state: FL

facility_name: Alachua Academy

summary: QI Detention - FY25-26 - 11 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Alachua Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3440 NE 39th Avenue
Gainesville, Florida 32609
Review Date(s): July 8 - July 11, 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:
Meghan Thrasher, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Patrick Brock, Office of Education, North Central Education Coordinator (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Interviews)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 2)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor North
Region (Standard 5)
Forrest Hallam, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Alachua Regional Juvenile Detention Center MQI Program Code: 89
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Alachua County / Circuit 8 Number of Beds: 45
Review Date(s): July 8 -11, 2025 Lead Reviewer Code: 203
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
1.05 R ight Interactions (R I)
4.12 E pisodic/First A id C are/E m ergency C are
5.11 C onfinem ent U nder Tw enty-Four H ours
5.13 C ontinuity of O perations P lanning (C O O P ) D rills
5.14 E scape D rills
5.15 Fire D rills
O v e ra ll R a tin g S u m m a ry
2.08 R
Failed R atings
eview of Y outh in S ecure D etention and H om e D
5.03 Ten-M inute C hecks*
5.06 K ey C ontrol
5.12 C onfinem ent O ver Tw enty-Four H ours
5.16 S earch and C ontraband P rocedures
etention
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
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a to r R a tin g s
S ta n d a rd 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 * S a tis fa c to ry
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a tis fa c to ry
S ta ff C o d e o f C o n d u c t S a tis fa c to ry
In c id e n t R e p o rtin g C C C * S a tis fa c to ry
R ig h t In te ra c tio n s (R I) L im ite d
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a tis fa c to ry
In -S e rv ic e T ra in in g S a tis fa c to ry
G rie v a n c e s S a tis fa c to ry
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 * S a tis fa c to ry
D a ta T re n d A n a ly s is S a tis fa c to ry
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 n tio n if a p ro g ra m
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 rs . F a ilu re to d o
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 ).
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
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a to r R a tin g s
S ta n d a rd 2 - A s s e s s m e n t a n d P e rfo rm a n c e P la n
A d m is s io n S a tis fa c to
O rie n ta tio n S a tis fa c to
C la s s ific a tio n S a tis fa c to
N o tific a tio n o f J P O C irc u it G a n g R e p S a tis fa c to
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 S a tis fa c to
R e le a s e S a tis fa c to
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 S a tis fa c to
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n F a ile d
D a ily A c tiv ity S c h e d u le S a tis fa c to
E d u c a tio n a l A c c e s s * S a tis fa c to
C a re e r E d u c a tio n S a tis fa c to
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 n tio n if a p ro g ra m
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 rs . F a ilu re 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 ).
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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
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
* T h e D e p
b e lo w D e p
in a p ro g ra
aam rtm
rtm
a
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n t s
rt fo
a s id e n
ta n d a rd
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 t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
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 )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
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 *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
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
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
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 ).
te a tte n tio n if a p ro
d ic a to rs . F a ilu re to
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
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S a
S a
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tis fa
tis fa
tis fa
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tis fa
tis fa
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tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
m o p
s o w
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
e ra te s
ill re s u lt
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
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * S a tis fa c
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa c
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c
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 S a tis fa c
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 S a tis fa c
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa c
H e a lth -R e la te d H is to ry S a tis fa c
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 a tis fa c
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g S a tis fa c
S ic k C a ll P ro c e s s S a tis fa c
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 L im ite
O ff-S ite C a re /R e fe rra ls S a tis fa c
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 S a tis fa c
M e d ic a tio n M a n a g e m e n t S a tis fa c
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 S a tis fa c
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 S a tis fa c
P re n a ta l C a re /E d u c a tio n S a tis fa c
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 n tio n if a p ro g ra m
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 rs . F a ilu re
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 ).
to ry
to ry
to ry
to ry
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to ry
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ry
to ry
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to ry
to ry
to ry
to d o
Standard 5: Safety and Security
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 57
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th * 5 .0 1 S a tis fa c to ry
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t* 5 .0 2 S a tis fa c to ry
T e n -M in u te C h e c k s * 5 .0 3 F a ile d
C e n s u s C o u n ts a n d T ra c k in g 5 .0 4 S a tis fa c to ry
L o g b o o k M a in te n a n c e a n d R e v ie w s 5 .0 5 S a tis fa c to ry
K e y C o n tro l 5 .0 6 F a ile d
V e h ic le s a n d M a in te n a n c e 5 .0 7 S a tis fa c to ry
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s * 5 .0 8 S a tis fa c to ry
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s 5 .0 9 S a tis fa c to ry
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s 5 .1 0 S a tis fa c to ry
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs 5 .1 1 L im ite d
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs 5 .1 2 F a ile d
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills 5 .1 3 L im ite d
E s c a p e D rills 5 .1 4 L im ite d
F ire D rills 5 .1 5 L im ite d
S e a rc h a n d C o n tra b a n d P ro c e d u re s 5 .1 6 F a ile d
* 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 n tio n if a p ro g ra m
o p e ra te s 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 rs . F a ilu re to
d o s o w ill re s u lt in 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 ).
O v e r a ll R a t in g S u m m a r y f o r S t a n d a r d 5
T h is s ta n d a r d h a s r e c e iv e d a s ta n d a r d -le v e l r a tin g o f F a ile d , a fo llo w -u p r e v ie w o f th e p r o g r a m s h a ll b e c o n d u c te d
w ith in s ix (6 ) m o n th s o f p u b lic a tio n o f th e p r o g r a m r e p o r t.
Program Overview
The Alachua Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Gainesville, Florida. The center serves youth in Alachua, Baker,
Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwanee, and Union
counties in Circuit 8, and is co-located with the Juvenile Assessment Center (JAC). Male and
female youth who are detained pending adjudication, disposition, or placement in a residential
commitment program are housed in the forty-five bed center. Youth are provided services which
include youth orientation, behavior management, safety and emergency procedures,
transportation, mental health, and healthcare services. The center’s educational services are
provided by the Alachua School Board. The center’s management team includes the assistant
superintendent, two administrative assistants, six juvenile justice detention officer (JJDO)
supervisors, and twenty-one JJDOs. Mental health and healthcare services are provided
through the contracted provider, VitalCore Health Strategies, LLC. Mental health services are
provided by one acting designated mental health clinician authority (DMHCA), two licensed
clinical staff, and one non-licensed staff. Clinical services provided by the center include mental
health and substance abuse evaluations, mental health treatment planning, individual, group
and family therapy, mental health crisis intervention services, on-site psychiatric services, and
availability for substance abuse services for youth with co-occurring disorders. Medical services
are provided by one designated health authority (DHA), two advanced practice registered
nurses (APRNs), four full-time registered nurses (RNs), and one part-time RN. The medical
clinic maintains nursing coverage Monday through Friday, from 7:00 a.m. to 7:30 p.m., and on
weekends, from 7:00 a.m. to 5:30 p.m. Food services are provided by Department staff and
include menus, meal planning, meal schedules, special diets, nutritional analysis, daily
allowance, food preparation, health certifications, food product standards, sanitation, and
cleaning. Staff are responsible for the custody and control of youth in their care, providing youth
supervision twenty-four hours a day, seven days a week. The center has four living modules
which are divided by male and female; two are currently non-operational due to a remodeling
project taking place. There are eighty-two security cameras at the center, of which eighty-one
were operational. At the time of the annual compliance review, the center was under a major
remodel. Two living modules were closed to all operations. There were inappropriate words
written in chalk located in the middle atrium; however, the center is also being re-painted. Other
than the construction, the center was free of clutter and debris. At the time of the annual
compliance review, the center had eighteen vacancies, which included five JJDO I’s, ten JJDO
II’s, one food support worker, one maintenance mechanic, and one superintendent position. In
response to the superintendent vacancy, the center was assigned superintendents from other
detention locations on a rotating basis to ensure operations remained uninhibited and the
interview, usually completed by the center’s superintendent, was completed by the assistant
superintendent who remains a constant presence while the center attempts to fill the vacancy.
During the course of the review, the center had two more JJDO II positions become vacant
making a total of twenty vacancies.
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 a facility operating procedure to ensure all staff, contracted providers,
volunteers/interns, and mentors with access to youth undergo a criminal history background
check prior to hiring or providing services. A review of the center’s staff roster showed the
center hired twenty-one new Department staff and eleven contracted staff since the last annual
compliance review. A review of personnel records for all newly hired staff showed a background
screening reflecting each received clearance from the Department’s Background Screening Unit
(BSU) for Department staff and Clearinghouse for contracted staff prior to each staff’s hire date
and/or contact with youth and confidential youth records. One staff was initially deemed
ineligible; however, an exemption was obtained prior to the staff working with youth. Nine of the
twenty-one Department staff did not receive a passing score on the pre-employment
assessment, moving forward the center will be conducting remediation training for any staff not
receiving a passing score. All the newly hired contracted staff were added to the clearinghouse
employee roster. Two staff were labeled as being on a different center’s roster; however, they
assist at the current location as needed. The center’s Annual Affidavit of Compliance with Level
2 Screening Standards was completed on January 29, 2025. The Annual Affidavit of
Compliance with Level 2 Screening Standards for school board employees was completed on
January 28, 2025.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all staff, 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 one contracted staff was applicable for the
completion of a five-year rescreening since the last annual compliance review. The rescreening
was submitted timely and 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 addressing the code of conduct. At hire, each staff
signs the code of conduct acknowledging they have read and understood all expectations and
consequences of any violations. Seven staff were reviewed for a signed code of conduct form
and all seven staff’s personnel records contained a signed code of conduct. Two of the
reviewed staff had incidents of code of conduct violations and corrective action was completed
with staff for both those incidents. An additional staff record was reviewed, and the incident
resulted in staff being removed from contact with the youth. No commendations were received
during the annual compliance review period. The superintendent interview completed by the
assistant superintendent indicated the center follows the facility operating procedure regarding
staff code of conduct. If the policy is violated the disciplinary actions are followed and can range
from counseling to termination.
Seven staff were interviewed, and each indicated youth are allowed to call the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC) when it is requested. Six
staff indicated they notify the supervisor. Five staff indicated the supervisor makes the call.
Three staff indicated they notify the superintendent. Two staff indicated staff are allowed to call.
When questioned about profanity, five staff advised they have never observed staff using
profanity when speaking to youth, one staff stated it occurs occasionally, and one staff stated it
occurs often. Six staff had never observed a co-worker using threats, intimidation, or humiliation
when interacting with youth. One staff interviewed states they observed staff threatening youth
with confinement. One staff rated the working conditions are good, four staff rated the conditions
as fair, and two staff rated them as very poor.
All seven youth interviews indicated staff are respectful and had never heard staff threaten
youth. Six of seven youth indicated staff do not curse at youth, with one youth stating it occurs
occasionally. All youth indicated they feel safe at the facility and denied having ever exchanged
emails, telephone numbers, or social media contact information with staff.
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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 a facility operating procedure in place regarding incident reporting. A tour of the
facility was conducted, and the Florida Abuse Hotline and Department’s Central
Communications Center (CCC) phone numbers were posted through the facility. The center had
109 reportable CCC incidents during the annual compliance review period. Eleven incidents
were reviewed and found ten of the eleven incidents were reported to the CCC within the two-
hour time frame. The one not called in within the required time frame had corrective action taken
for failing to report in a timely manner. The review of incidents in logbooks and in the facility
management system determined incidents are being reported to the CCC appropriately. Seven
of the eleven CCC incidents were documented in the master control logbook at the time the
CCC was contacted as required,, four were not documented. During the annual compliance
review there were no additional internal incidents or grievances found needing to be reported to
the CCC. The superintendent interview completed by the assistant superintendent confirmed
the CCC hotline will be called within two hours of a reportable incident, reports can be made by
all staff, and staff and youth are authorized to contact the Florida Abuse Hotline.
1.05 Right Interactions (RI) Limited 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 a facility operating procedure to ensure staff use physical intervention
techniques in accordance with the Florida Administrative Code (FAC) requirements. The center
had thirty-four Protective Action Response Right Interactions model (PAR/RI) incidents since
the last annual compliance review. A review of nine PAR/RI Reports was completed, and six of
the nine were not completed on the same day as the PAR/RI incident, with three being
completed as required. One report did not contain statements from all the staff involved. Five
reports were not reviewed by a supervisor or a (PAR/RI) instructor. Five reports did not have a
post-RI interview conducted within thirty minutes after the incident. Six of the PAR/RI incidents
were not reviewed by the superintendent within seventy-two hours. A review of the internal
incidents and logbooks did not indicate there were additional PAR/RI incidents which did not
have a report. None of the reviewed PAR/RI incidents were applicable for mechanical restraints
or required a post PAR/RI medical review. All seven staff interviews indicated staff attempt to
de-escalate situations prior to physical interventions or the use of mechanical restraints. An
interview with the assistant superintendent indicated PAR/RI reports are reviewed in the
Department’s Facility Management System (FMS) daily for the purpose of monitoring incidents
and providing feedback to help reduce incidents. The center’s PAR/RI rate is 3.23 which is
below the statewide detention rate of 13.49.
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1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has a facility operating procedure to ensure pre-service training is in accordance
with Florida Administrative Code (FAC). The center abides by the detention center statewide
annual training plan. The annual training plan serves as a written list of training curricula for all
state-operated secure detention centers in Florida. A review of seven staff records indicated all
staff completed all pre-service training requirements within 180 days of hire, had a new staff
orientation completed within thirty days, and successfully completed the academy training. The
center had two employees hired within 180 days who had not completed the academy training
at the time of the annual compliance review; however, had completed all required training prior
to being in the presence of any youth. All pre-service trainings were documented in the
Department’s Learning Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center maintains a facility operating procedure to ensure staff successfully complete
ongoing in-service training, as required. The center requires twenty-four hours of in-service
training for staff through a combination of the Department’s Learning Management System
(SkillPro) and instructor-led classes. The policy requires supervisors to complete an additional
eight hours of supervisory training annually. Seven staff training records were reviewed for in-
service trainings, including four direct care staff and three supervisory staff. All seven staff
records exceeded the Department’s minimum required training of twenty-four hours of in-service
training. All seven included all the required topics. Two of the three reviewed supervisory staff
had just been promoted and were still within their required time frame to complete their
additional eight hours of leadership trainings. The third supervisory staff had completed the
additional eight hours of leadership training as required. The center’s licensed nursing staff
provide in-service training on girls’ healthcare annuals to all non-healthcare staff involved in the
supervision of girls. The center has an annual in-service calendar approved by the assistant
secretary of Detention and the director of Talent, Leadership, and Culture. The superintendent
interview completed by the assistant superintendent indicated supervisors receive management
training through the leadership academy and they are aware of the annual in-service training
requirements for staff.
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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 a facility operating procedure to ensure each youth has the right to grieve and
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. The policy indicates each youth has the right to grieve the actions of the center staff,
and youth cannot be punished for filing a grievance, whether it is substantiated or
unsubstantiated. The grievance process is explained to the youth during orientation. The
grievance process consists of three phases. The first is the informal phase which is completed
by staff whereby the youth and staff attempt to resolve the youth’s issue. A written grievance is
submitted to the juvenile justice detention officer supervisor (JJDOS). If the staff is unable to
resolve the issue, this begins the formal grievance process. The appeal phase requires a
response from the superintendent or designee. Grievance forms are electronically maintained in
the Department’s Facility Management System (FMS). Each grievance is forwarded to the on
duty JJDOS within the required time frame, through FMS, and the youth is informed of the
findings. The superintendent or designee then reviews the completed grievance form within
seventy-two hours of receipt, excluding weekends and holidays. Grievance forms were
observed to be posted and accessible to the youth on the living module. The center had no
formal grievances. A formal interview with the assistant superintendent confirmed in phase one
of the grievance process, a juvenile justice detention officer (JJDO) attempts to resolve the
youth’s grievance if the youth is not satisfied the grievances moves to phase two and is given to
the supervisor who has twenty-four hours to response. If the youth is not satisfied with their
response the grievance is given to the superintendent or assistant superintendent who has
seventy-two hours to respond to the grievance with a solution, and the decision is final. All
seven staff interviewed did not seem to be familiar with the phase one informal process, and six
of seven staff explained the phase two supervisory review of the grievance. One staff advised
he had never seen a grievance, but youth ask for them a lot. Youth surveys indicated none of
the seven youth have ever filed a grievance. Two youth were able to explain the process of
requesting a grievance form. Five youth were unclear on the grievance process. This
information was provided to the acting superintendent and assistant superintendent who
reported there will be an all hands meeting to address this with all staff as well as ensuring
moving forward all youth are aware of the grievance process.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has a facility operating procedure to ensure critical or special alerts are documented,
reviewed, and responded to appropriately. Alerts are entered into the Department’s Juvenile
Justice Information System (JJIS), as well as the internal alert system. Internal alerts and JJIS
alert reports are distributed and reviewed daily by the juvenile justice detention officer
supervisors (JJDOS) and administration. Alerts are entered, downgraded, or discontinued in
JJIS by the appropriate staff on the date identified and/or when the alert is no longer applicable.
All alerts regarding youth medication or medical information are confirmed and verified between
the medical staff and youth’s parents/guardians. JJIS alert reports are reviewed daily by
supervisors and administrators. The center’s practice is to relay alert information to all staff
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during shift briefing. The center’s process for updating alerts is to review alerts during detention
review and follow-up accordingly. Alerts are reviewed upon intake and opened and closed
accordingly. No additional alerts were discovered which should have been in the alert system. A
review of seven youth records confirmed alerts are actively used in JJIS and updated or closed
as necessary. Each relevant alert was documented in either the center’s logbook and/or shift
report, as required. An interview with the assistant superintendent indicated upon admission the
officer completing the admission paperwork will ensure all critical and special alerts are added
to JJIS. The JJIS alert report will be reviewed daily by the supervisors and administrators to
ensure it correctly reflects the status of the youth. JJIS alerts are read aloud during shift
briefings, and medical and mental health staff are responsible for verifying and updating alerts
for the respective areas. Six interviewed staff advised they are made aware of alert information
during shift debriefings, four advised from logbooks, two advised from alert forms, two from
JJIS, and one staff advised they are informed by radio. Regarding being made aware of issues
at the center, six staff advised they are made aware during shift debriefings, three from the
logbook, one stated from meetings, and one staff advised management does not inform staff
about issues. Three of seven staff rated the communication process for information sharing as
very good, one staff rated it as good, one rated it as fair, one rated it as poor, and one rated the
process as very poor. This information was provided to the acting superintendent and assistant
superintendent who reported there will be an all hands meeting to address this with all staff.
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 collects data in the Department’s Juvenile Justice Information System (JJIS) on a
daily basis, including Protective Action Response/Right Interactions model (PAR/RI) Reports,
the Department’s Central Communications Center (CCC) reports, alerts, confinements, Prison
Rape Elimination Act (PREA) documentation, and various additional reports. The center
conducts various meetings to include executive management, safety, detention services
administration, supervisor, and regional meetings where data trends and responses are
discussed. Information received from detention headquarters and/or regional administration
regarding data trends is shared with staff during meetings and shift debriefings. Providers are
included in weekly teams calls where data is reviewed to include health services and education.
This information is used to review vacancy trends, curriculum provided to youth, training,
PAR/RI, searches, and overall operations.
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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.
Seven youth records were reviewed for admission documentation. In all seven records, the
Admission Wizard documented the arrest affidavit/custody order, Detention Risk Assessment
Instrument (DRAI), and Suicide Risk Screening Instrument (SRSI) were reviewed. In all seven
records, the Admission Wizard documented a full-body and/or electronic search of the youth
was completed, the youth received a telephone call, and a medical, mental health and
substance abuse screening were completed. None of the youth were required to be offered a
youth meal. No observation of a youth admission was conducted as the center did not have any
youth admitted during the annual compliance review.
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
Seven youth records were reviewed for an orientation process. Six of seven youth received a
youth orientation within twenty-four hours of admission, and each signed an acknowledgement
form to document the contents were discussed. One youth did not sign an acknowledgment
form confirming an orientation was provided. No observation of an orientation was conducted
due to no youth being admitted during the week of the annual compliance review. The center
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has facility operating procedures which outlines orientations are to be provided verbally and in
writing and include rules and regulations, grievance procedures, visitation, telephone calls,
access to medical, mental health and substance abuse services, access to the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC), behavior expectations and
related consequences, possible new law violations for destruction of property, youth rights, and
Prison Rape Elimination Act (PREA) related information. Seven youth were interviewed. All
seven youth confirmed when they came to the center someone explained the rules, regulations,
daily schedule, education services, visitation, abuse reporting and behavior management
system.
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.
Seven youth records were reviewed for the youth classification process. In all seven reviewed
records, documentation confirmed a review of information concerning the youth’s history and
status including all elements required in the admission process. For all seven youth,
classification of youth included information related to mental illness, intellectual disabilities,
physical disabilities, history of violent behavior, gang affiliation, criminal behavior, history of
sexual offenses, vulnerability to victimization and sexually aggressive behavior (VSAB),
medical, suicide, escape and security risks, and any history of human trafficking. A review of
documentation determined the classification process includes all the required topics to be
considered prior to making room assignments including sex, height, weight, age, and level of
aggressiveness. An interview with the acting superintendent confirmed youth are assigned a
room based on their classification and are re-classified if changes in behavior or status are
observed and documented. Youth with a history of committing sexual offenses or of being a
victim of a sexual offense are placed in a room alone. The acting superintendent remains
informed of how to identity and address local youth gangs through communication with the
circuit’s juvenile probation officer gang liaison.
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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.”
Seven youth records were reviewed for notification to the juvenile probation officer circuit gang
representative for youth suspected of gang activity or involvement. None of the records were
applicable to gang involvement. Three additional youth records for youth identified with gang
involvement were provided. All three youth had gang alerts entered prior to admission to the
center. As such, notification to the circuit’s gang liaison was not applicable. The center does not
have a gang representative. The acting superintendent stated gang involvement is discussed
during the detention review.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
Seven youth records were reviewed for admission and storage of youth personal property. A
review of itemized personal Property Receipt Forms and valuable Property Receipt forms
showed four of seven forms included a youth and staff signature, and six of seven forms
included a letter of acknowledgement regarding unclaimed property, signed by the youth. Three
youth forms were missing the youth and staff signature, and one of the three forms was also
missing the letter of acknowledgement for unclaimed property signed by the youth. All seven
youth Property Receipt Forms included all money and personal items of value. Items were
verified and secured in a clear tamper proof property bag, which included the date, youth’s
name, Department of Juvenile Justice Identification (DJJID) number, and a listing of items in the
bag for all seven youth.
Three of seven youth refused to sign the Property Receipt Form; however, no documentation
was found showing the booking office notified the supervisor and the supervisor did not
document the youth’s refusal on the form in any of the three records. Other personal property,
including clothing, was placed in an assigned locker/bag as documented on the Property
Receipt Form in all seven records. The personal Property Receipt Form was placed in the
youth’s active record in all seven records. Seven youth records were reviewed for valuable
Property Receipt Forms. All valuable property was placed in a tamper proof bag and placed in
the drop safe, as required. The drop safe bound logbook included the date, time, youth’s name,
DJJID, printed name of the officer who secured the property and the officer’s initials, as
required. The valuable Property Receipt Form was placed in the youth’s active record for all four
records.
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No observation of the center receiving youth personal property could be made. Due to low
staffing levels, there were no staff available to escort the program monitor to view receipt of
personal property. A review of the Department’s Central Communications Center (CCC) reports
for the annual compliance review period did not show any incidents regarding youth property
valued over fifty dollars were reported; however, the CCC report showed in February 2025, a
youth’s personal property was missing. The report stated an internal investigation would be
initiated with a completion date of May 21, 2025. As of the annual compliance review, the CCC
remained open with a status of “In Progress.” The acting superintendent provided
documentation showing there were no updates regarding the youth’s property.
Seven youth were interviewed. Five youth confirmed when they arrived at the center, staff
checked their personal property and then had the youth sign a form stating the personal
property was correct. The remaining two youth did not remember signing a personal property
form. An interview completd by the assistant superintendent confirmed youth's personal
property is stored in a bag with a property sheet, which includes the youth's name, youth
picture, and DJJID documenting all the youth's property. The assistant superintendent also
indicated personal property is stored behind a locked door and youths valuable items are stored
in a locked file cabinet in the clerical office, under video surveillance, accessible by supervisors
or administration only. If property is not claimed, a letter is sent to the last known address; if not
claimed within thirty days, the items are then donated or destroyed. The superintendent or
designee ensures all money is counted and inventoried and a money order is sent to the
regional human resource office and forwarded to headquarters.
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.
Three closed youth records were reviewed for release procedures. The on-duty supervisor
reviewed the release paperwork received from the court and all paperwork related to release
prior to youth’s release in all three records. The youth’s identification was verified prior to
release in all three records. The identification of the parent/guardian or responsible adult was
verified prior to release in all three records. The identification card, used to verify the identities in
two records, was photocopied and placed in the youth’s record in both records. The remaining
youth was released to law enforcement. The law enforcement officer’s identity was verified, but
a photocopy was not made, as identification was made through the officer’s badge number.
None of the youth were applicable to having an Endangered Person alert. The youth and person
to whom youth is being released was reminded of future court dates in two applicable records.
In the remaining record, the youth was not applicable due to being transferred by law
enforcement to the county jail. All required parties signed all applicable release forms in all three
records. The date of admission and the date of release documented in the case record
correlated with the Department’s Juvenile Justice Information System (JJIS). The center had
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one release during the annual compliance review; however, an observation could not be made
despite requests to do so.
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.
Three closed youth records were reviewed for release of personal property, medication, and
aftercare instructions. One of three youth records was applicable to the youth being released to
the parent/guardian and the parent/guardian signed the receipt of property form upon release.
One youth was released to the jail and the other youth was transported to a commitment facility.
Documentation in all three records verified the youth was released to an appropriate person with
a copy of their identification. None of the youth were applicable to being released with
medication or with health or welfare issues. The center had no properties held for more than
thirty days requiring disposal during the annual compliance review period. The center had one
release during the annual compliance review; however, an observation could not be made
despite requests to do so.
2.08 Review of Youth in Secure Detention Failed 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.
An observation of the weekly detention review for the youth in secure detention was conducted.
All required staff were present for the review including medical, mental health, juvenile probation
officer, education and center staff coordinating the review, and included a discussion of the
necessary elements for proper management of youth placed in secure detention. A review of
documentation showed detention reviews were being uploaded as required in July 2024 and
three were missing in August, and the center was closed during September, October and
November, reopening in December. Two detention reviews were missing in December 2024,
one was missing in both February and March of 2025, and no other reviews were recorded
beginning in April 2025 through July 2025. A review of documentation showed several detention
review sign-in sheets were not signed by staff, and required participants were missing in the
majority of the detention review sign-in sheets reviewed. Medical and mental health staff were
not shown as being participants in any capacity in several of the review sign-in sheets.
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2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
Observations of activities and programming at various times of day were conducted in
accordance with the activity schedule. Wake up and personal hygiene, mealtimes, indoor
activities which promote education, problem-solving and life skills, bedtimes, groups, and open
program time were observed to be provided regularly. Recreation and physical activities were
unable to be observed. Youth were not given outdoor recreation time during the annual
compliance review due to contractors being onsite and needing the gate open for access;
therefore, activities were provided indoors. The daily activity schedule was posted in all living
areas. An interview with seven youth confirmed the center follows a daily activity schedule.
Seven staff were interviewed and six of seven stated the center’s daily activity schedule is
followed. The remaining staff stated the center does not have enough staff to move the youth in
a manner allowing adherence to the activity schedule.
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 a policy and procedures to provide educational access. The center provides
education services through the Alachua County School District and the 250-day calendar, which
is distributed over twelve months, including ten days used for teacher training and planning was
reviewed. A review of the daily school schedule revealed the center provides four seventy-five
minimum class blocks daily, fulfilling the weekly requirement of twenty-five hours of instructional
time. The center was closed from September 2024 through December 2024. A review of four
random dates in the logbook showed the daily class schedule was being followed. On two
reviewed days, the youth were ten minutes late returning from lunch. Further review of recent
logbook entries and video footage for three days showed the youth were returning to class from
lunch twenty minutes late; however, the youth arrive to school either early or stay later.
Seven youth were interviewed, and all seven reported they attend school Monday through
Friday. Each youth interviewed felt the school was preparing them towards General Education
Development platform (GED), high school, vocational, employment, and/or college. Seven staff
were interviewed, and all seven felt there was minimal interference in educational services. An
interview completed by the assistant superintendent also confirmed 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 facility 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. Seven youth were interviewed, and all seven reported they were
taking core classes such as 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 has a single licensed mental health professional who has been designated as the
acting designated mental health clinician authority (DMHCA). The DMHCA is on-site forty hours
each week and ensures the appropriate coordination and implementation of mental health and
substance abuse services are taking place. The Department maintains a contract with VitalCore
Health Strategies, LLC to provide mental health and substance abuse services to all applicable
youth in the center. The acting DMHCA is a licensed mental health counselor with a clear and
active license in the state of Florida expiring March 31, 2027. One other DMHCA was used
during the annual compliance review period, and the DMHCA had a clear and active license in
the state of Florida at the time of their employment at the center. The center has a back-up
DMHCA with a clear and active license in the State of Florida expiring March 31, 2027, who
provides coverage in the DMHCA’s absence. Copies of the DMHCA’s agreement and position
description were reviewed and confirmed the weekly hours of coverage are provided, as
required.
An interview with the DMHCA regional director of VitalCore confirmed the center provides
mental health and substance abuse services and each youth who enters the facility is screened
and evaluated by a mental health counselor within twenty-four hours to determine if mental
health/substance abuse services are warranted. All youth are informed of how to access mental
health services while in secure detention during the intake process. Youth who are prescribed
psychotropic medication are scheduled for an initial evaluation with the psychiatrist within
fourteen days of arrival and every thirty days thereafter until released. Youth who are not
prescribed psychotropic medication are seen by mental health staff by their fourteenth day for
mental health orientation. Youth receiving mental health services are seen by mental health
staff once a week, at a minimum. Any youth in secure detention by their thirty-first day receives
a Substance Abuse and Mental Health Assessment to determine if services are needed. The
DMHCA explained communication between the DMHCA and clinical staff takes place on an as-
needed basis with communication taking place daily, at a minimum.
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 clinical supervisor ensures the licensed clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
The licensed mental health professional is licensed under the appropriate Florida Statute
chapter and copies of the licenses are available on-site. The center has two licensed mental
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health counselors. Both licenses for each mental health professional was reviewed and were
clear and active in the State of Florida.
;l
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. There is one non-
licensed mental health staff providing services at the center. The clinical supervisor ensures the
non-licensed clinical staff working under their supervision are performing services they are
qualified to provide based on education, training, and experience. A review of documentation
reflected the non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the center during the annual compliance
review period. Direct supervision was recorded on the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form. The center does not have a Chapter 397 license, as such, all substance abuse services
are being provided by licensed mental health professionals only. The contract with the
Department confirms the center is not required to have any non-licensed clinical staff. The non-
licensed staff holds a master’s-level degree from an accredited university or college in the field
of counseling, social work, psychology, or other related human services field and completed
twenty hours of training and supervised experience in assessing suicide risk, mental health
crisis intervention, and emergency mental health services prior to conducting Assessments of
Suicide Risk as evidenced by a review of training records on the Department’s Learning
Management System (SkillPro).
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.
Seven youth mental health records were reviewed. All seven youth had a Suicide Risk
Screening Instrument (SRSI) and Massachusetts Youth Screening Instrument, Second Version
(MAYSI-2) completed in the Department’s Juvenile Justice Information (JJIS). The screening
documents were reviewed by detention staff and completed at intake for all seven youth. The
nurse and/or mental health staff completed the required sections in each of the seven SRSIs
and the completed entries included an accurate referral selection in the “Screening Results”
sections, as required. Four of seven applicable SRSIs included a “yes” response and each of
the four youth were placed on suicide precautions and a mental health referral was completed,
which documented the youth’s need for an Assessment of Suicide Risk (ASR). Four of seven
applicable SRSIs included a “yes” response when the youth had any open or closed suicide risk
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alerts in JJIS, as prompted within the JJIS SRSI navigation screen in red font. Two of the
MAYSI-2s was determined to be “invalid” due to all negative responses, the screenings were
marked as “invalid”, and the youth were referred for a comprehensive assessment on the
MAYSI-2 referral section, as required. The results of the SRSI and MAYSI-2 indicated a need
for further assessment in six of the seven records, which a referral was made, and the
superintendent/designee was notified. None of the youth’s MAYSI-2s indicated elevated suicide
risk subscales. The results of four of the MAYSI-2s indicated the need for comprehensive
assessment, and the screener referred all four youth for a comprehensive assessment within
the detention center.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Seven youth records were reviewed for mental health and substance abuse evaluations. Six of
the seven youth were identified after admission and referred to the center’s provider. Three of
the six applicable youth had a new evaluation completed by the center’s mental health provider
on-site by the youth’s thirty-first day. The remaining three applicable youth had not been at the
center for more than thirty-one days. Treatment recommendations were made which
corresponded to all diagnosed mental health or substance abuse disorders in all three records.
None of the youth were applicable to receive a new comprehensive assessment from a
community provider. The designated mental health clinician authority (DMHCA) was interviewed
and stated if a detained youth who was referred for Comprehensive Assessment by the Juvenile
Assessment Center (JAC) or juvenile probation officer (JPO) has not received an assessment
by the community-based service provider within thirty days, the detention center's mental health
provider shall administer a Comprehensive Mental Health Evaluation to the youth by the thirty-
first day in the center.
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.
Seven records were reviewed for treatment and discharge planning. All seven youth received
a mental health orientation within fourteen days of admission. Six of the seven youth required
an initial treatment plan and five of the six plans were in place within seven days of the onset of
treatment. The remaining youth declined services prior to the completion of the initial treatment
plan and the required documentation was found in the record. Each of the plans were
developed on the Department’s Initial Mental Health/Substance Abuse Treatment Plan form and
contained the reason for referral for treatment, initial Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnosis/symptoms, initial treatment methods to include
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counseling and frequency, initial treatment goals, psychiatric services including psychotropic
medication and frequency of monitoring, and medication the youth was admitted with, if
applicable. All five applicable plans included the signatures of the licensed mental health
professional and youth. All five applicable youth were assigned a mini treatment team as
evidenced by signatures of those team members on each plan.
Three youth were applicable for receiving an individualized treatment plan which was developed
for youth receiving mental health and/or substance abuse treatment in the center by the thirty-
first day of the youth’s admission. The remaining two youth have not been in the center long
enough for an individualized treatment plan to be completed. All three individualized treatment
plans included the youth’s DSM-5 diagnosis, symptoms which are treatment focused, treatment
goals which include mental health services if the youth has a mental illness, substance abuse
services if the youth has a substance-related diagnosis, and strengths and needs. One youth
was applicable for entering the center with psychotropic medications or being prescribed
psychotropic meditations. The psychotropic medications listed in the initial treatment plan
matched the psychotropic medications the youth was prescribed at the time the treatment plan
was developed in the applicable record. A review of the progress notes in the three applicable
youth’s records demonstrated each youth was receiving treatment services as stipulated in the
plan. A review of documentation reflected the individualized treatment plans were signed and
dated by each youth, mental health/substance abuse professionals, treatment team members,
and parent/guardian, or the center attempted to get the signature of the parent/guardian, in all
three applicable records. None of the three applicable youth required a thirty-day treatment plan
review at the time of the annual compliance review as their individualized plans had been
completed within the last thirty days. Upon consultation with the center and review of the youth
census, no additional applicable youth were available to review.
Given none of the youth reviewed records were applicable for Mental Health/Substance Abuse
Treatment Discharge Summaries, the center provided three additional records for review. All
three discharge plans were documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form and documentation supported copies were provided to the
youth, parent/guardian and Juvenile Probation Officer (JPO) at the youth’s discharge or
transition. All documentation included the completion on the day of service, signature of the
licensed mental health professional, and was uploaded into the Department’s Electronic Medical
Record within fourteen days. The center conducts treatment team reviews during the weekly
detention review meeting conducted every Wednesday at 3:00 p.m. An observation of the
meeting was completed and detention , mental health, medical, education, and probation staff
were in attendance to discuss applicable youth. The designated mental health clinician authority
(DMHCA) was interviewed and stated initial treatment plans are completed within seven days of
the onset of treatment and the individualized treatment plan must be completed by the thirty-first
day the youth has been in secure detention. A review of Individualized Treatment Plans,
Individualized Substance Abuse Treatment Plans or Integrated Mental Health/Substance Abuse
Treatment Plans must be conducted every thirty days while youth is in secure detention.
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3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
Seven youth records were reviewed for mental health and substance abuse treatment. Five of
the seven youth required treatment and were assigned a mini-treatment team. All five youth’s
assigned treatment team consisted of a mental health staff, one other staff from a different
service area, the youth, and the youth’s parent/guardian, if possible. Of the five applicable
youth, all five required mental health treatment and were receiving individual, group, and family
counseling according to the frequency of the plan and at a minimum of once a week. Four of the
five applicable youth required substance abuse treatment and a review of their plans and
progress notes indicated receipt of individual, group, and family counseling at the frequency
required by the plan. All five applicable youth had proper consent for treatment documented on
the Department’s Authority for Evaluation and Treatment (AET), Youth Consent for Substance
Abuse Treatment, and Youth Consent for Release of Substance Abuse Treatment Records
forms. All five youth records contained treatment notes documented on the Department’s
Counseling/Therapy Progress Note forms.
A video review was not conducted to review groups as the center is currently undergoing a
construction project which limits groups to two to three youth in mental health staff offices. Sign
in logs and progress notes were reviewed to ensure fidelity and compliance. Seven youth were
interviewed, and five stated they did not utilize mental health services. Of the two remaining
youth, one rated the services as good and one rated the services very good. The designated
mental health clinician authority (DMHCA) was interviewed and stated psychiatric, medication
management, and mental health and substance abuse counseling services are offered at the
center.
3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written suicide prevention plan detailing suicide prevention procedures which
is reviewed and signed by the designated mental health clinician authority (DMHCA) and
superintendent annually. The plan includes the identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referrals, communication,
notification, documentation, immediate staff response, and review process. The center has an
established review process for every serious suicide attempt or serious self-inflicted injury
(requiring hospitalization or medical attention) and a mortality review for a completed suicide
which includes the circumstances surrounding the event, procedures relevant to the incident,
training received by the staff involved, pertinent medical and mental health services involving
the victim, possible precipitating factors, and recommendations for changes in policy, training,
physical plant, medical or mental health services, and/or operational procedures, if any.
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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).
Seven youth records were reviewed for suicide prevention services. Four of the seven youth
were determined to be a suicide risk during their admission screening. An alert in the
Department’s Juvenile Justice Information System (JJIS) was initiated for the four applicable
youth when placed on precautionary observation (PO), and a suicide risk assessment
documented an assessment of the youth on the day of service. Each of the four applicable
youth were on a one-to-one level of supervision prior to the completion the Department’s
Assessment of Suicide Risk (ASR). All four youth had a qualified mental health professional
involved when placed on constant supervision and the suicide precaution observation logs were
completed in their entirety, to include documented “safe housing” areas and required signatures.
None of the four youth were released prior to receiving an ASR or while on suicide precautions.
Staff documented a consultation with the designated mental health clinician authority (DMHCA)
or licensed mental health professional on the mental health/substance abuse referral summary
and the superintendent or designee was notified immediately of suicide risk for all four
applicable records. The ASR or Follow-Up ASR was completed prior to the removal of youth
from PO, and there was documentation of a conference held by the superintendent and licensed
mental health professional to reduce the level of supervision in the four applicable records. The
discontinuation of close supervision was documented in accordance with the center’s suicide
prevention plan. All four suicide risk assessments were completed by a licensed mental health
professional and results of the assessments included recommendations for supervision follow-
up. A review of JJIS determined alerts were appropriately entered and removed following youth
removal from PO. A review of logbooks determined the beginning and ending times for PO were
documented for youth in all four youth records.
The designated mental health clinician authority (DMHCA) was interviewed and stated mental
health is immediately notified of any youth deemed to be in crisis and placed on precautionary
observation until the ASR can be completed and a determination to step down is made. Seven
staff were interviewed and each stated they would notify mental health staff if a youth was
suicidal and document supervision of the youth, with six of the seven stating they would keep
the youth in constant sight and sound. Seven youth were interviewed and stated none of them
had ever been placed on suicide precautions.
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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.
Seven youth records were reviewed for secure observation. None of the reviewed youth records
were applicable for secure observation. As such, the center provided two additional records for
review. No additional applicable youth had been placed on secure observation during the
annual compliance review period. For the two applicable youth, placement in secure
observation was authorized by the superintendent and designated mental health clinician
authority (DMHCA) and the secure room was designated in writing. The Health Status Checklist
was completed prior to placement in secure observation and the Suicide Precaution
Observation Logs were completed in their entirety for both youth. Within eight hours of
placement, a Follow-Up Assessment of Suicide Risk (ASR) was completed for both youth. Each
youth’s parent/guardian and juvenile probation officer (JPO) were notified of the youth’s
potential suicide risk as indicated by the ASR. Neither youth remained on observation beyond a
twenty-four hour period. Mental health staff provided supportive counseling services during
secure observation, and the observation log documented supervision for both youth. Both
youths’ level of supervision was reduced after a conference with the superintendent and
licensed mental health professional. The discontinuation of secure observation and step-down
to close supervision was documented in the center’s logbook and in each of the two youth
mental health records by mental health clinical staff.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Seven youth records were reviewed for Suicide Precaution Observation Logs, and four youth
were applicable. The Suicide Precaution Observation Logs were maintained for the duration the
youth was on suicide precaution in the four applicable records. The appropriate level of
supervision and observations of the youth’s behavior were documented in real time and not
exceeding thirty-minute intervals in all four records reviewed. None of the youth records were
applicable for warning signs. When warning signs are observed, the center has a policy
outlining the expectation of notification of the superintendent or designee and mental health
clinical staff be documented on the Suicide Precaution Observation Log. The logs were
reviewed and signed by each shift supervisor and signed by mental health clinical staff in all four
applicable records. All four logs documented safe housing requirements. A review of video
footage and corresponding documentation of youth on precaution observation or secure
observation confirmed the proper supervision was maintained for youth placed on precautionary
observation.
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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.
Seven pre-service and seven in-service staff training records were reviewed. Training included
suicide drills no less than quarterly, on each shift. Due to the ongoing construction projects, the
center has three accessible suicide response kits, which include a knife-for-life, wire cutters, and
needle nose pliers which are located in the sub-control, master control, and the electrical closet
in the courtyard. Suicide response kits are co-located with first-aid kits. Video review of the last
suicide drill was unable to be viewed as it was conducted in the conference room outside of
video coverage; however, a review of the documentation and an interview with the designated
mental health clinician authority (DMHCA), who conducted the drill, resulted in all the required
elements being present during the simulation. Though facility operating procedures require
quarterly suicide drills, the Department’s Office of Health Services requires monthly drills on
each shift. Given this requirement, the center was missing four drills in total. The drills
completed did involve all staff coming in contact with youth and did not utilize center youth in the
simulations. A review of training records did indicate all seven pre-service and all seven in-
service staff received semi-annual training in emergency response procedures relating to a
suicide attempt or incident of serious self-inflicted injury. All staff who come in contact with a
youth are required to participate in mock suicide drills held no less than quarterly each shift;
however, staff who were not present during a quarterly drill, have the opportunity to review each
drill scenario and procedures in an effort to understand the process and receive the necessary
training to respond to an incident of a suicide attempt or incident of serious self-inflicted injury in
the center. Seven interviewed staff stated suicide response kits were located in sub-control,
three stated they were located in master control, and one stated they are located in the
electrical closet in the courtyard.
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 a combined written Crisis Intervention and Emergency Services Care Plan for
mental health services which includes a notification and alerts system, means of completing
referrals including self-referrals, communication, supervision, documentation, and reviews.
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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.
A review of the center’s Emergency Care Plan confirmed it included immediate staff response,
notification, communication, supervision, authorization to transport for emergency mental health
or substance abuse services, transport for emergency mental health evaluation and treatment
under Chapter 394 Florida Statutes, Florida’s Baker Act, transport for emergency substance
abuse assessment and treatment under Chapter 397 Florida Statutes Marchman Act,
documentation, training, and review. The plan was approved February 27, 2024. A copy of the
plan is located in the office of the designated mental health clinician authority, medical office,
master control, briefing room, break room, conference room, and the offices of both captains.
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.
Seven youth records were reviewed for Crisis Assessments. None of the reviewed youth were
applicable for having a Crisis Assessment, as such, the center provided the one applicable
record during the annual compliance review period for review. The Crisis Assessment included
the reason for the Crisis Assessment, Mental Status Examination and interview, determination
of danger to self/others, initial clinical impressions, supervision recommendations, treatment
recommendations, recommendations for follow-up or further evaluation, and notification to the
parent/guardian of follow-up treatment for the applicable youth. A mental health alert was
entered into the Department’s Juvenile Justice Information System (JJIS) when the youth was
placed on precautions after completion of a Crisis Assessment. The youth was identified by
direct care staff or clinical staff as having acute emotional or behavioral problems, or acute
physiological distress. The Crisis Assessment was conducted by a licensed mental health
professional based on the needs of the youth immediately, as indicated by the time a referral
was submitted and the completion time of the crisis assessment. The youth was not an alleged
victim of a Prison Rape Elimination Act (PREA) event.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
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Seven youth records were reviewed for Baker and Marchman Acts. None of the reviewed youth
were applicable for being placed on a Baker or Marchman Act as such, the center provided
three additional applicable youth records during the annual compliance review period for review.
All three youth had a suicide risk alert opened while pending off-site transport, and were placed
on one-to-one supervision, which was documented on a Precautionary Observation Log until
release. The youth were placed on suicide precautions upon re-admission from a Baker Act or
Marchman Act facility in all three records reviewed. A mental health referral was completed for a
Mental Status Examination (MSE) for all three youth. The MSE was completed by a licensed
mental health professional in all three records, and each youth was maintained on a minimum of
constant supervision until properly transitioned to a lower level of supervision. The youth’s
supervision level was not lowered until an appropriate assessment was conducted and mental
health staff conferred with the licensed supervisor and superintendent or designee in all three
records. The discontinuation of the suicide risk alerts and mental health alerts in the
Department’s Juvenile Justice Information System (JJIS) and precautions/supervision were
based upon an Assessment of Suicide Risk and Crisis Assessment in all three records.
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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 designated health authority (DHA) who is clinically responsible for the medical
care of all youth in the center. The DHA is a board-certified physician (MD) whose license
expires on January 3, 2026. There is a back-up DHA MD whose license expires March 31,
2026. Both physicians have specialty training in Pediatrics. There are two advanced practice
registered nurses (APRNs) whose licenses expire on July 31, 2026, and April 30, 2026. The
DHA was on-site at least once a week during the annual compliance review period. The center
was closed from September 2025 through mid-December 2025. The DHA was interviewed and
verified duties as performing Comprehensive Physical Assessments (CPAs), periodic
evaluations, protocol review, and is on-site weekly and on call twenty-four hours a day/seven
days a week. Tele-medicine is not used at the facility. The DHA communicates to staff both in
person and by phone. They share on-site clinical services with the APRN. Information of
findings and instructions are kept in a folder in the medical clinic. The DHA is on-site at least
once a week to review all relevant youth medical information. The clinic manager is notified if
the DHA needs coverage and notifies the back-up. Chronic conditions are completed and
tracked in a log and the youth must be seen at least every ninety days or sooner based on their
condition.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
There are facility operating procedures (FOPs) for all health-related information at the center.
The designated health authority (DHA) and superintendent signed treatment protocols on March
12, 2025, and March 13, 2025, respectively. The psychiatrist reviewed and signed the protocols
on July 3, 2025, and the nursing staff reviewed and signed on March 12, 2025. There were no
new policies or changes in policy during the annual compliance review period. There are cover
pages signed and dated by the staff on the dates they reviewed the protocol. The psychiatrist
reviewed and, when needed, help develop any protocols related to psychiatric services and
psychotropic medication management. Newly hired healthcare personnel receive a
comprehensive clinical orientation given by a registered nurse (RN) or designated, licensed
healthcare provider.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures (FOPs) in place to ensure the completion of the
Authority for Evaluation and Treatment (AET) or Limited Consent authorizing specific treatment
while in the custody of the Department. Seven youth Individual Healthcare Records (ICHR)
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were reviewed, and all contained a legible AET. All seven AET forms were signed by the youth’s
parent/guardian and none of the seven had a court order pending. The AETs were obtained
prior to providing any health services to the youth and all seven were signed by a department
representative. All seven AETs were valid and none of the youth were involved with the
Department of Children and Families (DCF). One youth was over the age of eighteen and there
was a documented release of information within their healthcare record. The nurse’s interview
stated the AET is the responsibility of the Juvenile Probation Officer (JPO) to acquire. If the
parent or legal guardian is unavailable, the JPO shall set up an intake conference to obtain the
signed AET. For youth aged eighteen or older, the youth provides consent for themselves at the
point of contact of healthcare services and the consent is documented in each youth’s individual
healthcare record.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures (FOPs) to inform the parent/guardian of significant
changes in the youth’s condition and obtain consent when new medications and treatments are
prescribed. Seven youth records were reviewed, and four records revealed the youth needed
parent/guardian consent for over-the-counter medications and in all four records
parent/guardian gave consent. Written notifications on the Department’s Parental Notification of
Health Related Care were sent to the parent/guardian, and all gave consent. One youth out of
seven was taking psychotropic medication upon admission and staff witnesses all telephone
attempts and conversations. One youth had a new psychotropic medication ordered and the
verbal consent from the parent/guardian was obtained on page three of the Clinical Psychiatric
Progress Note (CPPN). Five youth had a Tuberculosis (TB) test upon admission, one youth
refused, and one had a current TB test on file. Five out of seven youth had a new medication
ordered and documentation to the parent/guardian was in the progress notes as well as an
acknowledgement of receipt of the CPPN form. Vaccines were obtained within thirty days of the
youth’s admission in all seven records. One youth required parental notification of required
vaccinations which was received and administered once consent was obtained. In all seven
youth records, parent/guardians did not claim religious exemption from immunization. During an
interview with nursing staff, the nurse was able to quote policy in regards to parental
notifications and time frames, as well as procedures for when a youth’s illness or injury requires
medical services or is life threatening, and for procedures regarding obtaining consent for
psychotropic medications. According to the interviewed nurse, vaccinations are not provided on
site. Immunization records are obtained through Florida Shots during the youth admission
process by medical staff and reviewed within twenty-four hours. If a parent/guardian claims
exemption and does not consent to vaccinations for religious reasons, a Religious Exemption
from Immunizations form provided by the Health Department is signed and authorized then
submitted to the detention center. Copies are maintained within each youth’s healthcare record
as well as the Department’s Electronic Medical Record (EMR) system.
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4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures (FOPs) for screening all youths with the Medical
and Mental health Admission Screening form. All seven records reviewed had the medical and
mental health screening completed within twenty-four hours. Four youths were screened by a
juvenile justice detention officer (JJDO) and three youths were screened by a registered nurse
(RN). The youth screened by the JJDO had their screening reviewed by a licensed medical
staff. Each of the seven reviewed youth records confirmed they did not require a rescreening as
they did not leave the center. Three additional youth were reviewed for a rescreening because
there was a physical change in custody since admission. Each youth received a completed re-
screening each time a change in custody occurred, conducted by a JJDO and reviewed by the
RN within twenty-four hours. Nursing staff indicated the center roster is reviewed daily for newly
admitted youth. The screening unit completes the admission screening, and the nursing staff will
sign and date the bottom of the third page of the admission screening after it is reviewed. The
nursing staff also indicated anytime there is a change in physical custody after a youth’s
admission, a new healthcare admission screening is completed upon the youth’s return to the
center.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures (FOPs) for all youth to be oriented to the general
process of healthcare delivery services. The health education topics were documented on each
youth’s Health Education Record form. These topics included access to medical care access,
sick call, what constitutes an emergency, medications and side effect monitoring, right to refuse
care and how it is documented, what to do in case of an attempted assault or an assault, the
non-disciplinary role of healthcare providers, and general infection control/hygiene. One youth,
refused to receive any health education. Three of the youth had chronic conditions and received
instruction and education about their prescribed medication from an on-site licensed healthcare
staff. The education was recorded in each youth’s individual healthcare record.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures (FOPs) on designated health authority notification.
Seven individual healthcare records (IHCR) were reviewed for admission referrals and two
records were applicable; therefore, the center provided an additional record for review. The
applicable youth records had documentation they were all referred to the physician due to a
known or suspected chronic condition. None of the youth were identified as needing emergency
care upon admission. Notification to the Designated Health Authority (DHA) was documented in
all three youth’s IHCR within the required time frame following admission. Two of the three
applicable youth were taking psychotropic medications upon admission, and the psychiatrist
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was notified. The nursing interview confirmed the notifications are documented on the
admission progress note of the IHCR in the electronic medical record (EMR) by a licensed
medical staff. The nursing interview indicated the DHA is notified within twenty-four hours of
youth being admitted into the facility when notification is required. Nursing staff complete the
notification during their working hours, and during non-working hours, if non-health care staff
provide care after-hours, the non-healthcare staff providing the healthcare document what care
was given to youth on the report of healthcare by non-health care staff form to be reviewed by
clinical staff, then placed in the youth’s IHCR and EMR.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures (FOPs) for the Department Health-Related History
(HRH) form to be completed for all youth admitted into the physical custody of the center. Seven
youth records were reviewed and all seven youth received an HRH form completed within seven
calendar days of admission. The HRH was completed by a licensed nurse and was completed
prior to the comprehensive physical assessment (CPA). The medical doctor or advanced
practice registered nurse (APRN) reviewed the HRH and the review was documented in the
admission documents. A review of the HRH forms confirmed signatures and dates for the most
recent admission. The nursing interview confirmed the HRH shall be completed or reviewed by
nursing staff through interviews with the youth no later than seven calendar days of admission
to the facility.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures (FOPs) for the Comprehensive Physical
Assessment (CPA) to be completed for all youth admitted in physical custody of the center. The
FOPs stated what to do if an exam is not conducted and/or refused by the youth and the
operating procedures for Tuberculosis (TB) screening and rescreening process. Seven youth
records were reviewed and six had the CPA on the correct form. One youth refused to have a
CPA completed and a refusal form was documented and initialed by youth. Two of the
applicable youth were admitted with a current CPA with the correct medical grades on their
CPA. The other four applicable youth were either out of detention for two years or were a new
admission; however, all six youth had a new CPA completed within seven days of admission.
The newly completed CPAs were reviewed by the physician and had focused evaluations. All
sections of the CPA were marked with either an “O” or “X” in all six records. One youth agreed
to a genital exam, five had “youth refused” and signed a refusal form. The dates matched the
date of the exam and the refusal by the youth. The problem list was updated in all six applicable
records reviewed and each had a purified protein derivative (PPD) test within seventy-two
hours, which was documented on the individual healthcare record (IHCR). The date of the
results matched on both the CPA and on the Infectious and Communicable Disease form. None
of the reviewed youth records needed further evaluation. The nursing interview confirmed the
process for the CPA to be completed within seven days of admission and when a new TB test is
required, how it is read, and where it is documented.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures (FOPs) for evaluation and treatment for sexually
transmitted infections (STIs) and human immunodeficiency virus (HIV) risk factors. In all seven
youth records reviewed, the medical clinic screened and evaluated each youth for STIs. Two
youth required further evaluation and the Advanced Practical Registered Nurse (APRN) referred
both, and the referral was documented on each youth’s STI form. Both youth were tested, with
the results filed in on the Infectious Communicable Disease form and in each youth’s Individual
Healthcare Records (IHCR), None of the reviewed seven youth gave a consent for a
gynecological exam. None of the youth were out of the Department’s custody. All seven
reviewed ICHRs indicated each youth was offered counseling, testing and treatment, if needed,
for HIV. Four youth consented and received the HIV test and signed consent forms. Three youth
were tested on the same day of their admission, and one was tested the next time it was
available. The test results for each youth tested was filed in the youth’s IHCR and was reviewed
by a physician and documented on a sealed envelope. The four applicable youth’s records had
documentation of a pre-test/post-test on the Individual Health Education Record, but not the test
results. None of the applicable youth had their HIV status and/or STI diagnosis on the center’s
internal alert system. The nurse interview indicated all sexually active youth are clinically
screened by provider nursing staff and evaluated for STIs. After screening, each youth is
referred to the designated health authority (DHA) or APRN to determine if testing is required.
The screening and referral will be accomplished using the Department’s most current STI form.
Once the DHA or APRN reviews the STI Screening Form with the youth during the completion
of a Comprehensive Physical Assessment (CPA) or CPA Review, the practitioner will make the
determination as to if the youth will be referred for STI testing. The referral will be marked on the
STI screening form and the DHA or APRN will sign the form. The completed STI screening form
shall be uploaded to the Department’s Electronic Medical Record (EMR) system and filed in the
IHCR until which time all signatures captured on the form can be completed electronicly. If the
youth is referred for testing, the practitioner will document an order for the testing in the EMR
and the youth will be added to the STI log to be tested at the next available opportunity through
the Department’s contracted laboratory service. The results of STI tests will be noted on the
Infectious and Communicable Disease form and the lab results will be located in the IHCR
behind the corresponding tab as well as uploaded to the EMR after being reviewed by a
practitioner. Rescreening should be conducted if the sexually active youth has been out of the
Department’s custody and/or symptoms are present or there is a report of recent sexual activity.
Human Immunodeficiency Virus (HIV) results are uploaded to the EMR which is permission
based and secure. Youth who request HIV testing are placed on a list and receive pre and post
counseling with routine testing completed by an on-site licensed medical professional to include
the DHA and APRN, or sub-contracted provider who is certified by the Department of Health
(DOH). Pre and post counseling are documented on the Health Education Record with the
name of the provider documented in the comment section of the entry. If unable to complete
testing prior to discharge, youth shall receive instruction on how to obtain testing in the
community or through the local DOH. This shall be documented in the IHCR EMR.
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4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures (FOPs) ensuring sick call request forms from youth
are responded to quickly and handled appropriately. Seven youth records were reviewed for the
sick call process and four of the youth initiated the process. None of the youth had more than
three similar sick call complaints in a two-week history and none of the sick calls were regarding
severe pain. The nurse completed the sick call request form for the applicable youth and the
required form was filed in the youth’s Individual Healthcare Record (IHCR) in reverse
chronological order. None of the youth reviewed were in restricted housing of any type and all
four youth forms were documented with vital signs and treatment, in accordance with Health
Services Rule. The dates documented on the Sick Call Index corresponded to the completed
sick call forms in the IHCR. The daily schedule, posted schedule, and nurse’s interview
indicated sick calls were conducted daily and seen within at least twenty-four hours of
submission; however, one youth interviewed stated they were seen three days later from
submitting the request form. There are approved treatment protocols for the registered nurses
(RNs). The center has sick call Monday through Friday from 10:00 a.m. to 11:00 a.m. and from
2:00 p.m. to 3:00 p.m. On Saturday and Sunday sick call is from 7:00 a.m. to 7:30 a.m. and from
10:00 am to 11:00 a.m. The sick call hours are posted outside of the nurse’s station in the
hallway. Only the licensed RNs complete sick calls and the Juvenile Justice Detention Officer
Supervisors (JJDOS) review sick call requests as soon as possible and within four hours of the
request being submitted if there is not an RN on-site. For youth in restricted housing of any kind,
the supervisor on each shift would question the youth about medical related issues and
document such questioning on the shift report daily. One observation of a youth receiving sick
call confirmed the youth was escorted by a Juvenile Justice Detention Officer (JJDO) who was
trained and certified in Right Interaction. All elements of a sick call were met. Two of the seven
interviewed youth stated they were seen immediately upon filling out a sick call, one youth
advised being seen within an hour, and one youth advised within three days after completing
the sick call request. Three of the interviewed youth advised they never requested a sick call.
Five of seven youth indicated the nurse conducts the sick call, despite one of the five not having
ever requested one. Seven interviewed staff stated the nurse conducts and reviews sick calls.
The center’s administration was made aware of this response and advised they would retrain
staff to ensure they know supervisors can conduct sick calls in the absence of health care staff.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Limited Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures (FOPs) for the provision of episodic and first aid
care. Seven youth records were reviewed and three had an indication of required episodic care
while at the center. All three youth received treatment by a licensed healthcare staff, and it was
clearly documented in standard narrative charting. The nature of the complaint and findings of
the licensed healthcare was documented for all three youth. Treatment was documented and
one youth had to be taken to the emergency room. The healthcare staff presented education
and/or instruction to the youth and plans for follow-up, both of which were documented. The
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youth who received off-site care was placed on the alert list, and it was confirmed all three-youth
had parental notification completed and documented. There was an entry in the care log for all
three youth and none of them needed a follow-up evaluation. The first-aid kits are located in
master control (five in total total), B1 sub-control, breezeway, intake, mental health, captain’s
office, and kitchen for a total of eleven kits. Transportation checks out a first-aid kit from master
control every time they take a center van or car. Three first-aid kits were checked, and all had
designated health authority (DHA) approved contents. The center has an automated external
defibrillator (AED)/First Aid log completed each month to ensure items have not expired or
deteriorated in the kits and a review of the kits confirmed the upkeep. The center has two AEDs
on site; one is located on B1 hallway and the other is across from the medical office. The AED
procedures are located with the AEDs. On-site nursing staff checks the AED batteries on a
monthly-basis and documents the checks in a logbook. A review of the logbook confirmed the
nurse checks the AEDs monthly. The nursing staff conducted a self-test of the AED and
checked the expiration dates in front of the regional monitors with no issues noted. The nurse’s
station had a list of emergency numbers which was not observable by any youth. Fourteen staff
training records were reviewed and each were trained on the administration of the epinephrine
auto-injector and in first-aid and emergency care within the last year. The center maintains two
tubes of Narcan in the nurse’s office on a cart, and a log is set up to check the expiration dates.
As the Narcan expires, new tubes of Narcan are placed on the cart. All staff have access to the
Narcan and have been trained in the administration of Narcan. Seven staff were interviewed
and advised they can make a call to 911 if they felt it was necessary. Seven youth were
interviewed and rated the medical care at the facility. Four youth stated the medical care is
good, one youth advised the care was great, and two youth were not receiving medical services.
The Office of Health Services (OHS) completed a verification during the annual compliance
review due to a minor deficiency assigned May 21, 2025; however, it was unable to be
successfully closed and required a second verification requiring the deficiency to remain open at
the time of the annual compliance review.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures (FOPs) for off-site referrals ensuring there are
timely referrals, coordination of medical services, and health care providers for emergency and
non-emergency situations. All off-site services must be documented. The seven reviewed
Individual Healthcare Records (IHCR) found one youth was applicable for an off-site referral.
Two additional IHCRs were requested and reviewed. Each applicable reviewed IHCR indicated
the youth required off-site care, and each youth had the consultation report form completed and
filed. Each reviewed IHCR had parental notifications documented and the first aid/emergency
care log was completed. The discharge instructions and other applicable documents were filed
in the IHCR. The designated health authority (DHA) signed off on the off-site care findings,
instructions, and information. The three applicable youth required no follow-up testing or
appointments. The nurse’s interview confirmed the DHA is contacted upon youth’s return to the
center and the records are placed in the DHA’s folder for review and signature. There are
several ways the information is documented including on a monthly calendar/tracking board and
logs located in the medical clinic.
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4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures (FOPs) for youth with chronic conditions. Youth
with chronic conditions receive regularly scheduled evaluations and follow-up. The seven
reviewed Individual Healthcare Records (IHCR) found two youth were applicable for chronic
conditions. One additional IHCR was requested and reviewed. Each youth was identified on the
medical/mental health screening form with having a chronic condition. The Health-Related
History (HRH) form and the Comprehensive Physical Assessment (CPA) matched the
medical/mental health screening. None of the youth had a communicable disease, were taking
medication on an on-going basis, had an abnormal body mass index (BMI), taking anti-
tuberculosis medication, or were applicable for pregnancy. Each of the three youth had a
medical grade between 2 to 4; therefore, they were placed on the chronic conditions list. None
of the youth had been at the center more than ninety days therefore were not applicable to
receive a periodic evaluation. The Department’s Problem List was updated for all three youth
records and each youth was placed on a tracking log to track the need for periodic evaluations.
The designated health authority (DHA) interview indicated the center utilizes a log to track
chronic conditions and when periodic evaluations are due. The DHA advised periodic
evaluations are completed every ninety days. The interviewed nursing staff indicated chronic
conditions are tracked on a white board, and the clinic manager conducts weekly reviews of
records to ensure chronic conditions are addressed.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures (FOPs) for medication management. Medication
must be received, stored, inventoried, and provided in a safe and effective manner. Seven youth
records were reviewed and three of the youth were taking medication at the time of admission.
Prescription verification for each youth was documented in the chronological progress notes, in
the Individual Healthcare Record (IHCR), and in the Department’s Electronic Medical Record
(EMR). The designated health authority (DHA) and the psychiatrist were contacted to ensure
the orders were obtained for a continuing prescription and all medications had a current, valid
order. In each applicable record, if medications were continued, discontinued, or changed, the
DHA or the advanced practice registered nurse (ARPN) placed an order on the practitioner
order form. The documentation of prescription verification was located on the chronological
notes in the IHCR. The youth were not in any kind of restricted housing and over the counter
(OTC) medication not listed on the Authority for Evaluation and Treatment (AET) form was
administered according to the approved protocols. The standard Department’s Medication
Administration Record (MAR) was used to document all medication administrated and the start
and stop dates were clearly indicated. If needed and no licensed staff were on-site, non-
healthcare staff assist by bringing the youth to the clinic and initialing once youth takes the
medication. There were no undocumented explanations for lapses or errors in medication
administration and the nursing staff monitored for side effects weekly. The three youth’s
reviewed records confirmed none of the youth refused any medication. The MAR contained the
youth’s name, Department’s Juvenile Justice Identification System number, date of birth,
allergies, precautions, Medical Grade, medical alerts, a picture of the youth, the staff’s initials,
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and the youth’s initials. None of the youth required parenteral medication. Two of the three
youth reviewed came into the center on psychotropic medication and was monitored every thirty
days as required. There were not any standing orders, emergency treatment, or pro re nata
(PRN) orders for psychotropic medications. One youth was observed for medication
administration and verbal consent was obtained prior to administering. A juvenile justice
detention officer (JJDO) brought the youth and stood behind them while the medication was
administered. The APRN greeted the youth and told them why they were there. The medication
was administered by the same ARPN and identified the youth’s allergies and alert status. The
youth and the JJDO both initialed the MAR. The JJDO observed to ensure the youth swallowed
the medication.
The disposal of controlled and uncontrolled medication is the responsibility of the nurse and the
pharmacy consultant. The medications are inventoried before being disposed of in the presence
of the pharmacy consultant. The medications must be disposed of by using the Drug
Enforcement Agency (DEA) approved Drug Buster disposal system and with the state board of
pharmacy and DEA disposal plan. The documentation of disposed medication is maintained and
kept in the clinic. The interviewed nursing staff verified the clinic manager conducts training for
non-healthcare staff to assist with the administration of medications. The list of trained staff is
maintained in the front of the MAR logbook. Medications are ordered by the DHA, APRN, or
psychiatrist electronically or by way of the nurse following an order. Medication is dispensed by
Diamond Pharmacy and is delivered through FedEx and or/dispensed by a back-up pharmacy
then picked up by detention staff. All seven of the interviewed staff advised they do not provide
medications to youth. Of the seven youth interviewed, only one took medications and the youth
advised the nurse administers the medication.
4.16 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures (FOPs) for psychiatric services to include
evaluations, medication management, medical supportive counseling with diagnosed DSM-5
mental disorder, and psychotropic medication service. The current psychiatrist is board certified
by the American Board of Psychiatry. The psychiatrist’s license expiration date is March 31,
2026, and there is not a back-up psychiatrist for the center. The designated mental healthcare
administrator (DMHCA) stated mental health staff respond within twenty-four hours of mental
health referrals. The licensed clinician is on-call every day of the year at any time of the day.
Seven youth records were reviewed for psychiatric services. Three youth either entered the
facility on psychotropic medication or were referred for a psychiatric interview within fourteen
days of youth’s admission. The initial diagnostic psychiatric interview for each youth included
the history, mental status, Diagnostic and Statistical Manual of Mental Disorder (DSM)-5
diagnosis, treatment recommendations, and prescribed medication if needed. The clinical
psychiatric progress note (CPPN) contained documentation of the psychotropic medication for
each youth, explanation of the need for psychotropic medication, and the frequency of
medication management. All three youth had an in-depth psychiatric evaluation conducted
within thirty days of referral/admission. All the items in the three youth’s mental health past were
included in the evaluation as well as mental status examination and identification of individual,
family and environmental factors. All required information was documented for psychotropic
medications in all three youth records. Items monitored for the youth on psychotropic medication
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include side effects and youth’s adherence to the medication regime. Each youth’s record
confirmed the height, weight, blood pressure, parent contact, signature of the psychiatrist and
date of signature were all documented. The medical and mental health staff documented
monitoring for Tardive Dyskinesia monthly. The authority for evaluation and treatment (AET),
parent/guardian verbal consent and written consent were documented on the CPPN and the
acknowledgement of receipt of the CPPN respectively. The three youth reviewed were not in
foster care or eighteen years of age. Tele-psychiatry was not used in the three youth records
reviewed for medication management.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures (FOPs) for medication/sharps inventory. The
medical equipment classified as sharps were secure and inventoried using a descending count
as each sharp is used. All the medications in the clinic were identified and were in a secure
locked area. The medication cart has a lock, was organized and clean, and contained stock
items separate from youth specific medications. The controlled medications were stored
separately from other medications in a secondary locked box. Sharps, stock medical supplies,
and all controlled and uncontrolled medication were in a locked area inaccessible to youth. The
oral medications were not stored with injectable or topical medications and, although there were
no medications requiring refrigeration, the refrigerator was empty and had a lock. The clinic has
a log in which they document all sharps and over-the-counter (OTC) medications weekly.
Controlled medications of youth were inventoried from shift to shift and documented on the
youth’s individualized controlled medication inventory record. All medical training was conducted
by a registered nurse (RN) or higher. Two controlled medications (only two youth at the center
were taking controlled medication), three OTC medications, and three sharps were observed,
and the counts were all correct compared to the logs. Discrepancies after recounts are
documented as a medication error with notifications to the designated health authority (DHA),
superintendent, and a call the Department’s Central Communications Center (CCC). The
medications must be disposed of by using the Drug Enforcement Agency (DEA) approved Drug
Buster disposal system and with the state board of pharmacy and DEA disposal plan. The
documentation of disposed medication is maintained and kept in the clinic. The designated area
to store youth’s medication was observed. Nursing interviews confirmed the process for storing
medications and sharps in separate and secure areas inaccessible to youth, the requirements
for the storage and tracking on controlled substances, and requirements for conducting
medication counts and inventories.
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4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures (FOPs) for infection control procedures including
prevention, containment, treatment and reporting requirements related to infectious diseases.
Six youth records were reviewed, with one record not applicable for the youth refused to
participate in health education. Infection control training was completed with each youth within
seven days of admission. The infection control training consisted of hand washing techniques,
universal precautions, prevention of communicable diseases, vaccinations, and Center for
Disease Control (CDC) and Prevention guidelines for infection control. The exposure control
plan utilized by the center was written in accordance with Occupational Safety and Health
Administration (OSHA) and included all required elements for risk assessment and methods of
compliance. The plan lists the availability of hand washing facilities, the proper procedure for
disposal of sharps, maintaining a clean work site, specified signs and labels which includes
hazards to staff, procedures for handling contaminated laundry, post-exposure evaluation and
follow-up and a system of medical records keeping for staff with occupational exposure. The
infection control procedures include prevention, containment, treatment and reporting
requirements related to infections disease according to OSHA and the CDC guidelines. The
infection control procedures include infectious diseases of childhood, common colds, viral or
bacterial infections diseases, tuberculosis, hepatitis, and Human Immunodeficiency Virus (HIV),
and infectious diseases caused by blood-borne pathogens. The remaining infection control
procedures include outbreaks by other infectious agents, outbreaks of lice, Methicillin-Resistant
Staphylococcus Aures (MRSA), food-borne illnesses, bio-terrorist agents, and chemical
exposures in the workplace. The center has a comprehensive process for needle stick post-
exposure. The staff have access to protective equipment and access to a Hepatitis B
immunization. The center did have instances of infectious diseases or sexually transmitted
infections (STIs) which were reported to the local health department as required and there were
instances in which incidents reported to the local health department were also reported to the
Central Communications Center (CCC). There were three or more cases of any reportable
infectious diseases which needed to be reported to the local health department and/or the CDC,
and they were both notified as required. The superintendent or designee maintains a separate
file for documenting youth or staff who experience a facility exposure. Records are maintained
as confidential and kept for ten years as required. The reviewed pre-service and in-service staff
training records support staff completed training on the center’s exposure control plan. The
interviewed nurse indicated the exposure control plan is maintained in the clinic. Infection
control training is conducted by the clinic manager for medical staff. Medical staff are trained on
the exposure control plan within ninety days of hire and annually thereafter.
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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.
The center has facility operating procedures (FOPs) to provide access to prenatal care for all
pregnant youth. Health education is provided to both youth and staff. Only one pregnant youth
record was applicable for review during the annual compliance review period. Prenatal care
began immediately after determining the youth was pregnant. The advanced practice registered
nurse (APRN) did not need to provide routine, focused medical evaluations for the youth was
only at the center for five days. The prenatal care was provided at the recommended intervals
and an alert was entered into the center’s internal alert system for sleeping arrangements. The
youth did not complain of issues related to the pregnancy; however, daily monitoring for danger
signs of complications was provided. There was not a plan developed for post birth
psychological and physical care due to the youth only being at the center for five days. The
youth was educated on topics related to pregnancy, including alcohol and drug use, smoking,
nutrition, sexually transmitted infections (STIs), contraception, pre-natal care, birthing process,
postpartum care, and basic baby care. The APRN educated the youth on child/infant
development and parenting skills. The youth and was provided nutritious food in quantities
approved for a pregnant youth as ordered by APRN. The education provided to the youth was
documented in the health education record. The center has nursing protocols and treatment
plans for pregnant youth. The staff are trained in the same youth pregnancy education in which
the youth are, and the lead reviewer confirmed the training records represented the same. The
interviewed nurse verified staff are aware of the training, education, and care requirements for
pregnant youth.
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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.
Observations were made of youth supervision during the annual compliance review week. Staff
accounted for all youth with mandatory counts and staff remained in proximity for supervision of
the youth. Active supervision was observed within the two open living modules at the center
Youth did not leave the living modules for class, dining hall, or any other activity requiring line
movement functions due to the majority of the center being under remodel construction. Master
control authorizes all movement of youth and staff prior to movement on a normal basis;
however, due to the construction, there was no movement for master control to authorize.
Seven staff were interviewed about staffing for youth supervision. All seven staff advised there
is not enough staff to provide for the safety and security of youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has a behavior management system (BMS) which specifies appropriate and
inappropriate behaviors, rules, norms, and expectations for youth. The system includes rewards
for positive behavior and consequences for inappropriate behaviors. A review of the center’s
FOPs on the BMS ensure compliance with the components outlined in the center’s policies and
procedures. The center’s BMS guidelines were observed posted in all living areas and main
hallways of the facility. A review of the current documentation confirmed rewards and
consequences are given according to the BMS. The documentation is maintained by a
supervisory staff member and updated as the Juvenile Detention Officers (JDO) send
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communication about the youth through email. Due to the center’s current state of construction
and limited access to the building, rewards consisted of movie nights, special visitations with
family, and canteen. An informal interview with the detention administration revealed incentives
are typically given out during the weekend for youth who earn these privileges. No incidents of
group punishment were observed during the annual compliance review.
Seven staff were interviewed. None of the seven staff were able to clearly explain the behavior
management system. Three staff stated the BMS is not effective. Two staff advised staff do not
speak to youth to discuss consequences and one staff advised youth are not given the
opportunity to explain their behavior. Two staff advised youth are not spoken to about
alternative acceptable behavior. One staff reported seeing staff take meals, snacks, clothing,
education, or medical care from youth. Seven youth were interviewed. Three youth reported the
BMS as poor and none of the seven were able to explain the BMS level system with any clarity.
Three youth reported being sent to their room for punishment, and the room door being shut
and locked. All seven youth stated handcuffs or leg irons are not utilized to keep them from
hurting themselves. The superintendent interview completed by the assistant superintendent
stated detention services uses a three-level system to track youth behavior. All youth will start
on level one upon admission. Youth can level up after a total of seven days with appropriate
behavior. After seven days on level three, youth are considered a Peer Ambassador. Youth’s
continuation on level one status beyond seven days will be approved by superintendent or
designee. Level drops should be sequential unless the behavior is egregious or dangerous and
it warrants a drop to level one. This could include youth confinement, property damage, Prison
Rape Elimination Act incident, as examples.
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.
Ten-Minute checks were reviewed for the annual compliance review period. The center has
eighty-two cameras of which eighty-one were operational. The video system keeps recordings
for thirty-days. The center was operating on twelve-hour shifts at the time of the annual
compliance review. The center utilizes an electronic wand system in which staff touch the wand
to the door when conducting the checks. The electronic wand system then captures the time
and date as to when the check was conducted on each room. However, due to the statewide
outage within the Department’s Juvenile Justice Information System (JJIS), the center’s
electronic wand system was not operational. Ten-minute check sheets were placed on the
outside of each youth’s door in each living module. The staff was required to place the time
(real-time) and initial when each ten-minute check was completed.
A review of six separate dates and times of video observations across all living modules were
made to confirm the fidelity of the ten-minute checks. All reviewed samples showed ten-minute
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checks were late and the times did not match the documentation provided. Out of the thirty-six
checks, none were completed at the documented time on the check sheets, twelve checks were
observed to be conducted between one and twenty-two minutes late, five checks were not fully
completed. The staff was seen in front of the youth’s doors for extended periods of time, not
walking the entire living module, and checking each youth during their checks, additionally
during the video review, it appeared the staff were pre-filling out the check sheets located on
each youth’s door. One staff was observed on video sitting on a couch and appeared to be non-
attentive for an extended period of time. Administration was notified and made aware of the
video observation findings, at which time a report was called into the Department’s Central
Communications Center (CCC) reporting the possible falsification of ten-minute check sheets
and possible non-attentiveness during shift. The center also has an open deficiency for ten-
minutes checks.
The center is on a corrective action for ten-minutes checks which was opened in May 2025. A
review of the documentation revealed there were not weekly reviews completed by
management, which was also confirmed by the center’s administration. Observations of ten-
minute checks did not reflect checks were conducted in the required frequency to ensure the
checks are met with fidelity.
Seven staff were interviewed regarding how often room checks are completed when a youth is
placed in their rooms for sleeping (non-suicidal). All seven stated room checks were completed
every ten-minutes. One staff reported the center has just started ten-minute checks because
they knew Monitoring and Quality Improvement (MQI) was completing the annual compliance
review this week. The assistant superintendent was interviewed regarding the ten-minute check
process. They stated when a youth is placed in a room, whether for sleeping or other reasons,
officers shall conduct visual observations to ensure safety and security and notate those checks
on the Visual Observation Report (VOR) or by utilizing an electronic wand system. Visual
observation intervals should be varied but shall not exceed ten minutes between checks.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures (FOPs) to address census, counts, and
tracking, which requires staff to know the exact number and location of all youth under their
supervision. Counts were observed to be conducted by the master control operator calling for
and clearing a daily formal headcount over the radio. A sample of logbooks for twelve months,
one full day a month, was reviewed for the annual compliance review period during which the
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center was closed September, October and November, reopening in December. All applicable
reviewed months included documentation counts conducted: at the beginning of each shift,
following any emergency, emergency drills, prior to and following routine group movement,
anytime a population change occurs, randomly, at least once on each shift, and head counts.
Each reviewed month had documentation of counts being conducted during and after youth
movements. Six of the seven interviewed staff stated counts are conducted at the beginning and
end of each shift, and throughout the shift. One staff reported counts are conducted before and
after school and meals. All seven staff stated emergency counts are conducted when a youth is
believed to be missing. Five staff stated emergency counts are conducted when there is an
electrical outage or a major disturbance.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) for logbook maintenance. The center has
separate logbooks for master control, each living module, visitors, and vehicles. All but four
logbooks were found to be bound with numbered pages. Four of the logbooks did not have a
front or back cover but was still bound. Logbooks were observed to have dates documented at
the top of each page. All entries included the times of events in a.m. and p.m. with the name of
the youth and staff involved, a brief description of events, and the initials of the staff making the
entries. The logbooks reviewed did include all the incidents which impacted the safety and
security of the center. All errors were struck through with a single line and “void” written after the
error followed by the staff’s initials. One full day was reviewed each month during the annual
compliance review period except the months the center was closed to include September,
October, and November. The following elements were observed in the master control logbook:
emergency situations, incidents, documentation of receipt of medical and mental health alerts,
population counts at the beginning and end of each shift, population counts throughout shifts as
counts change, youth counts following emergency situations, youth group movement,
admissions and releases, and the presence of law enforcement. Six of ten Central
Communications Center (CCC) reports were documented in the logbook, and four were not
documented. Samples from the master control logbook and living module logbooks were
reviewed for one day each month of the annual compliance review period for all applicable
months during the previous twelve month period. All of the fire drills, names of youth placed in
confinement with the beginning and ending times, and the name of youth on precautionary or
secure observation along with the time it was initiated and ended were consistently documented
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in the logbooks reviewed. A review of the logbooks showed evidence of the superintendent or
designee not reviewing all logbooks on a weekly basis and did not provide recommendations as
to the completeness and accuracy of the information recorded. A review of the logbooks
revealed a juvenile justice detention officer supervisor (JDOS) reviewed the center logbooks
maintained in master control when assuming center responsibility, in each living area daily, and
maintained the logbooks in assigned living areas when accepting responsibility at shift change.
There was documentation observed in the logbooks of the staff in charge of the center touring
the youth living areas at least once during each shift.
During an interview with the assistant superintendent, it was confirmed the superintendent or
designee shall review all logbooks at a minimum of weekly and review the entries for the last
seventy-two hours. The reviewed documentation must be highlighted in yellow marker. A
supervisor must review the master control logbook, going back seventy-two hours, and
document their presence in the living area logbooks every shift.
5.06 Key Control Failed Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) describing the center’s process for key
control, issuance of keys to staff, key restrictions, inventory and tracking, storage, missing or
lost keys, and reporting and replacement of damaged keys. The master key inventory included
the following information: ring number, number of keys on each ring, who each key ring was
issued to, and the capability of each key. The center keys were placed on key ring hubs and
color coded according to function, officer keys were blue, supervisor keys were yellow,
administration keys were black, medical and mental health keys were white, food service keys
were green, education keys were brown, and emergency keys were red. The reviewed key
inventory revealed one of the four reviewed key rings on the inventory matched the actual keys
in use; however, three did not. Four samples of key rings were observed and compared to the
inventory key log with several discrepancies noted. Three of the four samples were missing
keys from the key ring, and one set had an extra key. One of the four samples was found to
have a broken key, and the chit numbers did not match the assigned numbers. Key storage was
observed in master control and all keys are kept in a locked storage box. The key box was
observed to not be easily accessible. Restricted keys are maintained in master control which is
secured with locked doors. All center keys were observed to be maintained on a tamper-
resistant ring. Emergency keys are maintained in the captain’s office in the administration
section of the building. The emergency keys are kept in two locked boxes. It was reported only
administrative staff and maintenance staff have access to the keys. The distribution of keys was
observed. The staff provide master control with their personal keys, in return they are provided a
set of facility keys at the start of their shift. Issuance of keys were not documented in the
logbook. The reviewed documentation included date and time of issue, name of staff issuing the
key ring, name of staff who received the key ring, and the time the key ring was returned;
however, not all entries were fully documented. There are several key sign-in/out log entries in
the key logbook where keys were signed out by master control staff however, there was no time
documented on when and/or if the keys were returned. During a review of the logbooks and
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inventory, it was found the center was missing a set of staff keys. The keys had been signed out
on July 1, 2025, and had not been returned. Administration contacted the Department’s Central
Communications Center (CCC) while on-site to report the missing keys. Administration also
attempted to ask the staff member as to the whereabouts of the keys. Staff who were issued
keys were observed throughout the annual compliance review week and did not always have
the keys in their possession. Two incidents occurred during the annual compliance review; one
staff left keys behind after being interviewed and another staff left keys on a table in lobby while
using the restroom. The staff were not observed to allow youth to handle center keys. Three
staff were informally interviewed about the number of keys on their key ring and the function of
each key. Two of the three staff had extra keys on their key ring. The superintendent’s interview
completed by the assistant superintendent outlined permanent key assignment procedures; all
operational keys, defined as the keys used by personnel who are charged with care and
custody of youth, are stored in a secure key box within the facility, excluding master control. The
shift supervisor, or designee, shall issue the operational keys to staff. Seven interviewed staff
stated medical, mental health, case management, and kitchen keys are restricted. Six staff
stated the youth personal property key was also restricted. All seven staff were able to articulate
the process for key control and explain the procedure for a missing and/or lost key.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has a facility operating procedure (FOP) requiring the center vehicles to be properly
maintained, contain safety and emergency equipment, and be operated in a safe manner. The
center ensures any vehicle used to transport youth is properly maintained and documentation
regarding the use and maintenance of each vehicle is maintained. Each vehicle used for
transporting youth shall pass an annual safety inspection. Each vehicle used to transport youth
is to be equipped with the appropriate number of seat belts, a seat belt cutter, a window punch,
a fire extinguisher, and an approved first-aid kit. At the time of the annual compliance review,
the center had seven operable vans and one sedan car, used to transport youth. The center
provided all maintenance and annual inspection paperwork from a certified mechanic. Weekly
inspection reports were provided in a folder for the four months prior to the review, the
remaining weekly inspection reports were held in detention services SharePoint. All eight
transportation vehicles had installed safety screens and were equipped with a fully charged fire
extinguisher, a window punch, the appropriate number of seat belts for each passenger, and a
seat belt cutter. The vehicle first-aid kits are stored in master control to be checked out each
time a vehicle is in use. The center maintains a log which had documentation of completed
vehicle inspections checking for contraband for each transport. The results of the inspections
are documented and stored in the center’s vehicle maintenance log/binder. A review of the
inspections showed all were completed, as required. The van logbook also contains each point
of destination, number of youth being transported, staff conducting the transport, and the name
of the staff riding in back. The time the transport began and ended was also maintained within
the logbook. A check of the center’s transportation vehicles was conducted during the annual
compliance review, and each vehicle was found to be locked. Seven random vehicles in the
parking lot were checked during the annual compliance review, and all were found to be locked.
There was not a transportation available for observation during the annual compliance review.
Six of the seven interviewed youth reported feeling safe while being transported, one youth
stated they did not feel safe due not being able to get out of the van if it were to flip over. All
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seven interviewed youth stated they have not seen anyone ever place contraband into a
vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains facility operating procedures (FOP) for tool inventory, tool maintenance,
youth access to tools, and use of tools and cleaning items. The level of security for the tool
room and kitchen was observed when tools were not in use. A review of ten tools was
conducted and all tools were found to be on the inventory sheet with no tools missing. No tools
were lost during the annual compliance review period. All tools were observed to be secured
and had tool markings for easy identification. The youth are not permitted to use tools, including
kitchen and medical equipment. The youth are permitted to use cleaning items such as mops,
brooms, and other common household items, under direct staff supervision. An observation of
youth using cleaning tools was conducted, youth were mopping the living module while in the
direct care of staff. The acting superintendent was interviewed, and reported the maintenance
mechanic is the staff who has access to the center tools. An informal interview with
maintenance staff was conducted to determine the practice for missing and/or damaged tools.
The maintenance staff advised the center goes on lock-down if a tool is found to be missing, all
rooms and youth are searched until the tool is located. If a tool is damaged or broken, an
incident form is filled out and a request is made for a replacement.
Seven staff were interviewed regarding the center’s practice for damaged or missing tools. Six
staff reported damaged tools are disposed of, if a tool is missing the center goes on lockdown,
the Department’s Central Communications Center (CCC) is called, and it is documented in the
logbook. One staff did not know the process. Seven youth were interviewed regarding the tools
they are allowed to use. One youth reported they are allowed to use mops and brooms. Six
youth stated they were not allowed to use any tools. An interview with the superintendent
completed by the assistant superintendent confirmed the facility tools are accessed by kitchen
staff, facility maintenance staff, superintendent, and assistant superintendent only.
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5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has an Emergency Care Plan which is incorporated in their Continuity of Operations
Plan (COOP). The center has facility operating procedures (FOP) which prohibits youth from
handling chemicals, toxic items, and cleaning agents. Only authorized personnel are permitted
to handle these items. Seven youth were interviewed regarding the use of chemicals. One youth
stated they use cleaner; however, staff are who spray the chemical and the youth uses a towel
to clean it up, six youth denied directly handling any chemicals at the center. All seven
interviewed staff confirmed no youth were allowed to use any tools or chemicals. The center
had a total of three locations which were observed to contain supplies of chemicals and
poisonous items. Each of these locations were observed to be secured and inaccessible to
youth. Five items were compared with the chemical inventory log. The outdoor tan storage shed
had a supply of chemicals, and there was an inventory log for each shelf within the shed. Four
of the five chemicals inventoried matched the log, and one did not. Mango Germicide cleaner
had a count of fifty-four on the log; however, there were fifty-six bottles on the shelf.
Administration staff stated the additional two Mango Germicide was never added to the
inventory due to a code blue being called when the staff was restocking chemicals. All listed
chemicals were observed in the outdoor shed and in the maintenance office. The custodial
closet had an updated inventory. Items used within the living module for cleaning are located in
the custodial closet in the courtyard area, which contains the SDS book for those items present.
The kitchen chemical closet and the custodial closet both had a current inventory of the items
located within those two areas. All items observed had a corresponding Safety Data Sheet
(SDS).
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 which indicates the disposal of all flammables,
toxic, caustic, and poisonous items. A review of the Department’s Central Communications
Center (CCC) report information revealed the center had no incidents involving chemical spills.
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The center’s administration reported they do not utilize any grease at the center; therefore, there
is no disposal. Dietary and other staff were also interviewed and indicated dirty mop water is
disposed of through pouring it into standard drains and mop sinks. An informal interview with
maintenance staff was conducted, in which they advised if there was an item needing disposal,
the center uses Leveda Brown Environmental Park.
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.
Fifteen confinement reports were reviewed for requirements of confinements under twenty-four
hours. All confinement reports confirmed youth were afforded three meals a day plus school and
evening snack, access to mental healthcare as needed, daily shower, education materials, and
notice of youth’s right to grieve confinement placement, with the exception of one not
documenting youth received a meal, and one not documenting access to education material
during school hours. All reviewed reports confirmed the supervisor approved the confinement
prior to placing youth in confinement, the youth was the only youth in the confinement room, the
room was searched, and the reason for the confinement was explained to the youth. A review of
Visual Observation Report (VOR) Logs found supervision of youth was completed as required in
ten of fifteen reviewed logs. Four logs were not able to be located, and one log started two
hours after youth was placed in confinement. None of the fifteen youth in confinement were
observed with a physical injury. The supervisor completed the required one hour confinement
initial review in ten of the fifteen reviewed confinement reports. Five initial reviews were
conducted one hour late. All fifteen confinement reports were fully completed before the end of
their shift. Fourteen of fifteen reviewed reports found all supervisory reviews were completed as
required. One report showed reviews were missed between an eleven and half hour period.
Each reviewed report found the supervisor was continually counseling the youth and
considering removal from confinement. None of the confinements were documented as
interfering with visitation. Ten of fifteen reviewed confinement reports showed the
superintendent or designee completed a review of each report within the required forty-eight
hour time frame. Five reports were reviewed two, nine, twenty-one, thirty-one, and thirty-eight
days late. None of the youth in confinement were applicable to being placed while pregnant.
The center also has an open deficiency for confinements under twenty-four hours. The
superintendent interview completed by the assistant superintendent stated behavioral
confinement is an immediate, short-term, crisis management strategy during volatile situations.
Supervision shall be documented on the confinement VOR Log at the minimum every five
minutes for the first hour in confinement and ten minutes after. The assistant superintendent
also stated the supervisor should conduct an initial confinement review with the youth no later
than two hours from the incident and a minimum of every three hours and document in
Department’s Facility Management System. The superintendent or designee shall review all
confinement reports within forty-eight hours, excluding weekends and holidays (unless it is their
regularly scheduled workday) and shall determine whether each confinement was appropriate
or inappropriate. Six of seven interviewed staff explained the process of placing youth in
confinement. One staff was unable to explain the process for placing a youth in confinement.
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5.12 Confinement Over Twenty-Four Hours and Confinement
Failed Compliance
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.
A review of confinements over twenty-four hours found only one confinement was applicable
during the annual compliance review period. The one applicable confinement report showed the
supervisor did not complete additional reviews as required or continued to counsel the youth.
Documentation could not be located to confirm the confinement was chaired by the regional
director, held either in person or by phone, two hours prior to the end of the twenty-four hour
period. The required email to the regional director, which would include the confinement report,
the discussion between the superintendent and mental health staff, or the chair’s decision to
extend the confinement, was not able to be located. Documentation was not able to be located
regarding mental health staff conducting regular sessions with the youth or the decision to
extend the confinement distributed to the regional director and the assistant secretary for
detention services. The youth was removed from confinement when they no longer presented
an imminent and substantial threat. The center also has an open deficiency for confinements
over twenty-four hours.
5.13 Continuity of Operations Planning (COOP) Drills Limited 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 maintains facility operating procedures (FOPs) establishing a procedure for
conducting drills to address the Continuity of Operations Plan (COOP). The center conducted
one out of the two required drills during the annual compliance review period which included a
hurricane scenario with evacuation. The reviewed drill did result in a critique or corrective action.
The reviewed drill included the type of drill, date and time, participants, a brief scenario, and
findings or recommendations. The superintendent interview completed by the assistant
superintendent reported the plan states COOP drills are conducted twice a year, fire drills are
conducted monthly, and escape drills are conducted quarterly.
5.14 Escape Drills Limited 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 maintains an Escape Prevention Plan to include the Department’s policies and
procedures regarding escapes. The center completed three of the four quarterly escape drills
required for the annual compliance period, the fourth quarter drills were not completed on either
of the two shifts. Seven staff training records were reviewed for completion of escape training,
and all had completed the required training. The logbooks were reviewed for documentation of
escape drills. The fourth quarter drills were not located in the logbooks due to the drill not being
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completed. All seven interviewed staff stated they have not participated in an escape drill. Four
staff stated they have participated in a medical or suicide drill, and one staff stated they
participated in a severe weather drill.
5.15 Fire Drills Limited Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention plan, and an evacuation plan addressing fire
prevention and safety in the center. Twenty-four fire drills were required for the annual
compliance review period. Fifteen out of twenty-four fire drills were conducted during the annual
compliance review period, seven of twelve were completed on first shift and eight of twelve on
second. Documentation of each drill was provided and logged in the master control logbook.
The center has a total of thirty-three fire extinguishers. Documentation was provided confirming
the center completes monthly checks on each extinguisher and the annual inspection for all
thirty-three was completed on January 28th, 2025. Five of the seven interviewed staff reported
participating in a fire drill, two staff stated they have not participated in one. Four staff stated fire
drills are conducted monthly, three staff stated they are not. Four of the seven interviewed youth
stated they have not been instructed on what to do in the event there is a fire, and three youth
stated they have been given instructions or participated in a drill.
5.16 Search and Contraband Procedures Failed 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 has facility operating procedures (FOPs) for search and contraband procedures.
Staff should wear gloves when conducting a frisk or room search. An electronic search consists
of the use of an electronic walk-through or hand-held wand device to locate metal objects. This
search shall be conducted during admission and following any transport. Staff and visitor
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searches are to be conducted by the juvenile detention officer supervisors (JDOS), who shall
search all staff and visitors. Searches shall be conducted on everyone at any time they enter the
secure area. Any person coming into the secure area shall be searched using an electronic
wand and their pockets shall be emptied. Searches shall be conducted in an area under video
surveillance. All bags, cases, jacket pockets, and any other extraneous items shall also be
searched. Observations of visitors and staff coming into the center were conducted throughout
the annual compliance review week. The center staff was observed not following FOPs with all
visitors, staff, and contractors regarding searches. Several visitors and contractors entered into
the facility with purses, bags, lunch boxes, or tool bags and none of the items were searched to
ensure no contraband was inside. All visitors and staff did walk through an electronic metal
detector. The center’s visitor log does not contain an attestation statement, there is a separate
document requiring a signature upon entering into the center. It was observed not all visitors
signed into the visitor log or signed an attestation form. Fourteen staff personnel records were
reviewed for a signed contraband attestation form, seven of those records being newly hired
staff. Twelve staff records contained the required form, two of the newly hired staff did not.
Every sleeping room shall be searched for contraband on each awake shift. In addition, every
room is required to be searched when a youth is released, prior to placing a newly admitted
youth into a room, and prior to confinement. A room search was unable to be observed during
the annual compliance review week. A review of documented room searches for one day of
each month of the annual compliance review period for each awake shift was completed.
Eighteen room searches were completed, due to the center being closed for three months of the
review period. No documentation was provided or logged in the center’s logbook showing room
searches were conducted upon a youth release or prior to a youth being assigned a room at
admission. Administrative staff stated room searches are documented electronically in detention
services SharePoint; however, the staff was unable to provide any documentation of searches
stored electronically. A review of the Department’s Central Communications Center’s (CCC)
showed a total of four incidents involving possible contraband introduced into the center. One
was suspicion of contraband, two involved youth medication, and one was reported after the
incident took place. All required procedures were followed for each incident. One of the four
incidents resulted in a staff being terminated, the other three were not substantiated. There was
no documentation of a strip search being conducted on a youth at any other time than
admission. The center currently has an open major deficiency under Search and Contraband
Procedure assigned March 1, 2024. The assistant superintendent reported searches shall take
place no more frequently than necessary to control contraband or to ensure safety. The results
of any search shall be documented in the logbook and electronically. Electronic search
(transport), frisk search (transport, visitation, contraband), and strip search (same gender) shall
be conducted on every youth prior to admission. Any item discovered during a staff/visitor
search which is unauthorized should be removed from the facility or placed in a secure locker, if
available. Law enforcement shall be contacted if any item is considered illegal as defined in
Florida Statute, or there is any evidence of any type of unlawful activity.
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source: DJJ

report_type: QI Detention

rule: Indicator 1.05

excerpt: Right Interactions (RI)

rule: Indicator 2.08

excerpt: Review of Youth in Secure Detention

rating: Failed Compliance

rule: Indicator 4.12

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.06

excerpt: Key Control

rule: Indicator 5.11

excerpt: Confinement Under Twenty-Four Hours

rule: Indicator 5.12

rule: Indicator 5.13

rule: Indicator 5.14

excerpt: Escape Drills

rule: Indicator 5.15

excerpt: Fire Drills

rule: Indicator 5.16

excerpt: Search and Contraband Procedures