facility_name: Leon Regional Juvenile Detention Center

summary: QI Detention - FY25-26 - 10 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Leon Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
2303 Ronellis Drive
Tallahassee, Florida 32310
Review Date(s): December 9-12, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Andre Watson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, Northeast Central Education Coordinator (Standard 2)
Katherine Gomez, Office of Secretary, Government Operations Consultant (Standard 2)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Brad Taylor, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: Leon Regional Juvenile Detention Center MQI Program Code: 32
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Leon County / Circuit 2 Number of Beds: 50
Review Date(s): December 9-12, 2025 Lead Reviewer Code: 228
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 57
Lim ited R atings
4.02 Facility O perating Procedures
4.14 C hronic C onditions/Periodic E valuations
4.15 M edication M anagem ent
5.06 K ey C ontrol
5.07 Vehicles and M aintenance
5.09 Inventory of and A ccess to all Flam m able, Toxic, C austic, and Poisonous Item
5.11 C onfinem ent U nder Tw enty-Four H ours
s
2.05 A
Failed R atings
dm ission and S torage of Y outh Personal Property
5.03 Ten-M inute C hecks*
5.05 Logbook M aintenance and R eview s
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 57
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
In d ic a to r R a tin g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g *
F iv e -Y e a r R e s c re e n in g /R e n e w a l
S ta ff C o d e o f C o n d u c t
In c id e n t R e p o rtin g (C C C ) *
R ig h t In te ra c tio n s (R I)
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts *
In -S e rv ic e T ra in in g
G rie v a n c e s
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n *
D a ta T re n d A n a ly s is
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
g ra m o p e ra te s
d o s o w ill re s u lt
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 57
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
In d ic a to r R a tin g s
S ta n d a r d 2 - Y o u th M a n a g e m e n t
A d m is s io n
O rie n ta tio n
C la s s ific a tio n
N o tific a tio n o f J P O C irc u it G a n g R e p re s e n ta tiv e
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty
R e le a s e
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s
R e v ie w o f Y o u th in S e c u re D e te n tio n
D a ily A c tiv ity S c h e d u le
E d u c a tio n a l A c c e s s *
C a re e r E d u c a tio n
tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
F a ile d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
g ra m o p e ra te s
d o s o w ill re s u lt
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 57
In d ic a to r R a tin g s
S ta n d a rd 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s
3 .0 1 D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
3 .0 2 L ic e n s e d M H /S A C lin ic a l S ta ff *
3 .0 3 N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
3 .0 4 M H /S A A d m is s io n S c re e n in g
3 .0 5 M H /S A E v a lu a tio n
3 .0 6 T re a tm e n t a n d D is c h a rg e P la n n in g
3 .0 7 M H /S A T re a tm e n t
3 .0 8 S u ic id e P re v e n tio n P la n *
3 .0 9 S u ic id e P re v e n tio n S e rv ic e s *
3 .1 0 S e c u re O b s e rv a tio n *
3 .1 1 S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
3 .1 2 S u ic id e P re v e n tio n T ra in in g *
3 .1 3 M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
3 .1 4 E m e rg e n c y C a re P la n *
3 .1 5 C ris is A s s e s s m e n ts *
3 .1 6 B a k e r a n d M a rc h m a n A c ts *
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte
b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
N
n tio n if a p ro g ra
rs . F a ilu re to d o
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
o n -A p p lic a b le
m o p e ra te s
s o w ill re s u lt in
Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 57
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
In d ic a to r R a tin g s
S ta n d a rd 4 - H e a lth S e rv ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n
D H A /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g
S ic k C a ll P ro c e s s
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re
O ff-S ite C a re /R e fe rra ls
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s
M e d ic a tio n M a n a g e m e n t
P s y c h ia tric S e rv ic e s *
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n
P re n a ta l C a re /E d u c a tio n
tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
S a tis fa c to ry
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
L im ite d
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
n tio n if a p ro g ra m o p e ra te s
rs . F a ilu re to d o s o w ill re s u lt
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* Failed
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Failed
5.06 Key Control Limited
5.07 Vehicles and Maintenance Limited
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 Limited
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Limited
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will
result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Overall Rating Summary for Standard 5
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be conducted within six
(6) months months of the original annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 57
Program Overview
The Leon Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Tallahassee, Florida. The center serves youth in Leon, Gadsden,
Wakula, and Franklin counties in Circuit 2. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Leon County School Board. The
center’s management team includes the superintendent, two assistant superintendents one
administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, and thirty-
one JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore. LLC. Mental health services are provided by nine staff: one designate
mental health clinician authority (DMHCA) and eight licensed mental health staff, with one of the
eight resigning as of November 2025. 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 ten staff: one designated health authority (DHA), one advanced practiced
registered nurse (APRN), seven registered nurses (RN), and one licensed practical nurse
(LPN). The medical clinic maintains nursing coverage seven days a week, eight hours a day.
Food services are provided by Department staff and include menus, meal planning, meal
schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has three living modules which are divided by male and female.
There are sixty-three security cameras at the center, of which fifty-one were operational. The
center was orderly and clean and well-manicured minus some vegetation on secure fencing
razor wire. Some living unit modules were recently painted. No new graffiti was observed. At the
time of the annual compliance review, the center had eleven vacancies, which included eight
JJDO Is, two JJDO IIs, and one food service worker (FSW).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPS’s) addressing initial background screening
for all Department staff, volunteers, and contracted staff. Sixteen staff were hired since the last
annual compliance review. Reviewed documentation confirmed each staff had a background
screening completed prior to contact with youth or confidential youth records. Each staff had a
reviewed criminal history report. No staff required an exemption to be obtained prior to working
with youth. Fourteen of sixteen staff had a pre-employment assessment tool administered and
each had a pre-employment assessment passing score documented. The remaining two staff
were not direct care staff therefore not applicable.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures (FOPs) to ensure all staff, contracted providers,
volunteers, mentors, and interns with access to youth undergo a criminal history background
check every five years. A review of staff personnel records found four department and two
contracted staff were applicable for the completion of a five-year rescreening since the last
annual compliance review. Each rescreening was submitted timely, and each contracted staff
had an eligible rating in the Clearinghouse.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 57
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures (FOPs) addressing the staff code of conduct.
Center staff adhere to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, horseplay, personal relationships with youth, or any other violations.
Management takes immediate action to investigate or address all allegations or violations of the
code of conduct. Six staff personnel records were reviewed, three for commendations and three
for discipline, and each contained a signed code of conduct. Three staff records were applicable
for disciplinary action for violation of code of conduct for the annual compliance review period.
Two of the three staff received written reprimands as part of management’s response to
violation of code of conduct. The remaining staff received an oral reprimand as part of
management’s response. Three staff personnel records were reviewed for commendations. All
three records indicated staff received commendations for employee of the month. Seven youth
were interviewed, and each reported not being stopped from reporting abuse to the Florida
Abuse Hotline. All youth reported staff are respectful when talking with youth. Five of seven
youth reported never hearing staff use curse words when speaking to youth. The remaining two
youth reported occasionally hearing staff use curse words when speaking to youth. Youth
responses was brought to the attention of the center’s superintendent who informed staff
retraining will be conducted to address youth concerns. All youth reported never hearing staff
threaten youth. All youth reported feeling safe in the program. All youth reported not having
exchanged electronic mail, telephone numbers or social media contact information with staff.
Seven staff were interviewed, and each was able to articulate the center’s process for allowing
youth to call the Florida Abuse Hotline or the Department’s Central Communication Center
(CCC). Three of seven staff reported never having observed a co-worker using profanity when
speaking to youth. Three of seven staff reported once observing a co-worker using profanity
when speaking to youth. The remaining staff reported occasionally having observed a co-worker
using profanity when speaking to youth. Six of seven staff reported never having observed a co-
worker using threats, intimidation, or humiliation when interacting with youth. The remaining staff
reported once having observed a co-worker using threats, intimidation, humiliation when
interacting with youth. Four of seven staff reported working conditions at the center as being fair.
Two of seven staff reported working conditions at the center as being good, and the remaining
staff reported working condition at the center as being very good. Staff responses were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 57
introduced to the superintended who reported a staff retraining will be conducted to address
concerns. The superintendent was interviewed and was able to explain the center’s employee
code of conduct, stating the center’s employee code of conduct consist of staff being placed on
no youth contact if necessary while investigation. Staff may receive discipline up to termination if
findings are valid. Statements are collected from all parties involved, and depending upon the
incident, youth will be escorted to medical for further observation in addition to mental health
providing treatment as needed. Youth's parents and CCC and or the Florida Abuse Hotline will
be notified as well.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures (FOPs) addressing incident reporting. There was a
total of 108 incidents reported to the Department’s Central Communications Center (CCC)
during the annual compliance review period. Nine CCC reports were reviewed. Eight of nine
CCC reports reflected the incidents were reported within the required time frame. The remaining
CCC report indicated the incident was reported ten minutes late. Logbook review confirmed six
of nine CCC incidents were documented in the center’s logbook, and three were not
documented as required. There were no additional internal incidents/grievances which should
have been reported to the CCC. The superintendent was interviewed and reported physical and
mechanical restraints are logged in a mechanical and restraints binder.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures (FOPs) to ensure the center uses physical
intervention techniques in accordance with Florida Administrative Code. The center had a total
of 108 Protective Action Response (PAR)/Right Intervention (RI) reports for the annual
compliance review period. Nine RI reports were reviewed. A RI report was completed for each
use of a countermove, control technique or mechanical restraint. Eight of nine reviewed RI
report was completed by the end of the staff’s workday and eight of nine reports included a
statement from each staff involved, with one not being completed by end of the workday nor
including all statements from all staff. There were no RI reports which indicated serious injury to
youth or staff occurred. There were no RI reports indicating a youth alleged abuse of any type.
Each reviewed RI report was reviewed by a supervisor or certified RI instructor. Eight of nine RI
reports indicated a post RI interview was conducted with the youth by an administrator within
thirty minutes after the incident. The remaining RI post interview was conducted beyond the
thirty-minute timeframe. There were no RI reports which indicated a need for medical review.
Each RI report was reviewed by the superintendent after all other reviews with an added
comments within the required timeframe. The center had no additional RI incidents not
documented by a RI report. The center’s RI rate during the annual compliance review was
10.96, which is below the state Detention PAR rate of 13.67. Five staff were interviewed, and
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 57
each reported they try to speak with youth prior to using physical restraints or mechanical
restraints. The superintendent was interviewed and reported physical and mechanical restraints
are logged in a mechanical and restraints binder. The superintendent further reported PAR
incidents are reviewed in closed circuit television (CCTV) and the Department’s Juvenile Justice
Information System (JJIS) is where those incidents are logged and monitored.
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.
Seven staff training records were reviewed for pre-service training certification. Each staff
received all pre-service training within 180 days of hire. Each staff received a new staff
orientation training completed within thirty days of hire and each staff received completed
academy training consisting of 120 hours.
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.
Seven staff training records were reviewed for annual in-service training of which three were
supervisors. According to training records, five of seven staff completed all required in-service
trainings to include active shooter preparedness, First-Aid, cardiopulmonary resuscitation
(CPR), automated external defibrillator (AED), Human Trafficking, information security
awareness, mental health and substance abuse, Prison Rape Elimination Act (PREA), right
interactions (RI), professionalism, interpersonal communication and ethics, sexual harassment,
suicide prevention, trauma response practices, emergency care plan, infection control, exposure
control plan, escape prevention, and fire prevention/disaster procedures. The remaining two
staff training records completed all training with the exception of CPR, First-Aid, or AED
trainings being completed. The three identified supervisor records indicated staff completed the
additional minimum of eight supervisory training hours. All records indicated nursing staff
provided in-service training on girls’ healthcare annually. Trainings included monitoring,
observation, and emergency care of pregnant youth. The center maintains an annual in-service
training calendar which is updated as changes occur. The annual training calendar was
approved by the highest-ranking official at the center, the assistant secretary of the Office of
Detention Services, and the director of the Department’s Office of Talent, Leadership, and
Culture. The superintendent was interviewed and reported receiving all of Tier 1 trainings, and
currently scheduled for Tier 2 and will be scheduled for Tier 3 trainings soon. Annual RI, CPR,
First Aid, and the Department’s Learning Management system (SkillPro) trainings are completed
as required.
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1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures (FOPs) addressing youth grievances, ensuring
each youth has the right to grieve, is treated fairly, respectfully, without discrimination, and their
rights are protected. Grievance forms are accessible for youth access. The center had a total of
two grievances completed during the scope of the annual compliance review period. Each
grievance was documented within the Department’s Facility Management System (FMS). Each
grievance was responded to in the required time frame according to the center’s FOP. Each of
the grievances were resolved at the formal phase. Seven youth were interviewed, and each
youth reported knowing and were able to articulate the center’s grievance process. One youth
rated the grievance process as very good, one youth rated the grievance process as good, and
the remaining five youth reported never having utilized the grievance process. Seven staff were
interviewed, and each was able to articulate the center’s grievance process. The superintendent
was interviewed and reported youth grievances and Prison Rape Elimination Act (PREA) forms
are located on each living module. Upon completion, youth and staff will discuss the alleged
matter. If resolved, the incident will be uploaded in the Department’s Juvenile Justice
Information System (JJIS), however, if the alleged incident is not resolved, administration will
take over the incident to resolve and document.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures (FOPs) addressing the process of entering and
sharing alerts information. Seven youth were reviewed for alerts entered by the center. A total of
eighteen alerts were reviewed. Each alert entered was able to be identified by name and title of
staff removing or updating the alert. Each alert contained a Juvenile Justice Information System
(JJIS) entry date, and each was entered within the appropriate timeframe. According to
documentation, JJIS alert reports are reviewed daily by supervisors and administrators. Alert
information is shared with staff daily through shift debriefings. Documentation review confirmed
the center’s review or identifying youth alerts. Alert updates occur as needed and when
appropriate within JJIS. A shift debriefing was unable to be observed during the annual
compliance review. There were no additional alerts found during the scope of the annual
compliance review which should have been entered into the alert system. Seven staff were
interviewed, and each staff reported they are informed of youth alerts through alert forms. Six of
seven staff reported they are informed of youth alerts through JJIS, and four of seven staff
reported they are informed of youth alerts by the center’s alert board. All were able to articulate
how management informs staff about issues within the program citing through logbooks, staff
debriefings, meetings and electronic mail. One of seven staff reported the center’s process for
communicating information is poor. Two of seven staff reported the center’s process for
communicating information is fair. Two of seven staff reported the center’s process for
communicating information is good, and the remaining two staff reported the center’s process
for communicating information is very good. The superintendent was interviewed and reported
youth alerts are discussed during shift briefings and provided to all staff. Kitchen personnel also
list youth food alerts on the alert board.
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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’s practices regarding data trend analysis consists of reviewing trends received from
SharePoint, Tableau, Juvenile Justice Information System (JJIS), center logbooks, and other
relevant information. The information is monitored and reviewed. Information is shared with staff
and administrators monthly as well as quarterly with providers and stakeholder through
detention review, department head and headquarter meetings, advisory board meetings, and
supervisor and routing staff meetings. The center reviews information identifying trends and
develops techniques to correct any identified deficiencies.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
A total of seven youth records were reviewed for admission process. All seven youth records
included a copy of the arrest affidavit/custody order. Six records included a copy of the
Detention Risk Assessment Instrument (DRAI), with the remaining record not being applicable
due to being a transfer from another detention center. All seven records included a Suicide Risk
Screening Instrument (SRSI) review. All seven records indicated a youth search was completed.
All seven records documented a youth telephone call to the youth’s parent was completed. All
seven records documented either the youth was provided a meal, or the youth refused a meal.
All seven records included documentation for medical/mental health/substance abuse
screening. Two youth admissions were observed during the annual compliance review. Due to
their time of admission, both youth were provided a meal. All admission procedures were
followed and both youth’s parent/guardians were called.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
A total of seven youth records were reviewed for orientation process. Each record reflected the
youth was provided an orientation within twenty-four hours. All seven records reflected a signed
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orientation acknowledgement. Two youth admissions and orientations were observed during the
annual compliance review. Youth orientations reflected verbal and written review of all required
orientation topics. Youth orientations included viewing the Prison Rape Elimination Act (PREA)
video in the intake screening area. Seven youth were interviewed, and all reported they
received an orientation at the time of admission.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
A total of seven youth records were reviewed for classification process. Each youth record
reflected a review of history and status. Youth classifications in each record included all required
elements, including mental illness, intellectual disabilities, physical disabilities, history of violent
behavior, gang affiliation, criminal behavior, history of sexual offenses, vulnerability to
victimization, medical, suicide risk, escape risk, security risk, and human trafficking history. The
classification process included all of the required topics such as sex, height, weight, age, and
level of aggressiveness. Youth were assigned to rooms based on their classification. Youth were
reclassified if changes were observed. Youth with histories of sexual offenses or youth identified
as victims of sexual abuse were placed in single rooms. The superintendent is the lead gang
contact for the facility. The center reported not having any gang affiliated youth during the scope
of the annual compliance review period. The superintendent stays informed about potential
gang affiliated youth by detention officers looking for gang alerts on the youth’s face sheet
during admission and contacting the assigned juvenile probation officer (JPO) if they need
additional information about the youth’s gang affiliation. The superintendent was interviewed
and reported the Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB),
Suicide Risk Screening Instrument (SRSI), Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2), and additional classification forms are used when considering youth's room
assignments.
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2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
A total of seven youth records were reviewed for notification of juvenile probation officer (JPO)
circuit gang representative. There were no youth who were applicable for gang affiliation during
the annual compliance review period. The facility reports there is a process in place to complete
referrals for suspected gang involvement and how to report suspicious, potentially gang-related
activity. There were no available youth records to review which included gang documentation
like photos, drawings, graffiti, or descriptions of gang signs. The superintendent is the lead gang
representative for the facility. During an informal interview, the superintendent reported
detention officers look for gang alerts on the youth’s face sheet during admission and contact
the assigned JPO by email if they need additional information about the youth’s gang
membership.
2.05 Admission and Storage of Youth Personal Property Failed 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.
A total of seven youth records were reviewed for admission and storage of youth personal
property. Six of seven records contained personal property receipts which included youth and
staff signature. The remaining youth was a transfer from another center and records reflect no
personal property at the time of admission. No youth records included a letter of
acknowledgement regarding unclaimed property. An informal interview was conducted with the
superintendent who acknowledged the omission and remedied the problem during the annual
compliance review by updating the youth admission/orientation packet to include the letter of
acknowledgement regarding unclaimed property so all future youth admission/intakes will
include this documentation. One of seven records included property items of value. The youths’
items of value were verified and secured in individual clear tamper proof property bags. The
documentation attached to the bag included the date, youth’s name, Department identification
number, and a list of items in the bag. Visual inspection through the clear bag confirmed the
items listed on the bag reflected the items in the bag. The tamper proof bag was stored in a
safe, located in master control. The drop safe was under video surveillance. The youths’
valuables were recorded in the drop safe logbook, including all applicable required information.
No youth record indicated the youth refused to sign the property receipt form. Documents in six
of seven records reflected other personal property was placed in an assigned bag and the bag
was stored in a locked storage room. The remaining record was of the transferred youth with no
property items. The signed property receipt form was included in six of seven youth records.
The remaining record was of the transferred with no property items. A request for additional
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records was made for a larger sample of records with valuable property. A total of two additional
records were reviewed for valuable property. All youths’ items of value were verified and
secured in individual clear tamper proof property bags. The documentation attached to the bag
included the date, youth’s name, Department identification number, and a list of items in the
bag. The tamper proof bag was stored in a safe. Each youth’s valuables were recorded in the
drop safe logbook, including all applicable required information. Other personal property was
placed in an assigned bag as documented on the Property Receipt Form and the personal and
valuable property receipt forms were included in each record. Two youth admissions were
observed, including the documentation of property intake. Each youth’s personal property was
stored in a secure area. Access to the property room was limited to staff working in the
intake/release/transport division. A review of the Department’s Central Communication Center
(CCC) reports completed by the review team for the scope of the annual compliance review
period reflected there were no CCC incidents related to youth property valued over fifty dollars.
Seven youth were interviewed, and six of seven reported staff checked their personal property
and then had them sign a form stating the personal property was correct. The remaining youth
reported staff did not check personal property and have them sign a form stating the personal
property was correct. The superintendent was interviewed and reported youth’s personal
property is secured by storing property in a locked property room with valuables stored in the
master control safe. For unclaimed property, a letter is mailed to the youth’s family. If no
response is received after thirty days, the property is donated to a local nonprofit organization.
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.
A total of three closed youth records were reviewed for release process. The documentation
reflected the on-duty supervisor reviewed release paperwork for all three youth. The release
process for all three youth included a review of the detention court order or other release
documentation received from the court. All three youth’s identification was verified at the time of
release. Two of three youth were released to a parent/guardian and a photocopy of their
identification was included in the youth records. The third youth was released to a Department
staff member due to transport to a different Department placement, therefore a copy of the
Department transport staff’s identification was not required. None of the three records reviewed
included a youth with a Juvenile Justice Information System (JJIS) endangered person human
trafficking alert. Two of three records reflected the youth and person receiving youth were
reminded of future court dates. The third youth was released to a Department staff member due
to transport to a different Department placement, therefore not required. Two of three records
reflected all required parties signed all applicable release forms. The third youth was released to
a Department staff member due to transport to a different Department placement, therefore
Department staff member signatures were not required. All three youth records reflected the
youth’s admission date and release date on detention release paperwork aligns with the youth’s
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admission date and release date as reflected in the JJIS. One youth release was observed
during the annual compliance review. The release documentation was completed in JJIS. The
youth’s personal identification was verified. The youth and staff signed for medication and
property. The youth was released to local shelter staff and detention staff provided courtesy
transportation to the local shelter to complete the release at the shelter site. Shelter staff
identification was photocopied, and all necessary signatures were included.
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.
A total of three closed youth records were reviewed for release of youth personal property,
medication, and aftercare instructions. Two of the youth were released to a parent/guardian and
one was released to a Department staff person who transported the youth to another
Department facility. None of the youth were eighteen years old at the time of release and were
able to sign their own release paperwork. There was documentation verifying all three youth
were released to an appropriate person. Two youth records included a photocopy of the
parent/guardian’s identification. The third youth was released to a Department staff member due
to transport to a different Department placement. One of three youth was released with
medication. The medication receipt was signed by the person receiving the youth. Two youth
records indicated the parent/guardian was reminded of any health/welfare issues or pending
appointments. The third youth was released to a Department staff member due to transport to a
different Department placement. There were no available examples of youth property held
beyond thirty days, however, there were examples of unclaimed property. Two youth records
were reviewed, and each reflected the youth’s family was contacted by mail to inform them of
outstanding property. Following this documentation, the center mailed the youth’s property to
their family and provided mail tracking receipts. An observation of one youth release was
observed during the annual compliance review. The release documentation was completed in
the Department’s juvenile justice information system (JJIS). The youth’s personal identification
was verified. The youth and staff signed for the medication and property. The youth was
released to local shelter staff and detention staff provided courtesy transportation to the local
shelter. Shelter staff identification was photocopied, and all necessary signatures were included.
All required procedures were followed.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operational procedures in place for detention reviews. A review of sign-in
sheets and documentation of weekly detention reviews in the Departments Facility Management
System (FMS) for the annual compliance review period found the reviews were completed as
required with all required staff in attendance. A weekly detention review was observed during
the annual compliance review. During the detention review, all youth in the detention facility
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were reviewed individually. The handwritten notes were reviewed during the detention review
meeting. The meeting included representatives from detention medical detention mental health,
detention education, probation, and residential staff. The meeting was held by conference call.
Discussion for each youth included due out dates, post-release planning, commitment
placement dates, and pickup arrangements
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.
Various activities were observed during the annual compliance review week. Wake up/personal
hygiene, bedtimes, groups, and open program time did not occur while the review team was on-
site and therefore could not be observed. Observations included youth intake and admission,
mealtime, recreation, line movement, education, and recreation activities. Seven youth were
interviewed and all youth indicated the center has a program activity schedule which was
followed. Seven staff were interviewed and indicated the center’s daily schedule was 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 operational procedures to provide educational access. The center
provides education services through the Leon County School District and the 250-day calendar,
which is distributed over twelve months, including ten days used for teacher training and
planning. A review of the daily school schedule revealed the center provides three one hundred
min class blocks daily, fulfilling the weekly requirement of twenty-five hours of instructional time.
A review of five random dates in the logbook showed the daily class schedule was being
followed. Further review of recent logbook entries and video footage verified youth were
attending school as scheduled. Seven youth were interviewed, and all seven reported they
attend school Monday through Friday. Four youth interviewed felt the school was preparing
them either very well or well regarding preparation towards General Education Development
platform (GED), high school, vocational, employment, and/or college, while three stated it was
not going well in their preparation. Seven staff were interviewed, and all seven felt there was
minimal interference in educational services. The interview with the superintendent also
reported there is minimal interference with educational services.
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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. A discussion with the
lead teacher confirmed the center offers Type 1 career education development which includes
career learning strategies such as interviewing skills, résumé writing, and career exploration.
The career education programming includes communication, interpersonal, and decision-
making skill development. The center also has organizations from the community come in and
give presentations on various careers and educational paths. Seven youth were interviewed,
and all seven stated they take classes which include life skills, career choices, math, science,
history, reading, and social studies.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains a contract with VitalCore Health Strategies, LLC for the provision of
mental health services. A review of the contract management folder confirmed the program’s
current designated mental health clinician authority (DMHCA) was approved. The center has
identified a single licensed DMHCA, who is a licensed mental health counselor (LMHC) holding
an active, clear license with an expiration date of March 31, 2027. During the annual compliance
review period, the DMHCA was on vacation on two occasions and appropriately designated a
LMHC to provide coverage during absence. This LMHC holds an active, clear license with an
expiration date of March 31, 2027. In addition, the center has an approved back-up DMHCA
with an active, clear license expiring March 31, 2027; however, this individual was not utilized
during the review period. A review of sign-in and sign-out logs and position descriptions
confirmed the DMHCA is on-site weekly, in accordance with contractual requirements, to ensure
the coordination and implementation of mental health and substance abuse services. An
interview with the DMHCA confirmed the DMHCA oversees the coordination and daily operation
of all mental health and substance abuse services within secure detention. Responsibilities
include ensuring all youth are screened at intake, informed of how to access mental health
services, and referred to psychiatry within fourteen days of admission for those prescribed
psychotropic medications, with ongoing follow-up as needed. All youth receive weekly
treatment, and those detained for thirty days receive a Substance Abuse and Mental Health
Assessment (SAMH) to determine additional treatment needs. Services provided include suicide
risk and crisis assessments, psychiatric services, SAMH-II evaluations, and individual and group
treatment. The DMHCA maintains regular communication with clinical staff through daily
contact, weekly supervision meetings with interns, and ongoing communication by email,
telephone, and in person.
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 center maintains a contract with VitalCore Health Strategies, LLC to employ licensed
clinical staff who are qualified to provide mental health and substance abuse services based on
their education, training, and professional experience. During the annual compliance review
period, the clinical team consisted of seven licensed mental health counselors (LMHCs) and
one licensed clinical social worker (LCSW), all of whom operate under the direction of the
designated mental health clinician authority (DMHCA). In November 2025, one LMHC resigned,
reducing the clinical team to six LMHCs. A review of the contract management folder confirmed
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all staff credentials were properly reviewed and approved. Current professional licenses and
cardiopulmonary resuscitation (CPR) certifications were available on-site for all staff. Each
clinician holds a clear and active license in the State of Florida, with expiration date of March 31,
2027, and maintains a valid CPR certification.
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 center has facility operating procedures (FOPs) in place regarding non-licensed mental
health and substance abuse clinical staff. The center has one non-licensed clinical staff serving
in an internship capacity under the supervision of the designated mental health clinician
authority (DMHCA). The DMHCA ensures all non-licensed staff under their supervision provide
services consistent with their education, training, and professional experience. Documentation
review confirms the non-licensed mental health clinical staff received a minimum of one hour a
week of on-site, face-to-face direct supervision from a licensed mental health professional
during the annual compliance review period. This supervision was provided for the purpose of
overseeing and directing mental health services delivered within the program and was
appropriately documented on the Non-Licensed Mental Health Clinical Staff Person’s Training in
Assessment of Suicide Risk form, Practicum Hour Log, and Internship Live Supervision
Evaluation Form. The center does not maintain a Chapter 397 license, as the VitalCore contract
requires the employment of licensed professionals only, ensuring all substance abuse services
are provided exclusively by qualified, licensed staff. The non-licensed clinical staff is an intern
who holds a master’s degree in counseling from an accredited university and is completing the
required hours.
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 (FOPs) to ensure mental health and substance
abuse needs of youth are identified through a comprehensive screening process. Seven youth
records were reviewed. All records contained a completed Suicide Risk Screening Instrument
(SRSI), and five included a Massachusetts Youth Screening Instrument-Second Edition (MAYSI-
2) completed at intake and reviewed by detention staff. The two records without a MAYSI-2
reflected youth who were transferred from another center, where the MAYSI-2 had been
completed previously. Both screening instruments were documented in the Department’s
Juvenile Justice Information System (JJIS). All seven youth records indicated a nurse and/or
mental health staff completed the required SRSI sections, including accurate referral selections
in the “screening results” section. Six of the seven youth had a positive “yes” response on the
SRSI, resulting in placement on suicide precautions and completion of a mental health referral.
Each of the six screenings also reflected a “yes” response indicating the presence of open or
closed suicide risk alerts in JJIS. The records for all six youth documented the need for further
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assessment, with appropriate follow-up referrals and notifications made to the
superintendent/designee. Four of the five MAYSI-2 screenings were marked as “invalid,” and
the youth were referred for comprehensive assessment as indicated in the MAYSI-2 referral
section. The remaining MAYSI-2 did not reflect elevated suicide risk subscales; therefore, no
additional assessment was required.
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 (FOPs) regarding mental health and substance
abuse evaluations. Seven youth records were reviewed for mental health and substance abuse
evaluations. Six of the seven youth were identified upon admission as requiring further
evaluation and were appropriately referred to the center’s provider. A new comprehensive
evaluation was completed for all six youth within the required timeframe, either within fourteen
days of admission or by the thirty-first day following admission. The remaining youth had not
been admitted long enough to require completion of an evaluation. All six completed evaluations
included treatment recommendations and contained all required elements. The
recommendations were appropriate and aligned with each youth’s diagnosed mental health or
substance abuse needs. Each comprehensive mental health/substance abuse evaluation was
completed using the Department’s required form. All comprehensive assessments are
conducted by the center and do not involve the use of community providers. An interview with
the designated mental health clinician authority (DMHCA) confirmed when a detained youth is
referred for a comprehensive mental health and/or substance abuse assessment by the
Juvenile Assessment Center (JAC) or juvenile probation officer (JPO) and has not received the
assessment from a community-based provider within thirty days of screening, the detention
center’s mental health provider completes a comprehensive mental health evaluation by the
thirty-first day of detention, regardless of whether the referral is based on initial screening
results or observed behavior.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures (FOPs) regarding treatment and discharge
planning. Seven youth were reviewed for treatment and discharge planning. All seven youth
received a mental health orientation within fourteen days of admission. Five of the seven youth
required an initial treatment plan, with two not being applicable. All five initial treatment plans
were documented using the Department’s Initial Mental Health/Substance Abuse Treatment
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Plan form. Each plan included the reason for referral, the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis and presenting symptoms, initial treatment
methods, including counseling and service frequency, and identified initial treatment goals. All
five youth were admitted to the center with active prescriptions for psychotropic medication.
There was a delay of approximately two weeks in one case due to the parent/guardian bringing
the medication to the center at a later date. Each initial treatment plan addressed psychiatric
services and prescribed medications. The plans included signatures from the mental health
professional and the youth. Documentation for all five cases confirmed assignment to the mini-
treatment team, with team members participating in the development of the initial treatment
plans. Five of the seven youth required an individualized treatment plan. All five individualized
treatment plans were dated and developed for youth receiving mental health and/or substance
abuse treatment by the thirty-first day of admission. Each plan included the applicable DSM-5
diagnosis, treatment-focused symptoms, identified treatment goals, including mental health
services for youth with a mental illness and substance abuse services for youth with a
substance-related diagnosis, and an assessment of strengths and needs. In all five cases, the
psychotropic medications documented in the initial individualized treatment plans were
consistent with the medications prescribed at the time the individual plans were developed.
Progress notes confirmed youth were receiving services in accordance with their treatment
plans. The individualized treatment plan included signatures from the youth, the mental health
professional, and treatment team members. Parent/guardian contact was documented in three
cases, and attempted contact was documented in the remaining two cases. Only three of the
five youth with treatment plans were applicable for a thirty-day review, as the remaining two
youth had not yet reached their initial thirty-day review date. Of the three applicable youth, two
received one thirty-day review, and the remaining youth received three thirty-day reviews. All
reviews were completed within the required timeframes and documented using the
Individualized Mental Health/Substance Abuse Treatment Plan Review form. Each of the
reviews included documented modifications, which were clearly identified on the review forms.
All completed reviews were signed by clinical staff, the youth, a licensed mental health
professional, and treatment team members, with parent notification appropriately documented.
All five youth with individualized treatment plans received treatment and services from a
licensed psychiatrist. None of the youth were identified as alleged victims under the Prison
Rape Elimination Act (PREA); therefore, no treatment plan revisions were required as a result of
a crisis assessment.
Two of the seven youth records contained a completed discharge plan documented on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form, finalized at
the time of the youth’s transition or discharge from the center. One additional discharge record
was requested and subsequently provided. In all three discharge cases, copies of the Mental
Health/Substance Abuse Treatment Discharge Summary were provided to the youth, the
parent/guardian, and the juvenile probation officer (JPO). All documentation practices reviewed
were consistent with the Department’s Statewide Electronic Health Record policy and
procedure. A mini-treatment team meeting did not occur during the annual compliance review
week; therefore, one could not be observed. An interview with the designated mental health
clinician authority (DMHCA) confirmed mental health and substance abuse services are
reviewed daily and, at a minimum, weekly. Individual treatment plans are reviewed at least
weekly and more frequently as needed. Youth prescribed psychotropic medication are evaluated
by psychiatry within fourteen days of admission, with an initial treatment plan developed within
seven days of the evaluation or upon completion of the fourteen-day orientation. An
individualized treatment plan based on the Substance Abuse and Mental Health (SAMH-II)
assessment is completed by the thirty-first day of detention and is reviewed every thirty days
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until release. The mental health and/or substance abuse provider meets with the center
administrator daily, at a minimum weekly, and as needed.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility operating procedures (FOPs) regarding mental health and substance
abuse treatment. Seven youth mental health records were reviewed for mental health and
substance abuse treatment. Five of the seven youth required treatment and were assigned to
mini-treatment teams. Documentation review confirmed each mini-treatment team consisted of
mental health staff, at least one staff member from a different service area, the youth, and
parents/guardians when available. All five applicable youth were required to receive and did
receive mental health treatment. Treatment plans for each youth included individual therapy and
group therapy, at a minimum frequency of once a week. Two of the five youth also required
substance abuse treatment and received services in accordance with their treatment plans.
Proper consents for mental health treatment were obtained for all five youth. Additionally,
appropriate consents for substance abuse treatment were on file for all five youth, including
those who did not require services. All reviewed treatment notes were documented using the
Department’s Counseling/Therapy Progress Notes and included all required elements. Video
review of three group therapy sessions revealed no areas of concern. Mental health staff were
observed to have adequate access to youth and sufficient confidential space to provide
treatment services. Video review further confirmed mental health group therapy sessions were
limited to ten or fewer youth with mental health diagnoses, and record review verified substance
abuse group therapy sessions were limited to fifteen or fewer youth with substance abuse
diagnoses. Interviews were conducted with seven youth, who were asked to rate the mental
health and substance abuse services they are currently receiving or have previously received.
Five youth rated the services as very good, one rated them as good, and one rated them as fair.
An interview with the designated mental health clinician authority (DMHCA) confirmed
individualized mental health and substance abuse treatment plans are reviewed at least weekly
and more frequently as needed. Youth evaluated by psychiatry within fourteen days of
admission and prescribed psychotropic medication receive an initial treatment plan within seven
days of the evaluation or upon completion of the fourteen-day orientation. An individualized
treatment plan based on the SAMH-II assessment is completed by the thirty-first day of
detention and reviewed every thirty days until release. Mental health and substance abuse
treatment services are provided by assigned licensed mental health professionals and
supervised interns at the center.
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3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a written suicide prevention plan which outlines comprehensive suicide
prevention procedures. The plan is reviewed and approved annually by the designated mental
health clinician authority (DMCHA) and the superintendent. The plan addresses the
identification and assessment of youth at risk for suicide, staff training requirements, suicide
precautions, levels of supervision, referrals, communication and notification protocols,
documentation standards, immediate staff response, and the required review process. In
addition, the center has an established review protocol for every serious suicide attempt or
serious self-inflicted injury, as well as a mortality review process in the event of a completed
suicide. This review process includes an examination of the circumstances surrounding the
incident, applicable center procedures, relevant training received by involved staff, medical and
mental health services provided to the youth, potential precipitating factors, and resulting
recommendations.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures (FOPs) regarding suicide prevention services.
Seven youth mental health records were reviewed for suicide prevention services. Six of the
seven youth were determined to be at risk for suicide. Five of the six youth were admitted to the
center and immediately placed on precautionary observation (PO). The remaining youth was
placed on PO following an incident observed by staff. For all six-youth placed on PO, the
documented start date and time of PO were consistent with the Department’s Juvenile Justice
Information System (JJIS) alert date and time. Each of the six youth had an Assessment for
Suicide Risk (ASR) referral which matched the JJIS alert and PO placement date and time. All
ASRs documented the assessment was completed on the day of service, as required. Five of
the six youth were placed on constant supervision, while the remaining youth was placed on
one-to-one supervision. Suicide precaution observation logs were fully completed for all records,
and a qualified mental health professional was involved in each instance. None of the youth
reviewed were released prior to receiving an ASR or while on suicide precautions. All six
records reflected documented consultation with the designated mental health clinician authority
(DMHCA) or a licensed mental health professional, as recorded on the mental health/substance
abuse referral summary. Additionally, all records indicated the superintendent, or designee was
immediately notified of the suicide risk. Each ASR was completed within twenty-four hours of
placement on PO. Two of the six youth required a follow-up ASR prior to removal from PO. All
six records included documentation of a conference was held involving the superintendent and
a licensed mental health professional to determine a reduction in the level of supervision.
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Documentation in all six records confirmed discontinuation of close supervision occurred in
accordance with the center’s suicide prevention plan. Suicide risk assessments for all six youth
were completed by licensed mental health professionals and included assessment results,
recommendations for supervision and follow-up, and appropriate documentation in the center’s
logbooks and ASR forms. The records also indicated administrative or supervisory staff provided
specific instructions based on the assessment findings and decisions. All six-youth had JJIS
alerts entered upon placement on PO and subsequently removed following discontinuation of
PO. Logbook entries reflected accurate start and end times of PO for five of the six youth;
however, the end time of PO was not documented in the logbook for one youth, as required.
Interviews were conducted with seven youth to determine whether they had ever been placed
on suicide watch while at the center. Four youth reported they had not been placed on suicide
watch, while three reported they had. Those who were placed on suicide watch indicated staff
monitored them continuously during this time. Interviews were conducted with seven staff to
assess their understanding of their responsibilities when a youth expresses suicidal thoughts. All
seven staff reported they would notify the mental health authority, search the youth’s room for
sharp objects, document supervision, and maintain continuous sight and sound monitoring.
Additionally, one staff member noted if a youth is upgraded to secure observation, they would
place the youth in a locked room. An interview with the DMHCA confirmed suicide risk
screenings are conducted by assigned mental health professionals and interns using the ASR,
Suicide Risk Screening Instrument, and Massachusetts Youth Screening Instrument-Second
Edition (MAYSI-2). Mental health referrals are responded to within twenty-four hours, and the
DMHCA is available on call twenty-four/seven. Youth identified as acutely suicidal are referred
immediately, placed on precautionary observation, and assessed by mental health staff as soon
as possible to determine the appropriate level of care. Notifications to the superintendent or
designee are documented prior to any change in supervision level, and communication with
security staff is recorded in the electronic medical record and control room logbook.
Parent/guardians and juvenile probation officers (JPO) are notified verbally and/or by email, as
appropriate. During the past six months, six incidents of self-harm or attempted self-harm were
reported; none of the involved youth are currently in the program.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures (FOPs) regarding secure observation. Seven youth
mental health records were reviewed for secured observation documentation. One of the
records was applicable for secure observation. Two additional records were requested, with one
record being provided as there were no other applicable records during the annual compliance
review period. A review of the two applicable records confirmed placement in secure
observation was properly authorized by the superintendent and the designated mental health
clinician authority (DMHCA), with the secure room designation documented in writing. Both
records included completed Health Status Checklists, Suicide Precaution Observation Logs,
and Follow-Up Assessments for Suicide Risk (ASR). Documentation further indicated the
parent/guardian and the juvenile probation officer (JPO) were notified of the youth’s potential
suicide risk, as identified through the ASR. Neither youth remained in secure observation for
more than twenty-four hours. Both records reflected mental health staff provided supportive
counseling services during the period of secure observation. Observation logs demonstrated
continuous supervision for the duration of secure observation for each youth. Additionally, the
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reduction in observation level occurred following a conference between the superintendent and
a licensed mental health professional, and the discontinuation was appropriately documented in
the center’s logbook.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures (FOPs) regarding suicide precautions and
observation logs. Seven youth records were reviewed for suicide precaution observation (PO)
logs. Six of seven youth records were applicable for suicide prevention services. For each of the
six applicable records, PO logs were consistently maintained for the entire duration of the
youth’s placement on suicide precaution. The logs reflected the appropriate level of supervision
and documented observations of each youth’s behavior in real time, with observation intervals
not exceeding thirty minutes. No warning signs were documented in any of the records;
therefore, notification of the superintendent or designee and mental health clinical staff was not
required. Each PO log was reviewed and signed by both the shift supervisor and mental health
clinical staff, and documentation confirmed safe housing requirements were met in all cases.
Additionally, video reviews were conducted for three youth on precautionary observation on
three separate days. The video reviews and corresponding documentation verified appropriate
supervision was maintained for the entire period each youth remained on precautionary
observation.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center maintains a Suicide Prevention Plan which includes established staff training
requirements. Seven pre-service and seven in-service staff training records were reviewed to
assess compliance with suicide prevention training standards. All reviewed staff completed the
required six hours of suicide prevention training. Training requirements also include suicide
response drills conducted no less than quarterly on each shift. The center maintains three
suicide response kits, each equipped with a knife-for-life, wire cutters, and needle-nose pliers,
and located on each module. Although suicide response kits are not co-located with first aid kits,
each kit is appropriately stocked with a cardiopulmonary resuscitation (CPR) mask, non-latex
gloves, and required first aid supplies. A video review of a suicide drill conducted on November
11, 2025, was completed and confirmed the drill was simulated and consistent with
corresponding documentation. Additionally, a review of twenty-seven drills conducted during the
annual compliance review period demonstrated mock suicide drills are held at least quarterly on
each shift and include all staff who have contact with youth, including kitchen and maintenance
personnel. Documentation confirmed all mock mental health drills involving a suicide attempt or
serious self-inflicted injury were simulated and did not involve program youth. The program also
provides semi-annual training on emergency response procedures, including mock training for
response to suicide attempts or incidents of serious self-inflicted injury, with CPR instruction
included. Staff members who were not present during a quarterly drill were provided the
opportunity to review drill scenarios and procedures to ensure understanding and receive the
necessary training to appropriately respond to a suicide attempt or serious self-inflicted injury
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within the center. Interviews were conducted with seven staff members to assess their
knowledge of the locations of the suicide kits, which contain a knife for life, wire cutters, and
needle-nose pliers. All seven staff identified master control and the medical area as locations for
the kits. Additionally, six staff reported sub control, and two staff reported the van bags as
additional locations.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures (FOPs) which establish procedures outlining
mental health crisis intervention services. These procedures are incorporated within the
Combined Emergency Services Plan. The plan includes a structured notification and alert
system, referral mechanisms including self-referral options, protocols for communication and
supervision, and requirements for documentation and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures (FOPs) outlining the process for providing
emergency mental health and substance abuse services. The center’s Emergency Care Plan
was signed on August 13, 2025, by the superintendent and the designated mental health
clinician authority (DMHCA). The plan addresses immediate staff response requirements;
notification and communication protocols; supervision standards; authorization for transport to
emergency mental health or substance abuse services; procedures for emergency mental
health evaluation and treatment; transport for emergency substance abuse assessment and
treatment; documentation requirements; staff training; and plan review processes. The
Emergency Care Plan is readily accessible to all staff and is maintained in both master control
and the medical department.
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3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures (FOPs) requiring the completion of a Crisis
Assessment for any youth exhibiting acute psychological distress. Seven youth mental health
records were reviewed; however, none of the youth had been identified as experiencing a
mental health crisis. As a result, three additional records were requested for review. The center
reported no crisis assessments were conducted during the annual compliance review period
3.16 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has a medical doctor who is assigned as the designated health authority (DHA). The
DHA has a license which is unrestricted and meets all requirements for independent and
unsupervised practice in Florida. The DHA license expires January 31, 2026. The center also
utilizes an advanced practice registered nurse (APRN). The DHA and APRN have a
collaborative practice protocol in place. A review of sign-in and sign-out logs during the annual
compliance review period, December 2024 through December 2025, confirm the DHA was on-
site at least once a week, with a week defined as the seven-day period beginning on Sunday
and ending on Saturday. There was no indication the center utilized tele-medicine during the
review period. The center may participate in tele-medicine and has a policy in place to address
if necessary. The DHA was interviewed, stating duties include performing comprehensive
physical assessments, conducting periodic evaluations, sick calls, taking phone calls from staff
when not on duty, and policy and procedure development. Staff call with urgent off-site care
findings, while routine off-site care findings are reviewed during weekly clinic visit.
Documentation of reviews are in youths’ medical records. Important medical issues pertaining to
the youth at the center are documented in the youth medical record weekly and as needed.
Medical staff meet weekly and as needed.
4.02 Healthcare Protocols, Policies, and Procedures [Contract
Limited Compliance
Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The Office of Health Services has an open deficiency pertaining to this indicator, whereas not all
medical policy and procedures and treatment protocols were appropriately reviewed and signed
by the designated health authority, the advanced practice registered nurse, psychiatrist, and
other medical staff at the center.
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.
Seven youth individual healthcare records (IHCR) were reviewed for authority of evaluation and
treatment (AET) requirements. Four of the seven had the original or legible copy of the original
AET form filed in the youths in the IHCR. Two of the remaining three were for youth eighteen
years of age or older, who signed the required release information form. The remaining one was
a Department of Children and Families (DCF) youth, where a court order was filed in the IHCR.
Each of the four applicable AET forms were signed by necessary parent, guardian, and
Department representative. Applicable AET forms were valid and were obtained prior to
providing medical services. Nursing staff were interviewed and were articulate the AET
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procedure and stated the AET is a required and critical document to ensure a youth’s health and
mental health needs can be met and services can be rendered.
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.
Seven youth individual healthcare records (IHCR) were reviewed for parental
notification/consent requirements. Five out of seven youth had documentation of parental
notification for over-the-counter (OTC) type medications beyond those covered by the
Department’s Authority for Evaluation and Treatment (AET), With two youth being over the age
of eighteen years old. In each of the applicable five cases, documentation was found of consent
provided for by the parent/guardian. Consents were documented on required Department forms.
Four of the seven youth were found to be taking psychotropic medications upon admission to
the center. One of the remaining three youth was later prescribed psychotropic medication.
Each youth requiring notification for new medication having been ordered had documentation of
attempted contact to the parent/guardian in the chronological progress notes. For the five-youth
admitted or later prescribed psychotropic medication, the acknowledgement of receipt for
clinical psychotropic progress note (CPPN) form was sent to the parent/guardian. Two out of
seven youth vaccines were verified within thirty days of a youth’s admission. The remaining five
youth did not have verifications for shot records completed within thirty days of admission. All
five youth vaccinations were verified at a previous admission to the center; however, none were
verified again for the current admission. None of the youth were applicable or in need of having
vaccinations administered while at the center. The nurse was interviewed and reported the
center will inform the parent or guardian of significant changes in the youth’s condition and
obtain consent when new medication and treatments are prescribed. Written parental consent is
required in certain circumstances. The appropriate parental notification of health-related care
form will be used for consent purposes. Verbal attempt at consent shall be documented in the
chronological progress notes. Parental notification of care without special consent shall be
accomplished by attempting verbal contact with the parent/guardian to notify them of care in the
following instances and shall be followed by written notification utilizing one of the appropriate
parental notification forms. If the parent or legal guardian cannot be contacted, alternative
measures are taken, which the center superintendent must document all efforts to contact the
parent or legal guardian. For new medication, verbal attempts/contacts/consents will be
documented in the chronological progress notes in the IHCR by the person attempting and/or
making contact with the parent/guardian. A staff member shall witness all telephone call
attempts and conversations. If an additional staff member is unavailable to witness call
attempts, the center will have an internal process by which the attempts are verified.
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.
Seven youth individual healthcare records (IHCR) were reviewed for healthcare admission
screening requirements. Each youth reviewed were in receipt of a medical and mental health
admission screening. Each screening was completed on the Department’s Facility Entry
Physical Health Screening form. The screenings were completed on the date of admission to
the center. Each of the screenings reviewed were completed by the juvenile justice detention
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officer (JJDO) at the center. One of the seven screenings was not reviewed with the youth by a
licensed nurse within twenty-four hours, being one date late. The remaining six screenings
were. Six of the seven youth reviewed were applicable for notification to the designated health
authority (DHA); all six-youth had documentation of notification to the DHA in the youth’s IHCR.
None of the reviewed youth changed physical custody since admission to the center. Three
additional youth records were requested and reviewed. For each of the three youth, the center
completed a healthcare admission re-screening for each time a change in custody occurred. In
each of the three re-screenings, a JJDO completed and were subsequently reviewed by a
licensed nurse within twenty-four hours. None of the youth were applicable to be in receipt of a
qualitative urine pregnancy screening test. The nurse was interviewed regarding how much time
passes before a nurse sees a newly admitted youth and stated generally within the first twelve
hours and always within twenty-four hours. Additionally, medical staff are notified when a youth
is admitted and are provided medical and mental health screening forms which are completed
during the admission process. When there is a change in physical custody, if the youth is being
detained at the center for less than twenty-four hours, at a minimum, vital signs are taken, and
the youth is questioned concerning medical needs, chronic conditions, medications, and any
medical complaints, followed by contact with the parent to verify the information provided by the
youth. Depending on the prior center the youth was transferred from, there may be a complete
intake completed with an event added to the health-related history.
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 a written facility operating procedures (FOP) which addresses practices for
youth orientation to healthcare services and health education and included all required topics.
Seven youth individual healthcare records (IHCR) were reviewed and confirmed youth are in
receipt of a general healthcare orientation with no exceptions. Each orientation was
documented on the appropriate Department form. Each youth with chronic conditions were
educated on their medical condition.
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.
Seven youth individual healthcare records (IHCR) were reviewed for notification requirements to
the designated health authority (DHA). Three out of seven youth were found to be admitted with
known or suspected chronic conditions. Each of these youth had a referral made to the DHA
within twelve hours. Notifications to the DHA/designee were documented within the youth’s
IHCR under chronological progress notes. None of the youth were identified or in-need of
emergency care upon admission. Four of the seven youth were admitted with current
psychotropic medications and the psychiatrist was notified. The nurse was interviewed
concerning process and timeframes for notifying the DHA and replied in situations where a
youth does not require immediate emergency transfer, the DHA or designee must be notified of
all youth admitted with identified chronic health conditions. This notification may be by
telephone, secure email, facsimile, or verbally if the DHA or designee is on the premises but
must be documented in the chronological progress notes of the IHCR. The purpose of the
notification is to keep the DHA updated about the types of medical conditions existing within the
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center. All notifications shall be documented on the intake progress note of the IHCR by the
licensed medical staff. If notification is made by non-healthcare afterhours, the report of health
care by non-health care staff form shall be used and placed in the youth’s IHCR. Priority
referrals to the center’s DHA, or designee will be made for youth who are admitted with known
or suspected chronic conditions not requiring emergency treatment on admission.
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.
Seven youth individual healthcare records (IHCR) were reviewed for confirmation of the Health-
Related History (HRH) process. Each youth had an HRH updated/completed within seven
calendar days of admission. Each of the youth’s HRH forms were updated/completed prior to
the completion of the comprehensive physical assessment (CPA). Each of the HRH were
completed by a licensed nurse or practitioner. The designated health authority (DHA) or
advanced practice registered nurse (APRN) reviewed each HRH, by documenting the review on
the HRH with a date and signature. Each HRH was reviewed by either the physician or
advanced practice registered nurse (APRN), which was indicated by the checkbox on the CPA.
The nurse was interviewed concerning who is responsible for completing the HRH, and replied
the HRH shall be completed no later than seven calendar days following the date of admission
and prior to the youth being subjected to extreme outdoor weather conditions including, but not
limited to, high heat indexes and frigid temperatures.
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.
Seven youth individual healthcare records (IHCR) were reviewed for the Comprehensive
Physical Assessment (CPA) and Tuberculosis (TB) screening requirements. All of the youth’s
physical assessments were completed on the appropriate Department form. Each of the youth
had a current CPA with no change in medical conditions on record or one was completed within
seven calendars days of admission with no exceptions. All reviewed CPA forms were completed
by a medical doctor, with a focus examination completed where a current CPA was utilized.
Each of the CPA forms documented the youth’s Medical Grade. Each CPA form had all sections
marked with an “O” or an “X”. Five of the youth refused the genital examination and four records
contained the refusal form, while the fifth record did not contain a signed refusal form. In each
IHCR the Department’s problem list was updated. Each youth had a verified tuberculosis skin
test (TST) documented in the IHCR. The results of the TST test were documented on the CPA
and Infectious and Communicable Disease forms. None of the seven youth required further
evaluation. The nurse was interviewed concerning how often the designated health authority
(DHA) completes a new CPA and stated a CPA will be completed within seven calendar days of
the youth’s admission. The CPA is current if performed within the last two years. The center
requests a new CPA be completed after one year from the previous CPA. In addition, nursing
staff were asked about the process and timeframes for TB screenings. The nurse stated all
youth are required to be screened for TB and accurate documentation of results will be
maintained by the center. There will be at least one verified TST, documented in the IHCR in
accordance with the Center for Disease Control and Prevention guidelines.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Seven youth individual healthcare records (IHCR) were reviewed for sexually transmitted
infection (STI) testing. There was only one youth applicable for the inclusion of STI screening.
An additional two records were requested to complete the minimum sample for youth who are
sexually active and were evaluated. In each of the applicable records, the youth were screened
and subsequently referred for further evaluation. Each youth had a screening and testing
documented accordingly on the appropriate Department form. None of the reviewed youth were
in receipt of a gynecological exam or out of the Department’s physical custody. There were
seven youth records reviewed to address practices for human immunodeficiency virus (HIV)
screening requirements. Each of the seven records found evidence each youth was offered
counseling, testing, and, if indicated, treatment/referral for HIV. Five of the seven youth were
applicable to be in receipt of HIV testing. The remaining two youth signed a refusal. For the five
youth who were completed testing, each had a documented consent form filed in the IHCR.
Each youth consenting for testing had testing completed within thirty days of the request.
Testing results were found filed according to policy and subsequently documented by the
practitioner. Pre-test/post-test counseling was found documented in the youth’s IHCR. Each of
the youth’s confidentiality was protected by not including the youth’s HIV status or any other STI
diagnosis on the program’s internal alert system. Nursing staff were interviewed and confirmed
screening and referral will be accomplished using the Department’s most current STI form for
screening youth for STI’s. After screening, youth will be referred to the DHA or designee within
seven days to determine if further testing is indicated. The results, and treatment, if necessary,
will be noted on the Infectious and Communicable Disease form and the lab results will be in the
IHCR behind the corresponding tab. All seven interviewed youth stated they can request an 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.
Seven youth individual healthcare records (IHCR) utilized to address practices for Sick Call
Process requirements. Only three of seven youth were applicable for the sick call process. A
total of three sick calls were reviewed. The youth completed a sick call request for each of the
sick calls, which were found documented on the Sick Call Referral Log. None of the youth
presented with a similar sick call complaint within a two-week period. There were no indications
of youth complaints of severe pain with which staff were unfamiliar. In one out of the three sick
call complaints completed, a licensed practical nurse (LPN) conducted the sick call. This sick
call was reviewed by a registered nurse (RN) and documented on the form. The remaining two
sick calls submitted were completed by the RN. None of the youth appeared to be in restricted
housing. Sick call forms were completed in accordance with Florida Administrative Code 63M-
2. Each sick call was found documented on the Sick Call Index. The dates listed on the Sick
Call Index corresponded to the completed sick call forms located in each youth’s IHCR. A
review of the daily schedule, posted sick call schedule, and nurse interview indicated sick call is
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conducted daily and youth are seen within at least twenty-four hours of submitting a sick call
request. Sick call is provided Monday through Friday 9:00 a.m. through 10 a.m. and 3:30 p.m.
through 4:30 p.m., and on Saturday and Sunday from 2:00 p.m. through 3:00 p.m. or as
deemed necessary. Sick call hours can be found posted in the medical department. Reviewed
documentation confirmed only licensed nursing staff were completing sick call. The center has
approved treatment protocols for medical staff and has a written policy which addresses
practices if no licensed staff are on-site. The center has a written policy which addresses
practices for youth in room restriction/confinement. There was no sick call observation
completed as no verbal and/or written request was made to medical throughout the annual
compliance review week. Nursing staff was interviewed and stated the center conducts Sick Call
seven days a week. The scheduling of sick call does not preclude the nursing staff from
addressing issues which youth as they arise. If these complaints are determined to be of a non-
urgent nature, they can be deferred until the following scheduled sick call. The nursing staff will
identify sick calls placed into the electronic medical record by reviewing the Sick Call Referral
Log. The sick calls will be triaged and screened for urgency; emergency conditions are not
inappropriately delayed for the next regularly scheduled sick call session. Only a licensed nurse
may conduct sick call. RNs must hold active and unrestricted licenses. LPNs, who provide
nursing services, must do so under the direction of a RN, ARNP, or physician and hold an active
license. They may provide nursing care which is pursuant to written treatment protocols
appropriate for LPNs which are developed, approved, and signed by the DHA. Seven youth
were interviewed and five stated they can be seen within a one day after making a sick call
request and one youth said within two days. The remaining youth said they have never
requested a sick call. Additionally, youth stated either the DHA or nurse conducts sick calls.
Seven staff were interviewed, and each agreed the nurse reviews and conducts sick calls, and
one staff said the supervisor.
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.
Seven youth individual healthcare records (IHCR) were reviewed for episodic/first-
aid/emergency care requirements. Out of the seven youth, there were a total of fourteen
episodic and/or first-aid on-site incidents reviewed. Each of the incidents was completed by a
licensed healthcare staff utilizing problem-oriented narrative. None of the youth received
episodic or first-aid care by a non-healthcare staff. In each event, the nature of the complaint
and the findings of the person rendering care was documented in the youth’s IHCR. Treatment,
education, parental notification, and when necessary, follow-up for future care was documented
accordingly. None of the applicable youth needed a referral for off-site care or were placed on
the alert list. The Episodic Care Log was completed for each event. The center has eighteen
first-aid kits, six of which are utilized for transportation. Three random first aid kits were opened
by licensed medical staff and examined for designated health authority (DHA) approved
contents. In one of the three kits reviewed, a bottle of saline was found expired. The two
remaining kits had saline which expired on the same date of review of the kits. One of three kits
had a bottle of hand sanitizer which expired November 2025. The medical department staff
checks each first-aid kit monthly; a review of the log demonstrated first-aid kits are reviewed for
this frequency. If a first-aid kit is found to have been used, contents are verified and replaced as
needed. First-aid kits have contents labeled and corresponding expiration dates listed on the
outside of the first-aid box. The center has two automated external defibrillators (AED). Each
had procedures located with them, along with valid battery and pads. The AEDs are checked at
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a minimum monthly by on-site medical staff. Nursing staff conducted a self-test of the AED with
no issues.
A review of simulated emergency drills was conducted for each shift. These drills were
conducted every month, on each shift, and unannounced. The only exceptions were on the
second shift, where out of a possible twelve drills, three were missing. The first and third shift
had twelve drills each completed. Florida Administrative Code only requires medical drills to be
conducted quarterly. Reviewed drills simulated an episodic care event which called for
immediate first-aid, AED, and/or administration of cardiopulmonary resuscitation (CPR)
techniques, and the initiation of the emergency procedures to follow when a life-threatening
emergency occurs. Documentation found the center ensured all staff with day-to-day direct
youth contact had the opportunity to participate in at least one emergency “man-down” drill
annually. The center maintains a training roster for those staff trained in the administration of an
epinephrin auto-injector; training was conducted by a registered nurse. Seven pre- and in-
service training records were reviewed, which demonstrated staff are trained in episodic care,
first-aid, and emergency care. Two of the fourteen staff were missing CPR training. The center’s
written policy and procedure pertaining to naloxone (NARCAN), addresses stock, inventory,
treatment, and training of staff for use of NARCAN if necessary. The center has NARCAN in the
medical department; one in the medication cart and one in the cabinet. The medical staff
inventory NARCAN supplies weekly. Nursing staff were interviewed and said the center has a
comprehensive process in place for the provision of episodic care and first-aid treatment.
Emergency medical and dental care will be available, including emergency medical services,
twenty-four hours a day. The center will track all episodic/emergency events using the
Department’s Episodic Care Log form. Non-healthcare staff episodic care documentation will
include utilizing the Report of Healthcare by Non-healthcare Staff. All youth will receive a follow-
up evaluation by licensed healthcare staff after each episodic/emergency event provided by
non-healthcare staff. Documentation will conform to professional standards in the youth’s
chronological progress notes. Seven youth were interviewed and three rated medical care as
good and four rated it as very good. Seven interviewed staff stated they are able to call 9-1-1 if
they feel it is necessary.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
Seven youth individual healthcare records (IHCR) were reviewed for completion requirements
concerning off-site care/referrals. There were only two out of the seven youth which were
applicable for off-site care/referrals. One additional youth record was requested and reviewed to
make a minimum sample of three records reviewed. The three reviewed youth required some
type of off-site care. Each had a Summary of Off-Site Care form completed and filed within their
IHCR. In addition, parental notifications and discharge documents were found filed in the
youth’s IHCR. The designated health authority (DHA) reviewed the discharge instructions. One
of the three youth required a follow-up appointment. The youth had a referral and subsequent
follow-up appointment documented in the IHCR. Documentation confirmed the referrals were
tracked and youth received timely follow-up care. None of the incidents were applicable for
being added to the Episodic Care Log. Nursing staff were interviewed and stated following off-
site care, youth are added to the provider’s log. The Summary of Off-site Care form shall
accompany the youth to the off-site provider, to be completed and returned to the center for
filing in the youth’s IHCR and uploaded into the electronic medical record. Upon the youth’s
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return, the documents sent back to the center must be reviewed in order to ascertain if there are
orders for referrals, lab work, exercise restrictions, alerts, or follow-up appointments. Referrals
must be entered on the center’s tracking log. Pertinent information about the referral must be
documented within the progress note. The DHA or designee shall initial all orders/information
sent back with the youth to the center.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Limited Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Seven youth individual healthcare records (IHCR) were reviewed for chronic conditions/periodic
evaluation requirements. Three out of the seven reviewed records were applicable for chronic
conditions/periodic evaluation requirements. Each of the youth were identified on the
Medical/Mental Health Screening form for having a current chronic condition. One youth was
prescribed medication for at least three consecutive months. The remaining two youth were
undergoing treatment for a physical health condition. The youth were appropriately classified
with a Medical Grade of two through four. None of the youth were identified as being pregnant.
Each of the youth were placed on the chronic condition list. Two of the three youth had not been
at the center long enough to be in receipt of periodic evaluation. The remaining youth was not
administered a ninety-day periodic review as required back in November. In addition, the
Problem List for this youth was not updated in accordance with Florida Administrative Code.
None of the youth required any anti-tuberculosis medication. None of the youth required any off-
site care. The center has a tracking mechanism in place to address periodic evaluations;
however, as observed, one of three youth’s evaluations was missed. The designated health
authority (DHA) was interviewed and replied when asked how often periodic evaluations for
youth with chronic conditions are completed and tracked, they stated every ninety days, tracked
through their medical records.
4.15 Medication Management [Contract Provider] Limited 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.
Seven youth individual healthcare records (IHCR) were reviewed for medication management
requirements. Five out of the seven youth were previously prescribed medication at admission,
with one youth being prescribed medication after admission. The admission medication was
verified prior to being admitted into the center. One youth had medication brought into the
center by the parent and was subsequently verified by medical staff. Verification for medications
brought into the center were all documented accordingly in each youth’s IHCR on the
Department’s form. The designated health authority (DHA), and when applicable the
psychiatrist, was contacted to obtain an order and resume prescribed medications. Five of the
six applicable youth with prescribed medication had a current, valid order and administered
pursuant to current prescription. The one remaining youth had a valid order; however, one of the
medication administration records (MAR) was documented with the wrong timeframe for
delivery of the medication. The written order was prescribed for thirty days, the MAR indicated a
ninety-day prescription. All youth medication orders were found documented on the practitioner
order form. None of the youth reviewed were documented as having been in restricted housing
during medication administration hours. Five out of the seven reviewed youth were given over-
the-counter (OTC) medications which were not listed on the Authority for Evaluation and
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Treatment (AET) form. Each youth utilized the standard Department MAR in the electronic
medical record (EMR) format and at times handwritten on printed MARs. There were indications
of non-healthcare staff administering medications after hours when a licensed staff was not on-
site with required protocols being followed. Training documentation was reviewed for non-
healthcare staff with no issues; training was provided by an on-site registered nurse (RN). Two
out of five youth taking medications had documented missed medications for multiple dates. For
one youth a medication was missed on one day and the remaining youth missed multiple
medications on four days. A Central Communication Center call was made by on-site medical
staff. All youth receiving medications did have side effect monitoring completed at least weekly.
Three youth were applicable for having refused medications. Two out of the three refusals did
not clearly mark with “R” on the MAR; however, a refusal form was signed by the youth. The
one remaining youth had the MAR marked appropriately, along with necessary refusal form.
One of the three youth had six missing refusals forms as documented by the MAR. All MARs
contained all required elements. Each MAR medication was initialed by the youth when
applicable. None of the youth required any parenteral medication. The center reports there are
no standing orders, emergency treatment orders, or pro re nata (PRN) orders for psychotropic
medications. A medication pass was observed during the annual compliance review. The
medication delivery was the sole responsibility of the nurse providing the medication to the
youth. Youth were observed being escorted to the medical department by a detention officer.
The RN identified themselves and asked the youth to identify themselves by name, along with
birthdate, and medication to be taken. The RN reviewed each youth’s MAR in the computer
which contained all required elements for administering medications. Medications were in
packages, whereas at time of administering medication, RN popped the medication out for
dispensing. The youth ingested the medication and RN followed up by looking in youth’s mouth,
making sure medication was swallowed. No non-healthcare staff were observed administering
medications during the annual compliance review. The nurse was interviewed and stated upon
admission to the center, the youth and parent/guardian (if available) will be interviewed about
the youth’s current medications, conducted as part of the medical screening within twenty-four
hours of admission, along with the when the Health-Related History form and/or the
Comprehensive Physical Assessment is completed. Only medications from a licensed
pharmacy, with a verified current, patient-specific label intact on the original medication
container, may be accepted in the center. If the prescription medication cannot be verified as
authentic, the prescription and contents shall be verified by the DHA or physician designee and
a medical evaluation of the youth completed, with documentation in the chronological progress
notes. After medication verification, the Department’s Medication Receipt, Transfer, and
Disposition form shall be completed, with copy of the form provided to the parent/guardian
(when parent/guardian is available). When the above defined verification process is successfully
completed, the licensed nurse must call to obtain an order from the DHA or designee to resume
the specified medications. This telephone order must be documented in the youth’s IHCR and
co-signed when the ordering practitioner is on-site. The medication will subsequently be
administered according to the instructions on the label. For situations when youth are admitted
and medical staff is not on duty, staff will refer to the physician’s protocol for trained non-
healthcare staff to receive and verify medications and assist the youth with self-administration. A
telephone order must then be obtained and documented by the incoming nurse on the next
shift. The protocol should only apply to critical medications for which a missed dose would
compromise the youth’s health. The protocol will list which specific medications to which this
would apply. The need for any further verification requires the notification of the DHA who then
must evaluate the youth. This is of particular importance if a youth is on a medication for a
chronic condition for which a dose should not be missed. Documentation of prescription
verification must occur in the chronological progress notes in the IHCR. OTC medications not
listed on the AET will be administered by approved protocols or practitioner’s order, unless the
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parent/guardian has prohibited the administration of OTCs by way of the AET. Seven staff were
interviewed and one stated staff are able to administer medication to youth, the remaining six
stated staff do not administer medication. Seven youth were interviewed and three youth replied
either a doctor or nurse administer medications. The remaining four youth stated they do not
currently receive medications.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
Seven youth individual healthcare records (IHCR) were reviewed for inclusion of psychotropic
medication. Five out of seven youth either entered the center on psychotropic medication or
were referred for a psychiatric interview. Each of the applicable youth were in receipt of an initial
diagnostic psychiatric interview and evaluation within fourteen days of the youth’s admission or
referral. Each of the evaluations and reviews included all necessary elements which addressed
referral reason, history, mental status, diagnosis, treatment, target symptoms, prescribed
medication, side effects, explanation for the need of medication, and youth adherence to
medication regime. The evaluations contained the signature and date of the practitioner
conducting the psychiatric evaluation, along with completion of the clinical psychiatric progress
note (CPPN) for each youth. The center completed the CPPN for each review regardless of
new, change, or discontinuance of psychotropic medication. Each youth had appropriate
consent in place for the continuance of administering psychotropic medications. Each youth was
seen at a minimum monthly for psychiatric evaluation, with the parent/guardian being contacted
if necessary for verbal consent of any new, changed, or discontinued psychotropic medication.
The center has a psychiatrist who has a license, which is clear and active, and expires January
31, 2028. The center does not employ an advanced practice registered nurse for psychiatric
services. The center does not participate in tele-psychiatry. The designated mental health
clinician authority (DMHCA) was interviewed and stated they meet with the psychiatrist at the
center weekly as well as by telephone twenty-four hours a day, seven days a week, and/or as
needed.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center was reviewed for medication and sharps inventory and storage practices. All medical
equipment classified as sharps and stock medications were found to be secured, locked in
designated areas, and inventoried by using a routine weekly perpetual inventory. The
medication cart within the center was clean/organized, with stock items separate from youth-
specific medications, and oral medications separate from injectable and topical medications.
The controlled substances had a perpetual inventory, a shift-to-shift inventory, and were found
locked behind two locks and separated from other medications. Medications which require
refrigeration were found stored in a secured refrigerator, which was found for medication only.
Documentation reviewed found non-healthcare staff were trained by a registered nurse in the
delivery and oversight of medication self-administration. A review of three controlled
medications was attempted; however, the center only had one controlled medication at time of
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the annual compliance review, with no exceptions found. A review of three over-the-counter
(OTC) medications was conducted with no exceptions observed. A review of three sharps was
conducted with no exceptions observed. All of the counts matched the ending inventories. The
area designated to store youth medication was observed with no issues. The nurse was
interviewed and asked about medication disposal. All outdated medications will be removed and
segregated from regular stock and placed in a designated secure locked quarantine area.
Outdated medications shall be destroyed at least monthly. Any non-expired pharmaceutical
product which has been subjected to improper storage conditions, contaminated in any way,
adulterated, or deemed to be unusable for any reason shall be placed in the designated area
and destroyed. A secured designated quarantine medication storage area shall be clearly
marked and designated separate and apart from usable medications. Any medication not
procured by a youth’s parent/guardian after a youth’s discharge from the center, shall be
destroyed after thirty days under the supervision of the licensed pharmacy consultant. A
registered nurse shall be responsible for the disposal of medications. Controlled and non-
controlled medications for disposal shall be inventoried prior to disposal and disposed in the
presence of the pharmacy consultant. Controlled and non-controlled medications must be
disposed of by utilizing the approved drug buster disposal system and in accordance with state
board of pharmacy disposal plan. Documentation of the disposal of all medication shall be
maintained.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
Seven youth individual healthcare records (IHCR) were reviewed for infection control, exposure
control, and education requirements. Each of the reviewed youth were in receipt of infection
control training within seven days of admission. The infection control training for each youth
included all elements required. The center’s exposure control plan was written in accordance
with Occupational Safety and Health administration (OSHA), which addressed risk
assessments, communicable and infectious diseases and procedures, and methods of
compliance. The hepatitis B immunizations are made available for staff through referral to an
off-site clinic. Staff have access to protective equipment. There have been no documented
instances in which infectious diseases and or sexually transmitted infections needed to be
reported to the local health department. The superintendent maintains a separate file which
contains any documents for youth and staff who have experienced center/occupational
exposure for a ten-year period. A total of fourteen staff training records were reviewed: seven
pre- and seven in-service. All staff received training in the center’s specific exposure control
plan. The nurse was interviewed and confirmed a copy of the exposure control plan is available
to them. Also, the nurse stated a registered nurse conducts infection control training for staff,
which is completed annually.
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4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
Seven youth individual healthcare records (IHCR) were reviewed for prenatal care and
education. None of the sampled youth met eligibility for prenatal care and education; therefore,
an additional three records were requested. The program has had only one youth for the scope
of the annual compliance review. The one youth had prenatal care which began immediately
upon determination the youth was pregnant and continued until discharge/transfer from the
center. The youth was in the center for approximately fifteen days. Upon review of
documentation, it was noted there was no internal alert entered for vital nutrition and health
awareness for staff. In addition, no alert was entered into the center’s internal alert system
regarding the youth’s sleeping arrangements. There was no indication the youth complained of
any pregnant related issues. The youth was seen daily for monitoring of any pregnancy
complications. Health education related to pregnancy and post-birth care was provided to the
youth and documented within the youth’s IHCR. A review of seven staff in-service training,
covering youth prenatal healthcare, was completed with no exceptions. The center has
protocols and treatment plans for pregnant youth. The nurse was interviewed and discussed
what services are provided to pregnant youth. Prenatal care shall be provided by an obstetrician
and/or perinatologist once it is determined the youth is pregnant. The designated health
authority (DHA) shall collaborate with the obstetrician and/or perinatologist in the oversight and
management of the youth’s pregnancy. The DHA shall be responsible for ensuring the center
procedures are in place to provide necessary and appropriate health care services to the
pregnant youth and youth who are parents. The DHA or designee shall provide a routine,
focused medical oversight evaluation of the youth’s pregnancy every thirty days. Seven youth
were interviewed concerning having been in receipt of prenatal, obstetrical, or gynecological
services when needed at the center; four youth said yes, and the remaining three said services
were not needed.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
Active supervision of youth was observed each day of the annual compliance review week.
Youth and staff were observed in adherence to the daily activity schedule. Youth were seen in
classes during education time, medication pass, and mealtimes, as well as groups through
video review. Youth were accounted for at all times with no youth observed unsupervised.
Master control was observed conducting formal headcounts as well as authorizing and
documenting youth movements in the master control logbook. Six of seven interviewed staff
reported they felt the center had enough staff to provide for the safety and security of both youth
and staff. One reported they did not feel this way. One staff commented the administration at the
center is trying to do everything they can to get staff hired and help cover the floor. All seven
interviewed staff reported room checks are to be done every ten minutes.
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’s behavior management system (BMS) includes rewards for positive behaviors and
consequences for inappropriate behaviors. BMS postings were observed in youth living areas.
The center has dry erase boards located in living areas with youth names and levels. According
to the detention superintendent, the levels are updated weekly by an assigned staff member.
Level changes are documented in the center’s logbook. Seven youth records all contained
documentation each youth signed for and received the orientation handbook upon admission,
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which outlined the center’s BMS. Incentive calendars are also posted in each living area which
showcase incentives youth may earn depending on their level earned. Documentation reviewed
did not find any instances of inappropriate use of restrictions or group punishment. The center’s
facility operating procedures have not been updated to reflect Detention Services new BMS.
The superintendent stated the youth orientation packet was updated which includes the new
BMS rules. Calendar incentives are subject to change based upon youth behavior, staffing, or
scheduling. The superintendent also stated the level system used for the BMS has been
authorized by the Department. Seven interviewed staff were able to summarize the center’s
BMS and define what rewards may be offered to youth such as canteen, extra phone calls,
pizza parties, and extra snacks. Six of seven staff reported they felt the BMS was effective. One
staff reported they felt the old system was better. All seven staff stated staff speak with youth to
discuss consequences being imposed, and youth are given opportunities to explain their
behaviors, while giving youth alternative acceptable behaviors to employ. Staff also reported
they receive feedback daily and weekly as far as their implementation of the center’s BMS. All
seven staff reported the only things which may be taken from youth as a result from a
consequence are points and levels. All seven interviewed staff stated they have not observed a
staff encouraging a youth to beat up another youth. Seven youth were interviewed concerning
the center’s BMS. Three of seven rated the BMS as good and four rated it very good. All seven
youth were able to summarize the process and give examples of rewards they are able to earn
as part of the BMS. All seven youth reported staff use the rewards the same. None of the youth
reported youth are allowed to punish other youth. Each youth reported at some point they have
been sent to their room for punishment at the center. All seven youth reported consequences
they received were fair, and the only things taken from them were their levels or points.
5.03 Ten-Minute Checks (Critical) Failed 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 utilizes the electronic wand system to conduct observation checks while youth are in
their rooms. Five random days, each of thirty-minute increments, were selected for video review
of ten-minute observation checks. Five checks were completed late. The late checks were
completed, one , two, twenty-four, thirty-eight, and forty-five minutes late. The G Module was
unable to be reviewed due to cameras not functioning properly. The center had a total of sixty-
three cameras. Center administration reported twelve cameras were currently not working. A
work order was submitted August 2025 to address the issue. Video recordings are available up
to thirty-days. A sample of wand reports were observed for the scope of the annual compliance
review. One day each month was selected to review a thirty-minute period each month. Based
on the observations made for these reports, four checks were documented as three minutes
late, one was four minutes late, one was seven minutes late, one was nine minutes late, and
four were two minutes late. Several additional checks observed were one minute late. Weekly
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management oversight of ten-minute observation checks is documented within the SharePoint
system. A review of this documentation found weekly oversight was captured with the exception
of no documentation from December 2024 through May 13, 2025, and none for the month of
August 2025. Seven interviewed staff reported observation checks are done every ten minutes.
The superintendent was interviewed and stated staff use the wand or visual observation reports
to monitor ten-minute checks to further ensure youth are safe and secure.
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).
One full day each month for the scope of the annual compliance review was reviewed for
completion of youth census counts and tracking. Documentation in logbooks was observed
showing population counts were being conducted as required at the beginning of the shifts and
for youth movement going from one location in the center to another. Counts were observed
documented for routine group movement as well. Random population counts were observed
documented within each shift at least once with few exceptions noted. For October 12, 2025,
there was no documentation found to show a random population count completed between the
two shifts. Observations of formal headcounts were observed conducted during the annual
compliance review week. The master control staff was seen calling for the headcount on the
radio and documenting and clearing the count within the logbook. Seven interviewed staff
reported youth counts are done at the beginning and end of each shift. All seven interviewed
staff were able to summarize the count tracking process as well as the process conducted when
a count is not reconciled. Staff provided examples of this such as stopping all movement at the
center and conducting re-counts until the numbers are correct. Seven interviewed staff provided
examples of when an emergency headcount may be conducted, such as in instances like youth
believed to be missing, when visibility is hindered, and after a major disturbance.
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5.05 Logbook Maintenance and Reviews Failed 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 maintains a master logbook within the master control room. Module logbooks are
also maintained for each of the youth living areas. Master control logbooks were reviewed for
the scope of the annual compliance review. Three of the logbooks had pages torn away from
the cover of the books. Entries were not notated in military time; however, none of the entries
observed included the times of the events in a.m. and p.m. Dates were documented at the top
of each page. The majority of entries impacting the safety and security of the center were
highlighted. All errors were struck through with a single line and “void” written with the staff
initials. Documentation of drills was observed along with population counts at the beginning of
each shift. For one of the months reviewed, the end of shift headcount was not observed being
documented in the master logbook, and one day all searches were not noted. Group movement
and admissions and releases were documented in all applicable days observed. One of the
days observed did not note searches being conducted. Youth on special precautions were also
observed in all applicable days reviewed. Twelve days, one day from each month, were
selected during the annual compliance review as the sample size for all the center’s logbooks,
to include module logbooks. The center provided seven module logbooks for review. The
logbooks were not assigned to individual modules. Instead, they were carried over between
modules as youth transitioned between different living modules. As a result, different logbooks
were used at various times, and the dates reviewed were not consecutive. Some logbooks
contained gaps, skipping certain months and days. Due to this, each logbook was reviewed
individually using the twelve selected sample days, resulting in a total of twenty days being
reviewed. Within this sample, only two weekly superintendent logbook reviews were
documented and only two required daily supervisor reviews were missing. For the supervisor
reviewing the master control logbook when assuming center responsibility, there was no
notation documentation for three of the twenty days reviewed. For the juvenile justice detention
officer (JJDO) reviews of the module logbooks when accepting responsibility for living area at
shift change, there was none noted for the B1 module logbook for one day. No documentation
was noted for the G1 module logbook for January 2025 through March 2025 and from
September 2025 through November 2025. No documentation found for the B2 logbook of these
reviews from July 2025 until November 2025.The superintendent was interviewed and stated
management should review and sign all logbooks for correction and documentation purposes.
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5.06 Key Control Limited 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 (FOP) which define key control and inventory and
issuance of facility keys. The FOPs notate the key assignment and usage including restrictions
on usage, inventory and daily tracking of keys, secure storage, procedures addressing missing
or lost keys, and reporting and replacement of damaged keys. A review of the Department’s
Central Communications Center (CCC) reports and an informal interview with the center’s
administration was conducted and found no issue with missing or lost keys for the scope of the
annual compliance review. The center maintains facility keys in a secure box located in the
master control room. Visitor keys are taken upon arrival to the center and placed in the master
control room prior to staff or visitors entering secure areas. Daily key sign-in and out logs were
observed documented for direct care staff entering the center to begin their shift. The staff are
assigned a key number, and the key inventory lists the number, name of staff the key is
assigned to, and the time the key is signed in and out. Issuance of keys were also observed
documented on shift reports. The facility keys are kept on a tamper-resistant key ring with the
key number and color-coded tab included. The color-coded hubs affixed to the rings were
observed as required. Emergency keys were observed with a red color hub on the ring. These
keys were not maintained separately from other facility keys as required by the center’s FOPs.
According to the center’s FOPs, emergency keys must be maintained in a secure and separate
location from other facility keys. The center maintains a master key inventory; however, the
inventory did not notate the number of keys on each ring and capability of each key. A sampling
of five sets of keys located in the secure key box were reviewed and found four of five notated
on the key inventory log. One set, a mental health key was hub color-coded correctly, but the
key was not present on the key log. In addition, one of the five sets of keys sampled were for
the kitchen. The key log indicated there were a total of three keys, but the actual ring had two
extra keys on it. Three random staff were approached and asked to present their facility
assigned keys to review. All three sets were found signed out correctly as identified on the key
inventory sign-out log. All three staff were able to explain the usage of the keys assigned to
them. For one staff, the key inventory log did not list the number of keys on each ring and
capability of each. The ring only was noted as the transportation keys, but there was a total of
seven keys on the ring. The staff assigned to these keys was of the function of each. The
master control operator was informally interviewed and stated regular floor staff do not receive
access to restricted keys such as youth records, medical keys, and property keys. The
superintendent was interviewed and confirmed permanent keys may be issued to staff such as
administration and maintenance. Seven interviewed staff provided examples of restricted keys
such as mental health records, youth property areas, medical records, kitchen, and case
management. All seven summarized the key control process.
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5.07 Vehicles and Maintenance Limited 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 reported having a total of seven vehicles used for transporting youth. All vehicles
were observed secured when not in use. Inspections of each found them to be clean with the
appropriate number of seatbelts. One vehicle had a can of aerosol disinfectant spray in the front
passenger seat. Three of seven did not have a fire extinguisher. According to the maintenance
staff, the center administration reported several of the vehicles were recently acquired and have
yet to have all items placed in them. All had documentation of an annual vehicle inspection by a
certified mechanic. The center maintains an assigned numbered travel bag with emergency
items in the bag for each vehicle. The bags are kept in the transportation office until taken with
them when the vehicles are checked out for use. The bags are to include the approved first-aid
kits, vehicle logs, and other emergency items required. An inspection of each bag revealed two
of seven did not include a seatbelt cutter, three of seven did not have the window punch, and
one bag did not have the first-aid kit. The maintenance staff and transportation staff stated the
newer vehicles have been acquired and some of the emergency items have recently been
ordered and arrived at the center to be placed with the assigned vehicle. During the annual
compliance review, the center placed missing emergency items in the assigned bags. Vehicle
logs were observed for all vehicles, and each was used to transport youth at some point during
the annual compliance review scope. The superintendent was interviewed and stated in the
event a staff needs to use a vehicle to transport youth, staff may take from another bag to
ensure all items are present on the transport. The center’s maintenance staff conducts monthly
maintenance inspections for all vehicles and the information is documented on the Department’s
Vehicle Maintenance Inspection form containing all required elements. The information is
uploaded into the Department’s Detention SharePoint site. A review of this documentation was
observed. The site only allowed information to be able to reviewed back to July of 2025. All
documentation was present with the exception of vehicle inspections for three of seven vehicles
for the month of November 2025. Vehicle logbooks were reviewed and sampled for the scope of
the annual compliance review. The logbooks documented the vehicles were checked for
contraband, the destination, the number of youth, and the time the transport began and ended.
The logbook documentation did not specify the name of the staff member riding in the back with
the youth. In two documented instances, there was documentation of only one staff conducting
the transport, but two staff were noted as present. An observation of a youth transport was
unable to be observed during the annual compliance review week as no transports were
completed while the review team was on-site. Seven youth were interviewed and all reported
they felt safe when staff were transporting them. None of the seven interviewed youth reported
ever witnessing someone placing contraband in a transport vehicle.
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5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOPs) which outlines the tool inventory,
management, and youth access to and use of tools, and cleaning items. All areas observed to
have tools were secured and inaccessible to youth. A sample of ten tools were observed and
compared to the inventory forms provided. Seven of these were maintenance tools.
Observations found maintenance tools secured and located on a shadow board system in the
maintenance office. The seven tools observed were all marked with a sticker corresponding with
the tool name on the inventory form. All were accounted for as notated on the inventory form. An
additional three tools were observed from the kitchen area. The tools were classified as sharps
and were in the kitchen knife locked cabinet in the kitchen area. All items were accounted for as
indicated on the tool inventory form. Inventories for all tools were observed completed for the
annual compliance review scope and signed by the superintendent/designee. The maintenance
office had a Tool Sign-in/out form hanging on the door inside the office area. The issuance and
return of the maintenance tools was not completed as required, as the maintenance staff
reported he is the only staff who has taken any tools out of the office to work on a project. The
maintenance staff and administration were advised of Detention FOPs which requires when it is
necessary for the maintenance mechanic (MM) to take tools onto the secure floor for a repair or
project, the tools shall be documented. The center’s superintendent reported a retraining for the
maintenance staff regarding tool issuance and return will be completed. A review of the
Department’s Central Communications Center (CCC) report information found no instance of
missing or damaged tools. The maintenance staff was interviewed and stated in the event a
vendor must enter the secure area of the facility, the maintenance staff is required to escort the
vendor in these areas. Seven staff were interviewed and were able to summarize the center’s
procedures in the event a tool was to go missing or be damaged. Staff gave several examples
such as stopping all movement and conducting a facility search of the item, notifying
administration if an item is broken, contacting the CCC if an item is not found, and notifying
maintenance of the issue. Seven interviewed staff reported youth at the center use only mops,
brooms, and scrub brushes. Seven interviewed youth reported they only use mops and brooms.
The center’s superintendent was interviewed and reported only administration and maintenance
have access to facility tools. The maintenance staff was interviewed and stated they have had
no missing tools for the scope of the annual compliance review and stated in the event a tool
was missing, administration would be notified.
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5.09 Inventory of and Access to all Flammable, Toxic, Caustic,
Limited Compliance
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.
According to the superintendent, the center’s safety plan and Emergency Care Plan is
incorporated into the center’s Continuity of Operations Plan (COOP). The center has facility
operating procedures which address inventory of and access to all flammable, toxic, caustic,
and poisonous items. Only authorized personnel are permitted to access these items. All items
were observed stored and inaccessible to youth. A review of five chemicals were sampled. All
were located secured in the kitchen janitorial closet. Two of the five items were notated on the
inventory form located in the closet with the items and had a corresponding Safety Data Sheet
(SDS). Both item amounts matched the inventory form. The remaining three items observed,
were not identified on the inventory form. In addition, none of these three had a corresponding
SDS. In addition, an observation of a transport vehicle found a can of aerosol disinfectant spray
in the passenger side compartment of the door. Seven interviewed youth all stated they do not
have access to chemicals at the center. Seven interviewed staff all stated youth are not allowed
to clean with substances which are toxic, flammable, or poisonous.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) which address the disposal of all
flammables, toxic, caustic, and poisonous items. An interview with the dietary staff reported the
program does not utilize grease; therefore, does not require an area for grease disposal. A
review of the Department’s Central Communications Center (CCC) report documentation for the
scope of the annual compliance review revealed no incidents involving chemical spills at the
facility. The superintendent reported they have not required any disposal of chemicals for the
scope of the review period. The medical staff was interviewed and reported biohazardous waste
is disposed of through an agreement with a biohazardous waste disposal company. The
company comes monthly to the program to dispose of the waste which is stored in marked
containers secured in the medical office. The medical staff also present documentation of
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invoices from the company as evidence of the process. The invoices are maintained in the
disposal log. The superintendent was interviewed and stated the center will follow facility
operating procedures when needing to dispose of any chemicals.
5.11 Confinement Under Twenty-Four Hours Limited 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 utilizes youth rooms for the purpose of placement in confinement. Room windows
were observed free from obstructions. The superintendent was interviewed and stated
confinements are tracked through the Juvenile Justice Information System (JJIS) and Visual
Observation Reports (VORs). A sample size of fifteen random confinements under twenty-four
hours were reviewed for completion requirements. The following exceptions were identified
regarding rights: provision of meals was not documented for six of fifteen reviewed; eight of
fifteen were missing documentation for staff providing education materials; and the one
applicable youth requesting mental healthcare was not documented as received/completed. All
confinements documented the youth receiving notice of their right to grieve a confinement, and
none were applicable for daily showers. Prior to placement in confinements, documentation
confirmed the supervisor approved all confinements, only one youth was placed in a
confinement room, the reason for confinement was explained to the youth, and the room was
searched. None of the youth had any observed physical injuries and none of the confinements
interfered with visitation. Fourteen of the fifteen reviewed confinements contained administration
review within forty-eight hours, with one missing an administrative review. Twelve supervisor
initial confinement reviews were complete within the required timeframe with three of fifteen
initial confinement reviews being late. One initial supervisor review was fifteen minutes late, one
was twenty-minutes late, and one was thirty-minutes late. Fourteen of fifteen VORs found
confinement supervision being conducted as required. One VOR reviewed had missing checks
for an hour and half gap. Ten confinement reports documented the supervisor conducted
additional reviews every three hours as required. Eight of the fifteen reviewed confinements did
not have the full report completed by the end of the shift, with seven being completed by the end
of the shift. Ten of the confinement reports documented supervisory reviews every three hours
as required. Five of the fifteen confinement reports were missing consistent documentation of
supervisory reviews, with one having a review twenty-four minutes late, one having a review two
minutes late, one having a review eighteen minutes late, one not having any reviews, and one
missing one review. Eleven of the confinement reports did not notate continual counseling of the
youth for consideration of removal from confinements, with only four reports documenting the
continual counseling.
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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 any 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 provided documentation notating Continuity of Operations Plan (COOP) drills were
conducted as required. The center conducted two drills annually, which included all required
elements such as the type of drill, date and time, participants, brief scenario, and findings and
recommendations. Both were severe weather-related drill scenarios. A hurricane drill was
included as one of the required drills, which occurred prior to June 1st, which is the start of
hurricane season. Corrective action was included when required for drill documentation. The
superintendent was interviewed and stated the center’s COOP is utilized as their
comprehensive safety/emergency program.
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’s superintendent stated the program’s escape prevention plan is incorporated within
their facility operating procedures (FOPs) and Continuity of Operations Plan (COOP). The
center had a COOP signed by the regional director on June 11, 2025. The center also maintains
FOPS which address the Escape Prevention Plan and escape drills. The center is required to
conduct escape drills at a minimum of quarterly on each shift. Drill documentation was
maintained in a drill binder and separated by shifts. Documentation provided included at least
one drill each quarter for all shifts. Seven staff training records were reviewed. Each staff had
completed training for escape prevention annually as required. Drills were documented on the
Department’s Drill Scenario form as well as within the master control logbook and coded as a
code green scenario. Seven staff were interviewed. All seven confirmed they have participated
in escape drills since the last annual compliance review.
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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 provided documentation of fire drills which were maintained in a drill binder
separated by assigned shifts. Based on a review of the documentation, the center conducts fire
drills monthly for each shift. Two dates reviewed, one for October 6, 2025, and one for another
shift completed October 8, 2025, had the date of the drill documented, but the participant sign-in
sheet was notated on a different date. It was noted as October 7th for the first one and October
5th for the other. The superintendent addressed this stating the dates were documented in error.
Documentation of drill scenarios included all required information such as the scenario itself,
participant, findings and recommendations, and date and time. The center documents drills on
the Department’s Drill Scenario form. Logbook documentation of the drills was also observed for
each drill. A copy of the logbook entry was included with each drill within the drill binder. The
center has a total of thirty-one fire extinguishers. The center provided documentation which
confirmed the fire extinguishers last received their annual inspection on July 29, 2025. Seven
interviewed staff all reported they have participated in drills for the scope of the annual
compliance review. All seven reported they participated in fire drills specifically. All stated fire
drills are conducted at least monthly. Seven youth were interviewed and all confirmed they have
been instructed as to what to do in the event 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
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 documents contraband searches within the Department’s Facility Management
System. Room searches were unable to be observed during the annual compliance review
week as none were conducted during the time the review team was on-site. No strip search was
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 57
notated as conducted other than during admission. During strip searches documented, two staff
of the same gender as the youth were noted as facilitating the search. Strip searches of the
youth are conducted individually and not in a group setting. Electronic searches of staff and
visitors were observed conducted prior to entering the secure facility. All bags, cases, jackets,
and other items were searched. All personal keys, cell phones, and other contraband items
were prohibited from entering the secure area. Room search documentation observed found
rooms were searched upon a youth release, as well as prior to placement of a youth into a
room. All rooms are searched for contraband on each wake shift. Searches are documented in
the center logbooks. A sample of room searches for one day each month of the annual
compliance review scope was observed and found searches were documented each shift as
required. The center reported having had no instances involving contraband which may have
compromised the safety or security of the center throughout the annual compliance review
scope. Search observations of staff and visitors were conducted as required throughout the
annual compliance review week. The center maintains separate visitor contraband attestation
forms which are completed upon arrival. All newly hired staff records contain a contraband
attestation form. Ten reviewed staff records contained this documentation. The center had two
incidents involving contraband which required reporting to the Department’s Central
Communications Center (CCC). One incident involved a vape pen, and the other was a cell
phone. For each applicable incident, the center documented the confiscation of the contraband
in the master logbook, and incident reports were completed identifying findings and the
disposition of contraband. Law enforcement was contacted for the vape pen incident.
Confiscated items were secured by the discovering officer and hand-delivered to the supervisor,
who documented the chain of custody of applicable incidents. The superintendent was
interviewed regarding contraband and search procedures and stated youth are searched prior to
departing from the Juvenile Assessment Center, and they are frisked, wanded, and strip
searched upon arrival at the facility. In the event a youth is found with contraband, the
superintendent stated depending on the type of contraband discovered, law enforcement is
contacted, and the agency abides by the investigations conducted the local law enforcement
agencies. Youth are placed in confinement, and the CCC is notified along with the North Region
Detention Services. All information is documented in the logbooks and in the Juvenile Justice
Information System (JJIS).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 57

report_type: QI Detention

file_name: LRJDC- FINAL- FY2526.pdf

program_name_raw: Leon Regional Juvenile Detention Center

rating: Failed Compliance

rule: Indicator 4.02

rule: Indicator 4.14

rule: Indicator 4.15

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.05

excerpt: Logbook Maintenance and Reviews

rule: Indicator 5.06

excerpt: Key Control

rule: Indicator 5.07

excerpt: Vehicles and Maintenance

rule: Indicator 5.09

rule: Indicator 5.11

excerpt: Confinement Under Twenty-Four Hours