state: FL

facility_name: Broward Youth Treatment Center

summary: QI Detention - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Broward Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
222 NW 22nd Ave
Fort Lauderdale, Florida 33311
Review Date(s): March 18-21, 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:
Acasha Pressley, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standard 3,
Interviews)
Alissa Spearman, Assistant Detention Center Superintendent, Collier Regional Juvenile
Detention Center (Standard 2)
Program Name: Broward Regional Juvenile Detention Center MQI Program Code: 207
Provider Name: Department of Juvenile Justice Contract Number: n/a
Location: Broward County / Circuit 17 Number of Beds: 95
Review Date(s): March 18-21, 2025 Lead Reviewer Code: 225
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 56 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 56 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 56 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 56 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Satisfactory
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will
result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 56 (Revised July 2023)
Program Overview
The Broward Regional Juvenile Detention Center is a state-owned detention center, operated
by the Department, located in Fort Lauderdale, Florida. The center serves youth in Broward
County in Circuit 17. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the ninety-five-bed center.
Youth are provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Broward County School District. The center’s
management team includes the superintendent, two assistant superintendents, two
administrative assistants, six juvenile justice detention officer (JJDO) supervisors, and fifty-two
JJDOs. Mental health and healthcare services are provided through the contracted provider,
VitalCore Health Strategies, LLC. Mental health services are provided by a licensed designated
mental health clinician authority (DMHCA), as well as one psychiatrist, five licensed mental
health counselors, and one licensed clinical social worker. Clinical services provided by the
center include mental health and substance abuse evaluations, mental health treatment
planning, individual, group and family therapy, mental health crisis intervention services, on-site
psychiatric services, and availability for substance abuse services for youth with co-occurring
disorders. Medical services are provided by one medical doctor, one advanced practice
registered nurse (APRN), one nurse manager, five registered nurses and one medical records
clerk. The medical clinic maintains nursing coverage Monday through Friday for eight hours a
day, with staff available twenty-four hours a day, seven days a week by telephone or in person
for consultation. Food services are provided by Department staff and include menus, meal
planning, meal schedules, special diets, nutritional analysis, daily allowance, food preparation,
health certifications, food product standards, sanitation, and cleaning. Staff are responsible for
the custody and control of youth in their care, providing youth supervision twenty-four hours a
day, seven days a week. The center has four living modules which are divided by male and
female. There are eighty-six security cameras at the center, of which sixty-two were operational.
A tour of the center was conducted during the annual compliance review and found it to be
clean with fresh scents and no insect infestation. The observed lobby area was clean and had
no broken furniture. The youth living areas and bathrooms were observed to be clean and the
bathrooms were functional. There was no graffiti observed at the center. The classrooms,
kitchen, and dining area were found to be clean and well organized. The exterior was free from
debris and the grass was manicured. At the time of the annual compliance review, the center
had fifteen vacancies, which included one assistant superintendent, three JJDO supervisors,
one other personal services (OPS) position, five JJDO IIs, four JJDO Is, and one facility
services worker (FSW).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures for initial background screening. The Department
ensures all staff, contracted providers, volunteers with access to youth and confidential youth
records are level two screened prior to initiating contact with youth. The Annual Affidavit of
Compliance with Level 2 Screening Standards was submitted to the Department’s Background
Screening Unit (BSU) on January 29, 2025, meeting the required deadline. The Annual Affidavit
for teachers was completed on January 31st, 2025. A review of the initial background screenings
for thirty-five newly hired staff confirmed completion prior to each date of hire. Since the last
annual compliance review, the center acquired nine contracted staff and thirty-three volunteers.
Each staff had background screenings completed prior to their start date. No direct care staff
required an exemption for a criminal history. The center uses an ergometric (ERGO) pre-
employment assessment tool for each direct care applicant. Thirty-one of thirty-five staff records
were applicable for completing the assessment with a passing score, according to the center’s
policy. Reviewed documentation verified this practice. Additionally, the center included all
applicable staff to the Clearinghouse Employee Roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures which require Department staff, contracted staff,
and volunteers to be rescreened every five years. At the time of the annual compliance review,
the center had ten staff applicable for five-year screenings. No contracted staff or volunteers
were eligible at the time of the annual compliance review. Documentation confirmed each
applicable staff screening was submitted to the Department’s Background Screening Unit (BSU)
within the required time frame.
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 56 (Revised July 2023)
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures regarding staff code of conduct. Staff are expected
to adhere to the code of conduct prohibiting any form of abuse, profanity, threats, harassment,
intimidation, personal relationships with youth, horseplay or any other significant violations. A
total of six employee records were reviewed, acknowledging receipt of the staff code of conduct,
which addresses professionalism, attendance, performance, negligence, insubordination, and
misconduct. A review of three staff records verified two staff received verbal reprimands and
one staff received a written reprimand. Each record confirmed management handled each with
immediate corrective action for staff violating center policies. Additionally, three staff receiving
commendations for exceptional performance were reviewed. Documentation confirmed staff
obtained employee of the month recognitions with gift cards. Seven youth were interviewed, and
six indicated they have never had to report abuse and one stated never being stopped from
reporting abuse. All seven youth confirmed all staff were respectful when speaking to youth at
the center. One interviewed youth stated staff occasionally use profanity when speaking to
youth. All seven interviewed youth confirmed feeling safe, never being threatened by the
center’s staff, or exchanging contact information with staff. Seven staff were interviewed during
the annual compliance review. Each staff was able to effectively explain the process for youth
needing to contact the Florida Abuse Hotline or the Department’s Central Communication
Center (CCC) to report suspected abuse. One staff reported observing staff using profanity
when speaking to youth while the other six stated they have never observed it. All seven staff
confirmed never hearing co-workers using threats, intimidation, or humiliation when interacting
with youth. Five staff confirmed working conditions were good while two stated they were fair.
The superintendent’s interview confirmed staff must communicate and interact with youth in a
manner which provides a role model of socially accepted behaviors.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures to ensure whenever a reportable incident occurs
the center notifies the Department’s Central Communications Center (CCC) within two hours of
the incident or within two hours of becoming aware of the incident. The program had 121
incidents since the last annual compliance review. Ten total incidents were reviewed and
reported successfully to the CCC within the required two-hour timeframe. Each reported incident
was documented in the center’s logbook and no additional internal incidents which should have
been reported to the CCC were noted during the annual compliance review. The
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56 (Revised July 2023)
superintendent’s interview verified all reportable incidents require CCC notification within the
two-hour timeframe and logbook documentation.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center utilizes Right Interactions (RI) as the Department approved physical intervention
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code and an RI Report is then completed and filed. At the time of the annual
compliance review, the center had a total of 626 RI incidents since the last annual compliance
review. A total of nine RI incident reports confirmed they were completed by the end of the
staff’s shift, as required. Each reviewed report included statements from each staff member
involved, supervisor signature, and a post incident interview with the youth by the administration
within thirty minutes. The superintendent or designee reviewed each report within seventy-two
hours. None were applicable for mechanical restraints, or serious injury reportable to the Florida
Abuse Hotline. A review of the center’s logbook confirmed there were no additional RI incidents
not reported. The center’s RI rate during the first quarter was 24.89 which is above the
statewide average RI rate of 9.79. Seven interviewed staff stated staff attempt to try to talk to
youth prior to utilization of RI or mechanical restraints. The superintendent’s interview verified
physical and mechanical restraints are reviewed through video and RI Reports.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures regarding detention staff training in accordance
with Florida Administrative Code. Each newly hired staff is required to complete pre-service
training within 180-days of their hire date, which includes web-based training on the
Department’s Learning Management System (SkillPro) and 120-hours of instructor-led academy
training. Seven staff training records were reviewed during the annual compliance review and all
seven staff successfully completed the pre-service certification training and new hire orientation.
Three staff completed staff orientation thirty days late; however, SkillPro was unavailable during
the chosen time. Training consisted of active shooter preparedness, cardiopulmonary
resuscitation (CPR), first-aid, automated external defibrillator (AED), human trafficking
intervention, information security awareness, mental health/substance abuse, Prison Rape
Elimination Act (PREA), Right Interactions (RI), sexual harassment, suicide awareness
prevention, trauma responsive practices and professionalism and ethics. All seven reviewed
staff completed the required web-based training and Juvenile Justice Detention Officer (JJDO)
Academy. Documentation provided by the center verified the trainings were recorded in SkillPro.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 56 (Revised July 2023)
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures requiring staff to complete twenty-four hours of in-
service training each calendar year after completion of pre-service certification. In addition,
supervisory staff must complete eight hours of training. The Department provides training
through the Department’s Learning Management System (Skill Pro) and instructor-led courses.
Seven employee training records were reviewed for compliance, which included three
supervisors and four direct care staff. Each record confirmed staff completed the mandatory
training topics within the required timeframes. All trainings were documented in SkillPro. A
licensed registered nurse (RN) provides annual training on girls’ healthcare education to non-
medical staff. The interviewed superintendent confirmed receiving certified public manager
training while staff is required to complete in-service and annual training by the Department. The
center provided an updated and signed annual in-service training calendar which was approved
by the superintendent, assistant secretary for Detention Services, and the director of the
Department’s office of Talent, Leadership, and Culture.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures which establishes each youth’s right to grieve and
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. The process includes a formal and informal phase, with the opportunity to appeal if
necessary. The informal phase consists of direct care staff attempting to resolve the issue by
verbally communicating with the youth. The formal phase requires youth to fill out a grievance
form, which is available and accessible throughout the center. A supervisor is required to review
and respond to a grievance within twenty-four hours. If a youth disagrees with the formal
response, an appeal can be filed. At the time of the annual compliance review, the center had
four grievances filed. Each grievance was filled out by the youth and a copy was maintained in
the Department’s Facility Management System (FMS). Direct care staff complete the FMS
entries, and a file is maintained for at least a year. Each grievance was signed and resolved
according to the center’s policies and procedures. Staff, youth, and superintendent interviews
confirmed the grievance process and access of forms.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 56 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures ensuring critical and special alerts are reviewed
and responded to appropriately. Alerts are required to be listed in the Department’s Juvenile
Justice Information System (JJIS) for youth safety. The administration and supervisory staff are
responsible for reviewing alert reports for accuracy and dissemination of updates to all direct
care staff during shift briefings. Direct care staff are responsible for updating alerts in the living
module and master control logbooks. Any changes must be documented and staff must be
notified accordingly. Nine youth alerts were reviewed to verify appropriate review, updates, and
documentation. Documentation provided by the center was reviewed and confirmed alerts were
discussed at shift briefings and maintained in JJIS. Logbooks were reviewed verifying the
center’s practice. Superintendent and staff interviews each confirmed the discussion of alerts
during briefings and documenting in logbooks.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center maintains a practice regarding data trend analysis. The superintendent confirmed
information is shared through meetings and briefings and can be referred to through a shared
network drive. The center utilizes the data analysis as a learning opportunity and teaching tool
as it relates to incidents, confinements, and RI Reports. Reviewed documentation confirmed this
practice.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 56 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures in place concerning youth admission into the center
to ensure proper screening, evaluation, and documentation of each youth detained in
accordance with Florida Administrative Code. Seven youth case management records were
reviewed for admission requirements. Each youth record contained an arrest affidavit/custody
order, a completed Detention Risk Assessment Instrument (DRAI), and a Suicide Risk
Screening Instrument (SRSI). Each record indicated the youth was searched by two officers of
the same gender. Each youth received a telephone call to their parent/guardian, a meal/snack,
and a completed evaluation for medical, mental health, and substance abuse at admission.
Each youth record documented the youth received and signed the orientation brochure within
twenty-four hours of admission. An observation of a youth admission was conducted during the
annual compliance review week. The juvenile justice detention officer (JJDO) reviewed the
arrest affidavit, DRAI, and custody order. The youth was searched by a same gender staff. The
youth reviewed the Prison Rape Elimination Act (PREA) video and was given the opportunity to
ask any questions. The JJDO offered the youth an opportunity to make a telephone call to their
parent/guardian and coordinated contact accordingly. The JJDO verified what was documented
on their Department’s Juvenile Justice Information System (JJIS) face sheet and contacted the
youth’s parent/guardian. The JJDO inquired about the youth’s mental health and medical history
with the youth’s parent/guardian and provided an opportunity for the parent/guardian to relay
any pertinent information to the JJDO. The youth was then given the opportunity to converse
with their parent/guardian and the telephone call was appropriately timed and monitored. The
youth was provided lunch upon intake.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 56 (Revised July 2023)
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures in place to ensure each youth admitted is notified
within twenty-four hours of the center’s rules and regulations, grievance procedures, visitation,
telephone calls, available medical, mental health and substance abuse services and how to
access them, how to access the Florida Abuse Hotline or the Department’s Central
Communication Center (CCC) for youth eighteen years of age or older, possible new law
violations for destruction of property, youth rights, expectations for behavior, and related
consequences for failing to meet behavior expectations. Seven active youth case management
records were reviewed. Each youth record had documentation showing an orientation was
provided within twenty-four hours of admission and each youth signed an orientation
acknowledgement brochure. Each reviewed youth record documented the orientation was
explained to the youth verbally and in writing by a juvenile justice detention officer (JJDO). The
brochure covered information related to rules and regulations, grievance procedures, visitation,
telephone calls, access to medical, mental health, and substance abuse services, access to the
Florida Abuse Hotline and CCC, behavior expectations and related consequences, possible
new law violations for destruction of property, youth rights, and Prison Rape Elimination Act
(PREA) related information. During the annual compliance review, an observation of the youth
orientation process was completed, and all the required elements were met. The center has an
orientation videotape for PREA which is viewed by each youth. Seven youth interviews were
conducted and each youth reported they were familiar with the orientation process.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 56 (Revised July 2023)
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures ensuring all youth admitted to the center are
classified by the admitting officer to provide the highest level of safety and security. Seven
youth case management records were reviewed and confirmed the information concerning the
youth’s history, status, and additional required documentation was included. The center
considers several factors such as gender, height, weight, age, level of aggression, mental
illness, intellectual disabilities, physical disabilities, history of violent behavior, gang affiliation,
criminal history, history of sexual offenses including sexual battery charges, vulnerability to
victimization, and sexually aggressive behavior (VSAB) screening results, medical, identified or
suspected suicide risk, escape risk, and security risks prior to placing the youth into a room. The
seven reviewed active youth case management records documented youth were assigned to a
room based on their classification and were reclassified if changes in behavior or status were
observed. Any 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 superintendent
remains informed of how to identify and address local gangs through posted alerts and
documentation in youth case management records. An interview with the superintendent
confirmed the center’s classification process.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures to ensure gang information is shared with the
identified juvenile probation officer (JPO) assigned as the circuit’s gang representative to
communicate suspected gang activity. The center’s assistant superintendent serves as the gang
representative and communicates with the JPO gang liaison and law enforcement officer (LEO)
by email when a youth is identified as a suspected gang member and shares all information
regarding suspected gang activity. Two active youth case management records were reviewed
and both youth were identified to be applicable for suspected gang affiliation. During this annual
compliance review, there were only two youth with suspected gang affiliation. The reviewed
email communication contained photographs of gang insignia or graffiti, when applicable, and a
corresponding email message to local law enforcement and the assigned JPO. The alert
information was entered into the Department’s Juvenile Justice Information System (JJIS)
during the youth’s admission. An informal interview was conducted with the gang representative
and confirmed the center’s practice. The center’s gang representative indicated it is the center’s
practice to forward all updates and/or information to the center’s superintendent, for the proper
distribution to the center’s supervisors and staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 56 (Revised July 2023)
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures in place related to ensuring the proper safe
handling and security of each youth’s personal property including valuables, which are collected
and secured at the time of a youth’s admission. Seven active youth case management records
confirmed each youth had a property form which itemized personal property, valuable property,
and youth and staff signatures. The seven reviewed records contained a letter of
acknowledgement regarding unclaimed property signed by the youth. Two of the seven youth
had valuable property which was placed in a clear tamper-proof bag with the youth’s name,
Department identification number (DJJID), date, staff name, and youth and staff signatures. The
valuable property is placed in a drop safe which is under video surveillance twenty-four hours a
day. The center has a drop safe logbook to document the time, youth’s name, name of the
officer securing the property, and the officer’s initials. Personal property such as clothes and
shoes are placed in the property bags and then placed into the secured property room. The
information documented on the bag included the date, the youth’s name, the DJJID, and a
listing of items in the bag. An admission process was observed during the week of the annual
compliance review. The observations confirmed the center’s practice. Three youth case
management records were reviewed for storage and security of valuable personal property.
Each contained a completed inventory form, which was documented in the safe logbook, and
property was stored in a clear tamper-proof bag. During the annual compliance review week,
observations of the center receiving youth personal property was completed. Property was
stored according to policy, access to property was limited to designated staff, and secured in a
locked room under video surveillance. A review of the Department's Central Communications
Center (CCC) reports since the last annual compliance review found no incidents regarding
youth property. Seven youth interviews were conducted and each youth reported upon
admission into the center. The staff checked their personal property and had them sign a
Property Receipt form. An interview with the superintendent regarding personal property
confirmed all youth have their personal property inventoried upon admission and youth property
is stored in a secured property room. The secured property room is under video surveillance
which has limited access to only the supervisor and administration. The superintendent
confirmed property deemed to be unclaimed property with receipt of letter will be donated.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 56 (Revised July 2023)
The center has facility operating procedures addressing youth releases. The juvenile justice
detention officer (JJDO) and the assigned juvenile justice detention officer supervisor (JJDOS)
completing the release shall verify the court authorization prior to releasing the youth. Proper
care must be taken to ensure all case information is reviewed to prevent the negligent release of
a youth. The JJDOS is responsible for verifying there are no holds, court orders, or any other
legal reasons prohibiting release from the center. Each parent/guardian is notified and confirms
the release. A copy of the parent/guardian photo identification card is placed in the youth’s case
management record prior to release. A review of three applicable closed youth case
management records revealed each record contained a detailed checklist utilized for each youth
release. Each reviewed record contained the appropriate documentation signed by the youth’s
parent/guardian or person taking custody of the youth. A copy of the photo identification card
was placed in each of the youth’s record. Each of the reviewed records contained
documentation confirming the youth and person to whom the youth is being released to were
reminded of any future court dates and signed all applicable release forms. Each reviewed
record documented the youth’s admission and termination dates correlated with the information
in the Department’s Juvenile Justice Information System (JJIS). During the time of the annual
compliance review an observation was conducted of a youth being released from the center,
which confirmed the center’s practice.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures to ensure the youth’s release from detention and
retrieval of personal property. The officer, the youth, and the youth’s parent/guardian, review
and sign the Property Receipt form, and account for all the youth’s personal property. The
center ensures there are provisions in place to ensure prescribed medications, along with
medical instructions, accompanye the youth upon release. Three closed youth case
management records were reviewed. Three reviewed records documented each youth and
parent/guardian signed the Receipt of Property form upon release. Each reviewed record
included documentation the youth and the person to whom the youth was being released to
were reminded of any health or welfare issues including medical, mental health and/or
substance abuse needs, and any pending appointments. After thirty days of a youth’s release, a
Notice of Impending Disposal of Property is mailed to the youth’s last known address. Personal
property not claimed is considered as abandoned and is disposed of according to the center’s
policy and Florida Administrative Code. During the annual compliance review, no applicable
reviewed records needed a Notice of Impending Disposal of Property letter to be mailed to the
youth and parent/guardian with a copy of the signed Property Receipt form. During the annual
compliance review week, an observation of a youth property release was conducted and
confirmed the center’s practice.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 56 (Revised July 2023)
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures ensuring the center conducts Detention Review on
a weekly basis for proper management of youth placed in secure detention and the appropriate
sharing of information. The youth are held in secure detention for the shortest time possible.
The superintendent appoints an appropriate staff to coordinate reviews. Observation of the
Detention Review process and the Detention Secure Log review was conducted during the
week of the annual compliance review. There were no discrepancies found during the review.
The Detention Reviews are conducted on a weekly basis, every Thursday at 10:00 a.m. to
address the status of each youth. The reviewed documentation for Detention Reviews since the
last annual compliance review confirmed all required participants attended the meetings through
a virtual platform. An interview with the superintendent regarding the weekly Detention Reviews
for secure detention and home detention placement youth, indicated the center follows all
policies and procedures.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures ensuring youth participate in constructive activities
by maintaining a daily schedule which is posted in all living areas, includes weekdays,
weekends, and holidays, and incorporates both structured and free time. Observations
confirmed the center provides and maintains a weekday, weekend, and holiday schedule posted
in all living areas. The schedule indicated the time frames of each daily activity provided to the
youth on a regular basis including wake-up, personal hygiene, mealtime, visitation at a minimum
of twice a week, recreation, physical activities including at least one hour of daily large muscle
exercise outdoors, indoors activities which promote education, problem solving and life skills,
shift change, bedtimes, groups, and open program time. Seven youth were interviewed, and
each reported the center has a daily activity schedule and the scheduled is followed. Seven staff
were interviewed, and each reported the center’s daily scheduled is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. Education in the
center is directly administered by the Broward County School District. The center has an activity
schedule which reflects the scheduled education and times. Before identifying the scheduled
start of academic classes, it must be noted due to the inhabitable conditions of the portable
classrooms situated outside of the center, all academic classes are being conducted within the
living modules. The teachers are mobile from class-to-class and the youth remain in their
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 20 of 56 (Revised July 2023)
assigned living module. A review of logbooks from March 2024 to February 2025 verified the
center successfully moved the youth to class on time for each reviewed date; however, on six
instances, teachers arrived late causing classes to start five to sixty minutes after the scheduled
time and four instances where teachers left earlier than the scheduled end time. An informal
interview with the center’s administration confirmed attempts to contact the school district
regarding this issue were made. Reviewed documentation confirmed the communication with
the district identifying the expectations of the teachers to follow the schedule and be available
for the start of the academic day. Seven youth and staff interviews confirmed there were
minimal interruptions to the class schedule. Five youth stated the center was preparing them
effectively while two youth stated moderately well for school or employment. The center’s
superintendent stated the ongoing classes were being conducted without interruptions.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide career education. The center provides
career education categorized as Type 1 which emphasizes soft skills, interpersonal, and
decision-making skills. Seven youth were interviewed and confirmed enrollment in math,
science, history, reading, career choices, and social studies.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures ensuring a single licensed mental health
professional serves as the designated mental health clinician authority (DMHCA) to oversee
appropriate coordination and implementation of mental health and substance abuse services.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The DMHCA is a
licensed clinical social worker (LCSW) with a clear and active license in the State of Florida,
with an expiration date of March 31, 2027. The DMHCA is a full-time staff and scheduled to be
on-site weekly, for enough time to ensure appropriate coordination and implementation of
mental health and substance abuse services were taking place. A review of the mental health
sign-in logbook confirmed the DMHCA was on-site, as required. The DMHCA is available seven
days a week, twenty-four hours a day, by way of telephone for consultation. At the time of the
annual compliance review the center did not utilize a back-up DMHCA. During an interview the
DMHCA indicated they communicate with detention and on-site mental health staff throughout
the day to address any mental health or substance abuse needs and outstanding issues or
processes concerning youth. The DMHCA ensures youth who are in the center for thirty days or
more, unless behavior warrants mental health services prior to thirty days, receive mental health
treatment through inviting them to treatment team to discuss what clinical interventions they
would like to work on while detained. Once the youth is opened for services the DMHCA will
track the youth’s progress and ensure services are provided by what is prescribed on the
treatment plan and communicate with the treatment team and parent/guardian accordingly.
Daily coordination with mental health staff, supervisors, and briefing with the superintendent, or
designee takes place throughout the day regarding youth who are high-risk or any youth who
may need assistance from mental health. Once each week during treatment team all youth who
are receiving mental health services are discussed using a team approach with education, the
superintendent, or designee, and medical. Additionally, every Monday the psychiatrist sees any
referred youth for telepsychiatry as needed.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department sustains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The center requires
mental health and substance abuse services to be provided by individuals with appropriate
qualifications. The clinical supervisor ensures the licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. A review of the licensed clinicians’ credentials confirmed two had an active
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 22 of 56 (Revised July 2023)
license in the State of Florida for a licensed mental health counselor (LMHC), with an expiration
date of March 31, 2027. Two staff were a licensed clinical social worker (LCSW) with an active
license in the State of Florida expiring on March 31, 2027. The Department maintains a contract
with VitalCore Health Strategies, LLC ensuring mental health and substance abuse services are
provided to all applicable youth in the center. The center does not have a Chapter 397 license
with the Department of Children and Families. Reviewed documentation confirmed only the
licensed mental health counselors were facilitating all substance abuse treatment and groups.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC ensuring mental
health and substance abuse services are provided to all applicable youth in the center. The
center does not have a Chapter 397 license with the Department of Children and Families. At
the time of the annual compliance review the center had one non-licensed mental health and
substance abuse clinical staff in accordance with current contract to include the required hours.
The non-licensed staff received direct supervision by the clinical supervisor for each week the
staff provided services. The staff supervision was documented on the Department’s form.
Additionally, the staff held a master’s-level degree from an accredited university or college in the
field of counseling, social work, psychology, or related human services field and the non-
licensed mental health clinical staff who conducted the Assessments of Suicide Risk completed
twenty hours of training and supervised experience in assessing suicide risk, mental health
crisis intervention, and emergency mental health services. A review of documentation showed
only the licensed mental health counselors were facilitating all substance abuse treatment and
groups.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures regarding the mental health and substance abuse
needs of youth who are identified through a comprehensive screening process. The center’s
policy requires referrals to be made when youth are identified with mental health and/or
substance abuse needs, and/or are identified as a possible suicide risk in accordance with
Florida Administrative Code. A review of seven youth mental health and substance abuse
records showed initial screening documents were completed by a probation officer and were
reviewed by a detention staff. A review of documentation showed the Suicide Risk Screening
Instrument (SRSI) was completed at the time of the youth’s intake and the Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) was completed in the Department’s Juvenile
Justice Information System (JJIS). Nursing staff completed the required sections of the SRSI
screening and completed entries to include the accurate referral selections in the “Screening
Results” section. Three of seven reviewed screenings showed the youth had positive “YES”
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 56 (Revised July 2023)
responses on the SRSI; therefore, the youth were placed on suicide precautions and a mental
health referral was completed, documenting the youth’s need for an Assessment of Suicide Risk
(ASR). Each of the three youth whose SRSI screening had a “YES” response had a suicide risk
alert entered in the Department’s JJIS. All seven reviewed screenings were completed by
trained detention staff. None of the seven reviewed youth were applicable for all negative
responses resulting in an “invalid” screening. Each reviewed screening indicated further
assessment was required and a referral was made. Each assessment showed the
superintendent was notified. Four of the seven reviewed MAYSI-2 screenings confirmed an
elevated suicide risk subscale, and the youth were placed on suicide precautions and referred
for an ASR. Four of seven results of the MAYSI-2 confirmed the need for a comprehensive
assessment and confirmed the screener referred the youth to mental health clinical staff for a
comprehensive assessment/Society for Adolescent Health and Medicine (SAMH) assessment
within the detention center.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures regarding the process to identify the mental health
and substance abuse needs of youth through a comprehensive screening. The center’s policy
requires the youth with identified needs to be referred for a further mental health and/or
substance abuse evaluation. A review of seven youth records showed each youth was identified
after an admission and was referred for an evaluation. Each of the seven youth was applicable
for a comprehensive mental health evaluation; however, none were applicable for an updated
substance abuse and mental health assessment completed by center staff. Each were
applicable for a new Society for Adolescent Health and Medicine (SAMH) assessment
completed by center staff and each assessment’s treatment recommendations were made and
corresponded with a diagnosed mental health or substance-related disorders. The
comprehensive mental health and substance abuse evaluation consists of the SAMH
assessment, which was completed in the Department’s Office of Health Services (OHS)
electronic medical record (EMR). At the time of the annual compliance review and interview was
conducted with the designated mental health clinician authority (DMHCA), indicating the
DMHCA will search the Department’s Juvenile Justice Information System (JJIS) to confirm if
the youth have an updated comprehensive evaluation. In the event the youth doesn't have an
updated comprehensive evaluation, the juvenile probation officer (JPO) will be contacted to
determine if one has been completed. If the JPO responds with an updated comprehensive
evaluation mental health will update and upload the comprehensive evaluation. In the event no
response is obtained from the JPO, mental health will complete a SAMH by the thirty-first day
and input the assessment in the EMR. Additionally, the DMHCA will search JJIS to confirm the
youth has an updated comprehensive evaluation.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 24 of 56 (Revised July 2023)
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures for mental health and substance abuse treatment
and discharge planning. The provider’s contract requires the superintendent and designated
mental health clinician authority (DMHCA), or mental health and substance abuse clinical staff
to ensure the development and review of an initial and/or individualized treatment plan for each
youth receiving mental health and substance abuse treatment in the center. A review of seven
youth mental health and substance abuse records indicated each was applicable for mental
health and substance abuse treatment services. Each of the seven youth received a mental
health orientation which was held within fourteen days of admission. Three of the seven youth
required a treatment plan. A review of documentation showed the initial treatment plans were in
place within seven days of the onset of treatment, and each plan was developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each applicable plan
documented the reason for referral for treatment, initial Diagnostic and Statistical Manual, Fifth
Edition (DSM-5) diagnosis/symptoms, initial treatment methods including counseling and
frequency, initial treatment goals, psychotropic medication and frequency of monitoring, the
medication the youth was admitted with to compare with the initial treatment plan, mental
health/substance abuse professional’s signature, and youth’s signature. Additionally, each of
the three-youth were assigned a mini-treatment team. Documentation confirmed the members
involved in development of the initial treatment plan were present. Each initial treatment plan
listed the psychotropic medications the youth was prescribed at the time of the treatment plan,
to include progress notes which validated the youth was receiving treatment services as
indicated on the treatment plan. Documentation showed each of the three applicable youth had
an individualized treatment plan. The individualized treatment plan was developed for youth
receiving mental health and/or substance abuse treatment in the center by the thirty-first day of
the youth’s admission. The plan included the DSM-5 diagnosis, symptoms which were
treatment-focused, treatment goals including mental health services if the youth have a mental
illness, and substance abuse services if the youth have a substance-related diagnosis, and the
youth’s strengths and needs. Additionally, the individualized treatment plan was signed and
dated by the youth, the mental health/substance abuse professionals, treatment team members,
and the parent/guardian. Two of the three applicable youth required three thirty-day periods
requiring individual treatment plan reviews and the other youth only required one. Each
individualized treatment plan was reviewed every thirty days by the treatment team and
modifications were documented on the review form and clearly identified as such. Reviewed
documentation indicated the individualized treatment plan reviews were signed and dated by the
clinical staff, youth, licensed mental health professional, treatment team members, and the
parent/guardian. The treatment plan included treatment and services provided by a licensed
psychiatrist. Two of the three applicable youth were an alleged victim of a Prison Rape
Elimination Act (PREA) event, where the youth’s treatment plan included or was revised to
include mental health treatment services which address the youth’s needs if the Crisis
Assessment indicated a need for adjusted or additional services. Three records were reviewed
for discharge summaries. Each of the three reviewed mental health and substance abuse
treatment discharge summaries were documented on the Department’s Mental Health and
Substance Treatment Discharge Summary form upon the youth’s discharge. A copy of the
treatment discharge summaries were provided to each youth, parent/guardian, and juvenile
probation officer (JPO). Each discharge summary included the completion day of service,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 25 of 56 (Revised July 2023)
signature of the licensed mental health professional and additional documentation was
completed and uploaded within fourteen days. During the annual compliance review, a mini
treatment team meeting was observed. In attendance was mental health, medical staff, and
education staff. At the time of the mini treatment team meeting, the youth’s education goals,
behavior, and medication were discussed. An interview was conducted with the DMHCA, and it
was revealed once the youth is open and receptive to engaging in services, mental health is
responsible for tracking the youth by using a caseload tool to ensure services are provided. The
DMHCA reviews caseloads with mental health staff and will meet with the youth to review the
comprehensive evaluation and process any information with the youth and utilize the
comprehensive evaluation as a basis for developing the youth's individual treatment plan. Once
a treatment plan is completed, mental health staff will ensure the youth is seen at least once a
week to address and review treatment plan needs and work on their identified goals and
objectives. Youth's progress will be monitored through attendance of treatment team and
treatment plan reviews will be conducted at least every thirty days. Mental health staff meet with
administration informally daily, and mental health staff formally meet with administration at least
two times a week during department head and treatment team meetings.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The provider has a written policy and procedures ensuring mental health and substance abuse
treatment planning focuses on treatment provisions to reduce or alleviate youth’s symptoms of
mental disorder or substance abuse impairment and enable youth to function adequately in the
juvenile justice setting. A review of seven youth mental health and substance abuse records
showed three of the seven youth required treatment and were assigned to a mini-treatment
team consisting of a mental health staff, a staff from a different service area, youth, and the
youth’s parent/guardian if possible. Each of the applicable youth received individual, group, or
family counseling provided according to frequencies required by their plans. The reviewed plans
included individual, group, and or family therapy prescribed at least weekly. Only one of the
three youth were applicable for substance abuse treatment. Reviewed documentation confirmed
each youth had an Authority for Evaluation and Treatment (AET). For the one youth who was
applicable for substance abuse services the proper consent for substance abuse treatment was
obtained through the signed mental health substance abuse form and for the release of records
the proper consent for substance abuse treatment records release was obtained through a
signed form. A review of treatment notes was conducted, and notes were documented on the
Department’s Counseling/Therapy Progress Notes form and included the required elements. At
the time of the annual compliance review, videos were observed and confirmed groups were
conducted, as scheduled. Observations revealed mental health staff at the center had adequate
access to youth and confidential space to provide treatment services. It was determined through
reviewed documentation and sign-in sheets, group therapy was limited to ten or fewer youth
with mental health diagnoses. Documentation review showed group therapy was limited to
fifteen or fewer youth with substance abuse diagnoses. An interview was conducted with seven
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 26 of 56 (Revised July 2023)
youth. Three of the youth stated mental health services are good and the other four youth stated
mental health services are very good. An interview with the designated mental health clinician
authority (DMHCA) confirmed youth who are at the center for at least thirty days or more, unless
behavior warrants mental health services prior to those thirty days, will receive mental health
treatment through inviting the youth to a treatment team meeting to discuss what clinical
intervention they would like to work on while detained. Once the youth accept services, mental
health staff will meet with the youth to review the comprehensive evaluation together and
process any information needed by the youth. The comprehensive evaluation will be utilized to
serve as a basis to develop the youth's individual treatment plans. Once the treatment plan is
completed mental health meets with the youth once a week for group/individual sessions to
work on their identified goals and objectives prior to the target date.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures summarizing the provision of psychiatric services to
youth in need, to include psychiatric evaluation, consultation, medication management, and
medical supportive counseling. The policy requires the center to provide psychiatric services to
the youth determined to need services, as indicated by symptoms of mental disorder or
substance-related disorder, or to youth who are treated with psychotropic medication after their
admission to the center. The center maintains a contract with VitalCore Health Strategies, LLC.,
for the provision of a licensed psychiatrist to provide psychiatric services for applicable youth in
the center. A review of the psychiatrist’s license confirmed they maintain a clear and active
license with an expiration date of March 31, 2026. The center does not utilize an advanced
practice registered nurse (APRN) and did not have a back-up psychiatrist used since the last
annual compliance review. The center utilizes tele-psychiatry inclusion, as needed. None of the
seven reviewed records showed the youth entered the center on psychotropic medication or
were referred for a psychiatric interview; therefore, three additional records were requested. A
review of three mental health and substance abuse records confirmed each of the applicable
youth entered the center on psychotropic medication were referred for a psychiatric interview
within fourteen days of the youth’s admission to the center. Each reviewed Clinical Psychotropic
Progress Note (CPPN) confirmed the Initial Diagnostic Psychiatric Interview included the youth’s
reason for the referral, the youth’s history of medical, mental health and substance abuse, a
Mental Status Examination, a Diagnostic and Statistical Manual, Fifth Edition (DSM-5)
diagnosis, treatment recommendations specific to mental health and/or substance abuse
diagnoses, prescribed medication, documentation of medication name, and an explanation of
the need for psychotropic medication. Each initial psychiatric interview documented the
medication name, an explanation of the need for the psychotropic medication, and the
frequency of medication monitoring/management for each youth. The CPPN showed the Initial
Diagnostic Psychiatric Interview included history of psychiatric illness, psychotropic medication
management, mental health treatment and/or substance abuse treatment, and assessment of
symptoms. Each of the three applicable reviewed CPPN’s revealed the Initial Diagnostic
Psychiatric Interview included the identification of individual, family, and/or environmental
factors which may potentially account for, influence or ameliorate the youth’s difficulties, DSM-5
diagnoses, prescribed medication, explanation of the need for psychotropic medication related
to the youth’s diagnosis, target symptoms, potential side effects, risks, and benefits of taking the
medication, signature of the practitioner conducting the psychiatric evaluation, and each CPPN
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 27 of 56 (Revised July 2023)
was clearly identified as a psychiatric evaluation. Reviewed applicable youth’s evaluations
included the youth’s name, date of birth, Department of Juvenile Justice Identification Number
(DJJID), diagnosis, target symptoms of each medication, evaluation and description of effect of
prescribed medication on target symptom(s), prescribed psychotropic medication, including the
name, dosage and quantity of the medication, normal dosage range, ordered dosage, frequency
and route of administration, reasons for changes in medication and/or dosage. Additionally,
included were side effects, youth’s adherence to the medication regime, height, weight, blood
pressure, applicable most recent serum drug levels or laboratory findings, whether there was
telephone contact with the youth’s parent/guardian to discuss medication, signature of the
psychiatrist, date of signature, and the documented monitoring for Tardive Dyskinesia monthly
as indicated on the CPPN. Each of the three youth records had a current Authority for
Evaluation and Treatment (AET) consenting the continuation of the psychotropic medication. All
three applicable youth records contained the third page of the CPPN when new psychotropic
medications were prescribed or if there were any changes to the existing prescription. At the
time of the annual compliance review none of the three youth were eighteen years of age while
in the center and was responsible for authorizing their health care and/or authorizing the release
of their healthcare records. The center provides the standard of psychiatric care delivered
through tele-psychiatry the same as rendered in-person; however, none of the reviewed youth
or parents/guardians agreed to participate in the tele-psychiatry session; therefore in-person
sessions were conducted. An interview with the DMHCA indicated most of the youth at the
center prefer face-to-face contact for all psychiatry sessions and each of the youth selected
parents/guardians agreed; therefore, a tele-psychiatry session consent was not obtained.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures and a Suicide Prevention Plan. The center has a
written plan detailing suicide prevention procedures, which was reviewed and signed by the
designated mental health clinician authority (DMHCA) and superintendent annually. The plan
included identification and assessment of youth at risk of suicide, staff training of at least six
hours of training annually on suicide prevention and implementation of suicide precautions,
which includes quarterly mock suicide drills for all staff who encounter youth on each shift,
suicide precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and review process. The center has an established review process
for every serious suicide attempt or serious self-inflicted injury requiring hospitalization or
medical attention, and a mortality review for a completed suicide. The multidisciplinary review
includes the circumstances surrounding the event, center procedures relevant to the incident, all
relevant training received by involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, recommendations, if any, for changes in
policy, training, physical plant, medical or mental health services, and/or operational
procedures.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 28 of 56 (Revised July 2023)
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures ensuring suicide prevention services. The policy
and procedures address supervising, observing, monitoring, and housing youth identified
through screenings, documentation, and observation as being at risk for suicide, and protect
youth with elevated risk of suicide in the least restrictive means possible. All youth identified as
having suicide risk factors by screening, information obtained regarding the youth, or staff
observations must be placed on suicide precautions and receive an Assessment of Suicide Risk
(ASR). None of the reviewed youth were applicable; therefore, three additional records were
selected. A review of mental health and substance abuse records indicated each youth was
placed on precautionary observation at the time of admission until an ASR was completed. The
Department's Juvenile Justice Information System (JJIS) showed youth alerts were entered in
the system. Reviewed documentation confirmed suicide risk assessment referral dates and
times. A review of documentation revealed the ASR was completed on the Department’s form.
All three applicable youth had a standard level of supervision prior to the completion of the ASR.
A review of documentation determined the Suicide Precautions-Observation Logs were
completed in their entirety by a qualified mental health professional to include safe housing
areas, and all required signatures and a mental health professional was involved. Each record
showed mental health staff documented there was a consultation with the designated mental
health clinician authority (DMHCA) or licensed mental health professional on the Mental
Health/Substance Abuse Referral Summary form. All three applicable youth records revealed
the superintendent, or designee was notified immediately of suicide risk, and the ASRs were
completed within twenty-four hours. A review of documentation indicated each youth had a
Follow-Up ASR completed prior to their removal from precautionary observation. Reviewed
documentation showed a conference was conducted by the superintendent and licensed mental
health professional to determine the reduction of the youth’s level of supervision. Reviewed
logbooks showed the date and time of discontinuation of suicide precautions was documented.
Each of the three applicable youth’s ASRs were documented as completed by a licensed mental
health professional and a review of the assessment results included recommendations for
supervision and follow-up. Documentation in the center’s logbook and on the suicide risk
assessment confirmed administration or supervisory staff provided specific instructions related
to the suicide risk assessment findings and suicide precaution decisions. A review of JJIS
determined alerts were appropriately entered and removed following each youth being removed
from precautionary observation. Additionally, reviewed logbooks determined beginning and
ending times were documented for youth placed on precautions. An interview with the DMHCA
indicated mental health staff document all meeting and communication with youth on
supervision in their electronic medical record (EMR), through means of the ASR, Suicide Risk
Screening Instrument (SRSI), progress notes, and/or chronological notes. Once it is decided if a
youth will remain on precautionary observation, detention staff will be notified of the
recommended supervision level of the youth. Mental health staff will contact the youth’s juvenile
probation officer (JPO), and parent/guardian on youth's status, as well as the recommended
supervision level.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 29 of 56 (Revised July 2023)
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures regarding secure observation. The policy requires
youth placed on suicide precautions to remain under secure observation if less restrictive
methods are not effective. A review of seven youth records were reviewed and none were
applicable; therefore, a request for three additional records was made. Each of the three
applicable youth’s placements were authorized by the superintendent and the designated
mental health clinician authority (DMHCA) and the secure rooms were designated in writing. A
review of the Department's Juvenile Justice Information System (JJIS) showed each youth had
a completed Health Status Checklist form completed prior to each youth’s placement in secure
observation. Reviewed documentation of the Secure Observation Logs revealed each was
completed in its entirety. A review of documentation showed within eight hours of placement, a
new Assessment of Suicide Risk (ASR) was completed for each of the applicable youth, and the
youth’s parent/guardian was notified of the youth’s potential suicide risk as indicated by the
ASR. Additionally, a review of documentation showed the youth’s juvenile probation officer
(JPO) was notified of a youth’s potential suicide risk as indicated by an ASR. A review of
documentation indicated each youth remained on secure observation beyond twenty-four hours,
a mental health professional provided written support for continuation and provided supportive
counseling services during secure observation status. A review of the observation logs was
conducted and showed documented supervisions were noted. Reviewed documentation
confirmed the level was reduced after a conference with the superintendent and licensed mental
health professional, which was conducted to determine the discontinuation of secure
observation and step-down to close supervision. Supervision levels were documented in the
center’s logbook as well as in the youth’s mental health record by mental health clinical staff.
3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures for the process to safely screen, refer, assess,
monitor, and protect youth with elevated suicide risk in the least restrictive means possible. A
review of seven youth mental health and substance abuse records showed none were
applicable for suicide precaution observation; therefore, three additional records were
requested. The three applicable youth mental health and substance abuse records confirmed
each youth had a maintained Suicide Precautions-Observation Log. Each youth’s appropriate
level of supervision and observations of the youth’s behavior was documented in real time and
did not exceed thirty-minute intervals. When warning signs were observed, there was a
notification to the superintendent or designee and mental health clinical staff documented on the
Suicide Precautions-Observation Log. A review of each of the three applicable youth logs
showed the logs were reviewed and signed by each shift supervisor and mental health clinical
staff. Each of the three logs documented the safe housing requirements. An observation of the
center’s video footage was conducted for three dates and the documentation of youth placed on
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 30 of 56 (Revised July 2023)
precautionary observation revealed each youth was placed on constant supervision and
supervision was always maintained by the detention staff.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures to address suicide prevention training. The policy
requires all staff who work with youth to be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions. Seven in-
service and seven pre-service staff training records were reviewed. Each of the seven reviewed
staff records showed trainings to include suicide drills held quarterly on each shift. The center
has a total of five suicide response kits located in master control, sub control on each of the
youth’s living modules, and in the medical department. The suicide response kits are co-located
with the first-aid kits. A review of documentation confirmed mock suicide drills were conducted
quarterly for the past twelve months and were completed on each of the center’s shifts, to
include Alpha (A), Bravo (B) and Charlie (C). A review of documentation showed the past twelve
months of suicide drills included the use of cardiopulmonary resuscitation (CPR), suicide
response kits, automated external defibrillator (AED) and first-aid. Drills were documented in the
logbook with a sign-in sheet to confirm the center’s staff participated in the drills. Each of the
trainings included mock suicide drills occurring quarterly on each shift, for all staff who
encounter youth to include maintenance and the center’s kitchen staff. Each mock mental health
drill was in response to a suicide attempt and/or incident of serious self-injury, were simulated,
and did not include any youth. The center provides semi-annual trainings on emergency
response procedures to include mock training in emergency response to a suicide attempt or
incident of serious self-inflicted injury to include the use of CPR. An interview with the
designated mental health clinician authority (DMHCA) confirmed if staff are not available at the
time of the mock drills, the staff will be updated during shift briefings and the simulation of the
drills are in the briefing room to include updates as needed. An interview was conducted with
seven staff at the center, and it was revealed the rescue tool, wire cutters, needle nose pliers
and suicide response kits are in master control, sub control, medical, and the shift supervisor’s
office.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures to make sure the center responds to youth in crisis
in the least restrictive means possible to protect the safety of the youth and others while
maintaining control and safety of the center. The center maintains a Combined Emergency
Services Plan which includes procedures such as notification and alert system, means of
referral including youth self-referral, communication, supervision, documentation, and review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 56 (Revised July 2023)
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a written Emergency Care Plan outlining mental health and substance abuse
emergency procedures for youth who are believed to be an imminent danger to themselves or
others because of mental illness or substance abuse impairment. The plan includes immediate
staff response, notifications, supervision, authorization to transport for emergency mental health
or substance abuse services, transport for emergency mental health evaluation and treatment,
transport for emergency substance abuse assessment and treatment, documentation, training,
and review. The plan was approved on January 21, 2025, and was last updated on March 20,
2024. The plan is in the superintendent’s office, mental health office, master control, and online.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has a written Emergency Care Plan indicating the response procedures for youth in
crisis. Seven youth records were reviewed, and none were applicable for a Crisis Assessment.
Three additional records were requested to meet the minimum requirement. Each of the three
assessments were completed the same day the youth was determined to be in crisis. All three
Crisis Assessment documented the reason for assessment, a Mental Status Examination and
interview, determination of danger to self and others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
evaluation, and notification to the parent/guardian of follow-up treatment. When applicable, a
mental health alert was entered into the Department’s Juvenile Justice Information System
(JJIS) when the youth was placed on precautions after completion of a Crisis Assessment. Each
youth’s assessment was completed by a licensed mental health professional within the required
time frame. All three youth were an alleged victim in a Prison Rape Elimination Act (PREA)
event and were offered ongoing mental health treatment services.
3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 32 of 56 (Revised July 2023)
The center has a written policy and procedures addressing Baker and Marchman Acts. A review
of seven youth mental health records revealed none were applicable for requiring Baker Act
procedures. Three additional records were requested to meet the minimum requirement. All
three youth were placed on suicide precautions upon re-admission following the Baker Act
placement. Each youth had a completed mental health referral for a Mental Status Examination
(MSE) completed by or under the direct supervision of a licensed mental health professional. All
three youth were maintained on one-to-one supervision until properly transitioned to a lower
level of supervision. Documentation showed supervision levels were lowered for each youth
after an appropriate assessment was conducted by a licensed mental health professional, and
mental health staff conferred with the licensed supervisor and superintendent or designee. Each
youth had a suicide risk alert in the Department’s Juvenile Justice Information System (JJIS),
and the discontinuation of the alerts and precautions were based upon an Assessment of
Suicide Risk.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 33 of 56 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures requiring a contractual agreement with a licensed
physician to serve as the designated health authority (DHA). The center maintains a contract
with VitalCore Health Strategies, LLC, which subcontracts with a licensed physician to serve as
the center’s DHA. The center has a board-eligible physician who is a licensed DO who holds an
unrestricted license with an expiration date of January 31, 2027, and meets all requirements for
independent and unsupervised practice in Florida to serve as the DHA. The physician’s
specialty training is in pediatrics and demonstrated prior experience in treating primary health
care needs of adolescents. Additionally, the center utilizes an advanced practice registered
nurse (APRN) who has a Collaborative Practice Protocol (CPP) in place with the physician who
is serving as the center’s DHA. A review of the sign-in and sign-out logs during the annual
compliance review period confirmed the DHA was on-site at least two hours each week, with a
week defined as the seven-day period beginning on Sunday and ending on Saturday. While the
DHA was on vacation or scheduled absences, the center has a back-up DHA who was utilized
once. The back-up DHA has a license with an expiration date of March 31, 2026. When the
DHA designated another medical doctor (MD) to provide the clinical services on-site, the DHA
performed the administrative duties to include supervising the medical department at the center,
completing the Comprehensive Physical Assessments (CPA), policy and procedure
development, completing sick call, and completing episodic evaluations. The DHA is
responsible for revising and editing all policies and procedures for medical and non-medical
personnel. A review of documentation revealed the sign-in and sign-out of the tele-medicine
practitioner was utilized. The tele-medicine was used for three out of every four weeks with the
Department’s approval. An interview with the center’s DHA revealed they are on-site once each
week, communicate with the center’s staff by direct telephone calls regarding youth’s medical
needs, and they are available twenty-four hours a day, seven days a week by telephone for on-
site clinical services. The DHA ensures all off-site care findings are valid and updated on a log
with all information ready to be reviewed. Additionally, if coverage is needed in the DHA’s
absence, it is arranged by direct communication with another physician.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures (FOPs) for all health-related protocols utilized.
Reviewed documentation confirmed all representatives from relevant disciplines signed the
appropriate sections of the FOPs and conducted an annual review of all healthcare protocols.
The center’s designated health authority (DHA) signed January 8, 2025, the superintendent
signed January 28, 2025, the psychiatrist signed January 28, 2025, and nursing staff signed
January 30, 2025. Documentation revealed changes in policies were made during the year were
reviewed, signed, and dated by each nurse on the individual policy change and signature page
with the specific policy listed, date of revision, and signatures. At a minimum, an annual review
of medical policies, procedures, and protocols was conducted as required on January 30, 2025.
The psychiatrist reviewed and developed the FOPs, or other protocols related to psychiatric
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 56 (Revised July 2023)
services and psychotropic medication management. Reviewed documentation indicated FOPs
for all health-related procedures and treatment protocols were utilized at the center, all newly
employed healthcare personnel received a comprehensive clinical orientation to the
Department’s health care policies and procedures, given by a registered nurse (RN) and the
approval of treatment protocols or standing procedures were written and authorized by the DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures requiring the parent/guardian to be afforded the
right to give or withhold consent regarding the healthcare provided to the youth, which ensures
the completion of the Authority for Evaluation and Treatment (AET) for all youth admitted into
the center. A review of seven youth Individual Healthcare Records (IHCRs) confirmed an AET
was filed in six of the seven IHCRs. One youth was applicable for being over the age of
eighteen. The original AET form was filed for the six applicable records and/or legible copy with
the word “copy” was filed in the IHCR. The AET form was signed by the youth’s
parent/guardian, and the AET was obtained prior to providing medical services. Reviewed
documentation indicated each AET form was valid and signed by a Department representative.
One youth was eighteen years of age and there was a documented release of information form
in the IHCR. None of the reviewed youth were applicable for a limited consent for evaluation
and treatment.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures outlining requirements to ensure the
parent/guardian is notified of significant changes in the youth’s condition and obtain consent
when new medications and treatments are prescribed. A review of seven youth Individual
Healthcare Records (IHCRs) indicated five were applicable for notification to be included for
parental notification for over-the-counter (OTC) medications beyond those covered by the
Authority for Evaluation and Treatment (AET) Consent was provided by the parent/guardian,
and written notifications were sent utilizing the Department’s Parental Notification of Health-
Related Care form. Reviewed documentation revealed none of the seven youth were taking
psychotropic medications at admission. There were three youth placed on medications after
admission and documentation revealed new medication was ordered. Documentation confirmed
the attempted contact to the parent/guardian in the progress notes and written parental notices
were sent regardless of telephone notifications. There was evidence of written parental
notification/consent showing an attempt was made to obtain the signed parent/guardian consent
for each of the three applicable youth. None of the seven reviewed youth had Department of
Children and Family (DCF) involvement. Additionally, documentation confirmed each of the
seven reviewed IHCR’s verified vaccines within thirty days of the youth’s admission. An
interview with nursing staff confirmed parental notifications are required when there are
significant changes in the youth’s condition and when consent is obtained for new medications
and treatments prescribed. Nursing staff indicated the process for ensuring timely parental
notifications are made is to have nursing staff call right away to notify the parent/guardian when
new orders are given. An interview with the nursing staff confirmed the procedures regarding
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 35 of 56 (Revised July 2023)
informing the parent/guardian when obtaining consent for new psychotropic medications,
discontinuances, or psychotropic medication adjustments. All verbal attempts, contacts, and
consents shall be documented in the chronological progress notes in the IHCR by the staff
attempting and/or contacting the parent/guardian. For psychotropic medications, verbal
attempts, contacts, and consents shall be documented on the third page of the CPPN or on an
informed consent chronological progress note.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures to ensure each youth receives a screening for
health concerns upon admission, or at a minimum, each time the physical custody of the youth
changes and they are returned or re-admitted to the center. A review of seven Individual
Healthcare Records (IHCRs) indicated the Medical and Mental Health Admission Screening
Form was completed on the date of admission by a juvenile justice detention officer supervisor
(JJDOS). The screenings were reviewed with the youth by a licensed medical staff, within
twenty-four hours. None of the seven reviewed youth had a change in their physical custody
since their arrival. None of the youth were applicable to receive a qualitative urine pregnancy
screening test. An interview with the nursing staff indicated newly admitted youth are seen
within twenty-four hours of admission. The staff is notified when youth are admitted to the center
by intake packets placed in the medical mailbox located in the administration area as youth are
admitted to the center. Additionally, the medical clinic manager reviews the daily census for any
changes in the number of youth.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures for youth orientation to healthcare services. A
review of seven Individual Healthcare Records (IHCRs) confirmed each youth received a
general care orientation on the day of admission to the center. Each record contained a
completed Department Health Education Record form documenting the youth’s orientation to
the center’s healthcare services within twenty-four hours of admission to the center. Each youth
orientation included topics addressing access to medical care, sick call, what constitutes an
emergency and when to notify staff, medication processes to include side effect monitoring, the
right to refuse care and how it is documented, what to do in 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. Each youth received a general healthcare orientation, and the
health education topics were documented on the Department’s form.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 56 (Revised July 2023)
The center has facility operating procedures to ensure the designated health authority (DHA) is
notified when youth are admitted to the center. It is the center’s practice to notify the DHA of all
new admissions regardless of their medical condition and the notification is documented in the
admission chronological progress note. A review of seven Individual Healthcare Records
(IHCRs) revealed three were applicable for known or suspected chronic conditions and had
evidence of a referral to the physician/advanced practice registered nurse (APRN). None of the
applicable youth’s identified chronic condition was in-need of emergency care upon admission.
Each of the three-youth had notification to the DHA documented in the youth’s chronological
progress notes within their IHCR and documentation confirmed the DHA was notified within
twelve hours of admission, and no later than noon the day following admission. None of the
youth were currently taking psychotropic medication upon admission. An interview with nursing
staff indicated the DHA is notified at the time of the youth’s admission when a youth has a
serious or chronic condition.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures ensuring the nursing staff complete the
Department’s Health-Related History (HRH) form prior to the Comprehensive Physical
Assessment (CPA). A review of seven Individual Healthcare Records (IHCRs) confirmed the
HRH was completed within seven calendar days of the youth’s admission and was
updated/completed prior to the CPA focused evaluation, as evidenced by signature and date.
Reviewed documentation confirmed each CPA was completed by a licensed nurse, was
reviewed by the designated health authority (DHA), and a review of the HRH forms confirmed
signatures and dates for the most current admission. An interview with nursing staff confirmed
the HRH is completed within seven days of admission and is completed by a licensed nurse or
practitioner.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures (FOPs) ensuring each youth admitted shall receive
and/or shall have on record a current Comprehensive Physical Assessment (CPA) and Health
Related History (HRH) form completed no later than seven calendar days of admission into the
center. A review of seven Individual Healthcare Records (IHCRs) showed each youth’s CPA
was completed on the Department’s CPA form with a current CPA on file at admission. One of
the reviewed CPA’s were completed by the center’s medical doctor and the other six were
completed by the center’s advanced practice registered nurse (APRN). Each showed the
youth’s Medical Grade on the CPA. Each youth received a new CPA upon admission into the
center. None of the youth were applicable for a focused evaluation upon readmission. All
sections of the CPA were marked with an O, or an X. Documentation revealed each youth
refused a portion of the exam, and it was clearly marked on the CPA as a refusal on the date of
the exam, with a refusal form filed in the youth’s IHCR. Each youth’s Problem List was updated.
Additionally, for each of the seven youth there was at least one verified Tuberculosis Skin Test
(TST) formerly purified protein derivative (PPD) test documented in the IHCR within the last
year or a chest x-ray if the TST was refused. The results of the TSTs documented on the CPA
and Infectious and Communicable Disease (ICD) forms matched. Each Tier I Tuberculosis (TB)
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 56 (Revised July 2023)
screening was completed within seventy-two hours. There was a review of the center’s FOPs
for appropriate documentation of when any part of the exam is not conducted and/or refused by
the youth with no discrepancies and the center’s FOPs were reviewed for TSTs and the
rescreening process which aligned with the program’s practices. An interview with nursing staff
confirmed the designated health authority (DHA) completes the CPA no later than seven
calendar days following the date of admission.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures in place to ensure all youth entering the center are
clinically screened, evaluated, and treated, if necessary, for sexually transmitted infections
(STIs) and human immunodeficiency virus (HIV). The center’s policy and procedures reflected
HIV test results are only disclosed to the youth with the youth’s legally authorized
representative, health care providers during the course of consultation, diagnosis, or treatment
of the individual the Department of Health for purposes of reporting and controlling the spread of
disease, health facility staff committees conducting center monitoring, evaluation, and service
reviews, medical personnel who have been subjected to a significant exposure, and health care
facility personnel or agents for the healthcare provider who have a need to know in the course
of patient care activities or administrative operations. A review of seven Individual Healthcare
Records (IHCRs) showed six were sexually active and clinically screened and evaluated for
STIs. Each youth screened showed the date of the evaluation. The date of the testing for the six
applicable youth was noted, with the date the testing was performed. Testing, screening results,
clinical evaluations, and diagnoses were documented on the infectious and communicable
disease (ICD) form, excluding HIV results and filed in the lab section of the six youth’s IHCRs.
All HIV test results were filed in a confidential sealed envelope as required. Reviewed
documentation revealed each of the six youth was offered counseling, testing, and if indicated,
treatment/referral for HIV. The six applicable youth received HIV testing and there was evidence
of documented consents from each youth obtained by the center. Reviewed documentation
confirmed pre-test/post-test counseling was documented on the individual health education
record and/or was in the youth’s progress notes and the youth’s confidentiality was protected by
not including the youth’s HIV status or any other STI diagnosis on the center’s internal alert
system. An interview with seven youth confirmed each youth was able to ask for and HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures ensuring all youth can make sick call requests and
have their complaints treated appropriately through the sick call system. Sick call care, including
dental complaints are available to all youth. A review of seven Individual Healthcare Records
(IHCRs) revealed six were applicable for sick calls. Each youth’s sick call was documented on
the Sick Call Referral Log. None of the applicable youth were presented with similar sick call
complaints three or more times within a two-week period. None of the six applicable youth had
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 38 of 56 (Revised July 2023)
complaints of severe pain with which staff was unfamiliar and the youth’s medical condition
could not be determined. Documentation showed each of the six youth and nursing staff
completed a Sick Call Request form found in the IHCR in reverse chronological order, with
documentation in accordance with Florida Administrative Code. The dates listed on the Sick Call
Index corresponded to the completed Sick Call Request forms in the IHCR. A review of the daily
schedule, posted schedule, and nursing interview indicated sick calls were conducted daily, as
pursuant to contract requirements and there was approved treatment protocols for the
registered nurse (RN). Documentation revealed sick call care is provided to youth Monday
through Friday from 9:00 a.m. to 11:00 a.m. and Monday through Friday from 6:00 p.m. to 7:00
p.m. The DHA is on-site on Thursday’s from 5:00 p.m. to 8:00 p.m., the APRN is on-site
Monday and Tuesday 4:00 p.m. to 7:00 p.m. and Sunday 8:00 a.m. to 12:00 p.m. and the
psychiatrist is on-site Thursday from 2:00 p.m. through 6:00 p.m. An observation of the center’s
confirmed sick call hours were posted in medical and in each of the youth’s living modules and
only nursing staff conduct sick calls. When there is not a licensed nurse on-site, the center has
procedures whereby the shift supervisor reviews all sick call requests as soon as possible and
within four hours after the request is submitted. An observation of a sick call during the week of
the annual compliance review confirmed the youth was escorted to the sick call by a Right
Interaction (RI) certified staff. Additionally, the sick call observation confirmed the medical
provider identified themselves and stated why the youth was there, the youth was seen in a
private area with no other youth present to hear or see the examination, the youth was
examined by the nurse/practitioner and not just interviewed, and the medical staff was able to
maintain privacy while the officer was located by the door of the medical area. An interview with
nursing staff confirmed only a nurse conducts sick calls or the DHA if on-site, sick calls take
place in the medical clinic twice a day, and a youth is referred to the DHA when presenting with
similar complaints. Interviews with seven youth showed four youth were seen immediately after
making the request, two youth stated they were seen within one day, and the last youth stated
they had never had a sick call concern. An interview with seven staff stated nursing staff and the
DHA completes sick calls.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures ensuring there is a written plan to provide twenty-
four-hour emergency medical, mental health, and dental care to youth, as needed, in response
to unexpected illnesses, accidents, or conditions requiring immediate attention or an immediate
professional assessment to determine the severity. A review of seven Individual Healthcare
Records (IHCRs) showed three youth required on-site first-aid or episodic care with dates and
times noted. Each of the three-youth received episodic care or first-aid by a licensed healthcare
staff documented in problem-oriented sections with subjective, objective, assessment, and plan
(SOAP) elements and the nature of complaints were documented, with findings of the rendered
care included. Documentation showed the treatment rendered, if a referral to off-site care was
needed, education/instruction provided to youth, the plans for follow-up/future care, and the
youth was placed on an alert list. Each applicable youth IHCR showed parental notification, an
entry in the Episodic Care Log was completed, and the youth received a follow-up evaluation
from a licensed healthcare staff the next time a licensed staff was on-site, or sooner if
warranted. A center observation was conducted and showed the center’s first-aid kits are in
master control, sub control, and five additional first-aid kits are placed in each of the transport
vehicles. Three first-aid kits were inspected, and each were found to be fully stocked with the
designated health authority (DHA) approved contents. A review of documentation confirmed the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 39 of 56 (Revised July 2023)
center’s process for ensuring contents are maintained and stored in accordance with guidelines
to prevent expiration or deterioration is through nursing staff conducting monthly checks of the
contents with documentation of any inconsistencies found. The center has two automated
external defibrillators (AED) located in medical and in master control and the procedures were
found in a binder. The AED batteries and pads are checked by medical and an outside medical
provider, to confirm each are operable. Reviewed documentation indicated an outside provider
services the center’s two AEDs. During the annual compliance review nursing staff checked the
expiration dates, conducted a self-test of the AEDs and there were no issues discovered. The
AEDs are made with an internal battery, which is serviced by an outside provider, and an
observation of the AED’s light had an indication of green. Documentation showed the AED
batteries were changed on August 28, 2023, with an expiration date of the pads on December
28, 2025. The AED pads were changed on August 28, 2023. A review of documentation
revealed drills were simulated of an episodic care event which calls for immediate first-aid, AED,
administration of cardiopulmonary resuscitation (CPR) techniques, and the initiation of the
emergency procedures to follow when a life-threatening emergency does occur. The center
maintained proper documentation of each monthly drill with an effort to ensure, at a minimum,
all staff with direct contact on a day-to-day basis had the opportunity to participate in at least
one emergency drill annually. Additionally, there was a list of emergency numbers, including the
Poison Information Control Center posted and accessible for non-licensed and licensed staff
throughout the center, as well as inaccessible to each youth at the center. Reviewed
documentation showed authorized direct care staff were appropriately trained on the
administration of the epinephrine auto-injector and a review of seven staff training records
reflected requirements were met regarding episodic, first-aid, and emergency care. NARCAN®
training was embedded within the Department’s Learning Management System (SkillPro) CPR
course. The center’s nurses are responsible for conducting and simulating staff trainings on
NARCAN® and its use with an instructor-led class for the supervisors trained and approved for
medication administration. The center’s NARCAN® is maintained behind a locked door in the
locked medication cart which is accessed only by licensed nurses and shift supervisors who
have completed the training on medication administration. The center maintains a perpetual and
weekly inventory of the NARCAN®. An interview with nursing staff indicated episodic care is
documented under a chronological note labeled as episodic care, and non-healthcare staff use
the non-healthcare staff protocols form. Seven interviewed staff stated they can call 9-1-1 as
needed. Seven youth interviews were conducted, and one youth rated medical services as
good, five youth rated medical services as very good, and the other youth has not received
medical services.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures for the provision of off-site emergency and non-
emergency referrals for medical care and treatment. Evaluations conducted off-site shall be
recorded on the Department's Summary of Off-Site Care Consultation Report form. The
designated health authority (DHA) reviews, signs, and dates the off-site care instructions. A
review of seven Individual Healthcare Records (IHCRs) showed no youth required off-site care.
Three additional IHCRs were reviewed, and the Summary of Off-Site Care Consultation Report
form was utilized and filed in the IHCR, off-site emergency care was documented on the
episodic first aid/emergency care log, and parental notification efforts were documented. Each
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 56 (Revised July 2023)
of the off-site care events were applicable for discharge documents, which were filed in the
IHCR. Documentation showed the DHA was notified of an emergency event with the date, time,
manner of notification, and the DHA reviewed and signed/initialed all off-site care findings,
instructions, and information. None of the three applicable youth needed follow-up testing,
referrals, or appointments. An interview with nursing staff stated the tracking of youth who are
sent off-site for emergency care is through the Department’s Central Communications Center
(CCC) and shift reports.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures ensuring youth who have been identified with a
chronic illness receive regularly scheduled evaluations and necessary follow-up treatment. A
review of seven Individual Healthcare Records (IHCRs) confirmed one of the seven youth were
identified on the Medical/Mental Health Screening form with a current chronic condition. Two
additional IHCRs were reviewed. Two of the three applicable youth were taking prescribed
medication on an on-going basis and classified with a Medical Grade two through four. One of
the youth was applicable for pregnancy. The three-youth identified with chronic conditions were
placed on the center’s chronic conditions list. Two youth received periodic evaluations at least
every ninety days as needed, and progress notes were completed for each completed periodic
evaluation. Evaluations were conducted every two to four weeks for the first eight months, every
two weeks during the eighth month, and weekly thereafter for the one pregnant youth. For two
of the three applicable youth periodic evaluations were conducted prior to renewing a
prescription medication which expired. Additionally, none of the applicable youth had an
evaluation conducted off-site. The Department’s Problem List was updated in accordance with
Florida Administrative Code. A review of medical documentation revealed there were periodic
evaluations tracked on the chronic physical health conditions roster. An interview with the DHA
and nursing staff stated periodic evaluations for youth with chronic conditions are completed
and tracked every ninety days.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures which outline the process of how medications are
to be received, stored, inventoried, and administered in a safe and effective manner. A review of
seven Individual Healthcare Records (IHCRs) showed none of the seven youth were taking
medication at admission. Three additional IHCRs were reviewed for taking medication at
admission and the medication was verified prior to the youth being admitted into the center. The
prescription verification was included in the chronological progress note, in the IHCR/electronic
medical record (EMR) or utilizing the Prescription Medication Verification Checklist form.
Reviewed documentation confirmed the designated health authority (DHA) and when
applicable, the psychiatrist was contacted to obtain the order to resume the specified
medications prescribed prior to admission, and all medications had a current, valid order, and
were administered pursuant to a current prescription. If current medications were continued,
discontinued, changed, or new ones were ordered, the DHA/advanced practice registered nurse
(APRN) placed an order on the Practitioner Order form and the documentation of the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 56 (Revised July 2023)
prescription was verified in the chronological progress notes in the IHCR/EMR. Each of the
three applicable youth had over-the-counter (OTC) medications not listed on the Authority for
Evaluation and Treatment (AET) form which were administered according to approved protocols
or practitioner’s order and the standard Department Medication Administration Record (MAR)
was used to document all medication and treatment. The MAR clearly indicated medication start
and stop dates. At a minimum, nursing staff documented side effect monitoring weekly on the
MAR, refusals were clearly documented on the MAR when applicable, and the youth signed the
Refusal of Treatment Form indicating the refusal, when applicable. Reviewed documentation
showed the MAR contained all required elements such as the youth’s name, Department of
Juvenile Justice identification number (DJJID), date of birth, youth allergies, precautions,
Medical Grade, medical alerts, and current picture of the youth. Documentation confirmed the
DHA or psychiatrist was notified upon admission for each of the three youth who were currently
prescribed with psychotropic medication. The youth records for the three applicable youth
entering the center on psychotropic medications, showed where the psychiatrist conducted an
Initial Diagnostic Psychiatric Interview, the youth received an Initial Diagnostic Psychiatric
Interview within fourteen days of admission, and the youth received a medication
monitoring/review every thirty days as required. Reviewed documentation confirmed staff
trained in medication administration are designated by name and title and were trained to do so
by a registered nurse (RN). At the time of the annual compliance review there was an
observation of at least one medication administration. The youth’s verbal consent was obtained
prior to observation. The youth was escorted to the medical station/medication administration
area by the assigned officer, the youth approached the nurse administering medication
individually, the medical provider identified themselves and stated why the youth was there, and
the same medical staff prepared and administered the medications. The nurse verified each
youth’s allergy and alert status, and the nursing staff and youth initialed the MAR. Staff
observed youth to make sure medication was swallowed and the OTC medication administered
was documented. An interview with nursing staff indicated the center has a process for
monitoring and tracking youth with chronic conditions and verifying each youth’s medication
regimen once admitted to the center. The center has a process for disposal of medication in
which a licensed health care professional shall be responsible for the disposal of medications.
Non-controlled medications for disposal shall be inventoried prior to disposal and disposed of in
the presence of a witness. The witness shall be a licensed health care professional or center
supervisor or designee. An interview with seven staff indicated one had been trained by an RN
on the administration of medication. The other three staff reported the nurse administers the
medication. An interview with seven youth confirmed three were taking medication, given by the
nurse, and the other four youth stated they do not take any prescribed medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures regarding the requirements for the storage and
inventory of medications and sharps ensuring all medication is inaccessible to youth at the
center. The medical equipment classified as sharps to include syringes, needles, scissors, and
suture removal kits were secured and inventoried utilizing a routine perpetual inventory
descending count as each sharp was utilized and disposed, all medications were identified and
secured in the locked area designated for storage of medications, the medication cart was
clean/organized with stock items separate from youth-specific medications, all controlled
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 42 of 56 (Revised July 2023)
substances had a perpetual inventory and were stored separately from other medications. All
medications were stored in a separate, secured, locked area, inaccessible to youth, narcotics
and other controlled medications were stored behind two locks, oral medications were stored
with injectable or topical medications, medications which required refrigeration were stored in a
secured refrigerator, which is used for medication only, the center’s perpetual and weekly
inventories of all sharps and stock over-the-counter (OTC) medications were conducted as
needed pursuant to the Board of Pharmacy regulatory requirements, and there was a shift-to-
shift inventory count of all controlled substances documented on the youth’s individualized
Controlled Medication Inventory Record, as required. Additionally, documentation showed non-
health care staff were trained in the delivery and oversight of medication self-administration by
the center’s registered nurse (RN). An observation of three controlled medications was
conducted showing all counts of inventories were accurate. A review of three OTC medications
was conducted, and each medication was validated and accurate. A review of three sharps was
observed, in which perpetual inventories were correct and verified weekly. All counted
medication and sharps counted matched the ending inventory numbers documented. The
reporting criteria and procedures regarding inventory discrepancies is for two nurses to recount
medication and review log to see what was administered and if there is a medication error it’s
reported to the director of nursing. Reviewed documentation confirmed the process for the
disposal and destruction of expired and/or discontinued medications is for the pharmacist to use
a pill destruction solution and document the destruction on a medication destruction log with the
pharmacy. The area designated to store youth medication was observed with no discrepancies
or concerns. An interview conducted with nursing staff confirmed the process in which
medication is disposed of monthly with the pharmacist using a pill destruction solution. Narcotics
are kept in a double locked drawer in the medical cart and counts are completed daily.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures in place and there is an approved plan for exposure
control and infection control ensuring staff, youth, volunteers, and visitors are not exposed to
infectious and communicable diseases. The infection control procedures in place include
prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to Occupational Safety and Health Administration (OSHA) federal regulations and the
Centers for Disease Control (CDC) and Prevention. A review of seven Individual Healthcare
Records (IHCRs) documentation showed the infection-control training was conducted within
seven days of admission and included hand-washing techniques, universal/standard
precautions, prevention/transmission of communicable diseases, vaccinations, and CDC
guidelines for infection control. A review of documentation revealed the Exposure Control Plan
was written in accordance with Occupational Safety and Health Administration (OSHA)
guidelines and included the risk assessment, all job classifications in which staff have the
potential for occupational exposure, and tasks or procedures which would cause the staff in the
job classifications to have an occupational exposure. In the methods of compliance section
there was notation of infection control practices. The engineering and work practice controls
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 43 of 56 (Revised July 2023)
included the availability of hand-washing facilities, procedures for proper disposal of needles
and other sharps, procedures for maintaining the work site in a clean and orderly manner, the
use of specified signs and labels to communicate hazards to staff, procedures for handling of
contaminated laundry, procedures for post-exposure evaluation and follow-up and the system of
medical record keeping for staff with occupational exposure. Reviewed documentation
confirmed the infection control procedures in place included prevention, containment, treatment,
and reporting requirements related to infectious diseases, according to OSHA and the CDC
guidelines, which included common infectious diseases of childhood, self-limiting, episodic
contagious illnesses, viral or bacterial infectious diseases, Tuberculosis, Hepatitis A, B, and C,
human immunodeficiency virus (HIV), infectious diseases caused by bloodborne pathogens,
other outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant micro-
organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures in the workplace.
The center’s process for needle stick post-exposure evaluation consists of taking care of staff,
notifying appropriate parties, cleaning the area, sending staff to urgent care, and counseling as
needed. The Hepatitis B immunizations were made available for staff on-site and the center’s
staff has access to protective equipment. Documentation confirmed the superintendent
maintained a separate file containing all documents for youth and staff who have experienced
an occupational exposure, all records were maintained as confidential for a ten-year period, as
required, and a review of seven pre-service and in-service training for staff indicated each
completed training on the center’s specific Exposure Control Plan, with no discrepancies. The
interview with nursing staff indicated a copy of the Exposure Control Plan was in administration
and medical cabinet, and only the nurse manager conducts the infection control training for all
staff. Infection control training is provided to youth by medical staff during the admission
process.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center maintains a written policy and procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. The center had one
pregnant youth admitted since the last annual compliance review. The youth had the provision
of prenatal care begin immediately, which continued through discharge from the center or
through postpartum. The youth was in the center for more than thirty days, and the designated
health authority (DHA) and/or advanced practice registered nurse (APRN) provided a routine
focused medical evaluation of the youth’s pregnancy every thirty days or sooner. A review of the
record indicated prenatal care was provided at recommended intervals and the youth was
placed on the center’s internal alert system for the provision of all nutrition and staff health
awareness. Review documentation indicated the youth was monitored daily for signs of
pregnancy complications. There was a documented plan for post-birth psychological and
physical care. Reviewed healthcare education information showed the pregnant youth had
completed prenatal education including the topics of alcohol and drug use, smoking cessation,
nutrition, sexually transmitted infections (STIs), contraception, prenatal care, birthing process,
postpartum care, basic baby care, child/infant development, and parenting skills. All youth
education was documented in the youth’s Individual Healthcare Record (IHCR). A review of
seven staff training records validated each staff received training specific to working with
pregnant youth. Staff training documentation reflected training was provided by the APRN at the
time of hire and annually, thereafter. An interview with the clinical nurse manager indicated the
center's process for routine monitoring of pregnant youth is for the youth to follow-up with an
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 44 of 56 (Revised July 2023)
obstetrician/gynecologist and provide the youth with a special diet. The center provides
educational topics to pregnant youth including nutrition, preterm labor, active labor, morning
sickness, prenatal vitamins, and other adverse effects of pregnancy such as preeclampsia.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 45 of 56 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures addressing active supervision of youth. During the
annual compliance review week, youth supervision was observed each day. Youth and staff
observations were made in the classrooms, on the modules, during mealtime and breaks, in the
intake area, and during line movements throughout the center. Observations confirmed the
detention staff maintained continuous sight supervision of the youth within their assigned areas.
Staff were positioned in the designated areas during line movements which supported active
supervision. Observed youth movement in the center confirmed youth were always in sight of at
least one detention officer, except for when placed in sleeping rooms or in a secure placement,
youth were accounted for and always accompanied by staff, master control authorized all
movement of youth prior to the youth being moved, and the interactions between youth and staff
demonstrated active supervision. Four of seven interviewed staff reported there is enough staff
to provide safety and security of the youth. Three staff members reported there was not enough
staff to provide adequate safety and security of the youth.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) requiring a behavior management system
(BMS) which offers a consistent set of rewards, privileges, and consequences for behavior. The
center’s rewards, privileges, and consequences are to motivate the youth to meet the center’s
expectations. During the annual compliance review, postings of the BMS were observed in all
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 56 (Revised July 2023)
living areas which clearly specified appropriate and inappropriate behaviors, rules, norms, and
expectations, rewards for positive behavior and consequences for inappropriate behavior. Daily
activities were observed to determine implementation of the BMS. A review of the center’s FOPs
on the BMS ensured compliance with the components outlined in the center’s policies and
procedures. A review of documentation confirmed positive rewards are given to youth to match
the BMS incentive calendar, and rewards and consequences are given in accordance with the
BMS. Reviewed documentation did not indicate any instances of inappropriate use of
restrictions or group punishment. Seven interviewed staff were able to explain the center’s BMS
process. Seven interviewed staff reported the center’s BMS is effective and reported staff speak
with youth to discuss the consequences before being imposed. Seven interviewed staff reported
youth are given an opportunity to explain their behaviors and staff speak with youth about
alternative behaviors. Seven interviewed staff were able to explain how supervisors provide
feedback to staff regarding the implementation of the center’s BMS. Seven interviewed staff
reported they have never seen a co-worker confiscate meals, snacks, clothing, education, or
medical care from a youth because they were acting out. Seven interviewed staff reported they
have never observed any staff encouraging youth to beat up another youth. Out of seven youth
interviewed, three rated the center’s BMS system as fair, three rated the system as good, and
one rated the system as very good. Seven interviewed youth were able to explain the difference
between each level and how you move from level to level. Each youth reported they are
rewarded with canteen, snacks, parties, video games, and extra phone time. Each youth
reported all staff use the rewards the same and youth are never allowed to punish other youth.
Seven interviewed youth reported they have never been sent to their room for punishment. Six
of seven interviewed youth reported when receiving consequences, the consequences were fair,
and one youth reported they had never received consequences. One interviewed youth reported
when consequences were given, points were taken away, four reported their level was reduced,
one reported nothing was taken away, and one reported they never received consequences. Six
of seven interviewed youth reported handcuffs or leg irons are not used on out-of-control youth
to prevent them from hurting themselves or others and reported they have never witnessed this
act. During an interview with the superintendent, it was confirmed the center uses a three-level
system which tracks youth behavior.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks. The center has
eighty-six cameras and sixty-two were operational. Video recordings are stored for thirty days.
Documentation was reviewed and verified work orders were submitted for the inoperable
cameras. Camera reviews were conducted for the last thirty days prior to the annual compliance
review. Reviewed documentation confirmed all checks were completed under the ten-minute
designated timeframe. Documents were provided to confirm weekly reviews of management
oversight. A review of video compared to ten-minute check logs for thirty-minute increments
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 56 (Revised July 2023)
from each shift on each living module, for a total of thirty-six checks was completed. Of all thirty-
six checks, all were completed within the required timeframe of under ten minutes.
Documentation of one sample of thirty-minute increments from each shift from the past twelve
months confirmed all checks were completed as required. Six interviewed staff reported room
checks are conducted every ten minutes when a non-suicidal youth is placed in their room for
sleeping or non-punishment reasons, and one staff reported every five minutes. During an
interview with the superintendent, it was confirmed staff shall visually observe any youth in a
room for sleeping purposes or any other time within a ten-minute interval while the youth is
placed in a room.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures requiring staff to always be aware of the exact
number and location of all youth under their supervision. A review of the master control
logbooks, for twelve months prior to the annual compliance review period confirmed
documentation for headcounts were conducted at the beginning and end of each shift, prior to
and following routine group movement, any time a population change occurs, randomly, at least
once on each shift, and youth movements. Seven interviewed staff reported youth counts are
conducted at the beginning and ending of each shift.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 56 (Revised July 2023)
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures regarding logbooks. The center maintains separate
logbooks in master control, each living area, for visitors, and for each vehicle. A review of
logbooks for the past twelve months revealed each logbook was bound with numbered pages,
had the date documented at the top of the page, all entries included the times of the events in
a.m./p.m. format with the name of the staff and youth involved, contained a brief description of
the events, and the initials of the staff making the entries. All entries impacting the safety and
security of the center, including medical/special needs and mental health alerts were highlighted
and all errors were struck through with a single line and had “void” written after the error
followed by the staff’s initials. Reviewed master control logbooks included emergency situations,
incidents, all drills, documentation of receipt of medical/mental health alerts, population counts
at the beginning and end of each shift, population counts throughout shifts as counts change,
youth counts following emergency situations, youth group movement, admissions and releases,
searches to include frisk, electronic, and full body searches, names of youth placed in
confinement, with the time confinement began and the time confinement ended, and name of
youth placed on precautionary/secure observation along with the time initiated and time ended.
Sample logbooks from master control and each living module was reviewed for one day each
month during the annual compliance review period, not exceeding twelve months. Reviewed
logbooks indicated the superintendent or designee reviewed all logbooks on a weekly basis and
provided recommendations as to the completeness and accuracy of the information recorded.
Juvenile justice detention officer (JJDO) supervisors reviewed center logbooks maintained at
master control when assuming center responsibility, the JJDO supervisor and/or lead officer
reviewed logbooks maintained in each living area daily, and JJDOs reviewed logbooks
maintained in assigned living area when accepting responsibility for a living area at shift change.
Reviewed documentation confirmed the superintendent or designee toured the youth living
areas at least once during each shift and documented the visit in each area’s logbook. During
an interview with the superintendent, it was confirmed management reviews the logbook in each
module on a weekly basis.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 56 (Revised July 2023)
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) detailing the requirements of the center’s
key control, issuance of keys to staff, and inventory of keys and tracking. Reviewed
documentation confirmed the center’s FOP on key control included the control and use of keys,
including key assignment and usage, restrictions on 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. A reviewed key inventory sampling
confirmed key rings on the inventory matched the actual key rings in use. The key storage area
was observed and confirmed keys were locked in a tamper proof box and keys were all color
coded and numbered for staff. Observation during the annual compliance review confirmed
distribution and collection of keys at shift change. It was observed staff returned assigned keys
prior to leaving the center and staff placed keys back in the secured tamper proof box.
Observation confirmed all restricted keys were locked in a tamper proof box in master control
and the supervisor’s office. The center keys were maintained on a tamper-resistant ring and
emergency key rings are in the supervisor’s office which supervisors only have access to.
Emergency key rings were included as part of the center’s key inventory. It was observed the
master key inventory included the ring number, number of keys on each ring, capability of each
key, and to whom the key ring was issued. Observations confirmed the center keys placed on
the key ring hubs system are color-coded. All officer keys are blue, supervisor keys are yellow,
administration keys are black, medical/mental health keys are white, food service keys are
green, education keys are brown, and emergency keys are red. Reviewed documentation
confirmed the issuance of keys and key ring numbers were documented on each shift report.
Documentation included the date and time of issue, name of staff issuing the key ring, name of
staff who received the key ring, and the time the key ring was returned. Observations confirmed
all staff who were issued keys always carried issued keys on their person, did not allow youth to
handle any keys, did not remove the keys from the center or the center’s grounds without
authorization from the superintendent, and the key box was not easily accessible while locked.
During the annual compliance review period, there was one incident reported to the
Department’s Central Communications Center (CCC) related to key control concerns. It was
reported the staff received a retaining memorandum for the first offense as a corrective action. A
sample of five key rings were observed and compared to the inventory and key log. It was
confirmed keys were present on the key log, the key tag matched the number of keys on the key
ring, and the number of keys on the ring matched the inventory. Three staff were informally
interviewed about their keys, and all three staff knew the correct number of keys on their key
ring and knew the function of all the keys on their assigned key ring. The informally interviewed
master control operator reported staff is assigned a color-coded key prior to entering a secure
area and contractors are given a colored key to coordinate with their designated work area.
Restricted keys include medical, youth and staff records, and youth property locker keys. The
restricted key staff are to turn in or secure away their personal items and receive the keys from
a supervisor. Seven interviewed staff reported medical records keys, youth property keys,
mental health record keys, case management keys, kitchen keys, and education keys are all
restricted. Each interviewed staff was able to explain the center’s key control process which
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 56 (Revised July 2023)
requires daily tracking of keys, a key log, program keys assigned to staff, inventory of keys,
youth not having access to keys, notifying master control of missing keys, center searches for
missing keys, youth searches for missing keys, key distribution during briefing, calling the CCC
if needed, staff signing-in and out keys daily, and teachers returning keys before leaving the
center. During an interview with the superintendent, it was confirmed permanent keys are
issued to staff and all operational keys are stored in a secure key box within the center. All non-
operational keys are stored in a secure box in master control. All keys are numbered, and all
staff must return their assigned key in and out daily.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures to address transportation procedures and the
maintenance and operation of Department vehicles. The center has seven vehicles and five are
used to transport youth. Two were not operable and recorded as surplus. Reviewed
documentation confirmed the maintenance staff/designee conducts monthly visual checks of all
transport vehicles which includes water coolant, lights, oil, emergency equipment, brakes, horn,
interior/exterior, and cleanliness. Reviewed documentation confirmed the maintenance
staff/designee conducts monthly visual checks of all transport vehicles which includes tires,
including spare, a battery test, windshield and wipers, windows, mirrors, and damage to include
all scratches and/or dents, and inspections are documented on the mandatory inspection form
and a copy of the form is maintained by the maintenance staff. Observations confirmed each of
the center’s seven vehicles had the appropriate number of seatbelts, a seatbelt cutter, a window
punch, a current fire extinguisher, and a first-aid kit with items approved by the designated
health authority (DHA). Reviewed documentation confirmed the van logbook documented
acknowledgement the vehicle was checked, destination, number of youth and staff names,
name of the officer riding in the back of the van, the time transport began, and the time transport
ended. Observation confirmed prior to the transport staff inspected the vehicle for contraband,
making sure the cage area of the vehicle is physically checked for objects and/or contraband,
ensured the vehicle had sufficient gasoline to reach the assigned destination, maintained copies
of current transportation procedures in each vehicle, verified seatbelts were securely anchored,
tested the security screen/cage to ensure it was secure, confirmed the vehicle folder contained
the vehicle logs, vehicle and mechanical restraint keys, gas credit card, and vehicle registration,
ensured a cellular telephone is assigned to the vehicle and it is charged and turned on prior to
departure, ensured the inspection was documented in the vehicle logbook, ensured the vehicle
was secured at all times, ensured all youth were searched prior to being placed in a vehicle, and
ensured youth and staff wore seatbelts. Observations confirmed after transport, the transport
staff ensured vehicles were searched for contraband, ensured vehicles were locked to prevent
the introduction of contraband, ensured youth were searched upon return to the center, and
ensured youth and staff wore seatbelts. Seven vehicles at the center were checked and it was
observed one maintenance van was unlocked behind a locked gated area; however, the van
was immediately locked by detention staff once notified. Seven interviewed youth reported they
feel staff are driving safely when transporting youth and have never seen anyone place
contraband in a transport vehicle.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 56 (Revised July 2023)
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures to address tool inventory and tool management
requirements. The center's maintenance and kitchen tool policies require inspections of tool
control areas to be conducted monthly, and the results of inspections are submitted to the
superintendent or designee. Tools are stored in a locked area when not in use. The center
maintains a perpetual inventory of all tools and the superintendent or designee reviews
maintenance tool inventories monthly. Kitchen staff conducts an itemized inventory of all
equipment, including kitchen knives and other hazardous kitchen implements, upon reporting for
duty. An inspection of the tool room and kitchen determined the level of security when tools are
not in use. Observation confirmed there were no tools listed on the inventory missing and there
were no tools not listed on the inventory. An informal interview with maintenance staff confirmed
it is the center’s practice to always accompany service vendors when in a secure area of the
center. Reviewed documentation confirmed there was a review of inventory used to document
the issuance and return of tools. The center allows youth to use cleaning items such as mops,
brooms, and other common household items, under direct staff supervision. During the annual
compliance review period, there was no observation of youth using cleaning tools. During an
interview with the superintendent, it was confirmed administration and maintenance has access
to center tools. Seven staff were interviewed and reported a lockdown is the center’s practice for
damaged or missing tools. Interviewed staff reported youth are allowed to use scrub brushes,
mops, brooms, and dustpans. Five of seven interviewed youth reported they do not use tools,
and two youth reported they use mops and brooms. A review of ten tools was completed to
confirm inventories were accurate. All tools were properly secured, had marking for easy
identification, and were accurately inventoried.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has a Safety Plan to ensure the proper use, storage, disposal, and inventory of
chemicals including poisonous, flammable, and toxic materials. A review of documentation
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 56 (Revised July 2023)
during the annual compliance review period confirmed the center maintained an inventory of all
flammables, toxic, caustic, and poisonous items. Observations confirmed the Safety Data
Sheets (SDS) were in a logbook, posted near the items, and available to staff. Only authorized
staff are permitted access to flammable, toxic, caustic, and poisonous items. Observations
confirmed all flammable, toxic, caustic, and poisonous materials are stored in secure areas
inaccessible to youth. Two of seven interviewed youth reported they clean with cleaning agents
such as bleach, laundry soap, window or toilet cleaners and five youth reported they do not
clean. Each youth reported they do not have access to flammable, toxic, caustic, and poisonous
items. Seven interviewed staff reported youth are not allowed to clean with substances which
are toxic, flammable, or poisonous. A review of five Safety Data Sheets (SDS), and the items
they were correlated to, confirmed each had the actual count of items observed on the ending
count on the inventory form, and SDSs were present for each item. There were no
discrepancies observed.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures regarding the disposal of flammable, toxic, caustic,
and poisonous items. During the annual compliance review period, the center did not have any
instances of chemical spills or disposal of any flammable, toxic, caustic, and poisonous items.
The center has a grease trap in the kitchen for grease designated for disposal.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures addressing the process of youth placed in
temporary confinement under twenty-four hours. Six of seven reviewed Confinement Reports for
youth placed temporarily in confinement confirmed youth were afforded the right of three meals
a day plus snacks. Seven reviewed reports confirmed youth had access to mental health care
as requested/needed, clean clothing, mattress/bedding, education materials, and notice of their
right to grieve a confinement. Four of seven youth were applicable for a shower based on the
time and duration of confinement. Seven reviewed reports confirmed prior to placing each youth
in confinement, the supervisor approved all confinements, staff placed only one youth in the
confinement room, the room was searched, and documentation of the search was entered into
the Department’s Facility Management System (FMS). Seven reviewed reports confirmed once
the youth was placed in confinement, the youth was supervised and supervision was
documented on the confinement Visual Observation Report (VOR) Log, at a minimum, every
five minutes for the first hour of confinement. Reviewed reports confirmed the reason
confinement was necessary and explained to the youth, the supervisor conducted an initial
confinement review with the youth within one hour of the incident, and the full report was
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 56 (Revised July 2023)
completed before the end of their shift. Reviewed reports confirmed the supervisor conducted
additional reviews with the youth at a minimum of every three hours and documented the
reviews in FMS. Additionally, the supervisors/staff continually counseled the youth and
considered removing the youth from confinement as soon as the youth was able to safely rejoin
the population and there was no threat to safety. Six of seven reviewed reports confirmed a
physical injury was observed and a healthcare professional was immediately notified for timely
assessment and treatment which was documented in the youth’s Individual Healthcare Record.
Seven reviewed reports confirmed the superintendent, or designee reviewed all confinement
reports within forty-eight hours, excluding weekends and holidays, unless it is their regularly
scheduled workday, and determined whether each confinement was appropriate or
inappropriate. Observation confirmed windows and cameras were free of
obstructions/scratches, so the youth may be visually observed. During an interview with the
superintendent, it was confirmed confinement is used as a short-term strategy used for
managing a youth's behavior, and it is tracked through FMS monthly. The superintendent
reported management reviews the use of confinement, lockdown, and restraints monthly. Seven
staff were interviewed, and one staff reported the center’s step by step process for placing youth
in confinement is to complete a confinement report, four reported to conduct and document ten-
minute checks, and six reported searching the confinement room. Six interviewed staff reported
youth who are placed in temporary confinement are provided education materials and one staff
reported youth are not provided education materials.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures to address the Continuity of Operations Plan
(COOP). Reviewed drill documentation confirmed the center conducted at least three COOP
drills during the annual compliance review period, as required, including at least one drill
completed prior to hurricane season. A review of the provided documentation confirmed the
number of COOP drills, scenarios, and any resulting critique or corrective action. Reviewed
documentation for all drills contained type of drill, date and time, participants, brief scenario,
findings, and recommendations. During an interview with the superintendent, it was reported the
COOP is the center’s comprehensive safety/emergency program.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 56 (Revised July 2023)
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures to address an Escape Prevention Plan. The
centers policy requires the center to conduct escape drills on a quarterly basis. Reviewed
documentation confirmed escape drills were completed on March 9, 2025, December 16,
September 17, and August 14, 2024. A review of seven training records confirmed staff were
trained in escape prevention annually. A review of the center’s logbook confirmed
documentation of each drill. Seven interviewed staff reported they participated in fire drills, two
reported they participated in major disturbance drills, four reported they participated in escape
drills, and six reported participating in medical, code white cut-down, code blue, code red, code
white, code green, and Continuity of Operations Plan (COOP) drills.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a written policy and procedures for addressing fire prevention and safety. A
review of the fire drills from the past twelve months confirmed the center conducts monthly fire
drills on each shift. Reviewed documentation confirmed the logbook documented each of the
drills and review of the drills. Reviewed documentation confirmed fire extinguishers are
inspected annually. Seven interviewed staff reported fire drills take place at least monthly. Six
interviewed youth reported they were instructed on what to do in case of a fire and one youth
reported they were not instructed on what to do in case of a fire.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 56 (Revised July 2023)
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) to address search and contraband
procedures. During the annual compliance review week, a youth admission was observed.
Observations confirmed staff wore gloves during a frisk and full body search on the youth prior
to admission. The search consisted of two staff, both same gender as the youth, and searches
of the youth was conducted individually and not in a group setting. The center conducts
electronic/wand searches on all persons entering the center. All bags, cases, jacket pockets and
other items were searched. All personal keys, personal cell phones, and other contraband items
are prohibited from entering the secure area. Observations confirmed rooms were searched
upon a youth’s release, rooms were searched prior to placing a new youth in the room, and all
rooms were searched for contraband on each awake shift. A review of random shift reports for
one day for each month during each awake shift for the annual compliance review period
confirmed youth room searches were documented and completed as required. The center did
not report any instances which may have compromised the safety or security of the center
throughout the annual compliance review period. Observations during the annual compliance
review week confirmed searches of staff, visitors, and contractors/vendors were completed
electronically and a frisk search was completed prior to entering the secure area. Reviewed
documentation confirmed the center’s visitor log did contain a contraband attestation statement.
Twenty reviewed staff records confirmed all staff had a contraband attestation form included in
their record. Five reviewed newly hired staff records contained a contraband attestation form.
Reviewed documentation confirmed the center documented confiscation of contraband in the
master control logbook, incident reports completed identified findings and disposition of
contraband, law enforcement was contacted if any found item was considered illegal, or if there
was evidence of any type of unlawful activity, confiscated items were secured by the discovering
officer and hand-delivered to the supervisor, the shift supervisor documented the chain of
custody of confiscated items, the Department’s Central Communication Center (CCC) was
notified of discovery and confiscation of illegal contraband, and the regional director or designee
was notified of discovery and confiscation of contraband. During an interview with the
superintendent, it was confirmed the center’s procedure for searching a youth is for a full body
search to be conducted in a private location with two staff members of the same gender. The
superintendent reported, if two staff members are not available, then one of the same gender
staff shall conduct the search while the other staff is positioned to observe the staff conducting
the search, without view of the youth. The superintendent confirmed contraband is confiscated,
the youth is confined, and law enforcement will be called if a youth or staff is found with
contraband.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 56 (Revised July 2023)

source: DJJ

report_type: QI Detention