state: FL

summary: QI Detention - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Volusia Regional Juvenile Detention Center Re-Review
Department of Juvenile Justice
(State-Operated)
3840 Old Deland Road
Daytona Beach, Florida 32124
Review Date(s): June 3 - 6, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Luis Rodriguez, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jeff Campbell, Office of Educational Services, Education Coordinator (Standard 2)
Melissa Johnson, Office of Accountability and Program Support, Regional supervisor (Standard
1 and 5)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 4)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Co-Lead)
BUREAU OF MONITORING AND QUALITY IMPROVEMENT
RE-REVIEW ADDENDUM
Program Name: Volusia Regional Juvenile Detention Center MQI Program Code: 139
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Volusia County / Circuit 7 Number of Beds: 50
Review Date(s): June 3 - 6, 2025 Lead Reviewer Code: 217
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 3 of 77 (Revised July 2022)
5.12 A
Lim ited R atings
1.01 Initial B ackground S creening*
2.10 E ducational A ccess*
ccess to all Flam m able, Toxic, C austic, and Poisonous Item
5.14 C onfinem ent U nder Tw enty-Four H ours
s *
3.12 S
Failed R atings
uicide Prevention Training *
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 77 (Revised July 2022)
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g *
F iv e -Y e a r R e s c re e n in g /R e n e w a l
S ta ff C o d e o f C o n d u c t
In c id e n t R e p o rtin g C C C *
P ro te c tiv e A c tio n R e s p o n s e (P A R )
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts *
In -S e rv ic e T ra in in g
G rie v a n c e s
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n *
D a ta T re n d A n a ly s is
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
SSSSSSSSS
g ra
d o
L im ite d
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
m o p e ra te s
s o w ill re s u lt
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 77 (Revised July 2022)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n
O rie n ta tio n
C la s s ific a tio n
N o tific a tio n o f J P O C irc u it G a n g R e p
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty
R e le a s e
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n
D a ily A c tiv ity S c h e d u le
E d u c a tio n a l A c c e s s *
C a re e r E d u c a tio n
tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
L im ite d
S a tis fa c to ry
g ra m o p e ra te s
d o s o w ill re s u lt
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 77 (Revised July 2022)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
3 .0 1 D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
3 .0 2 L ic e n s e d M H /S A C lin ic a l S ta ff *
3 .0 3 N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
3 .0 4 M H /S A A d m is s io n S c re e n in g
3 .0 5 M H /S A A s s e s s m e n t/E v a lu a tio n
3 .0 6 M H /S A T re a tm e n t
3 .0 7 T re a tm e n t a n d D is c h a rg e P la n n in g
3 .0 8 P s y c h ia tric S e rv ic e s *
3 .0 9 S u ic id e P re v e n tio n P la n *
3 .1 0 S u ic id e P re v e n tio n S e rv ic e s *
3 .1 1 S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
3 .1 2 S u ic id e P re v e n tio n T ra in in g *
3 .1 3 M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
3 .1 4 E m e rg e n c y C a re P la n *
3 .1 5 C ris is A s s e s s m e n ts *
3 .1 6 B a k e r a n d M a rc h m a n A c ts *
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte
b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
n tio n if a p ro
rs . F a ilu re to
g ra
d o
SSSSSSSSSSS
SSSS
m
s
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
F a ile d
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
o p e ra te s
o w ill re s u lt in
Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 77 (Revised July 2022)
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n
D H A /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g
S ic k C a ll P ro c e s s
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re
O ff-S ite C a re /R e fe rra ls
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s
M e d ic a tio n M a n a g e m e n t
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n
P re n a ta l C a re /E d u c a tio n
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
g ra m o p
d o s o w
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
e ra te s
ill re s u lt
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Limited
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Limited
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Failed
* 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 77 (Revised July 2022)
Summary
The Volusia Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Daytona Beach, Florida. The center serves youth in Flagler, Putnam,
St. Johns, and Volusia counties in Circuit 7. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Volusia County School Board.
The center’s management team includes the superintendent, one assistant superintendent, two
administrative assistants, eight juvenile justice detention officer supervisors (JJDOS), nineteen
JJDO IIs, and eighteen JJDO Is. Mental health and healthcare services are provided through
the contracted provider, VitalCore Health Strategies, LLC. Mental health services are provided
by one designated mental health clinician authority (DMHCA) and five licensed mental health
and substance abuse clinical staff. The center does not have any non-licensed mental health
and substance abuse clinical staff. 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), five registered nurses (RN), and one psychiatrist. The medical clinic maintains nursing
coverage Monday through Friday from 7:00 a.m. to 7:30 p.m. and Saturday through Sunday
7:00 a.m. to 5:30 p.m. Food services are provided by Department staff and includes 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 sixty-four security cameras at the center, of which sixty-
two were operational. The center was observed to need new interior paint throughout, new
ceiling tiles throughout, new window blinds in the multipurpose rooms, repair/replacement of
several interior secure doors, replacement of glass dormitory door windows, appropriate length
shower curtains, renovated youth showers, and repair/replacement of several exterior windows
and/or window framing. The modules, multipurpose rooms, and sub control rooms were
observed to be highly unorganized, lacked evidence of daily maintenance and cleaning, as food,
garbage and clothing debris was observed throughout the modules, and youth dormitory rooms
were in disarray and contained food and other debris. At the time of the annual compliance
review, the center had fifteen vacancies, which included five JJDOIIs and ten JJDOIs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Program Accountability Page 9 of 77 (Revised July 2022)
Standard1: Management Accountability
1.01 Initial Background Screening (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted on April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure all Department staff, contracted
providers, volunteers, mentors, and interns with access to youth and youth records have an
initial background screening with a determination of “Eligible” prior to contact with youth or
confidential youth records. Each background screening includes a criminal history report review.
The center’s FOP also ensures an Affidavit of Compliance with Level 2 Screening Standards is
completed annually as required. During the annual compliance review period the center did not
have any volunteers, mentors, or interns applicable for screenings; however, the center’s policy
does have directives for a background screened staff to be in sight of any non-screened
persons who may be within the center irregularly as outlined by Florida Administrative Code.
The center completed and submitted the current Annual Affidavit of Compliance with Level 2
Screening Standards, on the required form, on January 30, 2024, prior to the required deadline.
The local school board, on behalf of the center’s educational staff, completed and submitted the
current Annual Affidavit of Compliance with Level 2 Screening Standards, on the required form,
on January 26, 2024, prior to the required deadline. Eighteen initial background screenings for
newly hired staff were reviewed. All eighteen staff records contained a completed background
screening with an “Eligible” determination prior to the staff having any contact with youth or
youth records, documentation of a criminal history report review, and a pre-employment
assessment tool. Sixteen of eighteen reviewed staff records contained a pre-employment
assessment tool with a passing score; the remaining two records contained non-passing scores
on the assessment tool; however, they both included documentation of the required interview
and score adjustment for employment eligibility. The center had six contracted medical and
mental health staff hired during the annual compliance review period. All six contracted staff
records contained a completed background screening with an “Eligible” determination prior to
the staff having any contact with youth or youth records, documentation of a criminal history
report review, and each was added to the center’s Clearinghouse employee roster as required.
None of the eighteen reviewed staff or six contracted staff were applicable for a screening due
to being hired from another provider. Due to system issues, the Department’s Juvenile Justice
Information System (JJIS) was unable to be accessed and breaks in service were not able to be
reviewed.
During the re-review the center received a Limited Compliance rating for this indicator.
The center has facility operating procedures which require background screenings to be
conducted for all staff, volunteers, mentors, interns, and contracted providers with access to
youth and confidential youth records. The center did not have contracted providers, volunteers,
mentors, or interns who assisted or interacted with youth on an intermittent basis during the
annual compliance review period who did not need to be background screened. The center
completed and submitted an Annual Affidavit of Compliance with Level 2 Screening Standards
to the Department’s Background Screening Unit (BSU) on January 7, 2025. Teachers paid by
the local school board received an Annual Affidavit of Compliance with Level 2 Screening
Standards completed on January 7, 2025. The center had twenty-seven newly hired staff and
one newly hired contracted staff since the last annual compliance review: two administrative
assistants, one food service worker, eighteen juvenile justice detention officers (JJDOs), four
JJDO IIs, one registered nurse (RN), one maintenance mechanic, and one assistant
superintendent. A review of the Department’s BSU confirmed all newly hired staff had a
background screening completed prior to their hire date except for one. One staff required a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 77 (Revised July 2022)
new background screening prior to working with youth on November 8, 2024. The staff’s
previous employment was a contract provider which warrants a new background screening.
This staff was currently working with the youth prior to discovery of this information and was
asked to be removed and was pulled from youth contact by the superintendent during the
annual compliance review until further notice. The Department’s Central Communications
Center (CCC) was contacted and informed of this information. The remaining staff were all
eligible for employment and to work with youth. Twenty-five of the newly hired staff were direct-
care staff and were required to complete a pre-employment assessment, with all receiving a
passing score which was recorded in their employment record. The one contracted staff was
added to the Clearinghouse employee roster.
1.02 Five-Year Rescreening
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure all Department staff, contracted providers,
volunteers, mentors, and interns with access to youth and youth records have a rescreening
every five years. The center had six applicable staff eligible for a five-year screening within the
annual compliance review period. All six reviewed staff records contained documentation to
confirm the center completed and submitted the rescreen within the required timeframe, not
more than twelve months and at least ten days prior to the staff’s five-year anniversary date.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures requiring for a five-year background rescreening to
be conducted on all Department staff, volunteers, contracted providers, mentors, and interns
with access to youth and confidential youth records. A review of the center’s staff, volunteer, and
contracted provider rosters indicated the center had two staff requiring a background
rescreening during the annual compliance review period. Both staff had a rescreening
completed within the required time frame and submitted to the Department’s Background
Screening Unit (BSU) at least ten business days prior to their five-year anniversary date.
1.03 Staff Code of Conduct
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure all staff adhere to a code of conduct
prohibiting any form of abuse, profanity, threats, harassment, intimidation, “horseplay,” or
personal relationships with youth. The code of conduct also outlines the staff’s requirement to
maintain confidentiality for all youth. Three staff records with applicable violations of the code of
conduct were reviewed. Two of three staff records contained the original signed code of conduct
form; the remaining record was unavailable as the staff has since separated from the center,
and the staff record is maintained electronically, and physically off-site. Due to system issues
the electronic record was not available. A copy from the physical record was requested but not
received. Two of three reviewed violations were due to the staff’s refusal to complete a
mandatory shift hold over; the remaining incident was for missing ten-minute checks. Two of
three violations resulted in disciplinary actions through an oral/verbal reprimand; the remaining
violation resulted in disciplinary action through a notice of investigation. Three staff records were
reviewed for documentation of commendations received during the annual compliance review
period. All three commendations resulted in the staff being promoted within the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 77 (Revised July 2022)
Nine youth interviews were conducted. Four of nine reported they had never been stopped from
reporting abuse to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC); the remaining five youth confirmed they had never asked or needed to report
abuse. Seven of nine interviewed youth reported staff are respectful when speaking with youth;
the remaining two reported staff are sometimes not respectful; however, staff are respectful
most of the time. The center’s superintendent and assistant superintendent stated youth may
perceive consequences of undesirable behavior as disrespect. Three of nine interviewed youth
reported they had never heard staff use curse words when speaking with youth; five of nine
youth indicated this occurs occasionally; and the remaining youth reported staff use curse words
often. The center’s superintendent and assistant superintendent stated they have not heard staff
using profanity toward the youth. Seven of nine youth stated they had not heard staff threaten a
youth; one of nine reported hearing this occur once; and the remaining youth stated staff threats
are heard often; however, no examples or additional information was provided. The center’s
superintendent and assistant superintendent stated each reported incident is reviewed and
handled appropriately; they did confirm one incident did include a Department of Children and
Families investigation which was closed as unfounded. All nine interviewed youth reported they
felt safe at the center; one youth provided an additional statement regarding feeling unsafe only
with youth who tend to fight often. All nine interviewed youth reported they have never
exchanged emails, telephone numbers, or social media contact information with staff.
Nine staff were interviewed and asked to explain the process for reporting abuse to the Florida
Abuse Hotline or the Department’s CCC. Six staff included notification to the supervisor; one
staff specified notification to the superintendent; one staff confirmed a staff can call if needed;
and all nine staff confirmed youth are allowed to call upon request. Seven of nine interviewed
staff reported they have not heard staff using profanity when speaking with youth; one staff
reported this to occur occasionally; and the remaining staff reported this occurs often. One staff
stated youth made staff use profane language when youth were acting up and the other staff
stated they had observed a couple coworkers using profanity; however, the staff are no longer
employed at the center. Eight of nine staff confirmed they have not witnessed a staff threatening
a youth; the remaining staff reported to have observed a staff threatening a youth once;
however, stated the staff is no longer employed at the center. Four of nine staff reported the
working conditions to be good; three of nine reported them to be fair; one of nine reported
conditions were poor; and the remaining staff reported very poor working conditions. The
center’s superintendent and assistant superintendent provided staff shortage and youth
overpopulation as the primary reasons reported to them by staff for undesirable working
conditions.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOPs) which ensure staff adhere to a code of
conduct. Six staff were applicable for a violation of the code of conduct and each included a
signed code of conduct form in their personnel record. Each of the applicable records contained
a copy of the staff’s disciplinary action, which included the specific violation, as well as the date
of the violation. Each also contained management’s response with regards to action taken
because of the violation of the code of conduct. One of the applicable staff received an oral
reprimand, one received a written reprimand, and four a re-training memorandum. The center
was unable to provide record for any staff who received commendations during the annual
compliance review period. On December 18, 2024, a Christmas party was conducted for all staff
and on June 4, 2025, the administration team provided lunch for all staff. During the annual
compliance review week, seven youth were interviewed and stated they never had to report an
abuse call. Six youth stated staff are respectful when being talked too and one youth stated they
are not respectful and used profanity toward another youth. Five youth stated they never hear
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staff curse around youth, one youth said occasionally, and one youth said often. Seven youth
stated they never hear staff threaten other youth. Six youth stated they feel safe while they are
at the center and one youth stated the other youth are very aggressive and they did not feel
safe. Seven staff were interviewed, and each understood the process of allowing the youth to
call the Florida Abuse Hotline or the Department’s Central Communications Center (CCC) if
youth are eighteen years of age or older. The interviewed staff stated they would notify the
supervisor on shift and the administration team and would also document it in the logbook. Two
of the interviewed staff stated they have never observed co-workers using profanity while talking
to youth, one staff stated they had once, three stated occasionally, and one stated often. Four
staff stated they had never observed co-workers using threats, intimidations, humiliation when
interacting with youth, two staff said they had occasionally and one staff said often. One staff
stated the working conditions at the center were very poor, two staff stated poor, three staff
stated fair and one staff stated good. An interview was conducted with the center’s
superintendent who stated when staff are in violation of the code of conduct FOP, staff are
provided corrective actions. Staff shall adhere to a code of conduct which prohibits any form of
abuse, profanity, threats, harassment, intimidation, or personal relationships with youth. A staff
member is counseled and provided corrective action up to dismissal, if deemed necessary and
appropriate based off severity.
1.04 Incident Reporting (CCC) (Critical)
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The superintendent stated incidents are reported to the Florida Abuse Hotline and local law
enforcement in a timely manner. The Department’s Central Communications Center (CCC) is
called within the required two hours of initial knowledge with all known and required information,
including youth Department identification numbers, information about the incident, and those
involved. The administration team notifies regional staff within the required time frame.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures which require anytime a reportable incident
occurs, center staff notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring or within two hours of becoming aware of the incident. During the
annual compliance review period, a total of one-hundred and thirty-nine CCC incidents were
reported. A random sample of ten percent (thirteen) of these CCCs were reviewed. Twelve of
the thirteen incidents reviewed were reported within the required two-hour time frame. One
incident was reported twenty-one hours after the center became aware of the incident. Four
incidents were medical incidents, two were center disruption incidents, six were mental health
and substance abuse incidents, and one was a suicide Baker Act incident. All the incidents were
documented in the logbook as required. A review of internal incidents and grievances found no
additional incidents which should have been reported to the CCC. The superintendent was
interviewed and advised whenever a reportable incident occurs, a juvenile justice detention
officer supervisor or higher notifies the CCC within two hours of gaining knowledge of the
incident or event and all staff and youth are able to call the Florida Abuse Hotline at any time to
make a report.
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1.05 Protective Action Response (PAR)
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 204, through May 3, 2024. Due to
Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
Nine interviewed staff reported they try to talk with youth, utilizing verbal de-escalation, prior to
employing the use of any restraints. The superintendent reported all physical and mechanical
restraints are inventoried daily and the facility operating procedures (FOPs) are followed. The
superintendent confirmed the center’s administrative team reviews all Protective Action
Response Right Interactions Model Reports, along with video review, to ensure the FOPs and
Department policy are followed, and to ensure no excessive use of force is utilized.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures which require the use of Protective Action
Response (PAR) to be in accordance with Florida Administrative Code. Anytime staff use a
physical intervention technique, a PAR incident report is to be completed and filed in
accordance with the Florida Administrative Code. During the annual compliance review period,
the center had a total of 201 PAR incidents. Nine incidents were reviewed. All incident reports
were completed by the end of the staff’s workday except for one. The one incident report not
completed by the end of business day was not completed at all. Each of the eight completed
reports included statements from all staff involved. None of the incidents resulted in serious
injury to youth or staff, and no youth alleged abuse. All eight completed incidents were reviewed
by a supervisor or a PAR certified supervisor or instructor. A post-PAR interview was conducted
with each youth by an administrator within thirty minutes of each incident. None of the incidents
required a medical review and none resulted in the use of mechanical restraints. The
superintendent reviewed each incident within seventy-two hours. There were no additional PAR
incidents which were not documented by a report. The center’s PAR rate during the annual
compliance review period was 15.94, which is above the statewide detention PAR rate of 13.49.
Seven staff were interviewed and each of the staff stated they talk to youth prior to using
physical restraint or mechanical restraints. The superintendent was interviewed and stated
officers shall complete the mechanical restraints supervision log and ensure ten-minute
circulation checks are completed. Officers shall maintain constant, full, and direct visual
supervision of a youth in restraints. Officers shall have physical possession of the key to unlock
the mechanical restraints. Officers shall continue to employ verbal intervention to de-escalate
the need for mechanical restraints. The mechanical restraints shall be removed as soon as it is
safe to do so. Mechanical restraints shall never be used as a means of discipline. A supervisor
shall interview the youth no more than thirty minutes after the youth are placed in restraints and
minimum of every sixty minutes. The superintendent shall consult with medical, metal health,
and the regional director prior to authorizing mechanical restraints over sixty minutes and the
process must be followed every sixty minutes. All information will be documented in the logbook
or mechanical restraints log. The Superintendent or designee will review all reports for
compliance.
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1.06 Pre-Service/Certification Requirements (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure all newly hired staff receive the
required trainings within the first 180 days of employment. Nine staff records were reviewed for
pre-service training and certification requirements. Four of nine reviewed staff records contained
documentation each completed a new staff orientation within the first thirty days, Phase One,
and Phase Two (the academy) of the detention training and became certified within the required
180 days of hire. Two of nine reviewed staff records contained documentation each completed a
new staff orientation within the first thirty days and completed Phase One of training while
waiting to attend the academy; these staff are still within their first 180 days of hire. The
remaining three reviewed staff records, within the first 180 days of hire, contained
documentation each completed a new staff orientation within the first thirty days and are
working to complete Phase One. All staff had the required trainings prior to contact with youth
and youth records. The center did not have any returning/rehired staff this annual compliance
review period.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic training records were not available for review, and the center’s staff training files were
utilized for this annual compliance review.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures requiring all detention staff to be trained in
accordance with Florida Administrative Code. Staff must satisfy all pre-service certification
requirements within 180 days of hire. Seven pre-service staff training records were reviewed,
two of which were rehires. All seven completed new staff orientation within thirty days of hire.
Five of the seven staff completed phase one training as required. The remaining two were not
applicable, as they were re-hires. Five completed phase two training which consists of 120
hours of academy training. Two staff were not applicable. Five staff completed all required pre-
service training requirements and were certified within 180 days of hire. Two staff were not and
not applicable. All staff’s trainings were documented in the Department’s Learning Management
System (SkillPro) system.
1.07 In-Service Training
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure all staff receive the required annual trainings.
Nine staff records were reviewed for in-service training, and all nine records contained
documentation of current cardiopulmonary resuscitation (CPR), first-aid, and automated
external defibrillator (AED) certifications; protective action response (PAR)/Right Interactions
(RI) refresher training; and four hours of required in-person suicide awareness and prevention
training. All nine reviewed staff records contained documentation, evidenced by sign-in sheets,
each staff attended the required trainings for the emergency care plan, infection control, the
exposure control plan, escape prevention, and the fire prevention plan/disaster procedures. An
informal interview with the nurse on-site confirmed a registered nurse provides the annual girl’s
healthcare in-service training to all non-healthcare staff, and confirmed the training does include
the monitoring, observation, and emergency care of pregnant youth. The center’s annual in-
service training list included all required information and was approved by the Department’s
regional director on November 17, 2023, prior to the required deadline. The center maintains an
annual training calendar which is updated as changes occur.
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Due to Department-wide system outages at the time of the annual compliance review, the
electronic training records were not available for review, and the center’s staff training files were
utilized for this annual compliance review.
The superintendent confirmed training was completed through the Department’s Learning
Management System (SkillPro), as well as in-person trainings which included PAR/RI refresher
training and leadership training at headquarters. The superintendent requires their supervision
level staff to complete dos and don’ts of interviewing and customer service.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures which require all direct care staff to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year. In addition, supervisory staff must complete an
additional eight hours of training in areas specified in Florida Administrative Code. Seven staff
training records were reviewed for completion of in-service training during the previous calendar
year. All staff completed a minimum of twenty-four hours of annual in-service training, with each
staff completing training hours between forty-six and 152.5 hours. All staff completed training in
active shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking intervention, Information Security Awareness, mental
health and substance abuse, Prison Rape Elimination Act (PREA), Protective Action Response
(Right Interactions model), professionalism and ethics, standards of conduct, sexual
harassment, suicide awareness and prevention, and trauma responsive practices. Four
supervisory staff were reviewed for required supervisory level training. Three received a
minimum of eight hours of additional training in the areas of leadership, coaching, and personal
accountability. One was not applicable due to the annual year not being over until August 30,
2025 for this staff. All staff’s training was documented in the Department’s Learning
Management System (SkillPro). The center has a licensed nurse who provided in-service
education on girls’ healthcare to all non-healthcare staff who supervise or treat girls. The list of
in-service trainings was approved by the Department’s regional director for this year on
December 15, 2023. The center maintains an annual in-service calendar in the briefing area,
and this calendar is updated as changes occur. An interview with the superintendent was
conducted and he stated their management training is conducted during their Tier one through
three training. All pre-service training shall consist of 120 hours of certification training.
Detention staff shall complete twenty-four hours of annual in-service training and supervisory
staff shall complete eight hours of training each calendar year.
1.08 Grievances
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure youth have an established process in place to
file a grievance when a youth’s rights have gone unprotected or have been violated. The center
employs an electronic grievance system.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic records were not available for review.
Two of nine interviewed youth were able to describe what a grievance is and how filing a
grievance works; the remaining seven interviewed youth stated they did not know, were not told,
or had forgotten what a grievance is. The superintendent and assistant superintendent were
able to confirm all youth receive an orientation and handbook at admission into the center, and
grievance information is provided to them. Seven of nine interviewed youth stated they had
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never filed or needed to address a grievance; one youth reported the grievance process to
good; and the remaining youth stated it is fair.
Nine staff were interviewed and each staff was able to explain how a youth would file or make a
grievance and how the process works.
The superintendent confirmed the center’s grievance procedures and process, including the
required timeframes and the staff’s responsibilities in the process. The center maintains a
record of filed grievances for a period of three years.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures outlining how grievances are processed. The
center did not have any grievances since the last annual compliance review. A review of the
Facility Management System (FMS) in the Department’s Juvenile Justice Information System
(JJIS) confirmed the center did not have any grievances during the annual compliance review
period. During an interview with the superintendent, the superintendent advised there is an
informal phase and a formal phase for grievances. The informal phase is where a juvenile
justice detention officer (JJDO) attempts to resolve a complaint or condition with a youth using
effective communication skills. The formal phase is where a youth submits a written grievance
which results in a response from a supervisor. The JJDO supervisor (JJDOS) will give a
response by the end of the shift, otherwise within twenty-four hours. The JJDOS shall forward
each grievance form to the superintendent or designee upon completion. The superintendent
will review each grievance within seventy-two hours of receipt excluding weekends and
holidays. The superintendent's decision is final. Grievance forms are available for all youth in
each module. Seven youth were interviewed, and each stated they have never filed a grievance.
Five youth stated they were unsure what a grievance was, one youth stated it was a complaint,
and one youth stated you place a form into a box so staff can investigate. Seven staff were
interviewed and one of the staff was able to articulate all three phases of the grievance process.
One staff stated it is a written complaint from a youth who did not get food. Five of the seven
staff were unaware of the grievance process, and the superintendent was made aware. The
superintendent stated officers will be trained in the grievance process.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure all staff are informed and maintain current
information regarding youth alerts for the safety of youth, staff, and the center. The center
utilizes the Department’s Juvenile Justice Information System (JJIS) to enter, update, and
maintain a current list of youth alerts for youth within the center. Alerts are reviewed at each
shift briefing, which was confirmed by observation of a shift briefing and a review of shift briefing
reports.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic records were not available for review. In order to maintain safety and security during
the outages the center created and maintains an in-house document, a daily email, with all
known and new alerts for each youth in the center.
Nine staff were interviewed about the center’s alert system. Seven staff confirmed youth alerts
are reviewed at shift briefing; four staff reported alert information can be reviewed in the
logbooks; three staff indicated the center has an alert form; two staff stated JJIS is a location to
see youth alerts; three staff confirmed the center utilizes an alert board for staff review; and one
staff stated an email is a location to see youth alerts. Staff were also asked how administrative
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staff relay information about issues within the center. Seven staff confirmed this information is
presented at shift briefing; one staff stated issues are noted within the logbooks; and one staff
stated issues are relayed through emails. Four of nine staff reported these systems as good;
two staff stated the processes were very good; and the remaining staff rated these as fair.
The superintendent confirmed the center’s process starts with ensuring the Admission Wizard is
completed accurately at a youth’s admission to the center. Alerts are reviewed by intake staff,
supervisors, administration, and dietary staff to ensure all applicable alerts are maintained. The
superintendent confirmed youth alerts are presented at shift briefing; shift supervisors have a
current alert list in their possession for reference and to make updates as needed; youth alerts
are noted in the logbooks; and alerts are communicated between staff at shift change.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures which require all critical and special alerts for youth
to be listed in the Department’s Juvenile Justice Information System (JJIS). Supervisory staff is
to review the alert report daily and share alert information with staff during shift briefing. Medical
and mental health staff are also required to review alerts to ensure each alert is correctly
tracked and managed. Seven case management youth records were reviewed for alerts. The
seven youth had a total of twenty-three alerts. A review of the alerts confirmed each alert was
entered, updated, and/or closed, as required. All alerts were documented in the logbook for
each youth. The center utilizes an alert report generated in JJIS as their internal alert system. All
alerts entered in JJIS are documented on the internal alert system once the alert is entered. All
alerts matched in JJIS and the internal alert system. All alerts were verified prior to being
entered in JJIS. The JJIS alert report is reviewed daily by supervisors and shared during shift
briefing and alerts are entered in the logbook. A review of shift briefing minutes and an
observation of a shift briefing during the annual compliance review verified youth alerts are
shared and reviewed with staff. Alerts are updated as needed by mental health, medical, or
supervisory staff. All alerts are reviewed by the assistant superintendent or superintendent as
well. An interview with the center’s superintendent was conducted and the superintendent stated
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 the supervisors and
administrators to ensure it correctly reflects the status of the youth. Juvenile justice detention
officer supervisors shall ensure the detailed alert list is read aloud during shift briefings. Medical
and mental health staff shall review alerts to ensure each alert is correctly tracked and
managed.
Seven staff were interviewed and each staff stated they are informed of alerts during shift
briefing, through alert forms, JJIS, verbally and by suicide observation forms. Seven staff were
interviewed, and six stated they are informed about issues within the center by logbooks,
verbally and staff briefing. One staff stated they are not informed of any issues by anyone.
Seven staff were asked how effective the process is on communicating information and two staff
stated poor, three staff stated fair, one stated good and the last stated very good.
1.10 Data Trend Analysis
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure they collect, update, and maintain data trend
analysis. The data is utilized to make decisions regarding the center and youth. The center
provides their information for state data; and the center also utilizes the state data in decision-
making processes when applicable. The center’s administration participates in the weekly
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statewide headquarters/director’s call where center-specific and state data is shared and
discussed and in the monthly superintendent conference calls which also review this
information. The superintendent holds a captain’s weekly meeting with the assistant
superintendents to relay information from the other calls and meetings as well as to discuss
center-specific and youth issues; the center holds a monthly supervisors meeting to relay and
address in-house data and issues; and staff are provided pertinent information at the daily shift
briefings. The superintendent also participates in a bi-monthly meeting with providers and the
Department’s regional staff and attends the quarterly circuit meetings where data trends are
discussed. Community-based meetings, such as Community Advisory Board and the
Department of Children and Families administration, are utilized for the superintendent to share
current data trends with the stakeholders. A review of shift briefing reports, Detention Review
notes, agendas and minutes, and emails was conducted and confirmed the center’s data trend
analysis collection, maintenance, and distribution processes. The center utilizes a data
collection and analysis computer system to compile and maintain their data.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic records were not available for review.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center collects data in the Department’s Juvenile Justice Information System (JJIS) daily.
Data includes but is not limited to Protective Action Response (PAR) Reports, the Department’s
Central Communications Center (CCC) reports, alerts, staff vacancies, overtime, and
confinements. This data is compiled by headquarters into a report card which is disseminated to
the regional directors and then shared with center administration on a weekly basis. Center
administration shares this information with supervisors and department heads during the
monthly department head meetings and supervisor meetings. The information is then shared by
department heads and supervisors with their staff during their shift or department meetings. The
center shares pertinent information with stakeholders quarterly during the community advisory
board meetings. Agendas and meeting minutes are maintained for reference. During an informal
interview with the center’s superintendent, staff are advised to use the collected data to improve
their process by change of policy, additional training, scheduling, recruiting, and hiring.
Standard 2: Youth Management
2.01 Admission
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures regarding the youth admission process. Seven
youth case management records were reviewed to support they were admitted to the center as
required. A review of the arrest affidavit/custody order, Detention Risk Assessment Instrument
(DRAI), and Suicide Risk Screening Instrument (SRSI) was completed for all seven youth and
the admission wizard documented the forms as reviewed. Reviewed documentation confirmed
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all seven youth were searched upon admission, provided or offered a meal, and received a
medical, mental health, and substance abuse screening. Additionally, documentation indicated
six of seven youth made a telephone call; however, the remaining youth placed a call to their
Department of Children and Families guardian but there was no answer. A youth admission was
observed during the week of the annual compliance review week and confirmed all procedures
were followed, the youth was provided a meal and placed a telephone call to their
parent/guardian.
2.02 Orientation
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures ensuring all program orientation protocols are followed
with each youth being admitted. A review of nine youth case management records was
conducted. Each record had documentation to indicate the youth was provided an orientation
within twenty-four of admission and each signed an orientation acknowledgement form. Each
reviewed youth record documented the orientation was explained to the youth verbally and in
writing by staff. The orientation brochure covered all required information, to include Prison
Rape Elimination Act (PREA) related information. An admission was not observed during the
annual compliance review week; however, an informal interview was held with a staff who was
able to give the steps of an admission which includes the PREA video. The staff stated the
PREA video has not been played at admission due to a broken video player, which has not
been replaced. Five of nine interviewed youth confirmed the center’s rules, regulations, daily
schedule, education services, visitation, abuse reporting, and behavior management system
were reviewed with them at admission; the remaining four youth stated these topics were not
reviewed. The superintendent and assistant superintendent stated each youth signs off on these
items at orientation/admission, which was confirmed by a review of youth case management
records.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures regarding the orientation process. Seven youth
case management records were reviewed. All seven youth received an orientation within
twenty-four hours of being admitted to the center. All seven records contained a signed Youth
Orientation Checklist confirming receipt of the orientation brochure addressing rules and
regulations, grievance procedures, visitation, telephone calls, access to medical, mental health
and substance abuse services, access to the Florida Abuse Hotline and the Department’s
Central Communications Center, behavior expectations and related consequences, possible
new law violations for destruction of property, youth rights, and Prison Rape Elimination Act
(PREA) related information, including the PREA video. A youth admission was observed during
the week of the annual compliance review, which included all elements as outlined in the
center’s policy. Seven youth were interviewed, and six youth indicated they were informed about
the rules and regulations, daily schedule, education services, visitation, abuse reporting, and the
behavior management system upon admission to the center; however, the remaining youth
stated they were not informed when admitted to the center.
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2.03 Classification
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) for the classification of youth being admitted to
the center to ensure safety and security. The center’s FOPs listed all required elements. Nine
youth case management records were reviewed. Each record had classification documentation
with information concerning the youth’s history and status and were used to determine youth
room assignment. The classification included gender, height, weight, age, level of aggression,
mental illness, intellectual disability, physical disabilities, history of violent behavior, gang
affiliation, criminal history, history of sexual offense, Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) screening results, medical, suicide risks, and escape and security
risks. Youth with a history of committing sexual offenses or youth identified as a victim of a
sexual offense are not to be placed in a room with any other youth. The nine reviewed records
documented youth were assigned to a room based on their classification and reclassification if
any changes in behavior or status were observed. Two of nine were placed on single room only
(SRO) due to history of sexual offense; the remaining seven youth were not applicable.
The superintendent interview confirmed the center’s procedures for room assignments and
alerts, if applicable.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures addressing the classification process. Seven youth
case management records were reviewed regarding classification. Each of the seven youth
records contained information concerning each youth’s history and status. The classification
process included information from the admission documents, which reflected each youth’s
gender, height, weight, age, level of aggressiveness, mental illness, intellectual disabilities,
physical disabilities, history of violent behavior, gang affiliation, criminal behavior, history of
sexual offenses, the results of the Vulnerability to Victimization and Sexually Aggressive
Behavior form, medical needs, and suicide, escape, and security risks. The classification
process for each of the seven reviewed youth included all required elements. All reviewed youth
room assignments were based on the youth classification procedures, youth with a history of
committing sexual offenses or who were a victim of a sexual offense were placed in a room
alone. The superintendent remains informed of how to identify and address local youth gangs
by being notified by the local law enforcement (LE) agency, keeping in contact with the juvenile
probation officers, and/or the youth’s Facesheet. The LE offices conduct training and send
information to the superintendent concerning gang activity. An interview with the superintendent
indicated factors such as mental health status, physical health status, cognitive performance,
age, and prior victimization are all considered when making room assignments. Youth are
assigned to a room based off their classification and youth are re-classified if changes in
behavior or status are observed and documented.
2.04 Notification of Juvenile Probation Officer Circuit Gang Representative
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure gang information is shared with the circuit’s
gang representative. Nine youth case management records were reviewed. None of the nine
reviewed records indicated gang activity. An additional three records were requested for review;
however, the center was not able to identify any applicable youth due to Department-wide
system outages. An informal interview was conducted with the superintendent regarding youth
gang association and confirmed the gang representative for the circuit. The superintendent
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stated when a youth is identified as a gang associate at screening the Juvenile Assessment
Center (JAC) will notify the center, or the circuit gang representative will notify the center.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures addressing the exchange of information with the
juvenile probation officer (JPO) designated as the circuit gang liaison. Seven youth case
management records were reviewed. None of the seven reviewed records were applicable for
youth gang involvement. The center indicated there were no youth during the annual
compliance review period who were identified as having newly suspected gang involvement
while at the center. The center indicated the juvenile justice detention officer identified to serve
as the gang representative is on leave; therefore, the intake supervisor is the acting gang
representative. The center indicated the gang representative will send an email to the JPO
notifying them of any newly suspected gang involvement as soon as the center becomes aware
of any potential gang connection and the youth is placed in the Department’s Juvenile Justice
Information System according to their status of member or suspected gang member.
2.05 Admission and Storage of Youth Personal Property
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure the proper handling and security of youth
property, to include valuable property items. The staff completing the admission process collects
each youth’s property and documents each item on the personal property receipt form. Any
valuable items, including money, cellular telephones, and or jewelry is placed in a clear tamper
proof bag. The tamper proof bag is marked with the date, youth’s name, and Department
Identification number (DJJID). The list of items is written on the bag and the bag is placed in a
secured drop box. The staff securing the property will record the property in the center’s drop
safe logbook. The property safe is only accessible by limited staff including the superintendent,
assistant superintendents, and supervisors. The drop safe is maintained under camera
surveillance. Other property items from youth, including clothing and shoes, are placed in
garment bag which is marked with the date, youth’s name, DJJID, and a list of included items.
The property bag is then placed in a secured property room located in the intake processing
area. Nine youth case management records were reviewed. Eight of nine records had the youth
signature on the property form. All property documents had the staff signature on the form.
Seven of nine records included a letter of acknowledgement regarding unclaimed property,
signed by the youth. The remaining two did not. Three of nine reviewed youth records indicated
youth had valuable property. The property was placed in a clear tamper proof bag and placed in
a locked cabinet for each. The property logbook was reviewed, and each youth’s name was
logged; however, neither the DJJIDs nor the time of entry were logged. An observation of the
center receiving youth personal property was not completed, as there was no admission during
the annual compliance review week. Seven of nine interviewed youth stated staff checked their
personal property at admission and they signed a form stating the personal property was
correct; the remaining two youth did not remember signing a form for their property.
The superintendent was interviewed and confirmed the center’s procedures to secure and store
youth property, the disposal of unclaimed property, and who has access to youth property.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures addressing admission and storage of youth’s
personal property. Seven youth case management records were reviewed for admission with
personal property. The Property Receipt form was maintained in all seven youth records and
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included each youth’s and staff’s signature. The Property Letter of Acknowledgement regarding
unclaimed property was signed by six of the seven youth; however, the remaining youth record
did not include a Property Letter of Acknowledgement. The personal property, including
clothing, was placed in an assigned bag for each youth as documented on the Property Receipt
form. Three of the seven youth had valuable property. All money and personal items of value for
the three applicable youth were verified and secured in a clear tamper-proof property bag, which
included each youth’s name, Department of Juvenile Justice identification number (DJJID), a list
of items in the bag, and they were placed in a drop-safe under video surveillance. A review of
the drop-safe bound logbook indicated an entry for each youth with valuable property including
the date, time, each youth’s name, DJJID, printed name of the officer who secured the property,
and the officer’s initials. An informal interview with the superintendent indicated it is the center’s
process to document all property, including personal and valuable property on the Property
Receipt Reports. Observations were made of three valuable and seven personal property
samples. All seven personal property samples included a bag with a completed inventory form
for each youth’s personal property. A review of the drop-safe logbook confirmed an entry for all
three valuable property samples and observations confirmed they were stored in a clear tamper-
proof bag. An observation of the center receiving youth personal property was made during an
admission, which included all elements as outlined in the center’s policy. The center did not
have any Department Central Communications Center incident reports regarding youth property
during the annual compliance review period. The superintendent indicated all youth’s valuable
property is placed in a safe under video surveillance and then removed by intake staff and
placed in a locked file cabinet after being entered in the logbook. Only the intake staff and
supervisors have access to the valuable property stored in the locked file cabinet. Youth
clothing and non-valuable property are stored in a locked room with only intake staff and
supervisors having access. Youth are made aware all unclaimed property will be disposed of
after thirty days of when the youth leaves the center. The center sends out a letter to encourage
parent/guardians to pick up the property, prior to disposal. Unclaimed personal property, held
more than thirty days after the parent/guardian has been notified to either retrieve or make
arrangements to retrieve the property, is deemed abandoned and subject to disposal. The
center will donate the abandoned property to charity or place the property in a property
envelope and send it to the regional detention office. Seven youth were interviewed, and each
indicated they signed for their personal property collected during admission.
2.06 Release
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to address youth releases from the center. The staff
and the supervisor completing the release shall verify the court authorization prior to releasing
each youth. The supervisor must ensure all release documents are complete and ensure there
are no holds, court orders, or any other legal reason not to release a youth from the center. A
copy of each parent/guardian photo identification card is made and placed in each youth’s
record prior to release. None of nine reviewed youth records from the sample were applicable
for release. Three additional closed youth case management records were requested for review.
All three closed records contained the completed release wizard to include the youth’s name,
any open youth alerts at time of release, and any medication if applicable. Two of three closed
records had all required signatures on each release form; the remaining record was missing the
supervisor’s signature on the forms. An informal interview was conducted with the supervisor
and confirmed all release paperwork is reviewed prior to a youth being released. The supervisor
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also confirmed the court order is printed and reviewed prior to initiating a release. All three
reviewed records had a copy of photo identification of the adult whom the youth was released
to. None of the reviewed youth had endangered person alerts. Due to Department-wide
outages, the Department’s Juvenile Justice Information System (JJIS) could not be reviewed to
determine if the dates of admission and release documented in each case file correlated with
the dates in JJIS. A release was not observed during the annual compliance review week as the
team was not notified when a release was taking place. Two of three youth records contained
documentation of future court dates and notification to the youth and parent/guardian of the
future court date; the remaining record was not applicable.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOPs) to address the release of a youth. Three
closed youth case management records were reviewed. Each record had a copy of the
Detention Release form, which documented the on-duty supervisor reviewed all paperwork and
court documents related to each youth’s release. All three youth had their identification verified
prior to their release. The parent’s/guardian’s or responsible adult’s identifications were verified
prior to release for each youth, with a photocopied identification placed in each youth record.
None of the reviewed records identified the youth as an endangered person. Each youth and
the person to whom the youth was released were reminded of future court dates and signed the
release forms. The date of admission and the date of release documented in each youth’s
record correlated with the dates documented in the Department’s Juvenile Justice Information
System. An observation of a youth release during the annual compliance review week validated
the staff followed the center’s FOPs when releasing the youth.
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions
The center originally received a Limited Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
has facility operating procedures to ensure there is documentation of each youth’s property
being transferred upon release. Each youth’s personal property receipt form is required to have
the signatures of the youth, the staff completing the release, and the youth’s parent/guardian
confirming the property was reviewed and returned, matching what was logged in at admission.
The center has procedures to ensure prescribed medications, along with medical instructions,
are sent with each released youth. Three closed youth case management records were
reviewed, and all three records were missing the receipt of returned property. All three released
youth records had no medication to be released. Each reviewed record contained a copy of the
photo identification of the person who picked up the youth. The center did not have any
examples of property held for more than thirty days during the annual compliance review period.
An observation of the release process was not completed, as the team was not notified when a
release was taking place.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to ensure each youth’s property is stored securely
during admission and returned to the youth or parent/guardian upon release. Three closed
youth case management records were reviewed. Two of three youth records contained a
Property Receipt form signed by both eighteen year old youth upon release; however, the
remaining youth record was not applicable because the youth was transferred to another
detention center. Each record contained documentation verifying each youth was released to an
appropriate person to include a copy of their identification. In one applicable record the person
receiving the youth signed the Receipt of Medication form. In all three closed records each
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youth and the person to whom the youth was being released were made aware of any health or
welfare issues, such as medical, mental health, substance abuse needs, and pending
appointments. The center had no examples of property held over thirty days during the annual
compliance review period. An observation of a youth being released from the center was
conducted during the week of the annual compliance review. The releasing staff, along with the
on-duty supervisor, verified the youth was allowed to be released to the parent/guardian and the
parent/guardian’s identification was copied for verification purposes. The youth signed for and
received their personal property back.
2.08 Review of Youth in Secure Detention
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures to ensure the center conducts a weekly Detention
Review meeting for proper management of youth placed in a secure detention and appropriate
sharing of information between all involved and/or assigned staff. The superintendent or
designee coordinates each weekly Detention Review meeting. A Detention Review meeting was
observed during the annual compliance review week. A review of secure detention logs and
meeting documentation confirmed all required participants attended each meeting, either in
person, virtual conferencing, or by telephone.
The superintendent interview confirmed the weekly Detention Review meetings were held and
the required information was discussed regarding each youth in secure detention.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to ensure detention reviews are conducted, on a
weekly basis, for proper management of youth in secure detention, and information sharing. The
center holds detention review meetings every Wednesday. An observation of the weekly
detention review for youth in secure detention was conducted during the annual compliance
review week. The assistant detention center superintendent, the center’s lead teacher, the clinic
manager, the designated mental health clinician authority, probation officers, commitment
manger, the Department liaison, and the probation and detention review specialist were present
during the detention review meeting. Participants shared information regarding youth court
dates, release dates, medical, mental health, and educational concerns and needs. A review of
detention review documentation, since the last annual compliance review, revealed all required
and applicable participants attended the meetings either in person, telephonically, or by way of
video conference. An interview was conducted with the superintendent, who indicated detention
reviews are conducted weekly on Wednesday and confirmed the attendees. Youth court dates,
release dates, detention hearings, placement information, and other relevant information are
discussed during the detention review.
2.09 Daily Activity Schedule
The center originally received a Limited Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
has facility operating procedures (FOPs) to ensure a daily activity schedule is posted and
followed each day. Observations made during the annual compliance review week showed the
center was not following the posted daily schedule. Youth were not observed to be in the
scheduled location or engaged in the scheduled activity during two days of the annual
compliance review week. Scheduled bathroom breaks, meal break, and movement to physical
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education were also observed. The center regularly provided youth with daily hygiene, meals,
visitation, physical activity and recreation, and indoor activities.
All nine interviewed youth stated the center does not have nor do they follow a daily schedule;
however, observations found a daily schedule was posted on each living module. The
superintendent and assistant superintendent stated the schedule is posted and followed barring
any safety or security issues or unscheduled events. Nine interviewed staff indicated the center
follows the daily activity schedule.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The annual compliance review team observed youth participating in various activities, including
required activities at various times of the day, during the annual compliance review week. The
daily activity schedule was posted on each module. Seven youth were interviewed and each
indicated the center does have a daily activity schedule, which is followed. Seven staff were
interviewed, and all confirmed the center’s daily schedule is followed.
2.10 Educational Access (Critical)
The center originally received a Failed Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
has facility operating procedures to ensure educational access for youth. The Volusia County
School District provides the educational services and approves the 250-day calendar, which
incorporates up to ten days of teacher planning and/or training. The center’s daily bell schedule
meets the required twenty-five hours of instruction weekly. All youth have an opportunity to earn
course credit upon completion.
All nine interviewed staff, as well as the superintendent, responded there was minimal
interference to the daily school schedule; however, the youth responded differently, with only
one of the nine indicating they go to school Monday through Friday. The other eight youth said
they do not and indicated they have been locked down and there has not been enough staff to
take them to school.
The lead teacher confirmed school has been taking place on the living modules, as there is not
enough staff to be able to bring youth to the classrooms. When asked about how well they are
being trained for their next educational or employment placement, four youth responded with
very well, two said well, and three said not well with a comment they had only been to school
two times in the past two weeks.
A review of four randomly selected master control and two B1 module logbook entries indicated
youth are not following the daily school schedule. The biggest loss of time is getting the youth to
the classrooms first thing in the morning and additional time needed for the mid-morning break.
For the past several weeks, the school schedule has been disrupted due to the increase of
youth and the lack of staff needed to move youth to the classrooms. Video review of three days
reflected the school schedule was not being followed and there was less than two hours of
school for two days; and there was no movement of youth to school on the remaining day.
During the re-review the center received a Limited Compliance rating for this indicator.
The center has a facility operating procedures (FOP) to provide educational access. The center
provides education services through the Volusia County School Board. Education is provided
through a 250-day calendar, distributed over twelve months, which includes twenty days
reserved for teacher training and planning. The center’s daily bell schedule meets the required
twenty-five hours of instruction weekly. All youth have an opportunity to earn course credit upon
completion.
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The superintendent reported the center interferes minimally with educational instruction. A
review of a random three days since April 7, 2025, in the center’s logbook revealed classes
were taking place as scheduled except for May 20, 2025. While reviewing the logbooks, it was
discovered the G1 module had been split into two separate groups due to the high number of
female youth at the facility and the numerous behavioral issues among the female youth. The
female youth at the facility were only taken to school for a half day for each group; therefore,
they were receiving only half of the required twenty-five hours of educational instruction a week.
On May 20, 2025, the master control logbook, along with the module logbook, which contained
no documentation indicating they were taken to school. It was noted there were two code blues
on the module on the same day during school hours. The lead teacher confirmed the school
takes place in four separate classrooms. The lead teacher also reported the interference has
been minimal, except for the female groups being split into two groups for a half-day each.
Video observations were conducted for three days and showed the school taking place as
scheduled on May 10, 2025. On the other two days, on May 23,2025 the two female groups split
the school day in half. On June 2, 2025, the multi-purpose room-two group was late starting
school and left early for their last class. Seven interviewed youth reported the center was
preparing them very well or well for high school, a high school equivalency diploma (GED)
provided through the General Educational Development platform, vocational school,
employment, and/or college.
2.11 Career Education
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. An
interview with the lead teacher confirmed the center provides career education programming.
The program meets the requirements of a Type 1 program which incorporates communication,
interpersonal, and decision-making skills, as well as life skills and activities through career-
related instruction in class. Nine interviewed youth stated they are enrolled in a combination of
the academic courses.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
An interview with the lead teacher confirmed the center provides Type 1 career education
development integrated into the curriculum through XELLO. This includes Career Learning
Strategies such as interviewing skills and techniques, career interest, resume writing,
completing employment applications, and finances. Seven youth were interviewed and stated
they are enrolled in a combination of academic courses.
Standard 3: Mental Health and Substance Abuse
3.01 Designated Mental Health Clinician Authority (DMHCA)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has a licensed mental health counselor (LMHC) who has a clear and active license which
expires March 31, 2025. The LMHC became the designated mental health clinician authority
(DMHCA) March 2024. Starting December 2023 through March 2024, a licensed mental health
therapist (LMHT) was the acting DMHCA, who has a clear and active license, which expires
March 31, 2025. Prior to December 2023, another LMHC was the DMHCA, who had a clear and
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active license, which expires March 31, 2025. A back-up DMHCA is not required by contract;
however, the center’s LMHT is the back-up when needed. A review of the DMHCA sign-in and
sign-out logs, confirmed the DMHCA was on-site a minimum of forty hours a week since the
start of the contract June 12, 2023. The DMHCA was interviewed and described the role of the
DMHCA and the process and implementation of mental health and substance abuse services at
the facility. The DMHCA described the communication between the DMHCA and clinical staff as
occurring daily.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has identified one licensed individual to serve as their designated mental health
clinician authority (DMHCA) as required. The DMHCA is responsible and accountable for
ensuring appropriate coordination and implementation of mental health and substance abuse
services in the center. The DMHCA’s position is under the contracted provider, VitalCore Health
Strategies, LLC. The center’s DMHCA is a licensed mental health counselor with a clear and
active license, which expires March 31, 2027, and is required to be on-site forty hours each
week. Additionally, the DMHCA is on-call when not on-site for emergency mental health and
substance abuse related needs. The center has had only one DMHCA during the annual
compliance review period. The center’s back-up DMHCA is a licensed marital and family
therapist, with a clear and active license, which expires March 31, 2027. A review of the
DMHCA’s sign-in logs for the annual compliance review period and the DMHCA’s contract
requirements/job description was conducted. This review confirmed the DMHCA, or back-up
DMHCA, is providing the required weekly forty-hour coverage as specified by the contract. The
DMHCA was interviewed and described their role at the center as providing clinical supervision
and direction for the mental health and substance abuse services provided to youth and
families. In this position the DMHCA conducts mental health and substance abuse screenings,
comprehensive assessments, psychotherapy or professional counseling. The DMHCA and the
clinical staff at the center communicate daily and have meetings weekly as needed. The
DMHCA communicates with the center’s superintendent or designee on a daily and weekly
basis, as needed.
3.02 Licensed Mental Health and Substance Abuse Clinical Staff (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
Department has a contract with VitalCore Health Strategies, LLC, who provides all mental
health and substance abuse services for all applicable youth at the center. The clinical
supervisor ensures the licensed clinical staff working under their supervision are performing
services they are qualified to provide based on education, training, and experience. All licensed
staff working at the center are licensed mental health and qualified professionals licensed under
the appropriate Florida Statutes chapter. All the licensed mental health staff’s licenses were
reviewed and confirmed to be clear and active, all expiring March 31, 2025. A total of five staff
provided mental health and substance abuse services at the center since the start of the
contract in June 2024, three licensed mental health counselors and two licensed clinical social
workers.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center’s superintendent is responsible for ensuring mental health and substance abuse
services are provided by qualified staff. The center has a contracted provider who hires all
mental health and substance abuse clinical staff for the center. The contracted provider has two
full-time clinical mental health staff, in addition to the designated mental health clinician authority
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(DMHCA). Both licensed mental health clinicians were utilized during the annual compliance
review period, and each clinician has a clear and valid license, all expiring on March 31, 2027.
The DMHCA was able to provide each clinician’s license as they are available in a binder within
the DMHCA’s office.
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
Department has a contract with VitalCore Health Strategies, LLC, who provides all mental
health and substance abuse services for all applicable youth at the center. A review of the
contract found non-licensed clinical staff are not required. At the time of the annual compliance
review, the center did not have any non-licensed staff.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center’s superintendent is responsible for ensuring mental health and substance abuse
services are provided by qualified staff. Reviewed documentation supported all mental health
services are provided by licensed mental health professionals. The center does not have any
non-licensed mental health clinical staff. The center does not have a Chapter 397 license.
Reviewed documentation supported all substance abuse treatment and groups were facilitated
by licensed mental health counselors.
3.04 Mental Health and Substance Abuse Admission Screening
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due to
Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to ensure all youth have a mental health and
substance abuse comprehensive screening process at admission to identify any needs the
youth may have. A review of seven youth mental health records was conducted to verify this
process. All seven youth records contained a completed Suicide Risk Screening Instrument
(SRSI) and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) which were
completed by the Department’s probation staff prior to each youth being admitted to the center.
During the center’s intake process these documents are reviewed by detention staff, and
detention staff complete the required sections on the SRSI in the Department’s Juvenile Justice
Information System (JJIS). The center’s medical staff and/or mental health staff are also
responsible for completing a required section on the SRSI. All seven reviewed youth mental
health records contained documentation of both the SRSI and MAYSI-2 having been completed
in JJIS, and each required section of the SRSI was completed by the appropriate staff. Five of
seven reviewed youth records had at least one positive response on the SRSI; the remaining
two youth record did not have any positive responses noted. All five applicable youth records
contained documentation confirming each youth was placed on suicide precautions and
detention staff initiated a mental health referral which indicated the youth’s need for an
Assessment of Suicide Risk (ASR) at intake. All five applicable SRSIs also included a positive
response for having any open or closed suicide risk alerts in JJIS. None of the reviewed youth
records contained an invalid MAYSI-2 due to the youth providing all negative responses. All
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seven reviewed youth records had an elevated score in at least one domain on the MAYSI-2. All
seven reviewed youth required a referral based on the SRSI or MAYSI-2, and each record
contained documentation on the mental health referral, initiated at intake by detention staff, of
the MASYI-2 results requiring further assessment. The superintendent or designee notification
was documented in all seven of the reviewed youth records as evidenced by the electronic
signature in JJIS. All screenings located in the seven reviewed youth records were completed
by a trained staff, which was confirmed in the Department’s Learning Management System
(SkillPro).
3.05 Mental Health and Substance Abuse Evaluation
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The designated mental health clinician authority (DMHCA) was interviewed and described the
process for completing the youth’s initial screening and obtaining the comprehensive mental
health and/or substance abuse assessment.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures which ensures each applicable youth receives a
mental health and/or substance abuse assessment. A review of seven youth mental health
records was conducted, and each was identified and referred to the center’s provider for further
assessment. Four of the seven youth have been at the center for under thirty days; the
remaining three youth are applicable to have assessments completed. All three of the applicable
youth records contained documentation of a referral for assessment created on the date of
admission. All three applicable youth records contained a comprehensive assessment
completed; two youth had a new comprehensive evaluation, and one had an updated
comprehensive evaluation completed by the center’s contract provider prior to each youth’s
thirty-first day at the center. There was no community provider completed assessments in the
reviewed records. Each new or updated assessment completed at the center contained
treatment recommendations which corresponded to all mental health or substance abuse
related diagnoses. The designated mental health clinician authority (DMHCA) stated mental
health and substance abuse needs are identified through the screening process, and referrals
are made as a result of the screening assessments.
3.06 Treatment and Discharge Planning
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable. The designated mental health clinician
authority (DMHCA) was interviewed and stated all mental health and substance abuse services
are reviewed at a minimum of once a week at the management meeting. The DMHCA explained
the initial treatment plan is developed within seven days of the psychiatrist meeting with the
youth and the individual treatment plan is developed by the youth’s thirty-first day at the center.
The review of individualized treatment plans, individualized substance abuse treatment plans,
and/or integrated mental health/substance abuse treatment plans are conducted every thirty
days while the youth are in secure detention.
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During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center’s superintendent and designated mental health clinician authority (DMHCA) are
responsible for ensuring a treatment plan is developed for every youth receiving mental health
and/or substance abuse services. Each youth who receives mental health and/or substance
abuse services in the center is required to have a completed discharge summary upon release.
The discharge summary should include the focus of treatment received in the center and
recommendations for community-based services. Two of seven reviewed youth mental health
records required the youth to have a treatment plan because the youth was receiving services in
the center; two did not require an initial treatment plan; and the remaining three were not
applicable. Both youth records contained an initial treatment plan completed within seven days
of the onset of treatment which was documented on the required Department form. Each plan
had the reason for the treatment referral, initial Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnoses/symptoms, initial treatment method and goals, and
the signature of the licensed clinician, youth, and assigned mini-treatment team members. Both
reviewed initial treatment plans also included psychiatric services and medications; the
remaining plan was not applicable for psychiatric services. Three of seven reviewed youth
mental health records were applicable for individualized treatment plans to be developed as the
youth had been receiving services appropriating thirty-one days; one youth had not reached the
thirty-first day of services; and the remaining three records had not been receiving service for
the required length of time. The three applicable youth records contained an individual treatment
plan developed prior to the youth’s thirty-first day of services. Each individual treatment plan
was documented on the required Department form and contained all the required elements to
include the DSM-5 diagnoses and treatment-focused symptoms, treatment goals, and youth’s
strengths and needs. One youth required psychiatric services and medications, and
pharmacological interventions to be included as well. Two of the three applicable youth records
also contained progress notes validating the treatment services the youth has received as
outlined in the treatment plan; the remaining applicable youth refused services. Each
individualized treatment plan contained the dated signatures of the mini-treatment team and
youth. None of the applicable individualized treatment plans required any thirty-day reviews.
Neither of the reviewed treatment plans were applicable for Prison Rape Elimination Act (PREA)
services. A mini-treatment team meeting was not observed during the annual compliance review
week; despite multiple requests, the center did not come and get the reviewer. The DMHCA
confirmed treatment services are initiated prior to discharge for youth determined to need
mental health and/or substance abuse services while in the center. An initial treatment plan is
developed within seven days of initiation of services. The DMHCA confirmed youth receive
services once a week for one hour.
3.07 Mental Health and Substance Abuse Treatment
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
Nine youth were interviewed, and two youth stated mental health and substance abuse services
at the center are very good, two stated good, one stated fair, and one stated very poor; three
youth were not receiving mental health/substance abuse services. The designated mental
health clinician authority (DMHCA) was interviewed and stated youth who are receiving services
are seen by mental health and substance abuse staff at least weekly.
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During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures for mental health and substance abuse treatment
planning to ensure interventions are provided to reduce or alleviate a youth’s mental health
and/or substance abuse issues. Four of seven reviewed youth mental health records indicated
youth required treatment; the remaining three records were not applicable. Each of the four
applicable youth records contained documentation the youth was assigned a mini-treatment
team which included mental health clinical staff, center staff for a different service area, the
youth, and the parent/guardian, if possible. Each youth received mental health treatment in the
prescribed frequency and delivery method, at a minimum of once a week. Each record
contained a proper consent for treatment and treatment notes documented on the required
Department form. A review of video, logbooks, and records was conducted and confirmed
mental health groups were conducted as scheduled with ten or fewer youth in each mental
health group session. The center has not had any substance abuse groups conducted during
this annual compliance review period; if needed, youth would receive substance abuse
counseling in individual sessions. Mental health staff have adequate access to youth and
confidential space to provide treatment service in the center. Seven youth were interviewed; two
of seven stated the mental health services received have been very good; one rated the
services as good; and two youth stated services were fair. The remaining two youth were not
applicable as they do not receive mental health services. The designated mental health clinician
authority (DMHCA) interview confirmed the center’s procedures regarding required treatment
plans and reviews, comprehensive assessments, mini-treatment teams, intervention/strategies
of service delivery, and modifications/updates for treatment plans. The DMHCA also confirmed
the procedures for treatment plans addressing substance dependence are the same.
3.08 Psychiatric Services (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024.
Psychiatric services at the center are provided by a physician licensed pursuant to Florida
Statute, who is a board-certified psychiatrist. The psychiatrist’s license expires January 31,
2025. The center has a back-up psychiatrist, who has an equal licensure and who’s license
expires January 31, 2026. According to the provider’s contract, approved tele-psychiatry shall
be classified as on-site, where appropriate, to meet the needs of the youth. The designated
mental health clinician authority (DMHCA) was interviewed and stated psychiatric, mental
health, and substance abuse services are provided at the center, at a minimum weekly for all
applicable youth.
Due to Department-wide system outages at the time of the annual compliance review, youth
records were unable to be reviewed.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures for psychiatric services to include psychiatric
evaluations and consultations, medication management, and medical supportive counseling for
youth with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnoses/symptoms. Psychiatric services were provided by a physician with a clear and active
license, under Chapter 458, with an expiration date of January 31, 2027. The back-up
psychiatrist has remained the same for the annual compliance review period, and back-up
services are provided by a physician with a clear and active license, under Chapter 458, with an
expiration date of January 31, 2026, and with equal education to the primary psychiatrist. The
center had a contract with tele-medicine/tele-psychiatry inclusion. The designated mental health
clinician authority (DMHCA) interview confirmed the psychiatrist is on-site once a week, is
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bilingual, and is available on-call if needed. Seven youth mental health records were reviewed
and three contained documentation showing youth were prescribed psychotropic medications
and required medication management services. The remaining four records were not applicable.
All three applicable youth mental health records contained documentation to confirm each youth
was admitted to the center with psychotropic medication and/or was referred for a psychiatric
interview within fourteen days of admission. Two of the three youth referred for the initial
psychiatric interview had the evaluation completed as required; the remaining youth evaluation
was not completed and was twenty-one days late as of the annual compliance review week.
Both of the completed initial psychiatric interviews were on the required Department form and
contained all the required elements to include referral reason, youth history, mental status,
DSM-5 diagnoses, treatment recommendations, the prescribed medication name, explanation of
need, and frequency of monitoring. Each applicable record also contained a completed
psychiatric evaluation. The center utilizes the entire three-page Clinical Psychotropic Progress
Note (CPPN) form to document each evaluation. All three initial CPPNs were observed to be
fully completed with all required elements, dated signatures, and parent/guardian notifications, if
applicable. All medication management and Tardive Dyskinesia reviews, where applicable, were
also completed on a CPPN every thirty-days or as needed for each youth. All three youth
records contained a proper Authority for Evaluation and Treatment form. None of the youth
received tele-psychiatry services.
3.09 Suicide Prevention Plan (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center maintains a suicide prevention plan which is signed and reviewed by the designated
mental health clinician authority (DMHCA) annually and contains all required elements. Included
in the suicide prevention plan is an established review process for every serious suicide attempt
or serious self-inflicted injury and a mortality review for a completed suicide. This
multidisciplinary review included all required elements.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures for ensuring the safety and protection of youth with
an elevated risk of suicide. The center’s suicide prevention plan is reviewed and signed by the
superintendent and the designated mental health clinician authority (DMHCA) annually. The
plan contains all the required elements to include identification of youth with suicide risk, staff
training, suicide precautions, referral, communication and notification, documentation,
immediate staff response, and a review process. The center has an established review process
for every serious suicide attempt or serious self-inflicted injury requiring hospitalization and a
mortality review for completed suicides. The multidisciplinary review includes circumstances
surrounding each event, center procedures relevant to the incident, all relevant training received
by involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations, if any to changes in policy, training, physical plant,
medical or mental health services, and/or operational procedures.
3.10 Suicide Prevention Services (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) for suicide precautions which include
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supervision, observation, monitoring, and housing for youth identified as a potential suicide risk
through screening, collateral information, and staff observations. Each identified youth must be
placed on precautionary observation (PO) or secure observation (SO) with constant supervision
and have an Assessment of Suicide Risk (ASR) completed by a licensed mental health
professional. None of the nine reviewed youth mental health records were applicable for this
indicator. One additional youth record was requested, as the youth had three separate
instances of suicide observations and assessments. One of three incidents of PO was initiated
due to staff observation of at-risk or concerning behaviors; the remaining two incidents of PO
were after a youth returned to the center after a Baker Act. Each PO was started immediately or
upon readmission to the center from a Baker Act, and each had a suicide risk assessment
referral made as required. Due to Department-wide system outages at the time of the annual
compliance review, the Department’s Juvenile Justice Information System (JJIS) alerts were not
able to be confirmed or reviewed. All three ASRs were completed on the required Department
form within twenty-four hours. In two of three incidents, the youth was placed on constant
supervision while awaiting the ASR; the remaining incident occurred when the youth was on
standard supervision and the designated mental health clinician authority (DMHCA) was on-site
during the incident. Each of the three reviewed PO logs were completed in their entirety to
include safe housing and required signatures. All three ASRs occurred while the youth was in
the custody of the center. Documentation of the staff’s consultation with the DMHCA and the
immediate notification of the superintendent or designee was located on all three referrals. One
of three incidents required a Follow-Up ASR to be completed prior to removing the youth from
PO, and the Follow-Up ASR contained the documentation of the conference held by the
superintendent and licensed mental health professional. The two remaining incidents were not
applicable for a Follow-Up ASR as the youth was Baker Acted in both incidents. A licensed
mental health professional completed each of the reviewed ASRs which included the
assessment results and supervision recommendations. All three incidents were in the
appropriate logbook with beginning and ending times, as well as when each youth was taken
off-site for the Baker Acts and the youth’s return to the center. One of three incidents resulted in
the youth being placed in SO under the superintendent and DMHCA’s authorization and a
secure room assignment was made; the remaining two incidents were not applicable. Prior to
placement in SO a health status checklist form was completed and during the SO a supervision
log was completed in its entirety, including observations made of the youth’s behavior. The
youth was in SO for less than eight hours; therefore, a new ASR was not required, and the
youth was Baker Acted from SO. Supportive counseling was not initiated due to the short SO
period prior to being Baker Acted.
Three of nine interviewed youth confirmed they had been under suicide watch and staff always
watch the youth; the remaining six youth were not applicable. Nine staff were interviewed and
seven identified the task of notifying the mental health authority, six staff identified the task of
searching the youth and their room for sharp objects, six staff confirmed they place the youth on
constant sight and sound supervision, five staff identified the task of documenting the constant
supervision, and one staff noted they are to document it in the logbook and inform the master
control when a youth expressed suicidal thoughts. The superintendent interview confirmed
youth placed in SO have a staff placed at their door window, in direct sight of the youth at all
times, and documentation of the SO is completed on the required supervision log.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures for suicide precautions, which include methods
utilized for supervising, observing, monitoring, and housing identified suicide risk youth. Six of
the seven reviewed youth mental health records contained documentation of youth identified at
admission with an elevated risk of suicide. The remaining record did not have any suicide
prevention services documented. All six applicable youth were immediately placed on
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precautionary observation (PO), with a constant level of supervision at the time of admission. A
suicide alert was entered into the Department’s Juvenile Justice Information System (JJIS)
within minutes of identification, and a referral for an Assessment of Suicide Risk (ASR) was
made for each. Each ASR was completed on the required Department form, and a PO log was
also generated and completed on the required Department form for each applicable youth. Each
form was observed to be completed in its entirety. A qualified and licensed mental health
clinician completed each ASR within twenty-four hours and the notification to the superintendent
or designee was documented in each youth record. Consultation with the designated mental
health clinician authority (DMHCA) was documented on the referral summary section of the
ASR for each of the six applicable records. Each reviewed ASR contained all of the required
elements, to include the recommendations. All six applicable youth records contained
documentation of the conference with the superintendent and DMHCA to reduce the level of
supervision. Four of the six records confirmed the discontinuation of PO and closing the JJIS
suicide alert in each record was completed after this conference and in a timely manner; one
youth was sent for off-site care; and the remaining youth was still on PO during the annual
compliance review week. Each youth record contained documentation of a recommended
Follow-Up ASR and none of the youth were released from the center while on PO status. Two
PO events were not located in the logbook; the remaining four were documented in the logbook
as required. None of the youth records were applicable for secure observation. Seven youth
were interviewed and four reported they had been placed on suicide watch at the center; the
remaining three did not. The four applicable youth confirmed staff was watching them the entire
time. Seven staff were interviewed; and all seven staff confirmed the center would notify the
DMHCA. Two of the seven staff stated they would search the youth and their room for sharp
objects if a youth expresses suicidal thoughts. Three of seven stated staff begin the
documentation of supervision. Five of seven stated the youth is placed on constant sight and
sound supervision. None of the interviewed staff indicated a youth can be placed in a locked
room. The superintendent’s interview confirmed the center does utilize the secure observation
room for youth who present an imminent threat of self-harm or harm to others. The DMHCA
interview confirmed intake staff immediately review all screening instruments and forms upon
each youth’s arrival. The intake officer reviews the MAYSI-2 and the SRSI, and if the need for
an assessment is indicated by the SRSI or information obtained at intake suggests a youth is a
potential suicide risk, the youth is placed on suicide precautions and maintained on a minimum
of constant supervision until an ASR is completed by a mental health clinical staff. In the last six
months the center has had no youth who cut or attempted to cut; twenty-three youth who
hanged or attempted to hang themselves or put something around their necks; and eight youth
self-injured or mutilated themselves. Four of these youth were present in the center during the
annual compliance week.
3.11 Suicide Precaution Observation Logs (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure all youth on suicide precautions have
constant supervision from an assigned staff who documents observations of the youth’s
behavior at a minimum of every thirty minutes. None of the nine reviewed youth mental health
records were applicable for this indicator. One additional youth mental health record was
requested, as they had three separate suicide observations and assessments. All three
incidents had a corresponding Suicide Precaution Observation Log maintained during the
duration of the suicide precaution supervision, and each log was observed to have
documentation for the appropriate level of supervision and behavior observations made every
thirty minutes. All three logs included documentation of notification to the superintendent or
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designee and mental health clinical staff when warning signs were observed; signatures from
each applicable shift supervisor and mental health clinical staff; and safe housing requirements
identified. Three video observations, each a minimum of thirty minutes, were conducted and
verified the documented supervision matched the video observation.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to maintain precautionary observation (PO) for
youth identified with a suicide risk. Six of the seven reviewed youth mental health records
contained documentation which confirmed the youth was on PO. The remaining record did not
have any suicide prevention services documented. All six applicable youth were immediately
placed on PO and a PO log was maintained for each. Each PO log was observed to have each
youth’s behaviors documented at intervals not exceeding thirty-minutes. Each PO log contained
all the required elements of documentation to include review and signature of each shift
supervisor, review and signature of mental health clinical staff, safe housing requirements,
warning signs, and superintendent and mental health notifications. A review of video footage
and corresponding documentation was conducted. This review confirmed each observed youth
was properly supervised and maintained on PO.
3.12 Suicide Prevention Training (Critical)
The center originally received a Limited Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
has facility operating procedures (FOPs) to ensure all direct care staff receive annual training on
suicide prevention, to include risk factors, behavioral observations, and implementation of
suicide precautions. A review of eighteen direct care staff training records including nine pre-
service and nine in-service records, was completed. All reviewed staff training records
contained documentation of four hours of in-person suicide prevention training. Due to
Department-wide system outages at the time of the annual compliance review, a review of the
Department’s Learning Management System (SkillPro) for the required two-hour course was not
able to be completed. The center provided documentation of suicide drills held monthly,
exceeding the quarterly requirement, on each shift throughout the annual compliance review
period. The center has four suicide kits containing the required items and each is co-located
with a first-aid kit. The kits are in master control and each of the three sub control rooms. The
center had two shifts from May 2023 through December 2023 and held a total of sixteen suicide
prevention drills, eight on each shift, during this time. Three of sixteen drills contained all the
required elements, to include proper contacts made, life saving measure utilized within the drill
narrative, the supervisor recommendations, as well as all required signatures. The remaining
thirteen drills were all missing at least one, and up to four, required elements. The center has
had three shifts since January 2024 through the remainder of the annual compliance review
period. Four of twelve drills contained all the required elements, to include proper contacts
made, life saving measure utilized within the drill narrative and the supervisor
recommendations, as well as all required signatures; the remaining eight drills were all missing
at least one, and up to three, required elements. In the review of the first six-month period forty-
two of forty-eight staff, and in the second six-month period thirty-seven of thirty-eight staff
participated in at least one drill as evidenced by the drill sign-in sheets. There were five staff on
the roster of thirty-eight, with no documentation to support they participated in a required annual
drill utilizing cardiopulmonary resuscitation (CPR). Staff who are not present for mock drills can
review the drill scenario report.
Nine staff were interviewed and asked about the location of the suicide kits in the center. Five
staff reported one is in master control, seven staff reported there is a kit in each sub control, and
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six staff reported there is a kit in medical. An informal interview with the center’s administration
confirmed there are the same items in the nurse’s “go bag”; however, it is not a suicide kit for
staff to access, and a review of the location of each kit would be conducted at shift briefings.
During the re-review the center received a Failed Compliance rating for this indicator. The
center has facility operating procedures to ensure all staff who work with youth receive training
to identify suicide risk cues, learn suicide prevention, and precaution implementation. Fourteen
staff training records were reviewed, seven pre-service and seven in-service, and each staff
received the required two hours of suicide prevention on the Department’s Learning
Management System (SkillPro) and four hours of in-person suicide prevention training. The
center has four suicide response kits with all the required items, and each suicide kit is co-
located with a first-aid kit in master control and in each of the three sub controls. The suicide kits
were observed in plastic show boxes with lids which can be bent back to access the kits; one kit
was found to be unsecured. The center replaced each suicide kit with new boxes during the
annual compliance review week. The center provided a total of ten drills for review. Three of the
ten drill documentation packets did not have any information regarding the drill activity and
participants; one drill packet did not have any information regarding the drill activity and
participants and no signatures of administrative review; three drill packets had only instructional
information about the drill activities from the Department’s Office of Health Services emails and
no center-specific details; one drill packet did not have a staff sign-in sheet; one drill packet did
not have the superintendent’s, or designees review signature; and the remaining drill packet
documentation did not have information regarding a response with the first-aid kit nor in the
administrative review was the correction mentioned. The remaining two drills contained all the
required documentation. None of the reviewed drills involved cardiopulmonary resuscitation. No
staff training records were reviewed for the first six months of the annual compliance review
period due to a previous deficiency. Forty-four staff training records were reviewed for the
second six months of the annual compliance review period. Eleven staff completed at least one
suicide drill in the second six months. Staff who are not on shift when a drill is conducted do
have an opportunity to review the conducted drill; however, this does not count as participation.
Seven staff were interviewed about the location of the suicide response kits. One staff indicated
a suicide response kit is located in master control, and all seven confirmed there were kits in
each of the sub controls.
3.13 Mental Health Crisis Intervention Services (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure the least restrictive means/response
to protect the safety of youth and others while maintaining control is utilized for youth in crisis. A
review of the center’s combined emergency services plan was conducted and confirmed the
combined plan contains all the required elements, to include notification and alert systems,
communication and documentation, supervision, and incident review.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to ensure each youth is placed in the least
restrictive means possible for their protection and safety while maintaining control when a youth
is in crisis. A review of the center’s combined emergency services plan confirmed the combined
plan contains all the required elements, to include notification and alert systems, means of
referral, communication, supervision, documentation, and incident review.
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3.14 Emergency Care Plan (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure youth determined to be in imminent
danger to themselves or others due to mental health or substance abuse issues receive
emergency care services in accordance with the center’s emergency care plan. A review of the
center’s combined emergency care plan and crisis intervention plan was conducted and
confirmed the combined plan contains all the required elements, to include immediate staff
response, notifications and communication, supervision, authorization to transport for
emergency mental health or substance abuse services, transport for Baker Act and Marchman
Act, documentation, training, and review procedures. The center’s combined plan was approved
on April 8, 2024, and last updated on March 15, 2022. All staff have access to the approved
plan. The plan is in the superintendent’s office, medical, and mental health office, as well as
online for staff to access and review.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to ensure the center follows the emergency care
plan for any youth determined to be an imminent danger to themselves or others. A review of
the center’s combined emergency care plan was conducted and confirmed the combined plan
contains all of the required elements to include immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for Baker Act and Marchman Act, documentation, training,
and review procedures. The center’s plan was approved and last updated on August 23, 2024.
All staff have access to the approved plan. Copies are located in the superintendent’s office.
3.15 Crisis Assessments (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure youth demonstrating acute
psychological distress receive a detailed evaluation conducted by a licensed mental health
professional, or under the supervision of a licensed mental health professional, to determine the
level and severity of risk. A Crisis Assessment is only utilized when the presenting acute
psychological distress is not related to suicide risk factors. None of the nine reviewed youth
mental health records received these services. The center has not had any youth in need of a
Crisis Assessment during the annual compliance review period.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to ensure youth demonstrating acute psychological
distress receive a detailed evaluation conducted by a licensed mental health professional, or
non-licensed staff under the supervision of a licensed mental health professional, to determine
the level and severity of risk. A Crisis Assessment is only utilized when the presenting acute
psychological distress is not related to suicide risk factors. None of the seven reviewed youth
mental health records were applicable for a Crisis Assessment. The center was able to provide
three youth records with documentation of a Crisis Assessment completed during the annual
compliance review period. The reviewed record confirmed the Crisis Assessment was
conducted within twenty-four hours of the crisis identification by a licensed mental health
clinician. The completed Crisis Assessment contained all the required elements and information
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to include the reason for the assessment and identified acute emotional or behavioral problems,
the youth’s Mental Status Examination interview, determination of danger/risk, initial clinical
impressions, and supervision and treatment recommendations. None of the reviewed youth
records contained a recommendation for follow-up or further evaluation nor required the
notification of the parent/guardian. One of the three youth were referred for a crisis assessment
based on observations of direct care staff; the remaining two youth were referred as a result of
being an alleged victim of a Prison Rape Elimination Act (PREA) event.
3.16 Baker and Marchman Acts (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) to ensure youth believed to be an imminent
danger to themselves or others due to mental health or substance abuse issues receive
emergency services through Baker or Marchman Act procedures. None of the nine reviewed
youth mental health records were applicable for these services. Additional records were
requested, and one youth record was applicable and provided for review. The youth record had
two separate Baker Act incidents applicable for the annual compliance review period. The youth
was placed on precautionary observation upon re-admission to the center, a mental health
referral was completed for a Mental Status Examination (MSE), and the MSE was completed by
a licensed mental health professional after each Baker Act incident. One of two incidents had
documentation of the youth being maintained on constant supervision until properly transitioned
to a lower level of supervision, after an appropriate assessment was conducted by a licensed
mental health professional; the remaining incident the youth was sent out again under a Baker
Act.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOPs) to ensure youth believed to be an imminent
danger to themselves or others due to mental health or substance abuse issues receive
emergency services through Baker or Marchman Act procedures. One of the seven reviewed
youth mental health records were applicable for Baker or Marchman Acts. The center provided
two additional youth records, from the annual compliance review period, for the review of Baker
Acts. The center did not have any Marchman Acts during the annual compliance review period.
When each youth was re-admitted, the center immediately began to maintain constant
supervision and completed a mental health referral. A licensed clinical staff completed an
Assessment of Suicide Risk (ASR) which included a Mental Status Examination. Two of the
three youth were maintained on a minimum of constant supervision until properly transitioned to
a lower supervision level upon approval from the licensed supervisor and superintendent, or
designee; the remaining youth was still on precautionary supervision. Both applicable youth had
documentation of the Suicide Risk Alert, in the Department’s Juvenile Justice Information
System (JJIS), and was discontinued when the supervision level was lowered.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center’s designated health authority (DHA) is a board-certified physician, with an unrestricted
license and a specialty in family practice. The DHA’s license expires January 31, 2026. The
center has an advanced practice registered nurse (APRN) with a collaborative practice protocol
in place. A review of sign-in and out logs during the annual compliance review period confirmed
the DHA was on-site weekly since the last annual compliance review. The center has a backup
DHA with equal licensure, expiring January 31, 2025. The backup DHA was utilized three
separate dates during the annual compliance review period. The center utilizes tele-medicine,
has corresponding facility operating procedures, and maintains a Telehealth Log, documenting
the provider's name, date, time-in, time-out, youth's name, the Department’s Identification
number, chief complaint, and treatment order. The DHA was interviewed and indicated they are
on-site weekly and described their role as conducting periodic evaluations, conducting sick call,
focused physicals, Comprehensive Physical Assessments (CPAs), and episodic evaluations.
The DHA further stated they develop and review protocols, policies, and procedures documents
and act in collaboration with the medical staff in a decision-making role. While on-site the DHA
reviews the list of youth, orders, and other medical information with staff and is available by
telephone when not on-site. A folder is reviewed weekly for any off-site visits or evaluations for
all applicable youth. All youth receive a medical visit from the DHA upon return from an
emergency room or any additional off-site evaluations. All pertinent or urgent issues with youth
are addressed when the DHA is on-site or through telephone communication with the DHA.
When the DHA is not available, the clinical manager arranges for the backup DHA to cover.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures addressing tele-medicine. The center has a
licensed physician (MD) who holds an unrestricted license and meets all requirements for
independent and unsupervised practice in Florida serving as the designated health authority
(DHA). The DHA’s license expires on January 31, 2026, and his specialty training is in family
practice. The DHA works with an advanced practice registered nurse (APRN) who has a
collaborative practice protocol (CPP) in place. A review of the DHA sign-in and sign-out logs
during the annual compliance review period confirmed the DHA was on-site at least once a
week, other than for five weeks. Two of the five weeks no DHA was on-site, and the remaining
three weeks the DHA was on-site less than no more than nine days apart; however, not within
the seven-day week of the prior week. The DHA’s contract condition is once a week with no
hourly requirement specified. The DHA has four back-up DHAs who can be utilized in case of
vacation or scheduled absences. The back-up DHAs all had equal and unrestricted licenses,
meeting all requirements for independent and unsupervised practice in Florida. Three MDs
licenses expire on January 31, 2027, and one on July 23, 2027. One of the back-up DHAs was
utilized one week during the annual compliance review period. The DHA performs the
administrative duties and conducts the clinical services on-site with the APRN. The DHA
interview indicated the DHA performs the Comprehensive Physical Assessments (CPA), clears
youth for physical activities, responds to sick calls, reviews cases, and conducts focused
evaluations, as well as timely follow-ups. The DHA communicates through telephone calls,
documentation in the records, and on-site evaluations with the program staff regarding youth
medical needs. The DHA interview indicated the APRN is on-site twice a week and the DHA
once a week to provide on-site clinical services, and the DHA is available telephonically. The
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Office of Accountability and Program Support Page 40 of 77 (Revised July 2022)
DHA arranges back-up through the nurse manager, when unavailable. The DHA meets weekly
with the healthcare staff to review important medical issues pertaining to the youth at the center,
as well as using the records and telephone communication. The records are utilized to ensure
off-site care findings, instructions, and information is reviewed by the DHA/designee and the
nurses call the DHA frequently with updates. The DHA stated no concerns regarding the
healthcare of youth at the center.
4.02 Facility Operating Procedures
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) and treatment protocols which were reviewed
and signed by the designated health authority (DHA) on February 19, 2024. The signature line
for the superintendent’s review and signature was inadvertently left off the FOPs, according to
the Department’s Office of Health Services; therefore, the medical FOPs were not reviewed and
signed by the center’s superintendent. This is being rectified and will be updated in the near
future. The psychiatrist reviewed and signed the psychiatric FOPs on February 16, 2024.
Nursing staff reviewed, signed, and dated the cover page for the medical FOP's and treatment
protocols; all were reviewed and signed in the month of February 2024. There were no policy
changes or updates since the staff review in February 2024. In addition, the center maintains
health related procedures and treatment protocols. There was one healthcare staff hired since
the last annual compliance review, who received a comprehensive clinical orientation, provided
by a registered nurse, to the Department’s healthcare policies and procedures.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
On June 2, 2025, the designated health authority (DHA) and on September 10, 2024, the
superintendent signed and dated all respective treatment facility operating procedures (FOP).
The psychiatrist signed the applicable FOPs without noting a date. During the annual
compliance review week, the psychiatrist signed the FOPs again, noting a date. The nurses
reviewed, signed, and dated a cover page on which medical FOPs, treatment protocols, and
other procedures were listed; three signed October 23, 2024, one on November 25, 2024, one
on June 1, 2025, and one on May 13, 2024. The center did not have any new policies or
changes in policies made during the annual compliance review period. An annual review of
medical FOPs and protocols was conducted as required. The nurses signed a cover page, and
the DHA and superintendent signed the FOPs. The psychiatrist reviewed and developed the
FOPs and other protocols related to psychiatric services and psychotropic medication
management. The center utilizes FOPs including all health-related procedures and treatment
protocols. The center did not have any newly employed health care personnel since the last
annual compliance review. The approval of treatment protocols or standing procedures was
written and authorized by the DHA.
4.03 Authority for Evaluation and Treatment
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
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Office of Accountability and Program Support Page 41 of 77 (Revised July 2022)
The center’s nurse was interviewed and stated when a new psychotropic medication is
prescribed, discontinued, or the dosage is significantly changed, parental/guardian verbal
consent is documented on the Clinical Psychotropic Progress Note (CPPN) on page 3. Written
consent is documented on the Acknowledgment of Receipt of CPPN form. Any verbal
notification (in person or by telephone) is documented on a written Parental Notification/Consent
form, showing attempts to obtain the signed parent/guardian consent. The center obtains each
youth’s immunization records through Florida Shots upon admission. In the event the
parent/guardian is requesting exemption from immunizations, the parent/guardian must present
a certified documentation of exemption. It is reviewed by nursing staff and the designated health
authority and uploaded in the youth’s medical chart.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
Six of seven reviewed Individual Healthcare Records (IHCR) contained the original Authority for
Evaluation and Treatment (AET) form. Each AET was valid, as well as signed by the youth’s
parent/guardian and a Department representative. All six AETs were obtained prior to providing
medical services. The remaining one youth was in the care of the Department of Children and
Families (DCF) and a court order was uploaded in the Electronic Medical Record (EMR). The
court authorized all treatment procedures. None of the parents/guardians refused to sign the
AET, there were no pending court orders, and none of the youth were eighteen years of age or
older. The nurse interview indicated an AET is required prior to providing medical services and
needs to be signed by the parent/guardian and witnessed by a Department representative. The
AET is valid if the youth remain under any type of supervision, custody, or other form of legal
control by the Department, or for one year, whichever comes later, or until the youth's
eighteenth birthday. The center’s process is to notify the juvenile probation officer if a new AET
is required, as well as sending an AET to court with the youth for the parent/guardian to sign if
they are present. If the youth is in DCF care, then the case worker is contacted to obtain a
limited AET. Youth ages eighteen or older are responsible for authorizing their own health care
and release of their healthcare information and records. Those youth give verbal consent and
sign/initial for treatment and or medication rendered.
4.04 Parental Notification/Consent
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated parental/guardian notifications should be made
to inform parents/guardians of significant changes in each youth’s condition and obtain consent
when new medications are ordered, medications are stopped, youth are sent off-site for
treatment, whether scheduled or emergency, and treatments are prescribed. These notifications
are first done verbally and followed with a letter. The nurse contacts the parent/guardian by
telephone as soon as the change occurs. Then a letter is sent out explaining the medication
(given or started) or treatment rendered.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
Five of the seven reviewed Individual Healthcare Records (IHCR) were applicable for parental
notification/consent. The two remaining were not applicable. One of the five applicable IHCRs
had documentation of parental notification for over-the-counter (OTC) medications beyond
those covered by the Authority for Evaluation and Treatment (AET) and consent was provided
by the parent/guardian. The remaining four were not applicable for OTC medications. All five
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Office of Accountability and Program Support Page 42 of 77 (Revised July 2022)
IHCRs contained written notifications sent utilizing the Department’s Parental Notification of
Health-Related-Care: General or Parental Notification of Health-Related-Care: Medications
forms or the Acknowledgment of Receipt of the Clinical Psychotropic Progress Note (CPPN).
Two of the youth were taking psychotropic medications and a staff witnessed all telephone call
attempts and conversations for psychotropic medications. None of the youth required
vaccinations/immunizations. Two of the five youth required a new medication order and there
was documentation of attempted contact with the parent/guardian in the progress notes. The
two IHCRs contained written parental notices sent regardless of telephone notifications. Two of
the five youth had a psychotropic medication drug dosage changed and the parent/guardian
verbal consent for psychotropic medication was documented on page three of the CPPN and
written parental notification/consent showing an attempt to obtain the signed parent/guardian
consent was maintained in each IHCR. None of the five applicable youth were in the care of the
Department of Children and Families (DCF). Two of the seven youth were not applicable for
vaccine verification having been at the center less than thirty days. Four of the five remaining
IHCRs contained shot records obtained from the school each youth was attending and/or the
Florida Shots website, and vaccines were verified within thirty days of each youth’s admission.
The remaining one IHCR did not contain any shot records verified within the thirty days of the
youth’s admission. None of the youth required vaccinations.
The nurse interview stated parental notifications are made to inform the parent/guardian of
significant changes in the youth's condition and obtain consent when new medications are
ordered, medications are stopped, treatments are prescribed, and the youth is sent off-site for
scheduled or emergency treatment. These notifications are first done verbally and followed-up
with a letter. A nurse contacts the parent/guardian by telephone as soon as the change occurs
or an order is obtained requiring notification, and then a letter is sent explaining the medication
or treatment rendered. Whenever a new psychotropic medication is
prescribed/discontinued/drug dosage is significantly changed the parent/guardian’s verbal
consent for psychotropic medication is documented on page three of the CPPN and written
consent is documented on the Acknowledgment of Receipt of the CPPN form. Any verbal
notification is documented on the written parental notification/consent, showing attempt to obtain
the signed parent/guardian consent. The nurse stated all staff have the ability and responsibility
to call 9-1-1 under any circumstance requiring immediate medical attention or evaluation. The
designated health authority (DHA) is then notified of youth going to the hospital. The nurse said
the center does not provide vaccinations on-site; however, immunization records are obtained
and verified through Florida Shots website usually within twenty-four hours of arrival. If a
parent/guardian presents a certified documentation of exemption from immunization it is
reviewed by a nurse and the DHA and uploaded in the Electronic Medical Record (EMR).
4.05 Healthcare Admission Screening & Rescreening Form (Medical and Mental Health
Screening Form)
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated each newly admitted youth is seen by medical
staff the day of admission. If nursing staff are not on-site when the youth is admitted, the youth
is seen the following morning when medical staff return. Direct care staff or master control notify
medical of each newly admitted youth. In the event direct care staff complete the admission
screening the nurse signs on the third page of the screening form confirming a review of the
screening packet. When there is a change in a youth’s physical custody, upon return, the youth
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Office of Accountability and Program Support Page 43 of 77 (Revised July 2022)
is accessed for any changes in their medical condition. Vital signs are also obtained, and the
health-related history is reviewed with the youth.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
A review of seven Individual Healthcare Records (IHCR) indicated the Medical and Mental
Health Admission Screening Form was completed on the date of admission by a juvenile justice
detention officer (JJDO). The screening was reviewed with each youth by a nurse within twenty-
four hours. In all seven, notification to the designated health authority (DHA) was documented in
each youth’s IHCR. One of the seven youth had a change in physical custody since arrival. The
center was unable to provide the Medical and Mental Health Admission Screening Form for the
re-screening. The nurse interview stated each youth is seen the day of admission in the clinic;
however, if a youth arrives after the nurses are gone for the day, the youth is seen the following
morning. Supervisors and/or master control notify the nurses of newly admitted youth. The
nurses also receive medical and mental health screening forms/packets in the clinic mailbox for
each newly admitted youth. The juvenile justice detention officer supervisors complete the
admission screening and a nurse reviews and signs on the third page of the screening form. If
there is a change in physical custody since the youth's admission the youth is assessed/asked
for any changes in medical condition, vital signs are obtained, and the Health-Related-History
form is reviewed with the youth and any changes are documented on the form.
4.06 Youth Orientation to Healthcare Services/Health Education
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures addressing youth orientation to healthcare services in
the facility. The procedures address access to medical care, sick call, what constitutes an
emergency and when to notify staff, the medication process to include side effect monitoring,
the refusal process and how to document it, what to do in the case of a sexual assault or
attempted sexual assault, the non-disciplinary role of healthcare providers, and the review of the
list of healthcare contacts to ensure accuracy. A review of youth healthcare records was unable
to be completed at the time of the annual compliance review. The center utilizes the
Department’s Health Education form to document the orientation process for all newly admitted
youth.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures addressing youth orientation to healthcare
services/health education including access to medical care, sick call, what constitutes an
emergency and when to notify staff, medication process to include side effect monitoring, the
right to refuse care and how it is documented, what to do in the case of a sexual assault or
attempted sexual assault, the non-disciplinary role of the health care providers, and a review of
the list of healthcare contacts to ensure accuracy.
All seven reviewed Individual Healthcare Records (IHCR) contained documentation each youth
received a general healthcare orientation with the health education topics documented on the
Department form.
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Office of Accountability and Program Support Page 44 of 77 (Revised July 2022)
4.07 Designated Health Authority/Designee Admission Notification
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated nursing staff are required to
contact the designated health authority by telephone for all youth admitted with serious or
chronic conditions, which is documented on the center’s intake log as well as on the youth’s
admission form.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
Five of the seven Individual Healthcare Records (IHCR) reviewed were applicable for youth with
chronic conditions. The remaining two youth were not applicable. All five youth with known or
suspected chronic conditions were referred to the designated health authority (DHA). None of
the youth were in-need of emergency care upon admission. All five IHCRs contained notification
to the DHA/designee on the day of admission documented in the Chronological Progress Notes.
Two of the five youth were taking psychotropic medication upon admission and the psychiatrist
was notified. The nurse stated parental notifications are made to inform the parent/guardian of
significant changes in the youth's condition and obtain consent when new medications are
ordered, medications are stopped, treatments are prescribed, and the youth is sent off-site for
scheduled or emergency treatment. These notifications are first done verbally and followed-up
with a letter. A nurse contacts the parent/guardian by telephone as soon as the change occurs
or an order is obtained requiring notification, and then a letter is sent explaining the medication
or treatment rendered. When a new psychotropic medication is prescribed/discontinued/drug
dosage is significantly changed the parent/guardian verbal consent for psychotropic medication
is documented on page three of the Clinical Psychotropic Progress Note (CPPN) and written
consent is documented on the Acknowledgment of Receipt of the CPPN form. Any verbal
notification is documented on the written Parental Notification/Consent form, showing attempt to
obtain the signed parent/guardian consent. The nurse stated all staff have the ability and
responsibility to call 9-1-1 under any circumstance requiring immediate medical attention or
evaluation. The designated health authority (DHA) is then notified of youth going to the hospital.
The nurse said the center does not provide vaccinations on-site; however, immunization records
are obtained and verified through FLSHOTS website usually within twenty-four hours of arrival.
If a parent/guardian presents a certified documentation of exemption from immunization it is
reviewed by a nurse and the DHA, and uploaded in the Department’s Electronic Medical Record
(EMR).
4.08 Health-Related History
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated nursing staff are responsible for
completing the Health-Related History form, which is completed within seven days of each
youth’s admission. The designated health authority (DHA) completes the Comprehensive
Physical Assessment (CPA) within seven days of each youth’s admission. A new CPA is
needed every two years if the youth is a Medical Grade 1; however, if a youth’s Medical Grade
changes from a 1, a new CPA is created.
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Office of Accountability and Program Support Page 45 of 77 (Revised July 2022)
During the re-review the center received a Satisfactory Compliance rating for this indicator.
A review of seven Individual Healthcare Records (IHCR) found in six the Health Related History
(HRH) form was completed within seven calendar days of admission. In the remaining one
IHCR the form was completed two days late due to the nurses awaiting limited consent. In all
seven IHCRs the HRH was completed by a licensed nurse or practitioner prior to the
Comprehensive Physical Assessment (CPA)/focused evaluation, as evidenced by signature and
date. A licensed physician (MD)/advanced practice registered nurse (APRN) reviewed each
HRH. A review of the forms confirmed all signatures and dates were from the most current
admission. The nurse interview stated the nurses are responsible for completing the HRH form
within seven days of youth admission.
4.09 Comprehensive Physical Assessment/TB Screening
The center originally received a Non-applicable Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due to
Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated the designated health authority
(DHA) completes the Comprehensive Physical Assessment (CPA) within seven days of each
youth’s admission. A new CPA is needed every two years if youth is a Medical Grade 1;
however, if a youth’s Medical Grade changes from a 1, a new CPA is created. Tuberculosis (TB)
screenings shall be completed for each youth within seventy-two hours of admission if one is
not documented in the youth’s Individual Healthcare Record (IHCR) within the past year. Youth
are given a purified protein derivative (PPD) test one time a year and results are documented on
the CPA, Infectious Disease Form, and the TB tracking log. Gynecological exams are not
routinely completed for female youth, only if needed.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures addressing appropriate documentation of when any
part of the exam is not conducted and/or refused by the youth, and a tuberculosis (TB)
screening and rescreening process. In all seven Individual Healthcare Records (IHCR) each
youth’s physical assessment was documented on the Department’s Comprehensive Physical
Assessment (CPA) form. Three of the seven had a current CPA on file at admission, two of the
remaining four youth had a new CPA completed within seven calendar days of admission, and
the remaining two youth had a new CPA completed one and two days late, respectively. The
youth who had the CPA conducted two days late was due to the nurses having to wait until a
limited consent was received, the other youth was an oversight. Five of the CPAs were
conducted by an advanced practice registered nurse (APRN) and two by the designated health
authority (DHA). All seven had the Medical Grade documented on each CPA. None of the CPAs
were missing any elements. In three of the seven IHCRs a new CPA was not completed and a
current CPA with no changes in the youth’s medical condition was utilized. The current CPA
was reviewed as the three youth were examined by the DHA/APRN. The three youth received a
focused evaluation with each readmission where a new CPA was not initiated, and a current
CPA was used. All seven CPAs were marked with an “O” or an “X”. Two of the seven youth
refused part of the exam and the clinician wrote “youth refused” on the CPA and both youth
signed a refusal form which reflected the refused portion on the CPA exam and matched the
date of the exam. The Department’s Problem List was updated in all seven IHCRs and six of the
seven had at least one verified Tuberculosis Skin Test (TST) documented within the last year.
The remaining one TST had been conducted; however, not yet read during the annual
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compliance review week. In the six applicable IHCRs the results of the TST were documented
on the CPA and the Infectious and Communicable Disease (ICD) forms, and they matched.
Three of four applicable youth had a Tier I TB screening completed within seventy-two hours;
one was seven days late. None required further evaluation. The nurse in an interview said the
CPA is completed within seven days of admission by the DHA. A new CPA is needed every two
years for Medical Grade one and yearly for Medical Grade two and higher. TB screenings are
completed within seventy-two hours of admission if one is not documented in the youth's IHCR
within the past year. The youth are given a TST one time a year and results are documented on
the CPA, ICD, and the TB tracking log. The nurse states the center does not conduct
gynecological exams.
4.10 Sexually Transmitted Infection Screening/HIV Screening
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated each youth’s Sexually Transmitted
Infectious Disease form (STID) is reviewed by the designated health authority (DHA) and if
testing is ordered, with the youth's consent, a urine sample is requested from the youth and sent
to the lab for testing. If the screening indicates a need for further evaluation, the DHA or
advanced practice registered nurse (APRN) shall provide orders for specific testing, which is
completed within seven days. The orders are noted, followed up on, and documented. All
sexually transmitted infection screenings, evaluations, referrals, and testing are documented on
the STID form, as well as in a progress note which is in the youth’s Individual Healthcare
Record (IHCR). If a youth is out of the center’s/Department’s custody for more than thirty days
and/or symptoms are present, the nurse reviews and completes the STID form with the youth.
The form is then reviewed by the DHA and if testing is ordered, with youth's consent, a urine
sample is sent to the lab. Youth are required to read and sign a Human Immunodeficiency Virus
(HIV) form to indicate whether they consent or not to being tested for HIV. If the youth consents,
they are added to the HIV testing log. Currently the APRN is performing the testing and
documentation. Documentation of pre/post-test counseling is documented on the Individual
Health Education Record. In addition, a log is kept of youth requesting to be tested. HIV results
are given verbally to the youth. The DHA meets with youth individually, does HIV pre-counseling
and testing, then the youth is later brought back to go over results and post-counseling.
Documentation of pre/post-test counseling is documented in the youth’s Individual Health
Education Record.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
In all seven Individual Healthcare Records (IHCR) each youth was sexually active and was
clinically screened and evaluated for sexually transmitted infections (STI). All seven youth
required further evaluation and the designated health authority (DHA)/advanced practice
registered nurse (APRN) reviewed the screening tool and referred the youth, which was
documented on the STI form. All seven had testing ordered; however, three had not provided a
sample to be tested as of the annual compliance review week. In the remaining four the testing,
screening results, clinical evaluations, and diagnosis were documented on the Infectious
Communicable Disease (ICD) form and filed in the lab section of each IHCR. None of the youth
required a gynecological exam. One of the seven youth was out of the Department’s physical
custody and a re-screen was conducted. All seven IHCRs contained evidence each youth was
offered counseling, testing, and if indicated, treatment/referral for human immunodeficiency
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virus (HIV). None of the youth received HIV testing. Five of the seven consented to HIV testing
and were placed on the HIV provider list. The HIV provider comes once a month. The nurse
stated in an interview, nurses complete the STI screening form with the youth, the form is
reviewed by the DHA, and if testing is ordered and the youth consents a urine sample is
requested. If further evaluation is needed the DHA/APRN reviews the screening tool and
provides a specific order for testing within seven days. The orders are noted, followed, and
documented. The STI screenings, evaluations, referrals, and tests are documented on the ICD
form, as well as in a progress note. If a youth had been out of the Department’s physical
custody for more than thirty days and/or symptoms present the nurse will complete the same
process as a newly admitted youth. Youth are required to read and sign an HIV form to indicate
whether they consent or deny HIV testing. If youth consent, they are added to the HIV testing
log. The health department is providing HIV pre-counseling, testing, and post-counseling.
Documentation of pre/post-test counseling is documented on the Health Education Record. HIV
test results are given verbally to the youth and are documented on the ICD form. All seven
interviewed youth stated they could ask to be HIV tested.
4.11 Sick Call Process
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated the center’s designated health
authority (DHA) approved all treatment protocols. Youth who are in restricted
housing/confinement are assessed and evaluated for medical complaints or distress every
twenty-four hours which is documented in an episodic note. Any distress noted, when medical is
not on-site, direct care staff will contact the DHA. The center’s sick call hours are daily from 8:00
a.m. to 10:00 a.m. and as needed. Youth presenting with similar sick call complaints three or
more times within a two-week period are referred to the DHA or advanced practice registered
nurse (APRN). Youth notify direct care staff of a medical complaint, at which time staff enter a
sick call. Medical staff pull sick call twice a day. Medical staff have twenty-four hours to see the
youth; however, youth are often seen sooner. Youth are assessed and treatment, education,
and follow-up plans are completed. A licensed practical nurse (LPN) or registered nurse (RN)
complete all the sick calls. When a LPN completes sick call, the RN reviews the sick call within
twenty-four hours. The DHA conducts sick call when on-site. All sick calls are conducted in
medical. Nine youth were interviewed and three stated youth are seen within one day of
submitting a sick call, three stated within two days, and three stated more than three days. Eight
staff stated the nurse conducts sick call, while one stated the doctor conducts sick call. Nine
staff were interviewed and eight stated the nurse reviews sick calls and one stated the doctor
reviews sick calls. All nine stated the nurse conducts sick call.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOP) addressing when there is not a licensed
nurse on-site the shift supervisor reviews all sick call requests as soon as possible and within
four hours after the request is submitted. The FOP also addresses room restriction/confinement.
A review of seven Individual Healthcare Records (IHCR) indicated none were applicable for sick
call events. A sample of three more IHCRs was requested. The three applicable youth sick calls
were documented on the Sick Call Referral Log. None of the youth presented with similar sick
call complaints three or more times within a two-week period or had complaints of severe pain
with which staff were unfamiliar. All three youth and a nurse completed a Sick Call Request
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form. None of the sick calls were conducted by a licensed practical nurse (LPN) and none of the
youth had been in restricted housing. The Sick Call Request forms were filed in each youth’s
IHCR in reverse chronological order and were documented in accordance with the Department’s
Health Services Rule. All sick calls were documented on the Sick Call Index and corresponded
with the dates of the completed Sick Call forms located in each IHCR. A review of the daily
schedule, posted schedule, and nurse interview indicated sick call is conducted daily at least
once, as required. Sick call is conducted by a licensed nurse in the clinic in the morning daily
and as needed, and the hours were posted on the clinic door. The center has approved
treatment protocols for both registered nurse (RN) and LPN level staff. The center had youth in
room confinement, which were seen daily under episodic care events. A sick call event was
observed during the annual compliance review week. The youth was escorted to the clinic by a
juvenile justice detention officer (JJDO), with no other youth present. The JJDO was standing at
the door of the clinic being able to maintain visual observation but allowing privacy. The nurse
identified herself and asked the youth what the sick call complaint was, asked further questions,
checked vitals, and performed an exam while the youth was sitting on an exam table.
The nurse interview indicated the youth notify the JJDO of any medical complaints and the
JJDO enters the sick call in the system. The nurses review the sick call complaints twice a day
and a RN or LPN have twenty-four hours to see the youth in the clinic, but usually see them
earlier. The youth is assessed, vital signs, treatment, education, and a follow up plan is
completed. If an LPN conducts sick call the RN reviews the form within twenty-four hours. In
case the RN does not return within twenty-four hours the LPN will call the designated health
authority (DHA) to discuss the sick call. If the DHA is on-site will conduct the sick call. Youth
presenting with similar sick call complaints three or more times within a two-week period are
referred to the DHA/advanced practice registered nurse (APRN) and the youth is added to the
DHA list. The nurses stated they have DHA approved treatment protocols. The interview with
the nurse indicated youth in confinement are assessed for medical complaints or distress every
twenty-four hours and it is documented in an episodic note. If a JJDO notes any youth in
distress when medical is not on site, the JJDO must contact the DHA. Seven youth were
interviewed. Two of the seven stated when making a sick call request they are seen
immediately, one said within one day, two stated within three days, and the remaining two said
they had never asked for a sick call. Five of the seven indicated the nurse conducts sick call and
the remaining two stated they had never had a sick call complaint. Seven staff were interviewed
and three stated the nurse reviews sick call and one said the supervisor on night shift does. Five
stated master control reviews the sick call, master control lets the nurse know, the youth is
taken to the nurse, and staff enter the sick call into the system. All seven stated a nurse
conducts sick call.
4.12 Episodic/First-Aid Care
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center maintains first-aid kits and ensures all are fully stocked with designated health authority
(DHA) approved items. The registered nurse conducts monthly checks of each first-aid kit. All
items are checked and if expired, are replaced. Reviewed documentation confirmed kits were
monitored by a registered nurse monthly since the last annual compliance review. The first-aid
kits are located in medical, master control, the youth modules, the center’s kitchen, breakroom,
intake, and one in each classroom. There are seven first-aid kits for the center’s vehicles. A
review of three first-aid kits confirmed all contained the DHA-approved items. One first-aid kit
was located in a center van. The center has two automated external defibrillators (AEDs); one is
located in medical, and one is located in the sub-control between two youth modules. The AED
instructions are located with each AED. Nursing staff check each AED weekly and document on
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a weekly documentation checklist. The weekly checklist was reviewed and confirmed weekly
checks were completed since the last annual compliance review. An outside agency inspected
the AEDs on November 10, 2023, confirming each were operational. Each AED was checked
during the week of the annual compliance review confirming both were operational. The
batteries and pads, for each AED, were installed February 11, 2023. The pads for each expire
March 28, 2025. A review of the center’s documentation of required emergency drills was
conducted. The center held twenty-eight emergency drills during the annual compliance review
period, once a month on each shift. One of twenty-eight reviewed emergency drills was missing
a required element in the narrative and supervisor review documentation; the remaining twenty-
seven documented drills had all required staff response elements within the narrative or was
mentioned within the supervisor’s review of the drill. The center conducted announced and
unannounced emergency drills to simulate an episodic care event which included first-aid and/or
administration of cardiopulmonary resuscitation (CPR) techniques and the initiation of
emergency procedures for a life-threatening event. A list of emergency numbers is posted and
accessible to staff and not accessible to youth. Authorized direct care staff were trained on the
administration of the epinephrine auto-injector by the registered nurse on February 23, 2024.
Nine pre-service and nine in-service staff training records were reviewed. All eighteen staff
completed the training requirements regarding episodic, first-aid, and emergency care. The
center has a policy detailing the process of the use of Narcan. The center maintains Narcan in
medical in a locked medication cart, where juvenile justice detention officer supervisors, the
assistant superintendents, the superintendent, and nursing staff have access. Each staff who
has access was trained on the proper use of Narcan on February 23, 2023. The center’s
process for inventory for Narcan is the same as all other prescription medications. The center’s
nurse was interviewed and indicated the center maintains first-aid kits throughout the center and
for the center’s transport vehicles. Episodic care by licensed staff is documented in the
Department’s Electronic Medical Record (EMR) in an Episodic Care Progress Note and covers
all elements of a Subjective, Objective, Assessment and Plan (SOAP) note. Direct care staff
episodic care is documented on the Report of On-Site Care by Non-Healthcare Staff form.
Episodic care provided by direct care staff is followed up on by an evaluation by medical staff
when they return to the center. The center tracks youth who go off-site for emergency care, by
documenting it on the Off-site Care Log which is entered into the EMR. The nurse confirmed the
center had AEDs and medical staff tracks them weekly. Drills are completed monthly on each
shift, according to the nurse. Nine staff were interviewed and indicated they are able to call 9-1-
1 if they feel it is necessary. Nine youth were interviewed and three rated the medical care as
fair, five rated it good, and one rated it very good.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOP) addressing a process to ensure the contents
of first-aid kits are maintained and stored to prevent expiration or deterioration, as well as a FOP
addressing the access and use of Narcan. Four of the seven reviewed Individual Healthcare
Records (IHCR) had an indication each youth required on-site first-aid or episodic care. The
remaining three were not applicable. All four applicable youth received episodic care or first-aid
by a licensed healthcare staff documented in problem-oriented charting. None of the episodic
events were provided by non-healthcare staff, required referral to off-site care, or needed a
follow-up evaluation from a licensed healthcare staff. All episodic events were documented
including the nature of the complaint, the findings of the person rendering care, treatment
rendered, and each was entered on the Episodic Care Log. Two of the four required, completed,
and documented education/instruction for both youth. Two had plans for follow-up/future care,
and one required parental notification, which were noted. None of the youth required placement
on the alert list. The center had sixteen first-aid kits, seven were maintained in master control
area for youth transportation, one each in master control, kitchen, clinic, intake/transportation,
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classroom A, teacher’s lounge, and in the three modules. A review of three first-aid kits found
they were fully stocked with designated health authority (DHA) approved contents. A review of
first-aid kit documentation for the annual compliance review period indicated the kits were
inventoried monthly as required. The center has two automated external defibrillators (AED),
one in the clinic and one in the sub control room between modules B1 and B2. The AED
procedures are maintained with each AED. The nurses check to ensure the AED batteries and
pads are operable. A review of the AED checks indicated they were conducted monthly for the
annual compliance review period. Observations of the AEDs indicated they both were in working
order during the annual compliance review week, and both of the AED batteries and pads expire
on January 28, 2027. The batteries were changed last on July 27, 2023, and the pads on March
20, 2025. A review of the emergency medical drills, the center maintained for the annual
compliance review period, found they included cardio-pulmonary resuscitation (CPR)/AED
demonstration practiced annually, and they simulated an episodic care event which called for
immediate first-aid and/or administration of CPR techniques and the initiation of the emergency
procedures to follow when a life-threatening emergency does occur. The announced or
unannounced emergency medical drills were conducted at least quarterly on each shift. The
center ensures staff with direct contact with youth on a day-to-day basis have the opportunity to
participate in at least one emergency “man-down” drill annually. The center maintains a list of
emergency numbers posted and accessible for non-licensed and licensed staff and inaccessible
to youth in the clinic. A review of training documentation found all authorized direct care staff are
appropriately trained on the administration of the epinephrine auto-injector by a registered nurse
or higher. A review of seven pre- and seven in-service training records indicated all fourteen
staff met the training requirement regarding episodic, first-aid, and emergency care. The center
maintains four doses of Narcan in the locked medication cart in the clinic and the nurses
conduct perpetual and weekly inventories. The nurses and center supervisory staff have access
and were training on when and how to use the Narcan. The nurse in an interview verified the
location of the first-aid kits and the AEDs, as well as adding the AED procedures which is
located in a binder in the clinic. The nurse stated episodic care by a licensed medical staff is
maintained in the IHCR in an episodic care progress note and covers all elements of a
subjective, objective, assessment, and plan (SOAP) note. If a non-licensed staff conducts
episodic care, it is documented on the Report of On-Site Healthcare by Non-Healthcare Staff
and a nurse will complete a follow up evaluation. Youth who are sent off-site for emergency care
are tracked on the Offsite Care Log. Emergency medical drills are conducted monthly on each
shift. All seven staff interviews noted they can call 9-1-1 if they feel the need. Seven youth were
interviewed. Two rated the medical care at the center poor, two good, two very good, and one
had not received medical services.
4.13 Off-Site Care/Referrals
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated youth who are sent off-site for first-aid or
emergency care is logged in the Department’s Electronic Medical Record. Medical staff review
all hospital orders with the designated health authority (DHA). The DHA then gives orders to
follow in the center. The DHA reviews all findings, instructions, and follow-up information from
off-site care next time they are on-site. All follow-up, referrals, and appointments are notated on
the calendar and sent to medical staff through email. The Summary of Off-Site Care form is
utilized to track follow-up as well.
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During the re-review the center received a Satisfactory Compliance rating for this indicator.
One of the seven youth required off-site care. Two more examples were requested. In the three
applicable Individual Healthcare Records (IHCR) there was an indication each youth required
off-site care. All three IHCRs contained the Summary of Off-Site Care Consultation Report form
which was utilized for each off-site care event. In two of the three the off-site emergency care
was documented on the Episodic Care Log; the remaining emergency care was not. Two of the
three youth required and had parental notification efforts documented; the one remaining youth
was not required due to being eighteen years of age. All three had the discharge and other
applicable documents filed in each IHCR. Two were applicable and had documentation the
designated health authority (DHA) was notified of the emergency event. In all three IHCRs the
DHA/designee reviewed and signed/initialed all off-site care findings, instructions, and
information. One of the three youth required a follow-up appointment; however, due to being
released prior to the appointment the information was provided to the parent/guardian. The
nurse interview indicated the off-site care log in the Electronic Medical Record (EMR) is used to
track youth who are sent off-site for first aid or emergency care needs. The nurse stated the
hospital orders are reviewed with the DHA and the DHA will provide orders to follow for the
center. The off-site care findings/instructions/information is placed in a folder which is reviewed
by the DHA when on-site. The nurses track follow-up testing, referrals, and appointment with a
calendar and sending an email to communicate with the center staff. The Summary of Off-Site
Care form is utilized if youth is sent off-site and follow-up testing, referrals, or additional
appointments are requested by the provider.
4.14 Chronic Conditions/Periodic Evaluations
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated alerts are entered into the Department’s Juvenile
Justice Information System (JJIS) and the designated health authority (DHA) sees each youth
who has a chronic condition. The DHA was interviewed and stated youth with chronic conditions
are seen every three months, although often they are seen more frequently if warranted or
necessary. The nursing manager tracks periodic evaluations based on the recommendation at
the time of the medical evaluation following intake.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
A review of seven Individual Healthcare Records (IHCR) found three youth had chronic
conditions; however, none of the three had been at the center long enough to receive periodic
evaluations. Three more examples were requested. All six youth were identified on the
Medical/Mental Health Screening form with a current chronic condition. None of the youth had a
communicable disease, were identified as pregnant, required anti-tuberculosis medication,
required a periodic evaluation prior to renewing a prescription medication which expired, or
needed an off-site periodic evaluation. Two of the six were taking prescribed medication on an
on-going basis, and three were undergoing treatment for a physical health condition. All six
were identified with a chronic health condition and were placed on the chronic conditions list.
Two of the youth were classified with Medical Grade two to four and the remaining four with
Medical Grade five. A review of the progress notes indicated three of the six youth were
applicable and received a periodic evaluation at least every ninety days. All six youth had the
Department’s Problem List updated in accordance with the Health Services Rule.
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The nurse in an interview stated when a youth with chronic conditions is admitted the alerts are
entered, the designated health authority (DHA) is notified and the youth is seen, as well as the
youth is noted on the chronic condition binder/medical tracker log. The DHA in an interview
stated chronic conditions are usually evaluated every ninety days, with periodic evaluations
taking place quarterly or more often if needed. The nursing staff keep track of the periodic
evaluations.
4.15 Medication Management
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and indicated when youth arrive with medication upon
admittance a medication receipt is filled out and the nurse reviews the medication to ensure it is
from a licensed pharmacy, with a current, patient-specific label intact on the original medication
container in order to accept it. Medications shall have a current, valid order and are given as
ordered on current prescription or Practitioner Order form. The designated health authority
(DHA) or psychiatrist are contacted to obtain all orders to resume the specified medication each
youth is prescribed prior to admission. Supervisors are trained by the registered nurse to
administer medications and the staff approved list is located in the front of the medication book
in medical. The nurse stated medication pass is at 8:00 a.m., 5:00 p.m., and 7:00 p.m. daily.
Gynecological exams are not routinely completed, only if medical attention is needed. Youth
medications are procured; ten percent through a community pharmacy and ninety percent
through a vendor. The center utilizes a psychiatrist, who is on-site to provide individual therapy
and medication management. Nine staff were interviewed and two stated they administer
medication to youth and seven stated they did not. Nine youth were interviewed and five stated
the nurse provides their medication and four stated they do not take medication.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
A review of seven Individual Healthcare Records (IHCR) indicated four were applicable for
medication management, the remaining three were not. In two of the four applicable IHCRs
each youth was taking medication at admission, which was verified prior to youth being admitted
into the center and the Department’s Medication Receipt Transfer Disposition form was utilized.
The prescription verification was included in each IHCR/Electronic Medical Record (EMR) and
the designated health authority (DHA)/designee, and when applicable, the psychiatrist was
contacted to obtain an order to resume the specified medications prescribed prior to admission.
In all four IHCRs all medications had a current, valid order and were administered pursuant to a
current prescription, and if current medications were continued, discontinued, changed, or new
ones were ordered the DHA/designee/advanced practice registered nurse (APRN) placed an
order on the Practitioner Order Form. One of the four youth was in restricted housing and
documentation indicated the nurses completed daily visits and other required services. The
youth did not have any prescribed medications which needed to be administered. None of the
youth had over-the-counter (OTC) medications not listed on the Authority for Evaluation and
Treatment (AET) form administered. None of the youth were prescribed parenteral medication,
all medication was administered by a nurse, and there were no undocumented lapses or errors
in medication administration. One youth refused medications/treatment and the refusals were
clearly documented on the Medication Administration Records (MAR) and the youth signed the
Refusal of Treatment Form indicating the refusal. All four IHCRs contained the standard
Department MAR/EMR, which documented all medication and treatment, including clearly
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indicating start and stop dates. The nurses documented side effect monitoring weekly on each
MAR. Each MAR contained all required elements, including the nurse and youth initialing each
medication administration. Two of the youth were prescribed psychotropic medication and the
DHA or psychiatrist/psychiatric APRN were notified upon admission. One of the two youth who
entered the center on psychotropic medications received an initial diagnostic psychiatric
interview within fourteen days of admission. The remaining one youth did not receive a
psychiatric interview. The staff indicated the youth was in a mental health crisis at the time the
interview was to be conducted. One of the two youth was applicable and received medication
monitoring/review every thirty days as required. The remaining youth had not been at the center
long enough to require a thirty-day medication review. The center did not have any standing
orders, emergency treatment orders, or Pro Re Nata (PRN) orders for psychotropic
medications. Observation of medication administration was conducted during the annual
compliance review week. The nurse conducted the medication delivery which was her sole
responsibility during the time of administration. The youth was escorted individually to the clinic
by a juvenile justice detention officer (JJDO) allowing for privacy. The nurse identified herself
and stated the reason for the youth’s medication administration, as well as allergy and alert
status. The nurse removed the topical medication from the medication cart, placed it in a small
cup, and provided it to the youth, who applied the cream to the skin. The nurse and youth
initialed the MAR. No OTC medication was administered. The nurse interview indicated if a
youth arrives with medication a medication receipt is filled out, and the medication is reviewed
by the nurse to ensure it has a current, patient-specific label intact in the original medication
container from a licensed pharmacy. All medications have a current, valid order, and are given
as ordered on a current prescription or practitioner order. The DHA or psychiatrist are contacted
to obtain the order to resume the specified medications. The nurse verified the center utilizes
the Department MAR. The nurse stated supervisors are trained and can provide medication. A
list of approved staff is in the medication binder. The center conducts medication pass as
required at 8:00 a.m., 12:00 p.m., 5:00 p.m. and 8:00 p.m. The nurse stated they do not perform
routine gynecological exams. The nurse confirmed the center has a modified Class II permit,
and the majority of medications are procured through a vendor and a handful through a
community pharmacy as a backup. The nurse indicated the center has a psychiatrist who is on-
site once a week to see youth for thirty-day medication management and is on-call twenty-four
hours seven days a week for medication management, follow ups, and emergencies. Six of the
seven staff indicated in an interview they do not provide medications to youth, the remaining
one stated yes. Five of the seven interviewed youth stated they do not take medications. Two
stated a nurse provided medication and three also stated the staff will usually on the weekends
or when a nurse is not on-site.
4.16 Medication/Sharps Inventory and Storage Process
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center utilizes a perpetual inventory, in descending count, for all sharps. During the annual
compliance review week an observation of all sharps confirmed all were secured in medical, in a
locked cabinet. All medications were in medical, in a locked medication cart, inaccessible to
youth. Medical was clean and organized, with all medications in the locked medication cart. All
youth medications were separated. All controlled medications were stored in a separate locked
box, in the locked medication cart, and each had a perpetual inventory with a shift-to-shift count
documented. All injectable and topical medications are kept separate from oral medications.
The center has a refrigerator in medical, which is only used for medications. The controlled
medication inventories confirmed medical staff use each youth's Controlled Medication
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Inventory Record to document a shift-to-shift count of the medications. All non-healthcare staff
who provide medication to youth were trained in the delivery and oversight of medication self-
administration on February 23, 2024. The training was provided by the center’s registered
nurse. During the week of the annual compliance review, the inventory for three controlled
medications, three over-the-counter medications, and three sharps were reviewed, and all
counts matched the ending inventory. The nurse stated in the event there is a discrepancy in
medication inventories, nursing staff review all Medication Administration Records (MARs) and
inquire with each nurse. This process, often times resolves the discrepancy; however, if not, the
regional manager is contacted and depending on the medication the process moving forward
will be decided. Controlled substances are disposed of through the pharmacist who goes on-site
to the center. All medications are destroyed in the same fashion, with both nursing staff and the
pharmacist disposing of them with the liquid chemical destroyer. The center’s nurse was
interviewed and stated medication inventories are completed weekly and/or perpetually,
depending on the medication. Controlled medications are locked in a compartment in a locked
medication cart. The nurse stated the center has a contract with a local pharmacist who is on-
site monthly and reviews the medication cart, medication cabinets, medication refrigerator,
destroys medications, ensures everything is labeled appropriately, and reviews MARs and
sharps. The pharmacist also ensures licenses are up-to-date. The center maintains a copy of
the pharmacist license on-site.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOP) addressing the reporting criteria and
procedures regarding inventory discrepancies and the disposal and destruction of expired
and/or discontinued medications. Observation of the clinic indicated all sharps and stock over-
the-counter (OTC) medications are maintained in locked storage cabinets in the clinic
inaccessible to youth. A review of sharps and OTC inventories for the annual compliance review
period found they were conducted perpetually and weekly as required. The center did not have
any controlled substance on-site at the time of the annual compliance review week. The nurses
have a locked box in the locked medication cart, which is assigned to store controlled
medications. The clinic also has a medication only refrigerator which was observed to only
house medications. The medication cart was observed locked, clean, and organized with youth-
specific and injectable, topicals, drops, and liquids maintained separately. A review of training in
the delivery and oversight of medication self-administration was conducted and found thirty staff
were trained by a registered nurse (RN) or higher. Observation of a nurse completing three OTC
and three sharp counts found the final count on the inventory matched the actual count
observed. The nurse was interviewed and stated the center has an agreement with a consultant
pharmacist who visits monthly to review the medication cart, the medication cabinets, the
medication refrigerator, destroys medications, ensures everything is labeled appropriately,
reviews the MARs, and the sharps, as well as ensures licenses are up to date. Medications are
disposed between nurses and the pharmacy consultant. The nurse verified controlled
substances are locked in a locked compartment in the medication cart and all other stock
medications are locked in cabinets. Inventories for all stock and OTC medications are
conducted weekly.
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4.17 Infection Control/Exposure Control/Education
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center maintains an exposure control plan in accordance with Occupational Safety and Health
Administration (OSHA) standards. The exposure control plan includes all required elements. It
includes prevention, containment, treatment, and reporting requirements related to infectious
diseases, according to OSHA and the Centers for Disease Control and Prevention (CDC)
guidelines. The center has a process for needle stick post-exposure evaluations. Staff are
provided with a Hepatitis B Vaccination Program form to accept or deny the vaccine. All staff
have access to personal protective equipment. The center had no instances in which infectious
diseases and sexually transmitted infections (STIs) were reported to the local health
department, any instances in which incidents reported to the local health department were
reported to the Department’s Central Communications Center (CCC), any instances where
there were three or more cases of any reportable infectious diseases which needed to be
reported to the local health department and/or CDC, or any instances involving the quarantining
or hospitalization of at least ten percent of the total population of youth or staff. Nine pre-service
and nine in-service staff training records were reviewed, which confirmed biomedical
waste/exposure control plan training was completed on February 23, 2024 by the center’s
registered nurse. The center’s nurse was interviewed and stated the center’s exposure control
plan is available to staff and is located in the exposure control plan policy binder. The nurse
stated the center’s nurse manager provides infection control training for all staff and for youth
upon admission. The center routinely uses the county health department for youth
immunizations, Human Immunodeficiency Virus treatment, dental care, and prenatal care.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
A review of seven Individual Healthcare Records (IHCR) found all seven youth received
infection control training on the day of admission. The seven youth also had training in hand-
washing techniques, universal/standard precautions, prevention/transmission of communicable
diseases, vaccinations, and Center for Disease Control and Prevention (CDC) guidelines for
infection control. The center’s exposure control plan was written in accordance with
Occupational Safety and Health Administration (OSHA) conditions including all requirement for
risk assessment and methods of compliance. The center had infection control procedures in
place including prevention, containment, treatment, and reporting requirements related to
infectious diseases, according to OSHA and the CDC guidelines. The procedures included
common, infectious diseases of childhood, self-limiting, episodic contagious illnesses, viral or
bacterial infectious diseases, tuberculosis, Hepatitis A, B, C and human immunodeficiency virus
(HIV) infectious diseases caused by bloodborne pathogens, other outbreaks or epidemics
caused by any other infectious agent, whether spread directly or indirectly, outbreaks of
pediculosis and/or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other
antibiotic-resistant micro-organisms, food-borne illnesses, bio-terrorist agents, and chemical
exposures in the workplace. The center has a process for needle stick post-exposure
evaluation, and makes Hepatitis B immunization available for staff, as well as providing access
to protective equipment. The center did not have any instances in which infectious diseases and
sexually transmitted infections (STIs) had to be reported to the local health department, CDC,
the Department’s Central Communications Center (CCC) or involved the quarantining or
hospitalization of at least ten percent of the total population of youth or staff. A review of seven
pre and seven in-service staff training records found all were trained on the center’s specific
Exposure Control Plan. The nurse stated in an interview a copy of the Exposure Control Plan is
available to the nurses and is included in the facility operating procedures (FOP). A registered
nurse (RN) conducts infection control training for staff, and youth receive the training during
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admission. A RN also provides training to staff on the center’s Exposure Control Plan. The
nurse stated HIV testing and dental care services are routinely used through the county health
department.
4.18 Prenatal Care/Education
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and stated pregnant youth who are admitted to
the center are placed on a pregnancy diet, monitored monthly or as needed, provided health
education on pregnancy, provided prenatal vitamins, and any pregnancy-related orders are
provided by the designated health authority (DHA). All female youth are tested for pregnancy
upon admission if they verbally consent, at which time the DHA orders the testing. The nurse
manager provides non-licensed healthcare staff education on girls’ healthcare. Nine youth were
interviewed and all stated they needed no prenatal, obstetrical, or gynecological services while
at the center.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
A review of seven Individual Healthcare Records (IHCR) found none of the youth were
applicable for prenatal care. Three examples were requested. The center had only two youth
applicable for the annual compliance review period. The two applicable youth received prenatal
care immediately upon determination each was pregnant and continued until discharge/transfer.
Neither of the youth was at the center long enough to receive routine, focused medical
evaluations every thirty days. Both youth were placed on the internal alert system for vital
nutrition and health awareness for staff, and an alert was entered into the center’s internal alert
system regarding each youth’s sleeping arrangements. Neither youth complained of issues
related to pregnancy and there was no post-birth psychological and physical care plan
developed; both youth were at the center for only two and twelve days respectively. In the two
IHCRs daily monitoring for danger signs of pregnancy complications were documented. Both of
the IHCRs contained education provided to each youth, including alcohol and drug use,
smoking, nutrition, sexually transmitted diseases, contraception, prenatal care, birthing process,
postpartum care, basic baby care, child/infant development, and parenting skills. The education
was documented in each IHCR in the Health Education Record. The two applicable youth were
provided with nutritious food in quantities appropriate for a pregnant youth, and each received
routine monitoring by a nurse, including nutritional and weight status. Review of staff training
indicated a licensed nurse provided in-service education on youth’s prenatal healthcare annually
to all non-healthcare staff involved in the supervision or treatment of youth, which included
observation and monitoring of emergency care needs/symptoms of possible miscarriage. The
center has nursing protocols and treatment plans for pregnant youth. A review of seven in-
service training records found five had half an hour of in-service training in detention services
women health. The nurse interview indicated the center provides prenatal care to youth once
they know a youth is pregnant, an obstetrician appointment is scheduled, the youth is started on
a pregnancy diet, and is educated regarding prenatal care. The designated health authority
(DHA) assesses the youth monthly or as needed. Every female youth is routinely tested upon
admission only if verbal consent is received. Each pregnant female youth is given a handout,
and the nurses review shaken baby syndrome, difference of breastfeeding and bottle feeding,
what to expect with body changes, dietary needs, sudden infant death syndrome, post-partum,
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and more. All seven interviewed youth stated they did not require prenatal, obstetrical, or
gynecological services while at the center.
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) regarding active supervision of youth. During
the annual compliance review week, observations confirmed youth were actively supervised
during all daily activities such as school, recreation, medication pass, admission process,
transportation, mental health sessions, precautionary observation, and meals. Observations
confirmed positive interactions between staff and youth, youth were in sight of at least one
juvenile justice detention officer and accounted for at all times. All movement was reported to
and approved by the master control operator.
A random review of the center’s logbooks for the annual compliance review period found youth
counts were being consistently conducted. The center keeps track of the daily census through
counts being conducted randomly throughout the day, census being tracked in shift meetings,
module logbooks, master control logbook, the Department's Juvenile Justice Information
System (JJIS), and on a white board in master control.
Six of nine interviewed staff indicated they felt there was not enough staff to provide for the
proper and safe supervision of youth; however, the remaining three staff stated there was
adequate staffing.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) to ensure youth are actively
supervised by staff. During the annual compliance review week, youth supervision was
observed each day. Center staff were adhering to the daily activity schedule. On Tuesday
observations were made during the tour of the center. Thirteen youth were observed in
classroom one, with two staff and one teacher. The teacher was facilitating class. Living module
G1 had eight youth and one staff, with youth on a restroom brake from class. Living module B3
had fourteen youth and two staff, with youth on a restroom break. A line movement of eight
youth and two staff was observed leaving classroom two for a restroom break, the teacher was
in the classroom. One youth and two staff were observed in intake for an admission.
Classrooms three and four were observed, youth were on a restroom break, and each
classroom had a teacher present. On Wednesday an observation of the maintenance shed was
made and there were no youth present. Youth were observed on living module B1 with thirteen
youth and two staff, living module B2 had twenty-four youth and three staff, living module B3
had twenty-one youth and three staff and living module G1 had eight youth and one staff. One
youth with one staff was observed in medical. Visitation was observed with eleven family
members attending. Each family member turned in their personal keys to master control, signed
in on the visitation log and staff verified they were approved to attend visitation. Two additional
family members arrived and were verified by the inhouse juvenile probation officer and added to
the visitation list of the youth. Each of the thirteen family members were frisked searched and
removed their shoes. No bags were allowed in the center for visitation; family members were
told they could store their bags in a locker or return them to their car prior to being searched. An
ecteronic search of each visitor was conducted prior to entering the secure area. Family
members were escorted to the visitation room with two staff. On Thursday observations of living
module G1 found nine youth and two staff in the dining hall. Unit B2 had twenty-five youth and
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four staff at outdoor recreation. Staff were positioned around the recreation filed as required
providing supervision. An observation of one youth transport returning from court was
completed. There were two staff present, one the same sex as the youth. The youth was
observed to have a seatbelt on upon returning. The youth was frisked searched and escorted to
intake. The van was searched by staff. On Friday, the youth were observed to be in the
classrooms participating in class. Classroom one had thirteen youth, two staff with one teacher,
classroom two had twenty-four youth, three staff with one teacher, classroom three had twenty-
one youth, two staff with one teacher, and classroom four had eight youth, one staff, and one
teacher. All teachers were actively facilitating class and youth were engaging. Three full days of
group video was observed. On May 21, 2025, Impulse Control group was facilitated from 4:35
p.m. to 4:55 p.m. by the Licensed Mental Health Counselor (LMHC) and seven youth and one
staff were present. On May 28, 2025, Cognitive Distortions (CBT) was facilitated from 9:00 a.m.
to 9:15 a.m. by a Licensed Marriage and Family Therapist (LMFT) and six youth and one staff
were present. On June 4, 2025, Anger Management group was facilitated from 2:41 p.m. to 3:30
p.m. by the LMHC with eight youth and one staff present. Staff maintained continuous sight
supervision of all youth in their assigned area. Staff were observed supervising youth by
controlling line movements, positioning themselves appropriately, and giving clear directions to
youth. The center staff were interacting appropriately with youth. All movements were
authorized by master control prior to each youth being moved. A review of the center’s logbooks
during the annual compliance review period confirmed all movements were logged and counts
were conducted consistently. Tracking daily census is completed by conducting head counts
throughout the shift and documenting in the logbook. Seven staff were interviewed, and one
staff stated there were enough staff to provide adequate supervision. Six staff stated there is not
enough staff to provide adequate supervision. Additional comments were provided by four of the
seven staff where two stated more staff were needed, one if everyone would come in as
scheduled the need would be less, and one staff stated they are always short staffed.
5.02 Behavior Management System/Unauthorized Use of Punishment (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) in place providing a system of rewards and
privileges for positive behavior, and consequences for inappropriate behavior to encourage
youth to meet the center’s expectations utilizing a behavior management system (BMS).
Observations during the annual compliance review week indicated the center has postings of
the BMS in all modules clearly specifying appropriate and inappropriate behaviors, rules, norms,
and expectations. A review of point cards confirmed positive rewards and consequences are
given in accordance with the BMS and there were no instances of inappropriate use of
restrictions or group punishment. An interview with the superintendent confirmed the center
follows the BMS as detailed in the FOPs.
Two of nine interviewed youth rated the center’s BMS as very poor, two rated it as poor, four
rated it as fair, and one youth stated it was good. Eight of the nine youth were able to explain
the difference in levels and the types of rewards provided. The remaining one youth was unable
to explain the BMS because they stated it was never explained to them. All youth reported they
receive rewards for good behavior; however, the rewards are not consistently provided. Each
youth reported youth are not allowed to punish other youth in the center. Eight of nine youth
reported they have been sent to their room for punishment, and one youth stated they have not.
Seven of the eight youth reported when they were sent to their room the door was shut and
locked for the purpose of confinement. Five youth reported the consequences they received
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were fair, one stated they were not fair and the remaining three said they never received
consequences. All youth stated they lost points and levels as a form of punishment, and none
had ever witnessed youth being handcuffed or having leg irons when being out-of-control.
All nine interviewed staff explained the center’s BMS to include a point system, where the BMS
is located throughout the center, and all confirmed it is included in the youth handbook and
youth orientation. Each staff provided the types of rewards such as snacks, dinners, movie
nights, and haircuts. Seven staff reported things cannot be taken away from youth as a
punishment and the remaining two indicated things can be taken. All staff reported points and
levels can be taken away for punishment and all confirmed they have never seen a coworker
take meals, snacks, clothing, education, or medical care from a youth for acting out. Eight staff
reported the BMS is effective, and one said it needs improvement. All nine staff reported
speaking with youth to discuss consequences being imposed and allowing youth an opportunity
to explain their behavior. Each staff reported supervisors speak with them regarding how to
implement the BMS and areas of improvement, as well as receiving daily feedback, when
needed. All staff reported they have never observed another staff encourage a youth to beat up
another youth.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures requiring a uniform behavior management
system (BMS), which offers a set of rewards, privileges, and consequences for behavior. The
center has a system of rewards, privileges, and consequences to motivate youth to meet and
exceed the center’s expectations, including rewards for positive behavior and consequences for
inappropriate behavior. During a tour of the center during the annual compliance review week,
postings of the BMS were noted in all living areas which clearly specified appropriate and
inappropriate behaviors, rules, norms, and expectations. Incentive calendars were also
observed on the mods and the point cards of youth confirmed points were given or decreased
based upon daily youth behavior. A review of the male and female youth level card binders was
conducted for the annual compliance review period and confirmed youth are receiving their
rewards and being held accountable for their actions daily. The center prohibits the use of group
punishment and there were no instances of inappropriate use of restrictions or group
punishment displayed during the annual compliance review period. Seven staff were
interviewed, and all seven stated they had knowledge of the BMS and were able to explain the
system. All seven staff indicated the center's BMS included a level system, five referenced a
point system, and two of the staff stated the BMS is posted throughout the center. Five staff
indicated snacks and extra telephone calls are provided as rewards to youth, three staff
indicated slushies are provided, and one stated a later bedtime is provided. Three of the seven
staff believe the center’s BMS is effective; however, the remaining four staff do not believe the
BMS is effective citing the BMS is more effective with the boys than the girls at the center. All
seven said the staff speak with youth to discuss the consequences being imposed, giving youth
an opportunity to explain their behavior, as well as staff speaking with youth about alternative
acceptable behaviors. Staff indicated feedback is provided from supervisors regarding the
implementation of the BMS during individual meetings and youth behavior is discussed during
briefings with staff who have had direct contact with youth to adjust points, if needed. Six of
seven staff indicated feedback is received as needed and two staff additionally responded daily
and weekly. Four staff stated levels can be taken away as a consequence, four staff indicated
points can be taken away as a consequence, and one staff indicated nothing can be taken away
from youth due to inappropriate behavior. None of the staff had ever witnessed another staff
take meals, snacks, clothing, education, or medical care from a youth because they were acting
out. Six staff had never observed a co-worker encouraging youth to beat up another youth. One
staff provided an incident which was determined to be a supervision issue, and the center
indicated professionalism will be addressed with all staff. Seven youth were interviewed with five
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youth rating the BMS system as good and two youth stated it was fair. All seven interviewed
youth had a general knowledge of how the BMS works. One of the seven youth indicated
receiving haircuts are part of the reward system, four indicated telephone calls, five stated
snacks/food incentives, three stated later bedtime, one mentioned playing cards, and two stated
not much or did not receive any rewards yet. All seven youth indicated the staff are fair in
handing out the rewards and three provided specific examples of rewards. All seven youth
confirmed youth are never allowed to punish other youth. Six of the seven youth said they had
not been sent to their room for punishment with the door locked, and the remaining youth stated
they had been sent to their room to calm down with the door shut, not locked. Four youth who
received consequences stated the consequences were fair, three youth have never received
consequences, and one youth indicated they felt the consequences they received were not fair.
Four of the seven youth stated levels have been taken away as a consequence and the
remaining three youth have never received consequences. All seven youth stated they never
witnessed handcuffs or restraints being used. The superintendent was interviewed and reported
Detention Services uses a three-level system which tracks youth behavior. All youth start on
level one upon admission. Youth can level up every seven days with appropriated behavior and
after seven days on level three, youth are considered a Peer Ambassador. Level drops should
be sequential unless the behavior is egregious or dangerous to the point it warrants a drop to
level one.
5.03 Ten Minute Checks (Critical)
The center originally received a Limited Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
has seventy-two cameras with a recording capacity of thirty days. All cameras were working
during the annual compliance review week. The center utilizes a wand system for ten-minute
checks, which can be retrieved from an online system. During the annual compliance review
week, the online system was not accessible to review ten-minute check documents.
Video observations of six different dates, for at least thirty minutes each, including a random
sampling of the three modules, indicated ten-minute checks were not conducted as required on
two days. One of the two days had forty-two minutes between checks and the other day had
thirty-two minutes between checks. Three days of confinement checks were reviewed. Two of
the days had two checks conducted late. One check was conducted twenty-two minutes late
and another was thirty-six minutes late. All other checks were conducted as required by staff
looking into each youth room to ensure youth safety and using the wand to record the date and
time of the check. A review of weekly management oversight reports for the annual compliance
review period indicated they were conducted as required.
All nine interviewed staff indicated room checks are conducted every ten minutes when a youth
is placed in their room for sleeping or non-punishment reasons.
The superintendent interview indicated staff will ensure ten-minute checks are conducted on the
modules and are encouraged to begin checks on an eight-minute mark. All staff shall utilize the
wand to conduct ten-minute checks.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) requiring ten-minute checks to be
conducted when youth are in their rooms. The center has sixty-four surveillance cameras, and
sixty-two were operational during the week of the annual compliance review. A work order has
been submitted for repairs to the camera system. The center has the capacity to store video
recordings for up to thirty days. An electronic wand system is used in the center to document
and collect data of the ten-minute visual checks. Staff tap an electronic wand on the check point
sensors on the outside of each youth’s assigned sleeping room door and the data is
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downloaded as wand reports. A review of nine samples of video over seven different days and
their corresponding wand reports, including samples from each living module, revealed staff
conducted ten-minute checks as required. Staff were observed during video observation from
nine samples of thirty-minute increments from the 7:00 p.m. shift to the 7:00 a.m. shift looking
into the windows of each sleeping room before tapping the wand to the check point sensor. The
center was operating with two shifts from 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. for
the entire annual compliance review period. Management staff documented their weekly
reviews as required. A deficiency for ten-minute checks was closed on January 28, 2025. Seven
staff were interviewed, and all seven staff stated room checks are conducted every ten-minutes
when placed in their room for sleeping or non-punishment reasons. The superintendent was
interviewed and stated when a youth is placed in a room, whether for sleeping or other reasons,
officers shall conduct visual observations to ensure safety and security. Checks are notated on
the visual observation report (VOR) or by utilizing the electronic wand system. Visual
observation intervals should be varied but shall not exceed ten-minutes between each check.
5.04 Census, Counts, and Tracking
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures stating staff must always know the exact number and
location of all youth under their supervision. A review of logbooks for one day a month for the
annual compliance review period indicated counts were conducted at the beginning and end of
each shift, prior to and following routine group movement, anytime a population change
occurred, randomly at least once each shift, and following any emergency. Head counts and
youth movements were also captured in the logbook. Observations during the annual
compliance review week confirmed counts were being conducted as required.
Nine interviewed staff reported counts are conducted at the beginning and end of each shift, as
well as before and after school and meals. Eight of nine staff stated emergency counts are
conducted when a youth is believed to be missing, when visibility is hindered such as during an
electrical outage, and after a major disturbance. The remaining one staff reported an emergency
count is conducted every time there is an alert code called, also when counts are not correct, all
activities are stopped, and a recount is completed.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures to ensure staff always know the exact number and
location of all youth under their supervision. During the annual compliance review week, staff
were observed conducting counts before and after every movement. Counts were also
observed being conducted when youth transitioned to and from the dining hall for meals and
recreation. A thirty-minute count was called into master control by staff on the recreation field as
well. All seven interviewed staff stated counts are conducted at the beginning of each shift. Six
of seven staff stated counts are conducted at the end of the shift. Two of seven staff stated
counts are conducted before and after school and two of seven staff stated counts are
conducted before and after meals. One staff stated they conduct counts when youth move door
to door, room to room and ask for an emergency count when the count is off. One staff stated
they take visual count of who they see and check logbook to see if a youth was removed from
the living module. One staff stated all movements are stopped if the count is off and a head
count is conducted again. One staff stated a count is conducted until the count is correct. One
staff stated they do random counts throughout the day. One staff stated they conduct counts at
every movement and randomly. The final staff stated they conduct count at all movements.
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Seven staff were asked when emergency counts are conducted. Three of seven staff stated
when a youth is believed to be missing an emergency count is conducted, four stated when
visibility is hindered four stated after a major incident. One stated an emergency count is
conducted when the count is off. One responded they have not experienced a count being off
and the final staff stated an emergency count is conducted when weather issues occur, or a
code is called. A review of youth census, counts, and tracking was reviewed in the logbooks
from June 2024 through April 2025. All reviewed months reflects youth census, counts, and
tracking were documented at the beginning of each shift, following any emergency such as
power outages, and evacuations due to emergency drills when applicable. All reviewed months
reflects youth census, counts, and tracking were also documented prior to and following routine
group movement, population changes, random head counts each shift and youth movements.
5.05 Logbook Maintenance
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) outlining the use of logbooks to maintain a
chronological record of events, incidents, and activities. The center has separate logbooks for
master control, each module, visitor sign-in, and vehicles. A review of logbooks for three days a
month for the annual compliance review period indicated logbooks were bound with numbered
pages, the date was documented at the top of the page, all entries included the times of the
events with the name of the staff and youth involved, a brief description of the events, and the
initials of the staff making the entries. All errors were struck through with a single line and “void”
written after the error followed by the staff’s initials. The center staff did not highlight all entries
impacting the safety and security of the center, nor did a juvenile justice detention officer (JJDO)
supervisor and/or lead officer record comments regarding the corrected errors. The logbooks
included JJDO supervisors reviewing the master control logbook when accepting responsibility
for the center, and reviewing the living area logbooks daily. The JJDOs reviewed the logbook
entries from the previous shift when accepting responsibility for the living area. The name and
position of the reviewer was documented, as well as the date and time each review was
completed. The center does not utilize an electronic logbook. One of the master control
logbooks was found to be falling apart and had a tattered spine. The review of the master
control logbooks confirmed they included emergency situations, incidents, population counts at
the beginning and end of each shift and throughout shifts as count changes, mental health and
medical alerts, group movements, admissions, 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/secure observation began and the time precautionary/secure observation was
discontinued, and youth counts following emergency situations. The logbook documentation did
not include all fire and escape drills.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOPs) for logbook maintenance. The center has
separate logbooks for master control, each living module, visitors, and vehicles. A review of
three full days from eight logbooks during the annual compliance re-review period was
conducted. The review found all except for two were bound with numbered pages. Two of the
eight logbook’s cover had fallen off. Three days each month in each living module logbook and
master control logbook were reviewed. The master control logbooks and living module logbooks
contained the date documented at the top of the page. All entries included the times of events in
a.m./p.m. and not military time with the name of staff, youth, brief description of events, and the
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initials of staff making the entries. All entries impacting the safety and security of the center,
including medical/special needs and mental health alerts were highlighted. The master control
logbook had errors which were struck through with a single line and “void” written after the error
followed by staff initials. The master control logbook contained emergency situations, incidents
including the use of protective action response/right interactions (PAR/RI), calls to the Florida
Abuse Hotline and the Department’s Central Communications Center (CCC), except for CCC
number 202403837 on August 1, 2024. All contingency of operations (COOP) drills, monthly fire
drills, monthly medical drills and monthly mental health suicide drills were documented as
required. There was documentation of the center receiving medications from parents/guardians
when dropped off at the center and medical and mental health alerts. Counts were documented
for the beginning of shifts, end of shifts, emergency situations, group movement, admission, and
releases, when law enforcement is on-site, searches to include frisk and electronic, and youth
placed in confinement with start and end times. Youth placed on precautionary observation, or
secure observation were documented in the logbook as well with the date, and time initiated and
ended. A review of the master control and living module logbook’s indicated education was
conducted as scheduled with minimal interference except for May 20, 2025, where living module
B1’s second half of the girls did not attend class for the day. The juvenile justice detention
officer supervisor (JJDOS) reviewed the Master Control logbook when accepting responsibility
for the center and reviewed the living area logbooks daily. The juvenile justice detention officers
(JJDOs) reviewed the logbook entries from the previous shift when accepting responsibility for
the living area. Each logbook review designated the name and position of the reviewee and the
date and time the review was completed.
5.06 Logbook Reviews
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. A review
of logbooks for three full days each month during the annual compliance review period
confirmed the superintendent and/or the assistant superintendent review all logbooks on a
weekly basis and provide recommendations as needed. The review also confirmed the juvenile
justice detention officer supervisors (JJDOSs) review the module logbooks upon assuming the
responsibility of the center. The JJDOSs maintain the module living logbook daily and review
the logbooks at each shift change. The superintendent, assistant superintendent, or the staff in
charge of center toured the youth living areas at least once during each shift and documented
their visit in each area’s logbook. The superintendent was interviewed and stated management
reviews and signs the logbook every day.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) regarding logbook requirements. A
review of three full days of living modules and master control logbook, during the annual
compliance re-review period, was conducted. For each shift, the juvenile justice detention officer
supervisor (JJDOS) documents a review of the logbook was conducted. A review of the master
control logbooks revealed the supervisor accepted responsibility of the center at the beginning
of their shift. Review of the modules and master control logbook revealed the each were
reviewed by the superintendent or designee on a weekly basis and provided recommendations
as to the completeness and accuracy of the information recorded. Review of the module
logbooks revealed the juvenile justice detention officers (JJDOs) accepted responsibility for the
living area at shift changes. The review revealed the superintendent, assistant superintendent or
staff in charge of the center tour the youth living area at least once during each shift and
document his/her visit in each area’s assigned logbook. The superintendent was interviewed
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and stated the superintendent or designee shall review all logbooks at a minimum of weekly and
review the entries for the last seventy-two hours. The review documentation must be highlighted
in yellow marker. A supervisor must review the master control logbook, going back seventy-two
hours, and document their presence in the living area logbooks every shift.
5.07 Key Control
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) addressing key control, including key
assignment and usage, inventory, daily tracking and reconciliation of keys, secure storage of
keys not in use, procedures addressing missing or lost keys, and reporting and replacement of
damaged keys. The FOPs specified the key inventory shall include the ring number, the number
of keys on each ring, the capability of each key, and to whom the key ring is issued, as well as
the key ring hub system to be color-coded with officer keys are blue, supervisor keys are yellow,
administration keys are black, white for medical and mental health, green for food service,
education is brown, and the emergency keys have a red hub.
During the annual compliance review week, center staff did not have access to the computer
system which maintains the current key inventory or the Department’s Central Communications
Center (CCC) reports; therefore, the key inventory and CCCs were not reviewed.
Observations of the key storage area indicated the center has a large see-through key box
maintained on the wall in master control, which maintains all keys, other than the emergency
egress keys. The emergency keys are maintained in a small box in locked sub control rooms
and during an emergency the window of the box is broken to retrieve the keys. During the first
and second day of the annual compliance review week the master control room was unlocked
and the door was open, as well as the key storage box being unlocked and open. The last two
days of the ACR week the key storage box was locked and only accessible when the master
control operator unlocked the box. Observations of the distribution and the collection of keys
during the annual compliance review week indicated staff will enter the center, provide master
control their personal keys, and in return get center keys. Observations included restricted keys,
like education and medical, who have key numbers assigned to them. The staff receiving the
center key entered their name, the key number, and the date and time in the sign-in and out log,
and when leaving entered the date and time when the key was returned. The master control
operator placed the staff’s personal key in the secure key storage box on the hook with the
same number as the center key which was provided. The review team provided their personal
keys to master control, which were placed on the counter in front of the key storage box until the
team retrieved them at the end of each day. All center keys observed had a tamper-resistant
ring. Observations during the annual compliance review week indicated staff who were issued
keys carried them on their person at all times, did not allow youth to handle facility keys, and did
not remove the keys from the facility or the facility grounds without authorization from the
superintendent. Five key rings were observed, and all had the correct color key hub on the key
ring, according to the FOP. Three of the five staff were questioned, and one was able to indicate
the function of each key on the key ring, the remaining two did not know the function of one of
the keys each. A review of shift reports indicated each documented the issuance of keys and
key ring numbers.
The informal interview with the master control operator indicated the process for restricted key
usage is for the individuals, like medical, mental health, or education to only get the keys
assigned to the specified areas, and no other staff are allowed to use those keys.
All nine interviewed staff indicated the medical and mental health record keys are restricted,
seven stated the case management record keys are restricted, six said the kitchen keys are
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restricted, and two said the youth property area keys are also restricted. All nine staff indicated
the center’s key control process includes staff keys being given to master control upon entry,
personal keys are securely stored, and youth do not have access to keys. Eight staff stated the
center keys are assigned to staff and they will notify master control of missing keys, as well as
search youth for missing keys. Seven stated the facility is searched for missing keys, and six
staff also said daily tracking of the keys and a key log are part of the key control process, five
said visitor personal keys are given to master control upon entry, and three mentioned a chit or
token is provided to visitors. Two also mentioned a key is replaced when damaged as part of
the key control process.
The superintendent interview indicated permanent keys are issued to the administration team.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) detailing the requirements of the
center’s key control, issuance of keys to staff, inventory and tracking of keys, secure storage of
keys not in use, procedures addressing missing, or lost keys, and reporting and replacement of
damaged keys. Key assignment and usage depend on the staff’s role. Each key ring has a
tamper proof color coordinated key ring hub. For juvenile justice detention officers (JJDOs), they
receive a blue ring hub with four keys on it. The juvenile justice detention officer supervisors
(JJDOS) receive a yellow key ring hub which has ten keys on the ring. Keys which are not
assigned are secured in master control. Staff are to give a key to receive a key at the beginning
of shift to master control, at the end of shift they give their keys back to the supervisor to receive
their personal keys from master control. The keys assigned are logged on a paper log then
placed in SharePoint for the daily shift report, both logs have who the keys are assigned to, the
checkout time and check in time. Supervisors assign keys to their staff on each shift. Review of
the log for the annual compliance re-review period revealed the distribution and collection of
keys. When keys are missing, the center goes on lockdown and a sweep is conducted to locate
the keys. The center has within two hours to contact the Department’s Central Communication
Center (CCC) if the keys are not located. When keys are broken or damaged, a work order is
placed for the keys and the keys are then taken offline. Review of the key control book
confirmed the number of keys within the center, each key assigned to the set of keys and
purpose, and a label with the key number and how many keys are to be on the key ring. Review
of keys in master controls, displayed the assigned color to the purpose of keys; officer keys are
blue, supervisor keys yellow, administration keys black, medical and mental health are white,
food service are green, education keys are brown, and emergency keys are red. During
observations, it was revealed the key box is not easily accessible while locked, staff carry their
keys on their person at all times, staff don’t allow youth to handle center keys, staff do not
remove the keys from the center or center grounds without authorization from the
superintendent. If a staff left the center with keys, the staff would need to contact the center and
speak to a supervisor immediately and returned the keys to the center within two hours. In the
event a set of keys go missing, the supervisors are immediately notified and done so without
youth knowing. Review of the CCC history for the center did not have any instances of
discrepancies of key control. Three staff were formally interviewed about their keys. All three
staff had the correct number of keys on their key ring and knew the function of all the keys on
their assigned key ring. A sampling of key rings was observed and compared to the key
inventory and log; all five keys matched the key inventory. An informal interview with the master
control operator indicated restricted key are maintained separately in the key box and are only
distributed to the identified staff. Restricted keys include medical, staff and youth records and
youth property lockers. Seven staff were interviewed and asked what center keys are restricted;
five stated medical records, one stated youth property area and two stated kitchen. Five of the
staff also responded the supervisor keys with the black hub, the exit doors and gates, the
supervisor offices, the supervisors, administrators, yellow, black and brown keys, master keys
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and education are restricted. The superintendent was interviewed and stated permanent keys
are issued to staff. An informal interview was completed to clarify the answer, and the
superintendent stated only the superintendent keys and regional keys are assigned. The
regional keys are maintained in the superintendent’s office which is secure.
5.08 Vehicles and Maintenance
The center originally received a Failed Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. A review of
documentation for six youth transportation vehicles indicated two annual inspections could not
be confirmed. The remaining four vehicles had an annual inspection completed, two on April 2,
2024, and one each on April 9, 2024, and April 16, 2024.
The center was unable to provide the monthly visual transport vehicle checks for the annual
compliance review period, other than February to April 2024, due to an online system error. A
review of the two monthly visual checks indicated each included the water coolant, lights, oil,
emergency equipment, brakes, horn, interior/exterior, cleanliness, tires, battery, windshield and
wipers, windows, mirrors, and damage.
Observations of the six youth transportation vehicles indicated they all had the appropriate
number of seatbelts and a current fire extinguisher. Each vehicle had debris like empty water
bottles, old food containers, and jumper cables strewn in the area where the transporter and
passenger sit. The center maintains first-aid kits by the master control room for youth
transportation. Each of the locked first-aid kits contained the designated health authority
approved contents, a window punch, and a knife-for-life, which is utilized as a seatbelt cutter.
A review of twelve van logbook entries on various dates and times indicated nine were missing
the acknowledgement the vehicle was checked. All twelve had the destination, number of youth,
staff names, the time transport began, and the time the transport ended. An observation of a
transport indicated the transport staff inspected the vehicle for contraband, ensured it was
documented in the vehicle logbook, ensured the vehicle had sufficient gasoline to reach the
destination, maintained copies of current transportation procedures in the vehicle, verified the
seatbelts were securely anchored, tested the security screen to ensure it was secure, and
confirmed the vehicle folder contained the vehicle logs, vehicle and mechanical restraint keys,
gas credit card, and vehicle registration. The transport staff also ensured a cellular telephone
was assigned to the vehicle, charged, and turned on prior to departure, ensured the vehicle was
secured at all times, the youth was searched prior to being placed in the vehicle, and youth and
staff wore seatbelts. Seven Department vehicles and five other vehicles parked in the center
parking lot were checked. One of the Department vehicles was unlocked, and all other vehicles
were locked.
Eight of nine interviewed youth indicated they feel staff are driving safely when transporting
youth. The remaining one youth said no, and stated staff drive over the speed limit. Eight youth
said they had never seen anyone place contraband in a transport vehicle. One said yes and
specified having seen one of the youth’s parents/guardians bring contraband in. Staff
confiscated the contraband, and the parent/guardian is no longer allowed to visit. It should be
noted this incident was called into the Department’s Central Communications Center (CCC).
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of eight vehicles
which are used to transport youth. An annual inspection was completed by a certified mechanic
on all eight vans and documentation was provided to confirm the inspections. Documentation
was reviewed confirming monthly inspections were completed by the center’s maintenance
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mechanic, or staff, and included checking the vehicles water coolant, lights, oil, emergency
equipment, brakes, horn, interior, exterior, and cleanliness of the vehicle. Inspections are also
conducted on the tires, battery, windshield, wipers, windows, mirrors, and inspected for any
damages. A physical inspection of all the vehicles was conducted during the annual compliance
review week and each vehicle contained the appropriate number of seatbelts, a seatbelt cutter,
window punch, fire extinguisher, and first-aid kit. Each vehicle had an assigned logbook for
transport documentation which included acknowledgement each vehicle was checked,
destination, number of youth and staff names, name of the officer riding in the back of the van,
time transport began, and time transport ended. There were no transports scheduled during the
week of the annual compliance review for observation. An observation of a youth returning from
court was conducted during the week of the annual compliance review, the youth was observed
wearing a seatbelt. Two staff were observed transporting the youth, and one was the same sex
as the youth. Staff searched the youth prior to entering the center. Staff searched the vehicle for
contraband and ensured the vehicle was secured. The week of the annual compliance review all
eight vehicles from the center were checked to ensure vehicles were locked when not in use; all
vehicles were secured. Ten staff vehicles were checked to ensure they were secured and all ten
were found to be secured as required. Seven youth were interviewed and five stated they felt
staff are driving safely when transporting youth and two stated they have not been on a
transport. In addition, all stated they have never seen anyone place contraband in a transport
vehicle.
5.09 Tool Inventory and Management
The center originally received a Failed Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
has facility operating procedures (FOPs) addressing maintenance and kitchen tool inventories.
The center’s FOP requires kitchen knives to be inventoried daily in the morning, mid-day, and
evening, and all other kitchen utensils weekly. Inspections of the kitchen indicated six of the
eight knives were in the locked knife box and two were being used. Kitchen staff had to search
for the knives in use and found them after two minutes. The remaining kitchen tools were hung
on a peg board in the kitchen and maintained in a locked drawer. The requirement is for kitchen
tools to be maintained on a shadow board. The tool room, which is located in the maintenance
shed outside of the facility, is inaccessible to youth and locked. A review of the kitchen knife
sign-in and out log for the annual compliance review period indicated forty-nine entries were
missing either a count of the knives, the signature of the person counting, or the time of the
count. The kitchen tool and maintenance tool sign-in and out logs for the annual compliance
review period could not be reviewed, due to no logs being completed. The maintenance tools
had a sign-in and out log for the annual compliance review week, which coordinated with the
inventory. The kitchen tool inventory is stored on an online system which could not be accessed
during the annual compliance review week.
A total of ten kitchen and maintenance tools were observed as secure and correctly noted on
the inventory. One of the kitchen tools did not have any markings. The remaining nine tools from
the maintenance shed were all marked for easy identification. None of the inventories were
signed by the superintendent.
An informal interview with the superintendent indicated service vendors are escorted while they
are in the secure area of the center and must sign-in and out. The superintendent interview
indicated the administration team and maintenance staff have access to facility tools. An
informal interview with the maintenance staff indicated when there is a missing or damaged tool
administration will be notified, it will be noted it on the inventory, and a note is placed on the
spot for where the tool would be located.
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Nine interviewed staff indicated the center's practice for damaged or missing tools is to contact
master control and then conduct a search for the tool.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOP) to address tool inventory and
management requirements. Interviewed maintenance staff indicated inventory is conducted
monthly and forwarded to the center’s superintendent or designee for review. An observation
during the annual compliance review week found all tools were secured in the maintenance
workshop and kitchen office. All tools including the kitchen tools are stored on shadow boards
and are etched to identify them as Department property. The center maintains a strict inventory
of tools. A review of the tool sign-in and sign-out form noted all tools are checked out prior to
use and checked in after they are returned. Kitchen tools include knives and scissors and each
were stored in a locked box in the kitchen office which was found to be locked and secured. A
well-organized inventory of kitchen tools is maintained, and counts are documented at the start,
middle, and end of each day. Additionally, monthly inspections of the tool area were
documented. All tools were accounted for and there were no tools observed in the center which
were not listed on the inventory. The center reported they had no tools which needed replaced
since the last annual compliance review. An informal interview with the maintenance staff
indicated all service vendors are identified prior to entering the secure area of the center and
are always accompanied by a center staff. Seven staff were interviewed and five stated they
would notify a supervisor, master control, or administration if a tool was damaged or missing.
One staff stated they would search for the missing tool, and if a tool is broken, they would put it
in the trash and document it on the shift report. One staff stated they would ask on the radio if
another staff had the missing tool One staff stated if a tool is broken, they would not throw it
away. The interview with the superintendent revealed the only person authorized to have keys
to the maintenance shed and kitchen tools are maintenance staff, kitchen staff and
administrators. A review of ten tools found all to match the inventory, be secured in the
maintenance shed, and marked for easy identification. The inventory was signed by the
superintendent on a monthly basis.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures in place which prohibit youth from using cleaning
products, medical equipment, and accessing any tools. The policy outlines youth may use items
such as mops, brooms, and buckets under direct supervision of staff. Observations during the
annual compliance review week included a youth using a broom under direct staff supervision.
Nine interviewed staff reported youth are allowed to use mops, and brooms, as well as scrub
brushes under supervision. Nine youth were interviewed, and they all concurred they only use
mops and brooms. Each youth indicated they do not clean with bleach, laundry soap, window,
or toilet cleaners; however, a staff member may spray the chemical and just have the youth
wipe it off.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has facility operating procedures (FOP) to ensure youth do not have access to any
tool including kitchen or medical equipment. No tools were found unsecured, and youth were
not observed using any kitchen or medical equipment during the week of the annual compliance
review. The center only allows youth to have access to mops, brooms, and scrub brushes for
general cleaning under direct staff supervision. Observations were unable to be observed of
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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. Seven youth were interviewed
and each indicated they use mops and brooms. Seven staff were interviewed, and one indicated
youth use scrub brushes, three indicated youth use mops and brooms and four indicated youth
do not use tools.
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items
The center originally received a Failed Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
staff did not provide the center’s Safety Plan; therefore, it could not be reviewed.
A review of documentation during the annual compliance review period determined the center
does not maintain an up-to-date inventory of all flammables, toxic, caustic, and poisonous items.
Observations during the annual compliance review week indicated the kitchen had flammable,
toxic, caustic, and poisonous items under the sinks, next to the sinks, under an office table, as
well as in the kitchen shed, and none had any Safety Data Sheets (SDSs) or current
inventories. A locked sub control room between two modules also had three cleaning items, two
of which the bottles had no lids, and there were no SDSs or inventories maintained. Two locked
janitorial closets in the center hallway were observed, each with flammable, toxic, caustic, and
poisonous bottles and spray cans, some of which had no lids, and none had any SDSs or
inventories; the inventories were from more than one year ago. A review of five flammable,
toxic, caustic, and poisonous items in the maintenance shed indicated all counts were noted
correctly on a current inventory and none had any SDSs.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has a safety plan to ensure the proper use, storage, disposal, and inventory of
chemicals including poisonous, flammable, and toxic materials. Through observation during the
annual compliance review week, it was confirmed maintenance staff secure chemicals in a
chemical shed located outside of the center. Flammable items are maintained in a locked
flammable cabinet within the chemical shed. A sampling of five items in the chemical shed were
selected randomly for review and each had an SDS and accurate inventory of the selected five
chemicals.
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures indicating flammable, toxic, caustic, poisonous fluids,
and other dangerous substances may only be drawn or acquired by authorized personnel and
youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals or
respond to chemical spills. Observations were conducted during the annual compliance review
week and found all chemicals were securely stored in locations inaccessible to youth and only
authorized staff have access.
Nine youth were interviewed and stated they do not have access to flammable, toxic, caustic,
and poisonous items. Nine interviewed staff reported youth are not allowed to clean with
substances which are toxic, flammable, or poisonous.
During the re-review the center received a Limited Compliance rating for this indicator.
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The center maintains facility operating procedures (FOPs) ensuring the proper use, storage,
disposal, and inventory of chemicals including poisonous, flammable, and toxic materials. The
FOP also ensures limited access to flammable, toxic, caustic, and poisonous items. Only
authorized staff are permitted access and use to flammable, toxic, caustic, and poisonous items.
Youth are not permitted to use or handle hazardous chemicals. Three chemicals were observed
in an open office during the tour the week of the annual compliance review. One spray bottle,
one gallon of hand soap, and one gallon of disinfectant cleaner, with no safety data sheets
(SDS) observed. This is against the center’s FOP. The office was secured immediately by
administrative staff and the chemicals were returned to the chemical closet. Through
observations made during the tour the chemical closet between B1 living module and B2 living
module was observed to be unlocked and unable to be secured. Maintenance staff responded
and secured the chemical closet immediately after being notified by administrative staff.
Observations of B1, B2, B3, B4 and G1 living module utility rooms, and kitchen utility room had
inventories of all flammables, toxic, caustic, and poisonous items during the annual compliance
review week, as well as SDS sheets in a binder. Inventories had an accurate count of the
chemicals present. Seven youth were interviewed and stated they do not have access to
chemicals. Seven staff were interviewed and indicated youth do not have access to chemicals.
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items (Critical)
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) in place outlining the disposal of all flammable,
toxic, caustic and poisonous items. The FOP states the maintenance mechanic or other trained
staff shall be responsible for disposing of hazardous items and toxic materials in accordance
with the Occupational Safety and Health Administration standards.
The superintendent reported there have been no chemical spills or disposal of any flammable,
toxic, caustic, and poisonous items since the last annual compliance review, all chemicals are
utilized until they are empty, and they have not used grease for approximately two years.
The program utilizes a local vendor to dispose of flammable, toxic, caustic, or poisonous
materials when applicable.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) ensuring proper disposal of
hazardous items and toxic materials in accordance with Occupational Safety and Health
Administration (OSHA) guidelines. There were no chemical spills or disposal of flammable,
toxic, caustic, or poisonous items during the annual compliance review period. Kitchen staff
indicated grease is used for cooking and is disposed by an outside contractor. An informal
interview with the maintenance mechanic indicated all hazardous materials are disposed
appropriately.
5.14 Confinement Under Twenty-Four Hours
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
During an interview, the superintendent indicted the use and appropriateness of confinements
are tracked through supervisor and administrator reviews. The superintendent indicated
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management reviews are conducted daily to ensure accuracy and compliance to policy. Nine
staff were interviewed, and each was able to explain the center’s process for placing youth in
confinement. Each staff indicated the confinement room is searched prior to placing a youth.
Seven staff also indicated a confinement report is completed and ten-minute checks are
conducted and documented. Four staff indicated five-minute checks are conducted for the first
hour. Eight interviewed staff indicated youth placed in temporary confinement are provided
education materials. The remaining staff stated they are not.
During the re-review the center received a Limited Compliance rating for this indicator.
The center has facility operating procedures addressing the process of youth placed in
temporary confinement under twenty-four hours. The center had 603 instances of confinement
under twenty-four hours from between June 3, 2024 and May 29, 2025, with an average time of
confinement 20.12 hours. Twenty confinements reports were reviewed and found thirteen youth
were applicable for three meals a day plus snacks, ten had documentation of this being afforded
and three did not. Two of the twenty youth in confinement were afforded access to mental
healthcare as needed, the remaining youth did not require mental health services. Six youth
were applicable for a shower based on the time and duration of confinement and each
applicable youth was afforded the right of a shower. Six youth were applicable for receiving
clean clothing based on the time and duration of confinement and each applicable youth was
afforded the right. All twenty youth were afforded a mattress and bedding as required. Eighteen
youth were applicable for education material during education hours and there was no
documentation they were provided education materials while in confinement. All twenty
confinement reports reflected each youth was advised of the right to grieve the confinement
placement. For each of the twenty reviewed confinements, the supervisor approved all
confinements, the staff placed only one youth in the confinement room at a time, and the room
was searched and the search was documented on the confinement report. All twenty reviewed
confinements had all required checks completed including checks every five minutes during the
first hour for confinement. All twenty youth were supervised according to the detention
supervision matrix following the first hour of being placed in confinement. None of the twenty
youth placed in confinement showed signs or complained of a physical injury or illness. None of
the twenty youth placed in confinement had a chronic health condition including pregnancy. All
twenty youth placed in confinement had documentation the reason for being placed in
confinement was explained to them. The supervisor was late on five of the twenty initial
confinement reviews. One was one hour and fifty minutes late, two were an hour late, one was
twenty minutes late, and one was forty-five minutes late. For each confinement, the full report
was completed within the required time frame, the supervisor conducted additional reviews with
youth at a minimum every three hours, and the supervisor/staff continually counseled each
youth to consider removing the youth from confinement. None of the twenty confinement
placements interfered with visitation. The superintendent was late on two of the twenty
confinement reviews, one was eighteen days late and one was six hours late. The center had
no pregnant youth in confinement during the annual compliance review period. The
superintendent was interviewed and indicated behavioral confinement is an immediate, short-
term, crisis management strategy during volatile situations. Supervision shall be documented on
the confinement Visual Observation Report (VOR) Log at the minimum every five minutes for
the first hour in confinement and ten-minutes after the first hour. The supervisor shall conduct
an initial confinement review with the youth no later than two hours from the incident and a
minimum of every three hours and document in the Department’s Facility Management System
(FMS). The Superintendent or designee shall review all confinement reports within forty-eight
hours, excluding weekends and holidays (unless this is their regularly scheduled workday) and
shall determine whether each confinement was appropriate or inappropriate. Seven staff were
interviewed regarding the process of placing a youth in confinement and five responded they
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complete a confinement report, six stated they conduct and document ten-minute checks and
search the confinement room. One stated they talk to the youth and let them know what to
expect, indicating confinement is the last resort. One stated they must be told to place a youth in
confinement, they use verbal to walk the youth to the confinement room, search the youth and
room prior to placing the youth and conduct five-minute checks. One staff stated searching is
not done and the final staff stated they document youth behavior, visits and meals. Three staff
stated youth are provided education materials while in confinement and four stated they are not,
with one providing a response they have never seen education material being provided.
5.15 Confinement Over Twenty-Four Hours
The center originally received a Non-Applicable Compliance rating for this indicator during
the 2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. Due
to Department-wide system outages at the time of the annual compliance review, this indicator
could not be reviewed and is rated non-applicable.
During an interview, the superintendent indicted the use and appropriateness of confinements is
tracked through supervisor and administrator reviews. The superintendent indicated
management reviews are conducted daily to ensure accuracy and compliance to policy.
During the re-review the center received a Non-Applicable Compliance rating for this
indicator. The center did not have confinements over twenty-four hours during the annual
compliance review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills]
The center originally received a Limited Compliance rating for this indicator during the 2023-
2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The center
has facility operating procedures (FOPs) in place which include a Continuity of Operations Plan
(COOP). The plan indicates COOP drills shall be conducted and documented, at a minimum,
twice a year, with one drill being completed prior to the hurricane season. A review of drill
documentation for the past year found one of two required COOP drills was not completed. The
one completed COOP drill was a hurricane drill, which was completed on April 30, 2024, prior to
June 1, as required. The drill was documented on an emergency drill report form and included
all required information.
Eight of nine interviewed staff stated they participated in drills including major disturbances,
bomb threats, chemical spills, escape, and fire. One staff reported they were a new hire and did
not participate in any drills. One staff confirmed during daily debriefings they will talk about drill
scenarios. An interview was conducted with the superintendent and confirmed the center utilizes
a shelter, impact team, and FOP as part of their comprehensive safety program.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) establishing a procedure for
conducting drills to address the Continuity of Operations Plan (COOP). The center had a
deficiency closed on September 24, 2024. During the annual compliance review period, two
COOP drills were required. Two hurricane drills were conducted on May 31, 2025, first and
second shift, and November 13, 2024, first and second shift. The documentation of the drills
contained the type of drill, date, and time of the drill, who participated and what actions they
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took, a brief scenario and findings and recommendations from the observers. The
superintendent interviews indicated COOP drills are conducted two times a year, fire drills are
conducted monthly, and escape drills are conducted quarterly. Seven staff were interviewed and
four stated they participated in weather drills, one stated they participated in a major disturbance
drill, two stated they participated in a bomb threat drill, one stated they participated in a hostage
situations drill, one stated they participated in a flooding drill, two stated they participated in an
escape drill, four stated they participated in a fire drill, one stated none of the above, one stated
mental health and medical drills, and one stated code white cutdown.
5.17 Escape Drills
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures (FOPs) and a Continuity of Operations Plan which both
include the required Department elements regarding an escape prevention plan. A review of
escape drills for the annual compliance review period indicated they were completed quarterly,
as required. The center conducted more than the required drills for a total of nine drills, with
three of them being documented in the logbook. A review of seven in-service training records
indicated all staff had received the required escape prevention training annually. Five of nine
interviewed staff indicated they have participated in an escape drill. One staff stated they have
not participated in an escape drill due to being a new staff. The remaining three staff stated they
participated in other drills in the last year.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center maintains facility operating procedures (FOPs) to address escape drills and escape
prevention. During the annual compliance review period, the center was required to conduct
eight escape drills. Seven of the eight quarterly drills were conducted on each shift as required
and documented in the center’s logbook. The second shift drill for the fourth quarter was not
completed. Seven in-service staff training records and seven pre-service staff training records
were reviewed, and each staff completed training in security and escape prevention annually.
Seven staff were interviewed, and only two stated they have participated in an escape drill since
the last annual compliance review.
5.18 Fire Drills
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has a fire prevention plan which was approved by the local fire official. Each of the
center’s thirty-one fire extinguishers were inspected annually, as required. A review of
documentation for the annual compliance review period found the center conducted fire drills
monthly on each shift, with the exception of one drill on second shift in July 2023 and one drill
on first shift in January 2024. The center was running on two shifts from May 2023 through
December 2023. They began running on three shifts in January 2024, through the remainder of
the annual compliance review period. A total of thirty drills were reviewed and each drill was
documented on a Department form which included all required elements. Twenty-four drills were
documented in the logbook and six were not.
Eight of nine interviewed staff reported fire drills take place at least monthly. The remaining one
staff stated they do not.
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Three of nine interviewed youth reported they were instructed on what to do in case of a fire.
The remaining six reported they were not.
During the re-review the center received a Satisfactory Compliance rating for this indicator.
The center has a disaster plan, fire prevention plan, and evacuation plan addressing fire
prevention and safety in the center. The center conducted monthly fire drills on each shift, as
required, except for April 2025, April 2024, August 2025 and August 2024, for both shift one and
two. There were twenty-two fire drills required and eighteen were completed as required during
the annual compliance review period. All eighteen fire drills were documented in the logbook.
Fire evacuation plans were posted throughout the center. Each posting identified the primary
and secondary exit routes and locations of fire extinguishers, along with first-aid kits. All fire
extinguishers had a completed annual inspection, as required. Four of seven interviewed staff
indicated they have participated in a fire drill and two of seven stated fire drills are conducted
monthly. Seven youth were interviewed, and two stated they were instructed on what to do in
case of a fire and five stated they did not receive instruction. A follow-up was conducted by
reviewing the seven youth case management records and all seven had the orientation
acknowledgement form signed by the youth and staff upon admission. The orientation form
includes instruction on what to do in case of a fire.
5.19 Search and Contraband Procedures
The center originally received a Satisfactory Compliance rating for this indicator during the
2023-2024 annual compliance review, conducted April 31, 2024, through May 3, 2024. The
center has facility operating procedures addressing search and contraband procedures. A
review of logbooks indicated frisk searches are conducted prior to admission, and during
admission, as well as strip searches being conducted during the admission process. Frisk
searches are also completed when deemed appropriate by the shift supervisor, when there is
reasonable suspicion the youth is harboring contraband, and during facility-wide initiatives to
reduce the introduction of contraband. Searches are documented in the logbook, as well as in
reports in the Department’s Juvenile Justice Information System (JJIS). During the annual
compliance review week JJIS was not operational; therefore, strip searches, room searches,
and the Department’s Central Communications Center (CCC) documentation could not be
reviewed. A review of documentation indicated the center had six occasions which
compromised the safety or security of the center during the annual compliance review period,
wherein contraband items were found during searches. Two of the six incidents documented
confiscation of contraband in the logbook, the remaining four did not. All six instances were
called into the CCC, law enforcement was contacted, and the regional director or designee was
notified. Observations during the annual compliance review week indicated youth were
searched prior to transport with staff wearing gloves, electronic searches were conducted on all
persons entering the facility, as well as all bags, cases, jacket pockets, and other items being
searched. All personal keys, personal cellular telephones, and other contraband items were
prohibited from entering the secure area. The superintendent interview indicated the center’s
contraband procedures are once a youth arrives at the facility a law enforcement officer will
remove all restraints, staff will ask the youth if they are in possession of contraband, and they
will perform a pat down and strip search of the youth. Law enforcement will leave if no
contraband is found, otherwise a report is generated in JJIS.
During the re-review the center received a Failed Compliance rating for this indicator. The
center has a facility operating procedures (FOPs) addressing illegal contraband and prohibited
items. The FOPs address materials considered contraband and the system used to prevent the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 75 of 77 (Revised July 2022)
introduction of contraband into the facility. The FOPs also address searches. The annual
compliance review team was not able to find any documentation in the master control and
module logbooks to support frisk searches were conducted prior to admission or the completion
of an electronic search during the admission process. There was no documentation to support
when frisk searches were conducted when deemed appropriate by the shift supervisor, when
there was reasonable suspicion the youth was harboring contraband, or during facility-wide
initiatives to reduce the introduction of contraband. The superintendent informed the review
team searches are conducted and logged in the master control logbooks during intake and
random searches on youth. There was no documentation to support staff wear gloves during all
searches. There was no documentation to support two staff of the same gender of the youth are
conducting the strip searches when needed. There was no documentation to support if one staff
was a different gender of the youth. There was no documentation to support youth were striped
searched individually and not in a group setting. The superintendent informed the review team
strip searches are conducted on youth by two officers of the same sex and in camera view of
the officer conducting the search. The superintendent also indicated each search is conducted
separately and none in group settings. Video observation was conducted to observe how staff
and visitors are searched upon entering the building. Observations supported electronic
searches were conducted on all persons entering the facility. All bags, cases, jacket pockets,
and other items were searched. Video observation and documentation supported all personal
keys, personal cell phones, and any other items considered contraband were prohibited from
entering the secure area of the facility. There was no documentation to support rooms were
searched upon a youth’s release or prior to placing a new youth in the room. Logbooks were
reviewed for documentation to ensure room searches were conducted during each awake shift.
A sample of room searches for one day of each month since the last annual compliance review
was completed to ensure room searches were conducted during each awake shift. Eight of the
eleven days selected to review documentation of room searches were missing the
documentation. The superintendent indicated room searches are conducted each day during
awake hours and documented in SharePoint; however, documentation was not provided to the
annual compliance review team. A review of the Department’s Central Communications Center
(CCC) incidents confirmed there were two instances since the last annual compliance review
where contraband was found in the facility. Both incidents were documented in the master
control logbook and the documentation included contacting law enforcement. One of the two
incidents had a completed incident report. One of the two incident reports had been started in
the Department’s Facility Management System (FMS); however, was not completed. There was
no documentation to support either incident was reported immediately to the on-duty supervisor
or the regional director or designee. There was no documentation to support the confiscated
items were secured and hand-delivered to the supervisor. There was no documentation to
support the shift supervisor documented the chain of custody of the confiscated item. The
superintendent interview indicated searches should take place no more frequently than
necessary to control contraband or to ensure safety. The results of any search shall be
documented in the logbook and electronically. Electronic wand searches for transport, frisk
searches for transport, visitation, and contraband, and strip searches by the same gender staff
shall be conducted on every youth prior to admission. Any persons coming into the secure area
shall be searched using an electronic wand and their pockets shall be emptied. Searches
should be conducted in an area under video surveillance. Any unauthorized item discovered
during a staff/visitor search should be removed from the facility or placed in a secured locker if
available. Law enforcement shall be contacted if any item found would be considered illegal as
defined in Florida Statute, or there is any evidence of any type of unlawful activity.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 76 of 77 (Revised July 2022)
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Program Accountability Page 77 of 77 (Revised July 2022)

source: DJJ