance abuse treatment was obtained through the signed form.
Additionally, for the release of records the proper consent for substance abuse treatment
records release was obtained through a signed form. A review of treatment notes was
conducted, and notes were documented on the Department’s Counseling/Therapy Progress
Notes form. At the time of the annual compliance review, videos were observed and confirmed
groups were conducted, as scheduled. Observations revealed mental health staff at the center
had adequate access to youth and confidential space to provide treatment services. It was
determined through reviewed documentation and sign-in sheets, group therapy was limited to
ten or fewer youth with mental health diagnoses. Documentation review showed group therapy
was limited to fifteen or fewer youth with substance abuse diagnoses. An interview was
conducted with nine youth. All of the youth stated mental health services were very good. An
interview with the designated mental health clinician authority (DMHCA) confirmed youth who
are at the center for at least thirty days or more, unless behavior warrants mental health
services prior to those thirty days, will receive mental health treatment through inviting the youth
to a treatment team meeting to discuss what clinical intervention they would like to work on
while detained. Once the youth accept services, mental health staff will meet with the youth to
review the comprehensive evaluation together and process any information needed by the
youth. The comprehensive evaluation will be utilized to serve as a basis to develop the youth's
individual treatment plan. Once the treatment plan is completed mental health staff will meet
with the youth once a week for group/individual sessions to work on their identified goals and
objectives prior to the target date.
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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 and a corresponding Suicide Prevention Plan. The
center has a written plan detailing suicide prevention procedures, which was reviewed and
signed by the designated mental health clinician authority (DMHCA) and superintendent
annually. The plan included identification and assessment of youth at risk of suicide, staff
training of at least six hours of training annually on suicide prevention and implementation of
suicide precautions, which includes quarterly mock suicide drills for all staff who encounter
youth on each shift, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and review process. The center has an
established review process for every serious suicide attempt or serious self-inflicted injury
requiring hospitalization or medical attention, and a mortality review for a completed suicide.
The multidisciplinary review includes the circumstances surrounding the event, center
procedures relevant to the incident, all relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors,
recommendations, if any, for changes in policy, training, physical plant, medical or mental health
services, and/or operational procedures.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures ensuring suicide prevention services. The policy
and procedures address supervising, observing, monitoring, and housing youth identified
through screenings, documentation, and observation as being at risk for suicide, and protecting
youth with elevated risk of suicide in the least restrictive means possible. 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). Nine youth records were reviewed and seven youth records were applicable for
placement on suicide precautions. A review of mental health and substance abuse records
indicated five youth were placed on precautionary observation at the time of admission as a
result of their screening and two youth had a history of suicide alerts at the time of admission
and the center’s staff completed an ASR as part of their practice. The Department's Juvenile
Justice Information System (JJIS) showed youth alerts were entered in the system for all seven
youth. Reviewed documentation confirmed suicide risk assessment referral dates and times for
each youth. A review of documentation revealed the ASR was completed on the Department’s
form. Each youth was placed on suicide precautions prior to the completion of the ASR. A
review of documentation determined the Suicide Precautions-Observation Logs were completed
in their entirety by a qualified mental health professional to include safe housing areas, and all
required signatures and a mental health professional were involved. Each record showed
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mental health staff documented there was a consultation with the designated mental health
clinician authority (DMHCA) or licensed mental health professional on the Mental
Health/Substance Abuse Referral Summary form. All seven applicable youth records revealed
the superintendent, or designee was notified immediately of suicide risk, and the ASRs were
completed within twenty-four hours. A review of documentation indicated each youth had a
Follow-Up ASR completed prior to their removal from precautionary observation. Reviewed
documentation showed a conference was conducted by the superintendent and licensed mental
health professional to determine the reduction of the youth’s level of supervision. Reviewed
logbooks showed the date and time of discontinuation of suicide precautions was documented.
Each of the seven applicable youth’s ASRs were documented as completed by a licensed
mental health professional and a review of the assessment results included recommendations
for supervision and follow-up. Documentation in the center’s logbook and on the ASR confirmed
administration or supervisory staff provided specific instructions related to the suicide risk
assessment findings and suicide precaution decisions. A review of JJIS determined alerts were
appropriately entered and removed following each youth being removed from precautionary
observation. Additionally, reviewed logbooks determined beginning and ending times were
documented for youth placed on precautions. An interview with the DMHCA indicated mental
health staff document all meetings and communication with youth on supervision in their
electronic medical record (EMR), through means of the ASR, Suicide Risk Screening Instrument
(SRSI), progress notes, and/or chronological notes. Once it is decided if a youth will remain on
precautionary observation, detention staff will be notified of the recommended supervision level
of the youth. Mental health staff will contact the youth’s juvenile probation officer (JPO), and
parent/guardian regarding the youth's status, as well as the recommended supervision level.
Mental health staff are notified either through referral, telephone or by a center staff, verbally, or
in person. The DMHCA is on call twenty-four hours daily for any and all crisis/emergencies. An
interview was completed with nine youth. All nine-youth responded they have never been
placed on suicide watch at the center. An interview was completed with nine staff in reference to
their responsibilities when a youth expresses suicidal thoughts. All nine staff reported they
would notify the mental health authority, supervisor, and search the youth and their rooms for
sharp objects. Documentation of supervision is conducted, and the youth is placed on constant
sight and sound supervision. According to the interviewed staff an alert is entered into JJIS and
listed in the logbook.
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. A review of nine youth records indicated five youth records were
applicable. Each of the five applicable youth placements were authorized by the superintendent
and the designated mental health clinician authority (DMHCA) and the secure rooms were
designated in writing. A review of the Department's Juvenile Justice Information System (JJIS)
showed each youth had a completed Health Status Checklist form completed prior to each
youth’s placement in secure observation. Reviewed documentation of the Suicide Precautions-
Observation Logs revealed each was completed in its entirety. A review of documentation
showed within eight hours of placement, a new Assessment of Suicide Risk (ASR) was
completed for each of the applicable youth, and the youth’s parent/guardian was notified of the
youth’s potential suicide risk as indicated by the ASR. Additionally, a review of documentation
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showed the youth’s juvenile probation officer (JPO) was notified of a youth’s potential suicide
risk as indicated on each ASR. A review of documentation indicated none of the youth remained
on secure observation beyond twenty-four hours. Reviewed documentation confirmed the level
was reduced after a conference with the superintendent and licensed mental health
professional, which was conducted to determine the discontinuation of secure observation and
step-down to close supervision. Supervision levels were documented in the center’s logbook
and in each youth’s mental health record by mental health clinical staff.
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 nine youth mental health and substance abuse records revealed five youth records
were applicable. Each youth’s mental health and substance abuse record confirmed each youth
had a maintained Suicide Precautions-Observation Log. Each youth’s appropriate level of
supervision and observations of the youth’s behavior were documented in real time and did not
exceed thirty-minute intervals. When warning signs were observed, there was a notification to
the superintendent or designee and mental health clinical staff documented on the Suicide
Precautions-Observation Log. A review of each of the five applicable youth logs showed the
logs were reviewed and signed by each shift supervisor and mental health clinical staff. Each of
the five logs documented the safe housing requirements. An observation of the center’s video
footage was conducted for three dates and the documentation of youth placed on precautionary
observation revealed supervision was always maintained by the detention staff.
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 to be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions. Nine in-
service and nine pre-service staff training records were reviewed. Each of the nine reviewed
staff records showed training to include suicide drills held quarterly on each shift. The center
has a total of five suicide response kits located in master control, sub control on each of the
youth’s living modules, and in the medical department. The suicide response kits are co-located
with the first-aid kits. A review of documentation confirmed mock suicide drills were conducted
quarterly for the past twelve months and were completed on each of the center’s shifts, to
include Alpha, Bravo, and Charlie. A review of documentation showed the past twelve months of
suicide drills included the use of cardiopulmonary resuscitation (CPR), suicide response kits, the
automated external defibrillator (AED), and first-aid. Drills were documented in the logbook with
a sign-in sheet to confirm the center’s staff participated in the drills. Each of the trainings
included mock suicide drills occurring quarterly on each shift, for all staff who encounter youth to
include maintenance and the center’s kitchen staff. Each mock mental health drill was in
response to a suicide attempt and/or incident of serious self-injury, were simulated, and did not
include any youth. A review of video footage and corresponding documentation of suicide drills
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ensure they were conducted as documented. The center provides semi-annual training on
emergency response procedures to include mock training in emergency responses to a suicide
attempt or incident of serious self-inflicted injury to include the use of CPR. An interview with the
designated mental health clinician authority (DMHCA) confirmed if staff are not available at the
time of the mock drills, the staff will be updated during shift briefings, and the simulation of the
drills are in the briefing room to include updates as needed. An interview was conducted with
nine staff at the center, and it was revealed the rescue tool, wire cutters, needle nose pliers and
suicide response kits are in master control, sub control, medical, and 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 to ensure the center responds to youth in crisis in
the least restrictive means possible to protect the safety of the youth and others while
maintaining control and safety of the center. The center maintains a Combined Emergency
Services Plan which includes procedures such as notification and alert system, means of
referral including youth self-referral, communication, supervision, documentation, and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center maintains a written Emergency Care Plan outlining mental health and substance
abuse emergency procedures for youth who are believed to be an imminent danger to
themselves or others because of mental illness or substance abuse impairment. The plan
includes immediate staff response, notifications, supervision, authorization to transport for
emergency mental health or substance abuse services, transport for emergency mental health
evaluation and treatment, transport for emergency substance abuse assessment and treatment,
documentation, training, and review. The plan was approved on January 21, 2025, and was last
updated on March 20, 2024. The plan is in the superintendent’s office, mental health office,
master control, and on a shared network drive.
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
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respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center maintains a written Emergency Care Plan indicating the response procedures for
youth in crisis. Nine youth records were reviewed, and none were applicable for a Crisis
Assessment. Three additional records were requested to meet the minimum requirement. Each
of the three assessments were completed within the required timeframe. All three Crisis
Assessments documented the reason for assessment, a Mental Status Examination and
interview, determination of danger to self and others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
evaluation, and notification to the parent/guardian of follow-up treatment. A mental health alert
was entered into the Department’s Juvenile Justice Information System (JJIS) for each youth
being placed on precautions after the completion of a Crisis Assessment. Each youth’s
assessment was completed by a licensed mental health professional. All three youth were an
alleged victim in a Prison Rape Elimination Act (PREA) event and were offered ongoing mental
health treatment services.
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 addressing Baker and Marchman Acts. A review of
nine youth mental health records revealed none were applicable for requiring Baker Act
procedures. Three additional records were requested to meet the minimum requirement. Each
youth was placed on one-to-one supervision prior to the Baker Act. The supervision was
documented on a Suicide Precautions-Observation Log until the youth’s authorized release for
Baker Act. All three youth were placed on suicide precautions upon re-admission following the
Baker Act placement. Each youth had a completed mental health referral for a Mental Status
Examination (MSE) completed by or under the direct supervision of a licensed mental health
professional. All three youth were maintained on one-to-one supervision until properly
transitioned to a lower level of supervision. Documentation showed supervision levels were
lowered for each youth after an appropriate assessment was conducted by a licensed mental
health professional, and mental health staff conferred with the licensed supervisor and
superintendent or designee. Each youth had a suicide risk alert in the Department’s Juvenile
Justice Information System (JJIS), and the discontinuation of the alerts and precautions were
based upon an Assessment of Suicide Risk.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures to ensure clinical services are provided to all youth
in the center. The center maintains a contract with VitalCore Health Strategies, LLC, which
subcontracts with a medical doctor (MD) to serve as the center’s designated health authority
(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 January 31,
2028. Additionally, the center utilizes an advanced practice registered nurse (APRN) who has a
Collaborative Practice Protocol (CPP) in place with the physician who is serving as the center’s
DHA. The APRN and the DHA both signed the CPP agreement on August 14, 2025, and August
15, 2025. The APRN has a clear and active license to practice in the State of Florida, which
expires April 30, 2027. The DHA is responsible for revising and editing all medical policies and
procedures for medical and non-medical personnel. A review of the sign-in and sign-out logs
during the annual compliance review period confirmed the DHA was on-site at least two hours
each week, with a week defined as the seven-day period beginning on Sunday and ending on
Saturday. While the DHA was on vacation and/or on scheduled absences, the center has a
back-up DHA who was utilized on three separate dates. The back-up DHA has a clear and
active license in the State of Florida with an expiration date of March 31, 2026. When the DHA
designated another medical doctor (MD) to provide the clinical services on-site, the DHA
performed the administrative duties, which included supervising the medical department at the
center, completing the Comprehensive Physical Assessments (CPA), policy and procedure
development, completing sick call, and completing episodic evaluations. A review of the back-up
DHA sign-in and sign-out logs, confirmed a tele-medicine practitioner was utilized. An interview
with the center’s DHA indicated the medical staff are on-site Monday through Friday, the DHA
communicates with the center’s staff by direct in person communication or through emails
regarding youth’s medical needs, and they are available twenty-four hours a day, seven days a
week by telephone for on-site clinical services, for acute medical concerns, emergency
medicine, and for coordination of off-site care. The interviewed DHA reported the specific duties
of the DHA are to supervise the medical department and the designated APRN provides on-site
clinical services and coordination of off-site care. The DHA provides on-site clinical services and
ensures all off-site care findings are valid and updated on a log with all information ready to be
reviewed. Additionally, if coverage is needed in the DHA’s absence, the center has a back-up
DHA and the DHA has an APRN designee, who assists and provides on-site clinical services.
All off-site care findings, instructions, and information are reviewed by the DHA or by the APRN.
Additionally, the DHA indicated they meet with the medical staff on a weekly basis to review all
medical issues at the center.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures (FOPs) for all utilized health-related procedures
and protocols. The designated health authority (DHA), and the superintendent reviewed/revised,
signed, and dated the FOPs on December 30, 2025. The psychiatrist reviewed and developed
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the FOPs, or other protocols related to psychiatric services and psychotropic medication
management and signed the relevant policies on December 30, 2025. The center’s treatment
protocols were signed and dated by the DHA on October 7, 2025. Reviewed documentation
validated the licensed registered nurses (RNs) and the advanced practice registered nurse
(APRN) reviewed, and respectively signed and dated the cover page on the policies on January
8, February 18, March 21, May 13, May 20, June 20, September 18, October 7 and 8,
December 3, and December 30, 2025, in addition to January 6, 7, and 8, 2026. Documentation
revealed changes in policies were made during the year were reviewed, signed, and dated by
each nurse on the individual policy change and signature page with the specific policy listed,
date of revision, and signatures. The center’s non-healthcare staff protocols were signed and
dated by the DHA on October 7, 2025. Reviewed documentation showed FOPs for all health-
related procedures and treatment protocols were utilized at the center. VitalCore Health
Strategies, LLC has an established comprehensive clinical orientation for all newly employed
healthcare staff, which includes the Department’s healthcare policies and procedures. Reviewed
documentation found all newly employed healthcare staff received a comprehensive clinical
orientation to the Department’s healthcare 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.
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 nine youth Individual
Healthcare Records (IHCRs) confirmed an AET was filed in seven out of the nine IHCRs. The
original AET form was filed for the seven applicable records and/or legible copy with the word
“copy” was filed in the IHCR. Reviewed documentation indicated each AET form was valid and
signed by a Department representative. Each of the applicable reviewed youth were under
eighteen years of age. One youth was eighteen years of age and there was a documented
release of information form in the IHCR. Two of the nine youth were applicable for being under
the care and custody of the Department of Children and Families (DCF); however, only one was
applicable for the termination of parental rights. The applicable IHCR contained a limited
consent for evaluation and treatment and a court order authorizing treatment. An interview with
the nursing staff indicated all medical staff request the AET during the youth’s admission. The
nursing staff confirmed the procedure for documenting consent for youth who are eighteen
years of age or older.
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 parent/guardian is notified of
significant changes in the youth’s condition and obtain consent when new medications and
treatments are prescribed. A review of nine applicable youth Individual Healthcare Records
(IHCRs) indicated five were applicable for notifications to be included for parental notification for
over-the-counter (OTC) medications beyond those covered by the Authority for Evaluation and
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Treatment (AET). Consent was provided by the parent/guardian, and written notifications were
sent utilizing the Department’s Parental Notification of Health-Related Care form. Reviewed
documentation revealed two of the nine youth were taking psychotropic medications at
admission. For all new psychotropic medications, discontinuances, or psychotropic medication
adjustments, documentation confirmed there were verbal attempts, contacts, and required
consents which were documented in the chronological progress notes in the IHCR by the staff
attempting and/or contacting the parent/guardian. Additionally, for psychotropic medications, all
verbal attempts, contacts, and consents were documented on the third page of the Clinical
Psychotropic Progress Notes (CPPN) or on an informed consent chronological progress note.
There were two youth placed on medications after admission and consents were documented in
the chronological progress notes. Documentation confirmed the attempts to contact the
parent/guardian were documented in the progress notes and written parental notices were sent
regardless of telephone notifications. Two of the nine reviewed youth had Department of
Children and Families (DCF) involvement; however, only one was applicable for the termination
of parental rights. The applicable record contained the required court documentation. Nine youth
IHCRs were reviewed for vaccination status, and each contained a vaccination record from
Florida Shots, which was reviewed by medical staff within thirty days of the youth’s admission.
There were no Religious Exemption from Immunization forms which were submitted since the
last annual compliance review. An interview with the nursing staff confirmed the center’s
practice for obtaining parental consent, documenting attempted parental notifications, and the
procedures followed when there is a youth with an illness or injury which requires emergency
medical services. Nursing staff confirmed the center does not administer vaccinations on-site.
Additionally, the nursing staff explained the procedures for obtaining the immunization records
upon admission.
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 nine youth Individual Healthcare Records (IHCRs) found each had a Medical
and Mental Health Admission Screening form completed on the date of admission. Each
reviewed form was completed on the date of admission by a juvenile justice detention officer
(JJDO), and each indicated the screening was reviewed by a licensed medical staff within
twenty-four hours. Reviewed documentation validated the designated health authority (DHA)
was notified of the applicable youth at admission, as required. Each youth screening form was
completed in the Department’s Juvenile Justice Information System (JJIS), as required. Four of
the nine reviewed youth had a change in their physical custody since their arrival, and the
center completed a healthcare admission rescreening. Two youth were applicable and received
a qualitative urine pregnancy screening test. This was documented in the chronological
progress notes and included documentation of verbal and/or written consent. An interview with
the nursing staff confirmed the center’s practice for completing an admission screening within
the required timeframe. Additionally, the medical staff confirmed the process for rescreening if
the youth’s physical custody changes.
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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
healthcare delivery services at the center. A review of nine Individual Healthcare Records
(IHCRs) showed each reviewed IHCR included documentation to support the youth received a
general healthcare orientation within twenty-four hours of admission to 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 right to refuse care and how it is documented, what to do in the case of a sexual
assault or attempted sexual assault, the non-disciplinary role of the healthcare providers, and
general infection control/hygiene. A review of each of the youth’s Department Health Education
Records confirmed all required elements were addressed during the orientation process. Youth
with chronic conditions were educated on their medical condition by the on-site licensed medical
staff and the education was recorded in the youths IHCR.
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 a youth is admitted with
chronic health conditions. 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 nine Individual Healthcare Records (IHCRs) revealed seven were applicable for known or
suspected chronic conditions upon admission. One youth was identified with a chronic condition
and was in-need of emergency care upon admission. The reviewed record documented the
DHA was notified at admission, as required. Reviewed documentation confirmed the Medical
and Mental Health Admission Screening form was completed for each youth on the date of the
youth’s admission by the center’s registered nurse (RN) and the notification to the DHA or
advanced practice registered nurse (APRN), was documented in each youth’s IHCR/electronic
medical record (EMR), within the required timeframe. One youth was applicable for taking
psychotropic medications upon admission; however, another was applicable for being admitted
with psychotropic medications during a previous admission within the review period. Reviewed
documentation confirmed the psychiatrist was notified of both youth’s admissions. An interview
with the nursing staff indicated whenever a youth is admitted and identified with an emergency
or chronic condition the DHA is notified immediately upon the identification of the condition, and
the DHA is to be notified if there are any urgent medical needs. The DHA is notified by the
nursing staff, and it is documented in the youth’s EMR and in the youth’s chronological progress
note.
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4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures requiring completion, or review, and updating of the
Department’s standard Health-Related History (HRH) form. The center utilizes and completes
the standard Department HRH form for all youth admitted into the center’s physical custody. A
review of nine applicable youth 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). Each HRH form was completed by a
licensed nurse and reviewed by the designated health authority (DHA), as indicated by the
checkbox on the CPA. Each HRH reflected the most current admission into detention. A review
of the nursing interview confirmed the HRH is completed by the nursing staff, within seven days
of the youth’s admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures to ensure each youth in the center has a completed
Comprehensive Physical Assessment (CPA) upon their admission into the center. The CPA
form is to be completed and/or updated for all applicable youth admitted determining the health
and wellbeing of each youth. A review of nine applicable Individual Healthcare Records (IHCRs)
showed each youth’s CPA was completed on the Department’s CPA form. Four youth had a
current CPA on record and five records had a new CPA completed by the DHA. Each reviewed
CPA was completed within seven days of the youth’s admission and signed by the DHA or
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 the youth records documented a Tier 1 Tuberculosis
(TB) screening was completed on the Medical and Mental Health Admission Screening form.
Four of the youth were applicable for a focused evaluation upon readmission. All sections of the
CPA were marked with “O”, except for sections which were noted by the DHA or the APRN as
not being clinically indicated. Four of the reviewed records documented the youth refused part
of the exam and it was clearly marked on the CPA as a refusal on the date of the exam, with a
refusal form filed in the youth’s IHCR. The Department’s Problem List was updated, as required.
Each of the applicable youth had at least one verified TST formerly purified protein derivative
(PPD) test documented in the IHCR within the last year. The results of the TSTs were
documented on the CPA and Infectious and Communicable Disease (ICD) forms matched. The
center’s policy and procedures for 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. A review of the nursing interview indicated the DHA or APRN completes
the CPA once annually, and within seven days of admission. Additionally, updates or a new
CPA are completed if there are significant changes identified in the youth’s physical exam.
Nursing staff indicated TB screenings are provided to youth within forty-eight to seventy-two
hours from admission to the center if required. Additionally, gynecological examinations are not
routinely completed for female youth.
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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 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). The center’s practice is to screen the youth during
admission to determine if further testing is needed. Additionally, the center documents STI
screenings, evaluations, referrals, and maintains them in each youth’s Individual Healthcare
Record (IHCR). A review of nine IHCRs showed seven were sexually active and clinically
screened and evaluated for STIs. Each of the youth’s screenings showed the date of the
screening and/or if further evaluation was required. The center’s practice is to obtain counseling
and testing orders at the direction of the designated health authority (DHA) and/or the advanced
practice registered nurse (APRN). The date testing was ordered for the applicable youth was
noted and performed testing was documented. Testing, screening results, clinical evaluations,
and diagnoses were documented on the Infectious and Communicable Disease (ICD) form,
excluding HIV results. One applicable record documented a gynecological examination was
completed, and the center documented the youth’s consent which was maintained in the youth’s
IHCR. All laboratory documentation was filed in the lab section of the youth’s IHCRs. The center
had five applicable youth who consented to HIV testing. The five applicable youth received HIV
testing and there was evidence of documented consents from each youth were obtained by the
center, which were maintained in the youth’s IHCRs. All HIV testing was completed within thirty
days of the request and all results were filed in a confidential manner. Reviewed documentation
confirmed pre-test/post-test counseling was documented in the IHCR and each 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. There was one youth applicable for being out of the
Department’s custody for thirty days or more needing a rescreening. The applicable youth
received rescreening/HIV testing and there was documented youth consent, which was
obtained by the center, and maintained in the youth’s IHCR. An interview with the nursing staff
indicated all youth entering the center are screened for STIs and afforded the opportunity to
receive HIV testing and counseling services. If a youth STI requires further evaluation the youth
is referred to the DHA or APRN for further treatment/testing. STI results are documented on the
youth’s Infectious and Communicable Disease form and the laboratory results section of the
record and maintained in the youth’s IHCR or the youth’s electronic medical record (EMR). If a
youth has been out of the Department’s physical custody for more than thirty days, the medical
staff will complete a new screening during the new admission. The youth’s HIV testing results
are kept confidential in the youths IHCR and/or EMR. Additionally, HIV pre-counseling, testing,
and post-counseling are conducted by the certified HIV counselor. If further treatment is
warranted, the local health department is contacted for further education and treatment. Nine
youth were interviewed, and each reported they are able to request HIV testing.
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4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures to ensure all youth will be able to make sick call
requests and have their complaints treated through the sick call system. Sick call care, including
dental care, is available to all youth. The center conducts sick calls to respond to a youth’s
medical illness or injury of a non-emergent nature by a healthcare professional. A review of nine
Individual Healthcare Records (IHCRs) indicated six youth were applicable for having submitted
a sick call request. Each youth’s’ sick call was documented on the Sick Call Referral Log. There
were no instances of a youth presenting with a similar sick call complaint three or more times.
Each sick call was conducted by the licensed registered nurse (RN), within twenty-four hours.
When the youth had a complaint of severe pain, which staff were unfamiliar with and/or the
youth’s medical condition could not be determined, the medical staff immediately notified and
referred the youth to the designated health authority (DHA) or advanced practice registered
nurse (APRN). Documentation showed each of the six youth and nursing staff completed a Sick
Call Request form, which was found in the IHCR in reverse chronological order, and/or showed
progress notes which were documented in accordance with Florida Administrative Code. There
were no youth who were in restricted housing of any kind. The dates listed on the Sick Call
Index corresponded to the completed Sick Call Request forms in the IHCR for each youth. The
center maintains treatment protocols appropriate to the level of the provider conducting sick call,
which was approved and signed by the DHA on October 7, 2025. A review of the daily schedule,
posted schedule, and nursing interview indicated sick calls were conducted daily, as pursuant to
contract requirements and there were approved treatment protocols for the registered nurse
(RN). An observation of the center confirmed sick call hours were posted in the medical office
and in each of the youth’s living modules. Additionally, only nursing staff conduct sick calls.
Postings throughout the center indicated sick call care takes place seven days a week from 9:00
a.m. to 10:00 a.m. and between 3:00 p.m. and 5:00 p.m. The DHA is on-site once each week,
on Tuesdays. The advanced practice registered nurse (APRN) is on-site once a week on
Wednesdays. When there is not a licensed nurse on-site, the center has procedures, where
shift supervisors are trained in the center’s sick call procedures and review the sick call requests
in the absence of healthcare professionals. During the week of the annual compliance review,
one sick call was observed. The youth was escorted to the medical clinic by a Right Interactions
(RI) certified staff. The sick call observation confirmed the medical provider identified
themselves and stated why the youth was there. The youth was seen in a private area with no
other youth present to hear or see the examination. The youth was examined by the
nurse/practitioner and not just interviewed, and the medical staff was able to maintain privacy
while the officer was located by the door of the medical area. An interview with the nursing staff
confirmed the process for youth requesting to see a physician or nurse, indicating youth are
able to complete a sick call request at any time, these requests are reviewed by the shift
supervisor or designated center staff within four hours to determine if any immediate medical
attention is required. All sick call care is completed by either the nursing staff, or the DHA within
twenty-four hours. The nurse confirmed the medical staff are on-site daily and are on call
twenty-four hours a day, seven days a week. In the event a youth has a repeated sick call
complaint the medical staff will add the youth to the list for the DHA/APRN. The nurse confirmed
the center maintains a copy of the DHA approved treatment protocols in the medical office. The
nurse reported the process for youth in restricted housing is for the nurse to see the youth once
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each shift. Nine staff were interviewed, and each staff indicated the on-site nurse reviews sick
call requests. Additionally, two staff indicated authorized staff are able to review sick call
requests. An interview with nine staff confirmed the nursing staff and doctor conducts sick calls.
Nine youth were interviewed, and eight youth indicated they are seen immediately upon
submitting a sick call request. Eight of the nine interviewed youth indicated the sick calls are
conducted by the nursing staff and/or an authorized detention staff. One youth indicated they
have never submitted a sick call request.
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 to ensure a comprehensive process of episodic
care, first-aid treatment, and emergency care. The center utilizes an Episodic Care Log to
document episodic care and first-aid treatment. The log contains information to include the date,
name of youth, the youth’s Department identification number, nature of illness or injury,
treatment rendered, staff initials, nurse initials, verification of who provided episodic care, and if
the youth was recommended for off-site care. A review of nine youth Individual Healthcare
Records (IHCRs) showed six youth required on-site first-aid or episodic care with dates and
times noted. Each applicable record documented the 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. Documentation showed the treatment rendered, if a referral to off-
site care was needed, education/instruction provided to youth, the plans for follow-up/future
care, and each youth was placed on an alert list if required. Three of the reviewed instances of
episodic care required a referral to off-site care. Each applicable youth’s IHCR showed parental
notification, an entry in the Episodic Care Log was completed, and the youth received a follow-
up evaluation from a licensed healthcare staff the next time a licensed staff was on-site, or
sooner if warranted. The center maintains sixteen first-aid kits which are located throughout the
center. Four kits are located in each of the youth living modules/sub-controls, one is located in
the master control office, one is located in the medical office, one in the kitchen, one in the
mental health office, and eight first-aid kits are available for each of the transport vehicles. The
first-aid kits for each of the eight transportation vehicles are stored within master control. A
review of documentation confirmed the center’s process for ensuring contents are maintained
and stored in accordance with guidelines to prevent expiration or deterioration is through
nursing staff conducting monthly checks of the contents with documentation of any
inconsistencies found. Observations of three kits during the annual compliance review week
validated the kits were stocked with the designated health authority (DHA) approved contents.
An informal interview with the nursing staff indicated they conduct monthly perpetual counts of
the contents to ensure the integrity of the contents. The center maintains two automated
external defibrillators (AED). The center’s AEDs are located on a wall-mounted AED box in the
medical clinic and in the master control office. The AED procedures were in the AED box, as
well as audio instructions. The AED batteries and pads are checked by medical staff and an
outside medical provider monthly, to confirm each are operable. A review of the center’s AED
tracking sheets since the last annual compliance review confirmed they documented the
center’s practice. During the annual compliance review, nursing staff checked the expiration
dates, conducted a self-test of the AEDs, and there were no issues discovered. The AEDs are
made with an internal battery, which is serviced by an outside provider, and an observation of
the AEDs’ lights showed an indication of green. Documentation showed the AED batteries were
changed on May 25, 2022. The batteries in the AEDs had an expiration date of May 25, 2026,
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and the pads expire on April 25, 2028. Observations confirmed emergency contacts and
telephone numbers were posted in the medical clinic and in master control to include the
number for the statewide Poison Information Control Center which are accessible for the non-
licensed and licensed staff throughout the center, as well as inaccessible to each youth at the
center. A review of nine pre-service and in-service staff training records found each was trained
and held current certifications in cardiopulmonary resuscitation (CPR), first-aid, and AED. Each
of the nine training records supported each staff received the required training on the center’s
Emergency Care Plan, and the supervisory staff received training on the epinephrine auto
injector. All non-healthcare staff and nursing staff are required to maintain certifications. Only
healthcare and trained non-healthcare staff can administer the epinephrine auto injector for
youth requiring administration when indicated. Reviewed documentation supported the DHA,
the advanced practice registered nurse (APRN), and all nursing staff maintained current
certifications in CPR and AED. The center’s policy and procedures indicated emergency drills
are to be conducted for each shift on a quarterly basis at a minimum, and AED/ CPR
procedures must be demonstrated at least annually. A review of documentation and video
observation revealed drills simulated episodic care events which call for immediate first-aid,
AED, and/or administration of CPR techniques and the initiation of the emergency procedures to
follow when a life-threatening emergency does occur. The center maintained proper
documentation of each monthly drill completed during the last twelve months, with an effort to
ensure, at a minimum, all staff with direct contact on a day-to-day basis had the opportunity to
participate in at least one emergency drill annually. Additionally, it is the center’s practice to
discuss all drills during the staff debriefings and/or meetings. All documented drills included the
type of medical event, time the drill/event occurred, time 9-1-1 was called, if applicable, name of
the juvenile justice detention officer supervisor and healthcare provider in charge, healthcare
provider response time, type of medical care rendered, time the event concluded, clinical
manager/medical staff review, and critique. The center has a policy and procedures regarding
the use of NARCAN®. The center’s nurses are responsible for conducting staff training on
NARCAN® as a standalone, instructor-led class for the supervisors trained and approved for
medication administration. The center maintains NARCAN® in the locked medication cart which
is accessed only by the licensed nurses and authorized staff who have completed training on
medication administration. The center maintains a perpetual and weekly inventory of the
NARCAN®. An informal interview with the nursing staff indicated the center has not utilized
NARCAN® since the last annual compliance review. An interview with the nursing staff
confirmed the center has a total of sixteen first-aid kits. The first-aid kits are located within each
sub control for each living module, one in master control, one in the kitchen, one in the
administrative office, and eight for each transportation vehicle. The nursing staff confirmed the
center’s process for documenting and tracking on-site episodic care. The nursing staff
confirmed the center has two AEDs and was knowledgeable of the location of each AED and
where the procedures are located. The nursing staff confirmed the medical team conducts
monthly checks to ensure the AED pads and batteries are operable. The center utilizes a private
vendor who checks and changes the batteries and pads prior to the expiration date.
Additionally, the nursing staff indicated all emergency and medical drills are held monthly on
each shift. The nursing staff confirmed a list of emergency numbers are posted at each of the
nursing staff’s desks and are inaccessible to youth. Nine interviewed staff indicated they are
allowed to call 9-1-1, if needed. Nine youth were interviewed, and each rated the medical care
at the center as very good.
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4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures for the provision of off-site emergency and non-
emergency referrals for medical care and treatment. The center provides referrals and
coordination of medical services to ensure youth have timely access to off-site care services.
Evaluations conducted off-site shall be recorded on the Department's Summary of Off-Site Care
Consultation Report form. The designated health authority (DHA) reviews, signs, and dates the
off-site care instructions. A review of nine youth Individual Healthcare Records (IHCRs) found
there were three applicable youth for off-site care. Each applicable record contained a Summary
of Off-Site Care Consultation Report form, which was utilized and filed in the youth’s IHCR. Off-
site emergency care was documented on the Episodic First-Aid/Emergency Care Log, and
parental notification efforts were documented. Each of the off-site care events were applicable
for discharge documents, which were filed in the IHCR. Documentation showed the DHA was
notified of an emergency event with the date, time, manner of notification, and the DHA
reviewed and signed/initialed all off-site care findings, instructions, and information. Two of the
three applicable youth needed follow-up testing, referrals, or appointments. Each of the
applicable youth’s referrals were entered on the Sick Call Log and/or the center’s tracking log.
Reviewed documentation confirmed the referrals were tracked and youth received appropriate
and timely follow-up care. An interview with the nursing staff indicated youth who require first-
aid or emergency care are sent off-site and are tracked and documented on the Episodic First-
Aid/Emergency Care Log . The log is utilized by staff to ensure all hospital orders are followed.
The medical staff ensure the DHA or advanced practice registered nurse (APRN) are notified,
all hospital orders are followed upon the youth’s return, and during every on-site weekly visit.
Nursing staff ensure the DHA reviews and initials the off-site care findings, and maintains the
tracking log for follow-ups, referrals and appointments where all documentation is recorded in
the youth’s electronic medical record (EMR) and/or the medical tracker.
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. A review of nine youth
Individual Healthcare Records (IHCRs) found seven were identified on the Medical/Mental
Health Screening form with a current chronic condition. Six youth were undergoing treatment for
a physical health condition, four youth were taking prescribed medication on an on-going basis,
there were five youth classified with a Medical Grade between two and four, and two youth were
applicable for pregnancy. Reviewed documentation confirmed each applicable youth was
placed on the chronic conditions list. Periodic evaluations were conducted for each of the
applicable youth requiring periodic evaluations prior to renewing a prescription medication which
expired. Three youth were applicable to receive periodic evaluations at least every ninety days
or as needed, and three youth had not been in the center long enough to receive periodic
evaluations. Reviewed documentation and progress notes confirmed periodic evaluations were
completed for each of the three applicable youth. The center’s process requires pregnant youth
evaluations be conducted every two to four weeks for the first eight months, every two weeks
during the eighth month, and weekly thereafter for pregnant youth. Reviewed documentation
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confirmed the two applicable pregnant youth received periodic evaluations at a higher frequency
than the chronic condition requirements. One of the applicable youth had an evaluation
conducted off-site, which was documented on the Summary of Off-Site Care form and filed in
the youth’s IHCR. Additionally, the DHA’s receipt/signing off of the documents and follow-up
with the youth was documented. There were no indications of lapses in care or missed periodic
evaluations. The Department’s Problem List was updated in accordance with Florida
Administrative Code. There were no youth applicable for taking anti-tuberculosis medication. A
review of medical documentation revealed there were periodic evaluations tracked on the
chronic physical health conditions roster. An interview with the nursing staff indicated the center
monitors youth with chronic conditions. An interview with the designated health authority (DHA)
indicated periodic evaluations for youth with chronic conditions are addressed, tracked, and
reviewed every ninety days, to ensure ongoing monitoring and management for the youth’s
continuity of care.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures which outline the process of how medication and
pharmaceutical products are procured, dispensed, administered, and stored safely, accurately,
and in accordance with state, federal, and industry standards. The center’s practice is for
nursing staff to verify all medications have a current, valid order, and are given according to a
current prescription or practitioner’s order. Nursing staff verify medications with the
parent/guardian when they deliver the medication to the center. The Department’s Medication
Receipt, Transfer, and/or Disposition form is used to document medication received in the
original packaging from a licensed pharmacy with a current, legible, patient-specific label
affixed. All medications are delivered to the center in blister packs. A review of nine Individual
Healthcare Records (IHCRs) showed there was one youth taking medication upon admission.
Two additional IHCRs were reviewed for taking medication at admission. When current
medications were continued, discontinued, or changed, reviewed documentation confirmed the
designated health authority (DHA)/advanced practice registered nurse (APRN), placed an order
on the Practitioner Order form, as required. A review of each youth’s medications showed there
was a current, valid order. The prescription verification was included in the chronological
progress note, and in the IHCR/electronic medical record (EMR) for each youth. The center’s
policy and procedures indicate if a youth enters the center while on prescribed psychotropic
medication, the psychiatrist shall be notified upon the youth’s admission in order to obtain an
order to continue the prescribed medication. The psychiatrist was notified as required for the
applicable youth. When current medications were continued, discontinued, changed, or new
ones were ordered, the DHA/APRN placed an order on the Practitioner Order form as required.
No youth were applicable for restricted housing while taking prescribed medications. The center
maintains a written policy and procedures to ensure the usage of the standard Department
Medication Administration Record (MAR) by licensed healthcare staff and non-licensed staff, for
each youth receiving either prescription medications on a routine basis and/or over-the-counter
(OTC) medications. The reviewed MARs included all the required elements. Each of the nine
reviewed youth were applicable for 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 and listed on the MAR, which documented all medication and/or treatment.
The MARs clearly indicated the medication start and stop dates. The were no applicable youth
records for trained non-healthcare staff assisting in the delivery of medications when licensed
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healthcare staff were not on-site. There were no undocumented explanations for lapses or
errors in medication administration. A review of the standard MAR forms showed the forms
included the youth’s name, Department identification number (DJJID), date of birth, youth
allergies, precautions, Medical Grade, medical alerts, and current picture of the youth. At a
minimum, nursing staff documented side effect monitoring weekly on the MAR, refusals were
clearly documented on the MAR when applicable, and the youth signed the Refusal of
Treatment Form indicating the refusal, when applicable. Reviewed documentation reflected the
staff initialed each administered medication entry and each applicable youth documented their
initials on the MAR. There were no youth requiring parenteral medication at the center since the
last annual compliance review. The center did not have any standing orders for psychotropic
medications, no pro re nata (PRN) orders for psychotropic medications, or emergency treatment
orders for psychotropic medications. The center has a list of trained non-healthcare staff who
are approved to assist in the administration of medication. An observation of a medication
administration was conducted during the week of the annual compliance review. The youth’s
verbal consent was obtained prior to observation. The youth was escorted to the medical
station/medication administration area by the assigned officer, the youth approached the nurse
administering medication individually, the medical provider identified themselves and stated why
the youth was there, and the same medical staff prepared and administered the medication. The
nurse verified each youth’s allergy and alert status, and the nursing staff and youth initialed the
MAR. Staff observed youth to make sure medication was swallowed and the OTC medication
administered was documented. An interview with nursing staff indicated the center has a
process for monitoring and tracking youth with chronic conditions and medication upon entering
the center. Additionally, the nurse indicated the center has non-healthcare staff who are trained
by the clinical manager and are authorized to provide OTC medication to youth. An informal
interview with the center’s clinical manager confirmed the center’s non-healthcare staff were
trained by the nursing manager, on January 14, 2025. Nursing staff indicated the center
provides youth medications every day, at 8:00 p.m., 12:00 p.m., 5:00 p.m. and 8:00 p.m. or as
required, and all medications are documented in the Department’s MAR form. Additionally, the
center utilizes a private pharmacy for their prescription medication orders. Additionally, the
nursing manager indicated the center utilizes a chemical pharmaceutical drug disposal system
to dispose of expired and/or discontinued medications with the assistance of the consultant
pharmacist. An interview with nine staff indicated they do not provide youth with medication.
Nine youth were interviewed, and three stated the nursing staff provide the youth with their
medication, while six youth indicated they do not take medications.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures outlining the provision of psychiatric services to
youth in need, to include psychiatric evaluation, consultation, medication management, and
medical supportive counseling. The policy requires the center to provide psychiatric services to
the youth determined to need services, as indicated by symptoms of mental disorder or
substance-related disorder, or to youth who are treated with psychotropic medication after their
admission to the center. The center maintains a contract with VitalCore Health Strategies, LLC.,
for the provision of a licensed psychiatrist to provide psychiatric services for applicable youth in
the center. A review of the psychiatrist’s license confirmed they maintain a clear and active
license with an expiration date of March 31, 2026. The center does not utilize a psychiatric
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advanced practice registered nurse (APRN) and does not have a back-up psychiatrist. The
center is authorized to utilize tele-psychiatry for their psychiatric services. A review of nine youth
Individual Healthcare Records (IHCRs) reflected there were three youth applicable for entering
the center on psychotropic medications or were referred for a psychiatric interview within
fourteen days of the youth’s admission to the center. Two of the three youth records had a
current Authority for Evaluation and Treatment (AET) consenting the continuation of
psychotropic medication and one youth had a court order authorizing consent for treatment.
Each reviewed record contained an Initial Diagnostic Psychiatric Interview, which included the
reason for the referral, the youth’s history of medical, mental health and substance abuse, a
Mental Status Examination, a Diagnostic and Statistical Manual, Fifth Edition (DSM-5)
diagnosis, treatment recommendations specific to mental health and/or substance abuse
diagnoses, prescribed medication, documentation of medication name, and an explanation of
the need for psychotropic medication. Each initial psychiatric interview documented the
frequency of medication monitoring/management for each youth. Each was completed within
fourteen days as required. Each in-depth psychiatric interview was completed in coordination
with the initial psychiatric interview and included , the history of psychiatric illness, psychotropic
medication management, mental health treatment and/or substance abuse treatment,
assessment of symptoms, the identification of individual, family, and/or environmental factors
which may potentially account for, influence or ameliorate the youth’s difficulties, DSM-5
diagnoses, prescribed medication, explanation of the need for psychotropic medication related
to the youth’s diagnosis, target symptoms, potential side effects, risks, and benefits of taking the
medication, and the signature of the practitioner conducting the psychiatric evaluation. All three
applicable youth records contained the third page of the Clinical Psychotropic Progress Note
(CPPN) when new psychotropic medications were prescribed or if there were any changes to
the existing prescription. Each CPPN was clearly identified as a psychiatric evaluation.
Additionally, the reviewed evaluations included the youth’s name, date of birth, Department
identification number, diagnosis, target symptoms of each medication, evaluation and
description of effect of prescribed medication on target symptom(s), prescribed psychotropic
medication, including the name, dosage and quantity of the medication, normal dosage range,
ordered dosage, frequency and route of administration, reasons for changes in medication, side
effects, youth’s adherence to the medication regime, and/or dosage. Reviewed documentation
confirmed the youth’s parent/guardian telephone contact was documented, signature of the
psychiatrist, date of signature, and documented monitoring for Tardive Dyskinesia on the CPPN.
The center provides the standard of psychiatric care delivered through tele-psychiatry.
Reviewed documentation confirmed the psychiatrist provided tele-psychiatry services on a
weekly basis. An interview with the DMHCA confirmed the licensed mental health staff meet
with the psychiatrist to discuss psychiatric services during the tele-psychiatry services which are
held weekly or as needed.
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
medications/sharps are secured, inventoried by using a routine perpetual inventory and ensure
all medication is inaccessible to youth at the center. The dose-by-dose daily administration and
documentation of a medication is documented utilizing a perpetual inventory process for the
daily distribution of non-controlled prescription medications and over-the-counter (OTC)
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medications. Observations of the medical clinic were conducted during the annual compliance
review week and found the clinic to be secured, under lock and key. The medical equipment
classified as sharps, including syringes, needles, scissors, and suture removal kits were
secured and inventoried utilizing a routine perpetual inventory descending count as each sharp
was utilized and disposed, all medications were identified and secured in the locked area
designated for storage of medications, the medication cart was clean/organized with stock items
separate from youth-specific medications, oral medications were stored with injectable or topical
medications, medications which required refrigeration were stored in a secured refrigerator,
which is used for medication only, and all controlled medications had a perpetual inventory and
were stored separately from other medications. The locked medication cart is located in the
medical office which stores all oral, prescription, and OTC medications for youth. The center’s
practice is for two nursing staff to conduct shift-to-shift inventory counts of all controlled
medications. Narcotics and other controlled medications are securely stored and double locked
within the medication cart. The center’s perpetual and weekly inventories of all sharps and stock
OTC medications were conducted as needed pursuant to the Board of Pharmacy regulatory
requirements, and there was a shift-to-shift inventory count of all controlled medications
documented on the youth’s individual Controlled Medication Inventory Record, as required.
Additionally, documentation showed non-healthcare staff were trained in the delivery and
oversight of medication self-administration by the center’s registered nurse (RN) on January 14,
2026. An observation of three controlled medications was conducted showing all counts of
inventories were accurate. A review of three OTC medications was conducted, and each
medication was validated and accurate. A review of three sharps was observed, in which
perpetual inventories were accurate with verified weekly inventory. A review of the inventory
logs confirmed perpetual and weekly inventories were conducted on sharps and stock OTC
medications. Items designated as sharps are stored in a designated cabinet in the medical clinic
and are inaccessible to youth. An informal interview with the clinical nurse manager confirmed
the center conducts perpetual inventories with running balances which are maintained on all
controlled substances with a shift-to-shift inventory conducted by the nursing staff. The clinical
manager indicated the center’s inventory of medication is stored securely, and any narcotic
medications are maintained behind double locks within the medication cart. The center's clinical
manager indicated all discrepancies must be reported and all discrepancies are reported to their
supervisor, superintendent, and master control. Additionally, staff are required to initiate and
conduct a search. The clinical manager explained, when there is a discrepancy, all medication
must be recounted in an effort to find the discrepancy, and a call is made to the Department’s
Central Communications Center (CCC). Additionally, the nursing staff confirmed the center has
an agreement with the consulting pharmacist, who visits on a monthly basis and is responsible
for reviewing medication inventories, medication expirations, disposals, and to ensure the center
is in compliance with all laws and regulations. The center maintains a copy of the pharmacy
consultant license on-site, as required.
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.
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The center has facility operating procedures requiring the implementation of infection control
measures 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 nine youth Individual Healthcare Records (IHCRs) reflected each youth received
infection control training within seven days of admission, which included hand-washing
techniques, prevention/transmission of communicable diseases, and vaccinations. A review of
the center’s Exposure Control Plan/Infection Control Plan documentation showed the plan was
written in accordance with OSHA guidelines to include risk assessment and methods of
compliance. The plan addressed common childhood infectious diseases, self-limiting, episodic
contagious illnesses, viral or bacterial infectious diseases, tuberculosis (TB), Hepatitis A, B, and
C, human immunodeficiency virus (HIV), blood-borne pathogens, other outbreaks and
epidemics, and outbreaks of pediculosis. In addition, the plan included Methicillin Resistant
Staphylococcus Aureus (MRSA) and other antibiotic-resistant micro-organisms, food-borne
illnesses, bioterrorism agents, 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 reporting the stick to the immediate supervisor, documenting
the circumstances, route of exposure, and the source individual and their status. Results of
testing are to be made available to the exposed staff, as well as providing appropriate
counseling, and a referral to the nearest medical center/hospital or Department of Health for
post-exposure evaluation through worker’s compensation. The center ensures Hepatitis B
immunizations are made available for staff and staff have access to protective equipment as
needed. When applicable, infectious diseases are reported to the local health department
and/or CDC. There were no reportable incidents for which the local county health department,
CDC, or the Department’s Central Communications Center (CCC) had to be notified of an
infectious disease since the last annual compliance review. Documentation confirmed the
superintendent maintains a separate file containing all documents for youth and staff who have
experienced an occupational exposure, and all records were maintained as confidential for a
ten-year period, as required. A review of nine pre-service and in-service training records found
each staff completed Exposure Control Plan/Infection Control Plan training. An interview with
the nurse indicated the medical staff are responsible for providing detention staff with annual
training and education to youth on the Exposure/Infection Control Plan during admission. The
nursing staff indicated the Exposure/Infection Control Plan is available to staff and a copy of the
plan is located in the policy binder within the medical office. The nurse interview confirmed the
center utilizes the local county health department services which include TB testing/chest x-ray,
medication and follow-up treatment.
4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. Two of the seven reviewed
Individual Healthcare Records (IHCRs) were applicable for prenatal care and one additional
record was requested. In each of the three applicable IHCRs the youth received prenatal care
immediately upon determination of pregnancy until release from the center. The three youth
were placed on the alert log for vital nutrition, health awareness for staff, and sleeping
arrangements, and the designated health authority (DHA) and/or advanced practice registered
nurse (APRN) provided a routine focused medical evaluation of the youth’s pregnancy every
thirty days or sooner. Reviewed documentation indicated each youth was monitored daily for
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signs of pregnancy complications. There was a documented plan for post-birth psychological
and physical care. Reviewed healthcare education information showed each of the pregnant
youth had completed prenatal education including the topics of alcohol and drug use, smoking
cessation, nutrition, sexually transmitted infections (STIs), contraception, prenatal care, birthing
process, postpartum care, basic baby care, child/infant development, and parenting skills. All
youth education was documented in the youth’s IHCR. A review of nine staff training records
validated each staff received training specific to working with pregnant youth. Staff training
documentation reflected training was provided by the clinical manager at the time of hire and
annually, thereafter. An interview with the clinical nurse manager indicated the center's process
for routine monitoring of pregnant youth is for the youth to follow-up with an
obstetrician/gynecologist and provide the youth with a special diet. Additionally, the center
provides educational topics to pregnant youth including nutrition, pre-term labor, active labor,
morning sickness, healthy pregnancy prenatal care, and other adverse effects of pregnancy.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures to address active supervision of youth. Daily
observations were conducted during the annual compliance review. Youth and staff
observations were made during school time, on the living modules, during mealtimes and
breaks, in the intake area, and during line movements throughout the center. The detention staff
maintained continuous supervision of the youth within their assigned areas. The interactions
observed between staff and youth verified active supervision. Staff were positioned in the
designated areas and during line movements which supported active supervision. The juvenile
justice detention officers (JJDOs) and master control operators communicated to receive
authorization for all movement within the center. A review of the center’s master control logbook
confirmed headcounts were conducted on a consistent basis during the beginning and ending of
each shift and prior to youth movement. Nine staff were interviewed, and eight stated there were
enough staff to provide for the safety and security of the youth and staff. One staff stated, if one
shift does not have enough help safety lacks; however, there has always been enough help
because staff will have to work a double shift to ensure the safety and security of the youth and
staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures requiring a behavior management system (BMS)
which offers a consistent set of rewards, privileges, and consequences for behavior. The
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center’s rewards, privileges, and consequences are to motivate the youth to meet the center’s
expectations. The BMS is a three-tiered level system. Once the youth is admitted into the
center, the youth’s behavior level may increase or decrease depending on the youth’s behavior.
Observations during the annual compliance review week revealed postings of the BMS in all
living modules which clearly specified appropriate and inappropriate behaviors, rules, norms,
and expectations. The BMS indicated rewards for positive behavior and consequences for
inappropriate behavior. An interview with the superintendent confirmed this practice. The
center’s incentive calendar was posted on the living modules and throughout the center. All the
youth living modules had level boards, where youth can see their progress throughout the day.
Daily activities were observed and determined implementation of the BMS. A review of
documentation confirmed positive rewards are given to youth to match the BMS incentive
calendar, and rewards and consequences are given in accordance with the BMS. The
documentation reviewed did not indicate any instances of inappropriate use of restrictions or
group punishment. Nine staff were interviewed and were able to explain the center’s BMS
process in its entirety and each stated staff receive feedback daily, or as needed, on their
implementation of the BMS. Nine staff reported the supervisors provide feedback to staff
regarding the implementation of the BMS during shift briefings. Each staff stated youth are given
the opportunity to explain their behavior. Nine youth were interviewed and three of the nine
reported the BMS is fair. Four stated the system is very good. Two reported the system is good.
Each youth was able to explain the different levels of the system. Each youth reported peer
punishment is not allowed. All nine-youth stated they receive rewards based on their behavior.
Six youth reported being sent to their room as a punishment for fighting, using profanity, or
acting out. Three youth reported never being sent to their room. Six youth reported the
consequences were fair and three youth reported never receiving consequences. All nine youth
reported handcuffs or leg irons are never used to control youth.
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. Staff utilize an
electronic wand by tapping it on the check point sensors on the outside of each youth’s door.
The center has ninety-six cameras and sixty-five were operational. Video recordings are stored
for thirty days. Documentation was reviewed and verified work orders were submitted for the
inoperable cameras. Nine camera samples were reviewed for the thirty days prior to the annual
compliance review. Reviewed documentation and video confirmed all checks were completed
under the ten-minute designated timeframe and with fidelity. Documents were provided to
confirm weekly reviews of management oversight. A review of ten-minute check logs for thirty-
minute increments from each shift on each living module, for a total of thirty check samples was
completed. All checks were completed within the required timeframe of under ten minutes. Nine
interviewed staff reported room checks are conducted every ten minutes when a non-suicidal
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youth is placed in their room for sleeping or non-punishment reasons. An interview with the
superintendent confirmed the center’s practice.
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 requiring staff to always be aware of the exact
number and location of all youth under their supervision. During the annual compliance review,
master control officers were observed conducting scheduled and random census counts. All
movement within the center was stopped and officers called in their findings into master control
by radio. Once the count was verified, movement within the center was allowed to continue. All
findings were documented in the master control and module logbooks. A review of the master
control logbooks for twelve months prior to the annual compliance review period confirmed
documentation for headcounts were conducted at the beginning and end of each shift, prior to
and following routine group movement, any time a population change occurred, randomly, at
least once on each shift, and before/after youth movements. Nine interviewed staff reported
youth counts are conducted at the beginning and ending of each shift, before and after school,
and before and after meals. Each staff stated emergency counts are conducted when visibility is
hindered such as an electrical outage, after a major disturbance, and following any code call,
escape, disturbance, or medical/mental health emergency.
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
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area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures in place regarding logbook maintenance and
reviews. The center maintains separate logbooks in master control, each living module, for
visitors, and for each vehicle. A review of logbooks for the past twelve months revealed each
logbook was bound with numbered pages, had the date documented at the top of the page, all
entries included the times of the events with the name of the staff and youth involved, contained
a brief description of the events, and the initials of the staff making the entries. All reviewed
entries revealed safety and security of the center, including medical, special needs, and mental
health alerts, were highlighted. Reviewed logbooks reflected all errors were struck through with
a single line and voided and initialed by the person correcting the error. Reviewed master
control logbooks included emergency situations, incidents, fire and escape drills, population
counts at the beginning and end of each shift, group movements, admissions and releases,
presence of law enforcement, 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 and/or secure observation
began, and the time precautionary and/or secure observation was discontinued. Sample
logbooks from master control and each living module were reviewed for one day each month
during the annual compliance review period, not exceeding twelve months. Documentation
supported the center’s superintendent, or designee reviews all logbooks on a weekly basis. The
juvenile justice detention officer (JJDO) supervisor reviewed the logbooks maintained in master
control when accepting the responsibility of the center and each living module. The JJDO
reviewed the logbook maintained in living modules when accepting responsibility for the area.
Documentation supported the superintendent, assistant superintendent, or staff in charge of the
center will tour the youth living areas at least once during each shift and document their visit in
each area’s logbook. An interview with the superintendent confirmed the center’s practice.
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 detailing the requirements of the center’s key
control, issuance of keys to staff, inventory of keys, and tracking. All staff are trained in key
control prior to key assignment. Key assignment and usage pertain to the staff’s role. The
storage area was observed and confirmed each key ring has a tamper proof color coordinated
key ring hub. All officer keys are blue, supervisor keys are yellow, administration keys are black,
medical/mental health keys are white, food service keys are green, education keys are brown,
and emergency keys are red. A review of the key inventory sampling confirmed key rings on the
inventory matched the actual key rings in use. Keys which are not assigned are secured in the
supervisor’s office in a tamper proof lockbox. The staff are to give a key to receive a key at the
beginning of shift, and at the end of shift they give their keys back to the supervisor to receive
their personal keys. Observations confirmed key distribution was conducted during briefing by a
supervisor. Emergency key rings were included as part of the center’s key inventory. It was
observed the master key inventory included the ring number, number of keys on each ring,
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capability of each key, and to whom the key ring was issued. Reviewed documentation
confirmed the issuance of keys and key ring numbers were documented on each shift report.
Documentation included the date and time of issue, name of staff issuing the key ring, name of
staff who received the key ring, and the time the key ring was returned. Observations made
during the week of the annual compliance review confirmed all staff who were issued keys
always carried the issued keys at all times, did not allow youth to handle any keys, did not
remove the keys from the center or the center’s grounds, and the key box was not easily
accessible while locked. During the annual compliance review period, there was one incident
reported to the Department’s Central Communications Center (CCC) related to key control
concerns. It was reported all staff received a retraining memorandum for key control as a
corrective action. A sample of five key rings were observed and compared to the inventory and
key log. It was confirmed keys were present on the key log, the key tag matched the number of
keys on the key ring, and the number of keys on the ring matched the inventory. Three staff
were informally interviewed about their keys, and all three staff knew the correct number of keys
on their key ring and the function of all the keys on their assigned key ring. An interview with the
master control operator confirmed staff are assigned a color coordinated key prior to entering a
secure area, and contractors are given a colored key to coordinate with their designated work
area. Keys are turned in prior to departure. The restricted key staff are to turn in or secure away
their personal items and receive the keys from a supervisor. Nine staff were interviewed and
were able to explain the key control process in its entirety. The interviewed superintendent
reported permanent keys are not assigned.
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 to address transportation procedures and the
maintenance and operation of Department vehicles. The center has seven vehicles used to
transport youth. Documentation supported the maintenance mechanic completed monthly
vehicle checks. A review of the vehicle maintenance invoices revealed all vehicles received an
annual inspection within the previous year. Observations confirmed each of the center’s seven
vehicles had the appropriate number of seatbelts, a seatbelt cutter, a window punch, a current
fire extinguisher, and a first-aid kit with items approved by the designated health authority
(DHA). Reviewed documentation confirmed the van logbook documented acknowledgement the
vehicle was checked, destination, number of youth and staff names, name of the officer riding in
the back of the van, the time transport began, and the time transport ended. An observation of a
youth transport was conducted during the annual compliance review week. Prior to transporting
youth, staff inspected the vehicles for contraband, conducted a fuel check, maintained copies of
transportation procedures in the vehicle, verified the seat belts were operational, ensured the
security screen was secure, confirmed the vehicle folder included the logs, vehicle and
mechanical restraint keys, gas credit card, and vehicle registration. Following transport,
observations confirmed the van was searched for contraband, locked, and the youth was
searched. A security check was conducted of all vehicles, and all were locked when not in use.
The passenger door of one vehicle could not open with the key and could be only unlocked
when the door switch was activated. Nine interviewed youth reported they feel staff are driving
safely when transporting youth and have never seen anyone place contraband in a transport
vehicle.
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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 to address tool inventory and tool management
requirements. The center's maintenance and kitchen tool policies require inspections of tool
control areas to be conducted monthly, and the results of inspections are submitted to the
superintendent or designee. Tools are stored in a locked area when not in use. Observations
made during the week of the annual compliance review confirmed this practice. The center
maintains a perpetual inventory of all tools and the superintendent or designee reviews
maintenance tool inventories monthly. The reviewed inventory was accurate at the time of the
annual compliance review and there were no missing tools noted. Ten randomly selected tools
were compared against the inventory and the inventory was accurate. The center has a shadow
board to easily identify any missing tools. Kitchen staff conduct an itemized inventory of all
equipment, including kitchen knives and other hazardous kitchen implements, upon reporting for
duty. Observation of the kitchen confirmed no tools listed on the inventory were missing and
there were no tools found to be not listed on the inventory. An informal interview with
maintenance staff confirmed it is the center’s practice to always accompany service vendors
when in a secure area of the center. Reviewed documentation confirmed there was a review of
inventory used to document the issuance and return of tools. The center allows youth to use
cleaning items such as mops, brooms, and other common household items, under direct staff
supervision. Observations were unable to be observed of youth using cleaning tools during the
week of the annual compliance review as this activity did not occur while the annual compliance
review team was on-site. During an interview with the superintendent, it was confirmed
administration and maintenance staff have access to center tools. Nine staff were interviewed
and reported the center’s practice is to lock down the center for missing tools. Nine staff
reported youth are allowed to use scrub brushes, mops, brooms, and dust pans. Nine youth
were interviewed, and six youth stated the tools they use are mops and brooms, while three
youth stated 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,
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.
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The center has a Safety Plan to ensure the proper use, storage, disposal, and inventory of
chemicals including poisonous, flammable, and toxic materials. Reviewed documentation
revealed the center maintained an inventory of all flammable, toxic, caustic, and poisonous
items during the annual compliance review period. Safety Data Sheet (SDS) logbooks were in
the location where the chemicals are stored, and available to staff. Only authorized staff are
permitted access to flammable, toxic, caustic, and poisonous items. All chemicals were stored
away from the youth. During the annual compliance review week, the inventory was reviewed
for five selected chemicals and compared to the inventory sheets. All chemicals were accounted
for and the SDSs were present. Nine youth were interviewed, and seven stated they do not
clean with any type of cleaning agent such as bleach, laundry soap, window, or toilet cleaners.
Two youth stated, staff spray and they wipe it down. Nine interviewed staff confirmed youth are
not allowed to clean with substances which are toxic, flammable, or poisonous.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures regarding the disposal of flammable, toxic, caustic,
and poisonous items. The facility operating procedures list the procedures to follow in the event
of a chemical spill. An interview with the maintenance staff and reviewed documentation
confirmed the center did not have any instances of chemical spills or disposal of any flammable,
toxic, caustic, or poisonous items during the annual compliance review period. The maintenance
staff reported the center uses a local waste management company for chemical disposal and a
local company to dispose of kitchen grease.
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 addressing the process of youth placed in
temporary confinement under twenty-four hours. The center had 644 confinements lasting less
than twenty-four hours during the annual compliance review period. Fifteen Confinement
Reports were reviewed. Each Confinement Report contained documentation which ensured
each youth had the required meals, access to medical care as required daily, access to mental
health care as needed, daily shower, clean clothing, access to hygiene items, mattress/bedding,
and the right to grieve a confinement placement. None of the youth were applicable for needing
education materials. Fifteen reviewed reports confirmed prior to placing each youth in
confinement, the supervisor approved all confinements, staff placed only one youth in the
confinement room, the room was searched, and documentation of the search was entered into
the Department’s Facility Management System (FMS). All fifteen reports confirmed once the
youth was placed in confinement, the youth was supervised and supervision was documented
on the confinement Visual Observation Report (VOR) Log, at a minimum, every five minutes for
the first hour of confinement. Reviewed reports confirmed the reason confinement was
necessary and explained to the youth, the supervisor conducted an initial confinement review
with the youth within one hour of the incident, and the full report was completed before the end
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 58
of their shift. Reviewed reports confirmed the supervisor conducted additional applicable
reviews with the youth at a minimum of every three hours and documented the reviews in FMS.
Additionally, the supervisor/staff continually counseled the youth and considered removing the
youth from confinement as soon as the youth was able to safely rejoin the population and there
was no threat to safety. None of the reports confirmed a physical injury was observed. Each
report confirmed the superintendent, or designee reviewed all confinement reports within forty-
eight hours, excluding weekends and holidays, unless it is their regularly scheduled workday,
and determined whether each confinement was appropriate or inappropriate. Observation
confirmed windows and cameras were free of obstructions/scratches, so the youth may be
visually observed. An interview with the superintendent confirmed confinement is used as a
short-term strategy used for managing a youth's behavior, and it is tracked through FMS daily.
The superintendent reported management reviews the use of confinement, lockdown, and
restraints daily. Nine staff were interviewed, and all nine stated the center’s step by step
process for placing youth in confinement is to complete a confinement report, conduct and
document ten-minute checks, search the confinement room, and contact the supervisor and
document it in the logbook. Nine interviewed staff reported youth who are placed in temporary
confinement are provided with education materials.
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 address the Continuity of Operations Plan
(COOP). Reviewed drill documentation confirmed the center conducted at least two COOP drills
during the annual compliance review period, as required, including at least one drill completed
prior to hurricane season. Reviewed documentation for all drills contained the type of drill, date
and time, participants, brief scenario, and any resulting critique or corrective action. During an
interview with the superintendent, it was reported the COOP is the center’s comprehensive
safety/emergency plan.
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Office of Accountability and Program Support Page 56 of 58
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures to address an Escape Prevention Plan. The
centers policy requires the center to conduct escape drills on a quarterly basis. Reviewed
documentation confirmed escape drills were completed monthly during the center’s two shifts
since the last annual compliance review. A review of nine training records confirmed staff were
trained in escape prevention annually. A review of the center’s logbooks confirmed
documentation of each drill. Nine interviewed staff reported they participated in fire drills, escape
drills, and major disturbance drills.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a written policy and procedures for addressing fire prevention and safety.
Reviewed documentation supported the center conducted fire drills every month, on each shift
since the last annual compliance review. A review of the center’s logbook documented each of
the drills and review of the drills. Reviewed documentation confirmed fire extinguishers were
inspected annually. Nine interviewed youth reported they were instructed on what to do in case
of a fire. Nine interviewed staff reported fire drills take place at least monthly.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 58
The center has facility operating procedures to address search and contraband procedures.
During the annual compliance review week, a search was observed, and the staff thoroughly
frisk searched the youth, while wearing gloves, prior to admission. The search consisted of two
staff, both of the same gender as the youth, and searches of the youth were conducted
individually and not in a group setting. The center conducts electronic/wand searches on all
persons entering the center, with all items entering the secure area being examined, prohibiting
personal keys, personal cellular telephones, and any additional contraband items. Observations
confirmed rooms were searched upon a youth’s release, rooms were searched prior to placing a
new youth in the room, and all rooms were searched for contraband on each awake shift. The
center documents searches in a shared network drive. A review of random shift reports for one
day for each month during each awake shift for the annual compliance review period confirmed
youth room searches were documented and completed as required. The center did not report
any instances which may have compromised the safety or security of the center throughout the
annual compliance review period. Observations during the annual compliance review week
confirmed searches of staff, visitors, and contractors/vendors were completed electronically and
a frisk search was completed prior to entering the secure area. Reviewed documentation
confirmed the center’s visitor log did contain a contraband attestation statement. Five randomly
reviewed staff records confirmed each staff had a contraband attestation form included in their
record. Nine reviewed newly hired staff records contained a contraband attestation form.
Reviewed policies indicated the center is to document confiscation of contraband in the master
control logbook, complete incident reports, identify findings and disposition of contraband,
contact law enforcement if any found item was considered illegal, or if there was evidence of
any type of unlawful activity, secure confiscated items and hand-deliver to the supervisor,
document the chain of custody of confiscated items, notify the Department’s Central
Communication Center (CCC) of discovery and confiscation of illegal contraband, and notify the
regional director or designee of the confiscation of contraband. During an interview the
superintendent reported youth searches occur as often as needed. The superintendent further
stated if a youth or staff is found with contraband, administration and local law enforcement shall
be contacted.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 58

source: DJJ

report_type: QI Detention

file_name: Broward Detention Center -FinalReport-2526.pdf