state: FL

summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Pasco Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
28534 State Road 52
San Antonio, Florida 33576
Review Date(s): July 22 - 25, 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:
Gustavo Mazorra, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 2)
Evan Hald, Office of Education, Southwest Education Coordinator (Standard 2)
Miguel Rios, Brevard Regional Juvenile Detention Center, Assistant Superintendent II (Standard
5)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Video Review, Interviews)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Pasco Regional Juvenile Detention Center MQI Program Code: 363
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Pasco County / Circuit 6 Number of Beds: 36
Review Date(s): July 22 – 25, 2025 Lead Reviewer Code: 185
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 57
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 57
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 t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n S a tis fa c
O rie n ta tio n S a tis fa c
C la s s ific a tio n S a tis fa c
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
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
R e le a s e S a tis fa c
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
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 S a tis fa c
D a ily A c tiv ity S c h e d u le S a tis fa c
E d u c a tio n a l A c c e s s * S a tis fa c
C a re e r E d u c a tio n S a tis fa c
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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 ).
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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
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3 .0 2
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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
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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 ).
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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 S a tis fa c
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 ).
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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
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D e p a
o p e ra te s b e
d o s o w ill re
In d ic a t o r R a t in g s
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 * 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* S a tis fa c to ry
T e n -M in u te C h e c k s * S a tis fa c to ry
C e n s u s C o u n ts a n d T ra c k in g 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 S a tis fa c to ry
K e y C o n tro l S a tis fa c to ry
V e h ic le s a n d M a in te n a n c e 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 * 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 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 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 S a tis fa c to ry
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 N o n -A p p lic a b le
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 S a tis fa c to ry
E s c a p e D rills S a tis fa c to ry
F ire D rills S a tis fa c to ry
S e a rc h a n d C o n tra b a n d P ro c e d u re s S a tis fa c to ry
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
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
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 ).
Program Overview
The Pasco Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in San Antonio, Florida. The center serves youth in Pasco County in
Circuit 6. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the thirty-six-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 Pasco County School Board. The center’s
management team includes the superintendent, two assistant superintendents, two
administrative assistants, seven juvenile justice detention officer (JJDO) supervisors, and thirty-
six JJDOs. Mental health and healthcare services are provided through the contracted provider,
VitalCore Health Strategies, LLC. Mental health services are provided by one designated mental
health clinician authority (DMHCA), four licensed mental health counselors (LMHCs), and two
licensed clinical social workers (LCSW). Clinical services provided by the center include mental
health and substance abuse evaluations, mental health treatment planning, individual, group
and family therapy, mental health crisis intervention services, on-site psychiatric services, and
availability for substance abuse services for youth with co-occurring disorders. Medical services
are provided by one designated health authority (DHA), one advanced practice registered nurse
(APRN), eight registered nurses (RNs), and one licensed practical nurse (LPN). The medical
clinic maintains nursing coverage Monday through Friday, from 7:00 a.m. through 7:00 p.m.,
and on weekends, from 7:00 a.m. through 5:00 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 three living modules
which are divided by male and female. There are sixty-four security cameras at the center, of
which sixty-two were operational at the time of the annual compliance review. During the tour,
the center was clean. Two rooms in the girl’s module and one confinement room were found to
have graffiti. Two rooms in the girl’s module were off-line because the doors needed to be
repaired. At the time of the annual compliance review, the center had eleven vacancies, which
included two assistant detention superintendents, two administrative assistants, six JJDOIs, and
one JJDOII.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPs) requiring background screenings to be
conducted for all staff, volunteers, mentors, and interns who have access to youth and
confidential youth records. The center submitted the Annual Affidavit of Compliance with Level 2
Screening Standards to the Department’s Background Screening Unit on January 22, 2025. The
Pasco County School Board submitted its Annual Affidavit of Compliance with Level 2
Screening Standards on January 6, 2025, for teachers who are paid by the school board. Nine
staff were hired since the last annual compliance review. Each had background screenings
completed before their start dates, and criminal history reports were reviewed for each staff. All
newly hired staff were deemed eligible for hire; therefore, no exemptions were required. All
newly hired staff underwent pre-employment assessments and achieved passing scores, which
were documented in their personnel records. All staff were added to the center's employment
roster with the Agency for Healthcare Administration Clearinghouse.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures (FOPs) governing the five-year background
rescreening process. A background rescreening is required for all staff, volunteers, mentors,
and interns every five years, which begins from the initial date of employment. A review of the
center’s staff rosters confirmed three staff eligible for a five-year rescreening since the last
annual compliance review. A rescreening was completed for all three staff and submitted at
least ten business days prior to the five-year anniversary for each.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 57
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures (FOPs) which require all staff adhere to a code of
conduct. Three staff personnel records with commendations and three with violations of the
code of conduct since the last annual compliance review were provided for review. Each of the
six records included a code of conduct form signed upon hire. Documentation confirmed
management responded to each violation. Two of the three staff were terminated for a code of
conduct violation involving excessive force. The third received re-training for a violation of
improper supervision. Three staff received certificates of appreciation since the last annual
compliance review, which were presented to them during an all-staff meeting. Seven staff were
interviewed and asked about the process for allowing a youth to call the Florida Abuse Hotline
or the Central Communications Center (CCC), and all said youth can call whenever they want.
The seven staff were asked if they have ever observed another staff using threats, intimidation,
or humiliation when interacting with youth. Five staff said never, one reported they observed it
once, and one reported observing it often. Five said they have never heard staff use profanity
while speaking with a youth and two said they have heard it occasionally, but only one was
directed at a youth. The seven staff were also asked about working conditions at the center.
One staff said the conditions were very good, four said good, one said poor, and one said very
poor. Seven youth were interviewed and asked if they have ever been stopped from reporting
abuse to the Florida Abuse Hotline since they have been at this center. Three youth said they
have not, and four youth said they have never had to report abuse. All seven youth said staff
are respectful when dealing with youth and have never heard staff threaten other youth or
themselves. All seven youth said they feel safe at the center and have never exchanged
personal information with staff. The superintendent was interviewed and advised staff must
adhere to a code of conduct which prohibits any form of abuse, profanity, threats, harassment,
intimidation, or personal relationships with youth. The policy outlined for code of conduct applies
to all staff. If a staff violates this policy, it may result in discipline up to and including dismissal.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 57
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures (FOPs) which require the Department’s Central
Communications Center (CCC) be notified within two hours of an incident, or within two hours of
becoming aware of an incident. The center had ninety CCC incidents since the last annual
compliance review. Nine incidents were reviewed, and all were reported within two hours of the
center becoming aware of the incident. Each of the nine incidents were documented in the
center’s logbook. A review of internal incidents and grievances found no other incidents which
should have been reported to the CCC. The superintendent was interviewed and advised
whenever a reportable incident occurs, staff notify the CCC within two hours of becoming aware
of the incident. The superintendent also advised staff allow youth to contact the Florida Abuse
Hotline upon request..
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures (FOPs) governing right interactions (RI), which is
the Department’s approved protective action response (PAR) curriculum. The center is required
to use physical intervention techniques in accordance with Florida Administrative Code. Any
time staff use a physical intervention technique, a RI incident report must be completed and filed
in accordance with Florida Administrative Code. The center had a total of 134 RI incidents since
the last annual compliance review. Nine RI incidents were reviewed, and all were completed by
the end of the staff’s workday. Each report included statements from all staff involved and none
resulted in serious injury to the youth or staff. None of the RI incidents resulted in a youth
alleging abuse; therefore, no call to the Florida Abuse Hotline was required. Each RI report was
reviewed by a supervisor and either an RI instructor or an RI certified supervisor. A post-RI
interview was conducted with the youth within thirty minutes of the incident for all nine incidents
reviewed. None of the youth required a medical review. Eight of the nine RI Reports were
reviewed by the superintendent or designee within seventy-two hours, and one was reviewed
fourteen days late. There was no other RI incidents noted in internal incidents, grievances, or
logbooks which were not documented by a RI report. The center’s RI rate during the previous
quarter was 15.45, exceeding the statewide detention RI rate of 13.49. Seven staff were
interviewed, and all stated they attempt verbal de-escalation before using physical or
mechanical restraints. An interview with the superintendent confirmed the use of physical or
mechanical restraints is documented in RI and incident reports. If mechanical restraints are
used, they are to be approved by the superintendent or designee prior to use. The
superintendent also stated all RI incidents are reviewed by the administration, with follow-up
provided as needed for immediate concerns, including additional training or injuries sustained
by youth or staff. Leadership reviews the Department’s Facility Management System daily to
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 57
identify trends related to staff involvement, shift, and time of incident, in order to determine
patterns and take appropriate action as needed.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures (FOPs) requiring detention staff to be trained in
accordance with Florida Administrative Code. Detention staff must complete pre-service
certification requirements within 180 days of hire. Two staff were applicable for pre-service
training since the last annual compliance review. One of the two staff completed all pre-service
and certification requirements within 180 days of hire, including 120 hours of academy training.
The other staff was a rehire, and not applicable for pre-service certification requirements. Both
staff completed new staff orientation within thirty days of hire. The rehired staff completed all
annual update training requirements. Three staff still within 180 days of hire were reviewed. All
three completed over 136 hours of pre-service training, to include child abuse recognition and
prevention, cardiopulmonary resuscitation (CPR) certification, first-aid certification, automated
external defibrillator (AED) training, emergency procedures, FOPs training, Prison Rape
Elimination Act (PREA), professionalism and ethics, right interactions (RI), and suicide
awareness training before being in the presence of any youth.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures (FOPs) governing annual in-service training. The
FOPs require all direct care staff to complete twenty-four hours of in-service training, including
mandatory topics each calendar year, effective the year after pre-service/certification training. In
addition, supervisory staff must complete eight hours of training in the areas specified in Florida
Administrative Code. Seven staff training records were reviewed for in-service training, and all
completed the required twenty-four hours of annual training, with totals ranging from thirty-six to
eighty-seven hours. All staff completed each of the required courses. Three supervisory staff
training records were among the seven reviewed training records. Each of the three supervisory
staff completed a minimum of eight hours of supervisory training in the areas of coaching,
leadership, and personal accountability. All trainings completed were entered into the
Department’s Learning Management System (SkillPro). A licensed nurse provided in-service
education on female youth’ healthcare to all non-healthcare staff responsible for supervision or
treatment. This training included monitoring, observation, and emergency care for pregnant
youth. The center maintains an annual in-service training calendar, which is updated as
changes occur. The training calendar was approved by the highest ranking official at the center,
the assistant secretary of detention, and the director of the Department’s Office of Talent,
Leadership, and Culture. The superintendent was interviewed and advised they have completed
the tier one training and had begun on tier two training at the time of the annual compliance
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review. The superintendent confirmed the center has an annual training plan which requires all
staff to complete various training topics each month.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures (FOPs) which gives youth the right to grieve and to
ensure all youth are treated fairly, respectfully, without discrimination, and with their rights
protected. The grievance process consists of three phases: informal, formal, and an appeal
phase. During the tour of the center the week of the annual compliance review, grievance forms
were observed in each housing unit, available for youth to access as needed. The
superintendent was interviewed and outlined the phases of the grievance process, including
timelines. The superintendent also advised completed forms are maintained in the
superintendent’s office for a year. Seven youth were interviewed and six reported they had
never filed a grievance, and one stated the process was fair. All seven youth were familiar with
the grievance process. Seven staff were interviewed, and all were able to articulate an
understanding of the grievance process. A total of twenty grievances were filed since the last
annual compliance review. Five were reviewed, and all were found to have been resolved
without needing to go to an appeal phase. All grievances were addressed within the required
24twenty-fourtimeframe and documented in the Department’s Facility Management System.
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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 maintains facility operating procedures (FOPs) to ensure critical and special alerts
are documented in the Department’s Juvenile Justice Information System (JJIS). Seven youth
records were reviewed for alerts. There was a total of twenty-nine alerts among the seven
reviewed youth. A review of the center’s logbooks confirmed all applicable alerts were
documented. All the alerts entered by staff included the name and title of the staff entering or
updating the alert. A review of shift briefing reports confirmed alerts were reviewed with staff
prior to each shift. No additional alerts were identified during the annual compliance review
which should have been entered into the JJIS alert system. The superintendent was interviewed
and advised the JJIS alert report is reviewed daily by the supervisors and administrators to
ensure the report correctly reflects the status of each youth. Supervisors ensure the detailed
alert list is read aloud during each shift briefing. Seven staff were interviewed, and all confirmed
they are informed of alerts during shift briefing. Five staff reported awareness of alert forms
available for their review, and three indicted they could also check JJIS to locate youth alerts. All
seven staff said management informs staff about issues within the center mainly through shift
briefings. Some also said information is shared by documenting the logbook, during staff
meetings, through email, and verbally.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
An informal interview with the superintendent confirmed the center collects data weekly. The
data includes daily population by gender, committed youth pending placement, staff vacancies
to include new hires and separations, critical staff vacancies, critical maintenance issues, and
staff recognitions. The data collected each week is shared with supervisors during the monthly
shift supervisor meeting, and with all staff during all staff meetings. Copies of meeting agendas
were provided to the annual compliance review team, which confirmed the information is being
discussed with all staff. The center shares relevant information obtained from these reports with
the community advisory board during their quarterly meetings. Copies of advisory board
meeting agendas were also provided which supported this is being shared with the community
advisory board as well. The center uses this data to adjust staffing patterns, prepare for
upcoming events, gauge the need to increase recruitment efforts, and improve efficiencies.
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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.
The center has facility operating procedures addressing the admission process for youth. Seven
youth case management records were reviewed and confirmed each youth had an Admission
Wizard which indicated their arrest affidavit/custody order, Detention Risk Assessment
Instrument (DRAI), and Suicide Risk Screening Instrument (SRSI) were reviewed. Each youth
record included an Admission Wizard documenting a youth full-body search and/or electronic
search was completed by a staff of the same gender, a telephone call was provided, the youth
was provided with a meal, and a medical, mental health, and substance abuse screening was
completed. An observation of a youth admission was completed during the annual compliance
review week. The youth arrived at the center, and staff reviewed the youth’s documentation.
The youth was searched by a staff of the same gender, took a shower, dressed in their uniform,
and was offered a bagged lunch. The youth was able to make a telephone call to their
parent/guardian. Medical, mental health, and substance abuse screenings were completed with
the youth and parent/guardian.
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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
The center has facility operating procedures ensuring each youth receive a center orientation
within twenty-four hours of being admitted into the center. A review of seven youth case
management records found each youth received an orientation within twenty-four hours of
admission. Each youth record contained a signed Youth Orientation Checklist documenting the
topics discussed. An observation of a youth orientation was conducted during the week of the
annual compliance review. The observation confirmed the youth received an orientation, which
included all required elements, and then the youth signed the Orientation Checklist indicating
they were provided an Orientation Brochure. The required orientation video including Prison
Rape Elimination Act (PREA) guidelines was shown for the youth during the orientation. Seven
interviewed youth indicated someone told them about the rules and regulations, daily schedule,
education services, visitation, abuse reporting, and the behavior management system when
they came to the center.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures ensuring each youth admitted to the center is
classified to provide the highest level of safety and security. A review of seven youth case
management records found each youth was classified, and the classification process included a
review of information concerning the youth’s history and status including all documentation
required in the admission process. One youth had a physical disability, six had a history of
violent behavior, two had suspected gang affiliation, all seven had criminal behavior, three were
found to be vulnerable or sexually aggressive based on the Screening for Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB), one had a medical condition identified
on the Medical and Mental Health Admission Screening, and two reviewed youth had been
identified as being possible victims of human trafficking. Each youth’s classification included
these considerations. None of the reviewed youth were identified to have a mental illness,
intellectual disability, a history of sexual offenses, or to be an escape or security risk during
classification. The center’s classification process included all the required topics to be
considered prior to making room assignment, including youth’s sex, height, weight, and age and
level of aggressiveness. Each youth is assigned to a room based on their classification; and
youth with a history of committing sexual offenses or victims of sexual offenses are placed in a
room alone. The superintendent remains informed of how to identify and address local youth
gangs through completing gang training and having conversations with the center’s
transportation coordinator, who is the gang liaison. During an interview, the center’s
superintendent indicated the center utilizes the VSAB to identify a youth is vulnerable to
victimization or is an aggressor. Alert lists are reviewed to determine if youth have any open
Prison Rape Elimination Act (PREA) alerts , violent offenses, special needs, or are a victim of
human trafficking. All these factors are considered when assigning youth to a room.
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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.”
The center has facility operating procedures addressing the communication and documentation
of suspected gang activity. Seven youth case management records were reviewed for
suspected gang involvement, and one was applicable. An additional two records were reviewed.
All three applicable youth records included an email to the juvenile probation officer (JPO)
designated as the circuit gang representative notifying them of suspected gang involvement or
affiliation with a gang. Two of the emails indicated which gang the youth was suspected of
affiliating with and the reason for suspicion. The remaining email only indicated the youth had
suspected gang affiliation. One of the juvenile justice detention officer supervisors (JJDOS) at
the center serves as the center’s gang liaison. An informal interview with the JJDOS confirmed
the center will open a suspected gang affiliation alert for a youth when gang activity is
suspected. The center will then send an email to the youth’s JPO informing them an alert was
entered and explaining why. The JJDOS will then notify administration of the situation.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures outlining the process for taking each youth’s
personal property during admission. Seven youth case management records were reviewed for
personal property documentation. Each youth record included a signed letter of
acknowledgment regarding unclaimed property. Four reviewed youth had property when they
were admitted to the center. All four youth records included a Property Receipt Form listing all
their property. Three of the four Property Receipt Forms were signed by the youth, and all four
forms were signed by staff. None of the reviewed youth refused to sign their Property Receipt
Form. Each youth’s personal property was placed in an assigned locker, which was identified on
their Property Receipt Form. One reviewed youth had personal items of value. The youth’s
items were verified and secured in a tamper proof property bag; however, the bag was not clear.
Two additional tamper proof bags were reviewed, and both were clear. Each youth’s property
bag included the youth’s name, Department identification number (DJJID), a list of items placed
in the bag, and the date the property was received. The tamper proof bags were placed in a
drop safe and logged in a bound logbook. Each logbook entry included the date, time, youth’s
name, DJJID, and name of the juvenile justice detention officer (JJDO) making the entry.
Personal items of value are documented on the same Property Receipt Form as nonvaluable
property. An observation of the center receiving youth personal property was made during the
week of the annual compliance review. Staff received the youth’s property, completed an
inventory of the items, entered the inventory in the computer, and printed a Property Receipt
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Form listing the items. The form was signed by the youth and staff, and the property was placed
in a secure locker. Nonvaluable items are kept in a secure locker in the intake area, and items
of value are kept in a drop safe, which is under video surveillance in master control. Only
juvenile justice detention officer supervisors (JJDOS) and administration have access to youth
personal property. The center did not have any incidents regarding youth property valued at
over fifty dollars during the annual compliance review period. Seven youth were interviewed,
and four stated staff checked their personal property, and they signed a form stating their
property was correct. The remaining three youth did not come to the center with any personal
property, as they were transferred from other centers. The superintendent was interviewed and
confirmed the location where property is kept and indicated only JJDOSs and administration
have access to the property area. The superintendent stated all valuable property is placed in a
clear tamper proof bag, which is signed by the youth and intake JJDO, and placed in a drop
safe. The drop safe is always under video surveillance and nothing should be done with youth
property out of view of a camera. The superintendent stated property not picked up within thirty
days is considered abandoned. All abandoned property will be counted and inventoried. Any
abandoned money is accounted for, and a money order is made and sent to headquarters. All
other items are given to a local organization.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures ensuring the court’s authorization to release each
youth is verified prior to releasing the youth. Three closed youth case management records
were reviewed. Each record included documentation confirming the on-duty juvenile justice
detention officer supervisor (JJDOS) reviewed all paperwork related to release, including the
release paperwork received from the court, prior to the youth’s release. Each reviewed youth’s
identification was verified prior to release. Each reviewed youth record included documentation,
including a photocopied identification, confirming the identification of the parent/guardian or
responsible adult was verified prior to release. Each youth and person to whom the youth was
being released to were reminded of any future court dates, and all applicable forms were signed
by all required parties. One reviewed youth had an Endangered Person alert, and staff verified
the parent/guardian or responsible adult picking the youth up did not have pending or historic
child abuse investigations related to trafficking. The date of admission and release documented
in each youth’s record correlated with the dates in the Department’s Juvenile Justice Information
System (JJIS). An observation of a youth release during the week of the annual compliance
review confirmed staff obtained a copy of the youth’s parent’s/guardian’s identification and had
them sign the Identification Verification Form. The youth being released did not have any
medication to be released. Staff went to the living module and gathered the youth’s documents.
The youth was then taken to the intake area to change clothes, where their property was
removed from a locker. The youth and staff then signed the youth’s Property Receipt Form.
Staff released the youth in JJIS, verified the court order, and completed the Youth Release
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Wizard. The release was documented in the intake logbook and staff called the release on the
radio for the release to be documented in the master control and living module logbooks. Staff
then walked the youth to the front of the facility and the youth’s parent/guardian signed the
Property Receipt Form and Youth Release Wizard.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures outlining the process for retrieval of personal
property. Three closed youth case management records were reviewed. Two of the youth
records included a Property Receipt Form signed by the youth and parent/guardian indicating
they received their property. The remaining form was in the youth’s record but was not signed.
Each youth record included documentation verifying the youth was released to an appropriate
person with a copy of their identification. One reviewed youth was released with medication, and
the receipt of medications was signed by the person receiving the youth. Each youth and each
person the youth were being released to were reminded of any health or welfare issues and any
pending appointments. There were three examples during the annual compliance review period
of property held for more than thirty days. A Notice of Impending Disposal of Property Letter
was sent to each youth’s parent/guardian indicating they had thirty days to arrange for retrieval
of the property, or it would be considered abandoned. Thirty days had passed since two of the
letters were sent out, and one was still within thirty days. The center still had possession of the
property for all three youth. An observation of the release process during the week of the annual
compliance review confirmed the youth’s property was released to the youth, the Property
Receipt Form was signed by the youth, staff, and parent/guardian, and a copy of the youth’s
parent’s/guardian’s identification was taken.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures which indicate the center will conduct Detention
Reviews on a weekly basis to share information and ensure proper management of youth
placed in secure detention. A weekly Detention Review for youth in secure detention was
observed the week of the annual compliance review. The observation confirmed center staff,
including medical and mental health staff, education staff, probation staff, and residential staff
were present in person or on a video call. All participants signed in. The meeting was facilitated
by a juvenile justice detention officer supervisor (JJDOS), who went through each youth,
indicating their release date, court dates, upcoming transports, and commitment status, if
applicable. The weekly Detention Review documentation, including the sign-in sheet, agenda,
and youth specific information, was reviewed. A review of Detention Review documentation
since the last annual compliance review confirmed meetings were held weekly and all required
participants attended. Seven staff were interviewed and indicated management informs staff
about issues within the center through methods of communication including staff debriefings,
emails, alerts, logbooks, and verbal communication. One staff indicated they are rarely informed
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about things going on in the center. Four staff indicated the process for communicating
information is very good, two stated it is good, and one indicated it is poor.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures ensuring youth are provided the opportunity to
participate in constructive activities which will benefit them. Observations of youth in school, at
mealtimes, on break from school, and at medication pass during the week of the annual
compliance review found the center is following their daily activity schedule. Observation of the
center’s daily activity schedule confirmed youth are regularly provided activities, such as, wake
up, personal hygiene, mealtimes, visitation twice a week, recreation and physical activities, at
least one hour a day of large muscle exercise outdoors, indoor activities which promote
education, problem solving and life skills, bedtimes, groups, and open center time. During a tour
of the facility during the week of the annual compliance review, the daily activity schedule was
observed in all living areas. Seven youth were interviewed, and each youth indicated the center
has a daily activity schedule, which is followed. Seven staff were interviewed, and each
indicated the daily activity schedule is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to ensure educational access and education
services are provided through the Pasco County School District. A review of the daily school
schedule confirmed the center offers six fifty-five-minute class periods each day, meeting the
required twenty-five hours of weekly instructional time. The facility’s activity schedule aligned
with the education schedule and daily activity times. A review of video footage from three
randomly selected days and logbook entries from five days confirmed education classes were
held as scheduled. Seven youth were interviewed, and all reported attending school Monday
through Friday. Three youth stated the school was preparing them very well, while four
responded feeling well prepared for the high school equivalency diploma (GED), vocational
training, employment, or college. Seven staff were interviewed, and all reported minimal
interference with educational services. The superintendent also confirmed minimal interference,
clarifying only law enforcement and attorneys have unrestricted access during school hours,
while all other visitors are limited to non-school hours.
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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 established facility operating procedures to deliver career education to students,
offering a Type 1 program which includes communication, interpersonal, and decision-making
skills. The facility currently employs career education software to provide diverse career learning
opportunities. Seven youth were interviewed, and each reported they were taking core classes
such as math, science, history, reading, social studies, and life skills.
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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 contract with VitalCore Health Strategies, LLC to provide mental health
services at the center. The center employs a contracted full time designated mental health
clinician authority (DMHCA) who coordinates services and provides on-site coverage according
for forty hours each week, which was confirmed by review of sign-in sheets. The DMHCA is a
licensed clinical social worker (LCSW) with an active Florida license, expiring March 31, 2027.
The center has a back-up DMHCA with an active license expiring March 31, 2027. The DMHCA
provides oversight and coordination of mental health services, including the completion of
Assessments of Suicide Risk (ASR), supportive services, and individual therapy. The DMHCA
also provides clinical supervision of non-licensed staff. The center had no non-licensed mental
health staff since the last Annual Compliance Review. During the interview, the DMHCA
confirmed they oversee all mental health and substance abuse services provided at the center.
Responsibilities include conducting ASRs and follow-up ASRs, developing Initial and
Individualized Treatment Plans, completing discharge summaries, responding to mental health
referrals, and providing supportive counseling, brief interventions, and crisis support. The
DMHCA maintains regular communication with juvenile probation officers (JPOs), providing
psychiatric information, treatment updates, discharge diagnoses, and participating in weekly
detention review meetings. The DMHCA also conducts psychiatrist and treatment team
meetings with youth and medical staff and ensures coordination of services and referrals for
youth and their guardians upon release. The DMHCA confirmed they are on-site full-time and
are responsible for the coordination and implementation of all mental health and substance
abuse services at the center..
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has a contract with VitalCore Health Strategies, LLC to employ licensed clinical staff
qualified to provide mental health and substance abuse services based off their education,
training, and experience. The center has four licensed mental health counselors (LMHCs) and
four licensed clinical social workers (LCSWs) working under the direction of the designated
mental health clinician authority (DMHCA), who is also a LCSW. All of the LMHCs and the
LCSWs hold clear and active licenses in the State of Florida with expiration dates of March 31,
2027. Copies of licenses were available on-site.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has facility operating procedures (FOPs) in place regarding non-licensed mental
health and substance abuse clinical staff. The FOP outlines requirements for direct supervision,
education, and training. The center reported non-licensed mental health or substance abuse
clinical staff have not been employed since the last annual compliance review.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures (FOPs) to ensure the mental health and substance
abuse needs of youth are identified through a comprehensive screening process. Referrals are
made when youth are identified as having mental health or substance abuse needs or are
determined to be at risk for suicide, in accordance with Florida Administrative Code. Seven
youth records were reviewed, and all records confirmed the Suicide Risk Screening Instrument
(SRSI) was completed by probation staff at intake and reviewed by detention staff. The SRSI
was completed and documented in the Department’s Juvenile Justice Information System (JJIS)
for each youth. Nursing and mental health staff completed the required sections of the SRSI,
and the entries included accurate referral documentation in the “Screening Results” section for
each youth. The Massachusetts Youth Screening Instrument – Second Version (MAYSI-2) was
completed for three applicable youth. Four youth were transferred from another detention center
and were not applicable for a MAYSI. The three MAYSI-2 screenings were completed in JJIS.
The results of the SRSI or MAYSI indicated a need for further assessment for each of the seven
youth. A referral was made for each youth and the documentation supported the superintendent
was notified.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures (FOPs) regarding mental health and substance
abuse evaluations. Seven youth records were reviewed and three had an updated mental health
comprehensive evaluation within thirty days of their admission. Four youth had not been in the
center long enough to require completion of a comprehensive evaluation. Each of the three
updated comprehensive evaluations included all required elements, and contained
recommendations which corresponded with the youth’s diagnosed mental health or substance
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abuse disorders. Each Comprehensive Mental Health/Substance Abuse Evaluation included all
required elements consistent with the Department’s form.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center provides mental health and substance abuse treatment to any youth determined to
need services and to any youth who remains at the facility for more than thirty days. Six of the
seven youth received a mental health orientation within fourteen days of admission. One youth
had not been in the center for fourteen days at the time of the review and was not applicable for
orientation. Four of the seven youth required an initial treatment plan. One youth was
participating in mental health groups and did not have an initial treatment plan. The three
completed initial treatment plans were developed within seven days of the onset of treatment.
The initial treatment plans were documented using the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form (MHSA 015). Each plan included the reason for
referral, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis
and symptoms, initial treatment methods such as counseling and frequency, and initial
treatment goals. Three youth were admitted to the center with currently prescribed psychotropic
medication. Each of the three initial treatment plans addressed psychiatric services and
prescribed medications. Each initial treatment plan included signatures from the mental
health/substance abuse professional and the youth. Documentation for two of the three youth
supported the youth were assigned to the mini-treatment team. Documentation was missing for
one youth. The initial treatment plans for all three youth were signed by the youth and the
mental clinician. Three of the seven youth records included an individualized treatment plan
developed by the thirty-first day of admission and signed by the youth and all treatment team
members. The individualized treatment plans for the other three youth were not due at the time
of the annual compliance review. Three youth entered the center taking psychotropic
medication; however, one youth stopped taking the prescribed medication. An additional record
of a youth taking psychotropic medication was reviewed to make the sample size three youth on
psychotropic medication. Each individualized treatment plan addressed psychotropic medication
and monthly medication management visits with the psychiatrist. Each of the three plans
included the specific medication each youth was taking. Progress notes for all seven youth
confirmed each youth was receiving treatment services as outlined in their treatment plans. One
youth was applicable for Individualized Treatment Plan Reviews completed every thirty days.
Treatment plan reviews were completed and documented on the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan Review form (MHSA 017) and signed and
dated by all treatment team members. One youth was an alleged victim of a Prison Rape
Elimination Act (PREA) event. The youth’s treatment plan did not require any revisions as a
result of the completed crisis assessment. One of the seven youth records contained a
completed discharge plan documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form (MHSA 011), finalized upon the youth’s transition or
discharge from the facility. Two additional discharge records were requested; however, only one
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additional youth record was provided. In both discharge cases, a copy of the Mental
Health/Substance Abuse Treatment Discharge Summary was provided to the youth,
parent/guardian, and juvenile probation officer (JPO). All documentation practices reviewed
were consistent with FDJJ Policy 10030, Statewide Electronic Health Record, specifically
section II(E). Additionally, a mini-treatment team meeting was observed for two youth. The
sessions included participation from clinical staff and education personnel, with discussion
topics including medications, education, and behavior. Each mini-treatment session focused on
one youth.
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 mental health records were reviewed for mental health and substance abuse
treatment services. Six of the seven youth received a mental health orientation within fourteen
days of admission. One youth had not been in the center for fourteen days at the time of the
review and was not applicable for orientation. The designated mental health clinician authority
(DMHCA) indicated all youth receive a mental health orientation even if they are not receiving
services. The DMHCA explained all youth receive the orientation in case the youth require
treatment during their stay at the center. Six youth required mental health treatment, and none
required substance abuse treatment. All six youth received individual, group, and family
counseling as prescribed by the treatment plan. Documentation confirmed six of the seven
youth were participating in mental health groups. One youth did not have a treatment plan.
During the interview, the DMHCA clarified youth who wish to participate in group counseling
services are not required to have an Individualized Treatment Plan. Technical assistance was
provided by the Department’s Office of Health Services and an initial treatment plan was
developed for the youth during the week of the annual compliance review. Proper consent for
mental health treatment was obtained for six of the seven reviewed youth records. One youth
was under the custody of the Department of Children and Families (DCF) and had a court order
authorizing treatment under the Mental Health: Access to Emergency Treatment (AET)
provision. Two youth had signed the consent for substance abuse treatment; however, neither
youth had a substance abuse diagnosis. Each youth had treatment notes documented on the
Department’s Counseling/Therapy Progress Notes. The progress notes supported mental health
groups did not exceed ten participants. A review of facility video footage confirmed group
counseling sessions were conducted as scheduled. Seven youth were interviewed regarding the
Mental Health and Substance Abuse services they were receiving. Two of the seven youth rated
the services as fair, two rated them as good, one rated the services as very good, and two
reported they were not receiving mental health or substance abuse services at the time of the
interview. During the interview, the DMHCA, it was confirmed mini-treatment teams are held
every thirty days to review Individual Mental Health and Substance Abuse Plans with treatment
team members. The DMHCA described the mental health and substance abuse services
provided at the facility, which included Assessment for Suicide Risk (ASRs), follow-up ASRs,
initial and individualized treatment plans, discharge summaries, supportive counseling, crisis
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counseling, brief supports, mental health groups, and treatment team services. The DMHCA
also reported the ability to provide individual and group therapy, as well as clinical supervision
for unlicensed mental health staff.
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 Suicide Prevention Plan detailing suicide prevention procedure. The plan
included identification and assessment of youth at risk of suicide, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and review process which included all required elements. The center
has a multidisciplinary review process for each serious suicide attempt, serious self-inflicted
injury, and completed suicide. The review includes the circumstances surrounding the event,
relevant center procedures, training received by involved staff, medical and mental health
services provided to the youth, possible precipitating factors, and recommendations for changes
in policy, training, physical plant, medical or mental health services, and operational procedures.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Seven youth records were reviewed for suicide prevention services. One of the seven youth
records was applicable for suicide prevention services. The one youth had two separate
occasions where they received suicide prevention services. An additional youth record was
reviewed to obtain the total sample size of three. The first youth was determined to be at risk
during the admission screening and then again seven days later. The second youth was
determined to be at risk at the conclusion of a code white cut down. A suicide risk assessment
referral was completed for all three incidents. Observations confirmed alerts were entered in the
Department’s Juvenile Justice Information System (JJIS) for all three incidents. In all three
examples, the Assessment of Suicide Risk (ASR) was completed on the required Department
form and was documented in real time. In all three examples, each youth was placed on
constant supervision prior to the completion of the ASR. For each of the three incidents, the
suicide precaution observation logs were completed entirely to include safe housing areas,
required signatures, and the qualified mental health professional was involved. Neither youth
was released while on precautionary observation. Documentation in all three samples supported
there was a consultation with the designated mental health clinician authority (DMHCA) and the
superintendent or designee was notified immediately of suicide risk, the date and time the
referral was made, as well as the time the youth was placed on precautionary observation (PO).
All three ASRs were completed within twenty-four hours of the referral. Follow-up ASRs were
completed until each youth was placed on close supervision. In each incident, the date and time
the youth was discontinued from observation was documented, each youth was stepped down
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to standard supervision and all documentation was in accordance with the center’s suicide
prevention plan. All ASRs were completed by a licensed mental health professional with the
credentials of licensed clinical social workers (LCSW). All ARSs included the results of the
assessment including recommendations for supervision and follow-up. There was evidence in
the center’s logbook and ASR indicating staff was provided specific instructions for each youth
related to the ASR finding and precaution decisions. A review of JJIS determined all alerts were
entered and removed following the youth’s removal from PO. Logbook review determined
beginning and ending time of PO was documented for each youth. An interview with the
DMHCA indicated the initial suicide screening process begins at the Juvenile Assessment
Center (JAC) with the administration of the Massachusetts Youth Screening Instrument – 2
(MAYSI-2) and the Suicide Risk Screening Instrument (SRSI) to assist in identifying youth at-
risk of suicide. During the intake process at the center, the juvenile justice detention officer
(JJDO) the documentation completed at the JAC and continues to complete the SRSI. If
information obtained at intake suggests the youth is a potential suicide risk, the JJDO completes
a referral, and the youth is placed on suicide precautions and maintained on a minimum of
precautionary observation/constant supervision until an ASR is completed by a mental health
professional. The youth is also entered into JJIS as a suicide risk alert. Seven staff were
interviewed and asked what they would do if a youth expressed suicidal thoughts. All seven
indicated they would notify the mental health authority. Six staff indicated they would document
supervision of the youth. Four staff indicated they would provide constant sight and sound
supervision of the youth, Individual staff also expressed they would document the incident in the
logbook. Two staff indicated they would contact their supervisor and four staff indicated they
would talk to the youth. Seven youth were interviewed and two indicated they had been placed
on suicide watch while at the center and staff provided supervision while they were on suicide
watch. The other five youth indicated they had not been placed on suicide watch.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures (FOPs) to govern the use of secure observation.
One of the seven reviewed youth mental health records was applicable; therefore, two
additional records which were applicable, were requested and reviewed. All three secure
observations were authorized by the superintendent and the designated mental health clinician
authority (DMHCA). All three records contained documentation of the secure room designated
in writing, a completed Health Status Checklist prior to the secure observation placement, and a
completed Suicide Precautions Observation log. Each reviewed record contained
documentation of parental and juvenile probation officer (JPO) notification regarding the youth’s
potential suicide risk, as indicated by the completed Assessments of Suicide Risk (ASRs). None
of the three reviewed records had youth who remained on secure observation over twenty-four
hours. Each reviewed secure observation log contained documentation of supervision. The
reviewed logbook and each youth’s mental health record documentation confirmed the
supervision level for each youth was reduced following a conference between the
superintendent and DMHCA. Secure observation was appropriately stepped down to
precautionary observation (PO), as required.
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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 (PO) logs. One of the
seven youth records was applicable for suicide prevention services. The one youth had two
separate occasions where they received suicide prevention services. An additional youth record
was reviewed to obtain a total sample size of three. For each of the three samples, the PO logs
were maintained for the full duration the youth placement on suicide precaution, which included
the appropriate level of supervision, and the observation of each youth’s behavior documented
in real time and did not exceed thirty minutes. Each PO log was reviewed and signed by the
shift supervisor and mental health clinical staff, and the PO logs documented safe housing
requirements in each record. Video footage was reviewed for three youth and corresponding
documentation confirmed proper supervision was maintained for the duration each youth was
on precautionary observation.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has a Suicide Prevention Plan which includes the training requirements for staff.
Seven in-service and three pre-service staff training records were reviewed for suicide
prevention training. All pre-service and in-service staff completed six hours of suicide prevention
training, as required. The center has five suicide response kits, including a knife-for-life, wire
cutters, and needle nose pliers, which are located on each module, in the mental health and
medical offices and master control. Suicide response drills were conducted no less than
quarterly on each shift, in accordance with policy. Documentation confirmed each staff member
participated in at least one drill annually, which included the use of cardiopulmonary
resuscitation (CPR). There was no documentation provided to verify staff who were not present
during a scheduled quarterly drill had the opportunity to review the drill scenario and procedures
to ensure familiarity with the response process. During the interview, the superintendent
confirmed staff who miss a suicide drill are mandatorily required to attend the next scheduled
drill to ensure they receive the necessary training to respond appropriately to suicide attempts
or incidents of serious self-inflicted injury within the facility.
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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 established facility operating procedures outlining its mental health crisis
intervention services. These procedures are incorporated within the Combined Emergency
Services Plan. The plan includes a structured notification and alert system, referral mechanisms
including self-referral options, protocols for communication and supervision, and requirements
for documentation and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures regarding the process for emergency mental health
and substance abuse services. The center’s Emergency Care Plan was signed on July 14,2025
by the superintendent and the Designated Mental Health Clinician Authority (DMHCA). The plan
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for emergency
mental health evaluation and treatment, transport for emergency substance abuse assessment
and treatment, documentation, training, and review. The emergency care plan is accessible to
all staff through the center’s internal drive.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures to ensure a Crisis Assessment is completed for any
youth demonstrating acute psychological distress. Seven youth mental health records were
reviewed; however, none of the youth had been determined to be in crisis, so an additional
three records were provided. Each youth was identified by staff as having acute emotional or
behavioral problems, or acute psychological distress. All three youth had a Crisis Assessment,
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including the reason for assessment, a Mental Status Examination and interview, determination
of danger to self and others, initial clinical impressions, supervision recommendations, treatment
recommendations, recommendations for follow-up or further evaluation, and notification to a
parent/guardian of follow-up treatment, completed by a licensed mental health professional
within the required time frame.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has established facility operating procedures ensuring youth believed to be an
imminent danger to themselves or others due to mental illness or substance abuse impairment
receive emergency mental health or substance abuse services, including services under the
Baker Act or Marchman Act. Seven youth mental health records were reviewed, and none of the
youth required a Baker Act or Marchman Act; therefore, an additional three records were
reviewed for youth who required a Baker Act. For each applicable case, a suicide risk alert was
opened while the youth was pending off-site transport. The youth was placed on one-to-one
supervision, and supervision was documented on a Precautionary Observation log until the
youth’s authorized release. Upon re-admission from the Baker Act, the youth was placed on
suicide precautions. A mental health referral was completed for a Mental Status Examination,
conducted within the administration of the Assessment of Suicide Risk. The Mental Status
Examination was completed by or under the direct supervision of a licensed mental health
professional. The youth was maintained on a minimum of constant supervision until properly
transitioned to a lower level of supervision. The supervision level was maintained until an
appropriate assessment was conducted and mental health staff conferred with a licensed
supervisor and the superintendent or designee. For youth with a suicide risk alert in the
Department’s Juvenile Justice Information System (JJIS), the discontinuation of the alert and
precautions was based upon an Assessment of Suicide Risk. For youth with a mental health
alert in JJIS, the discontinuation of the mental health alert and constant supervision was based
on the Crisis Assessment.
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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 maintains a contract with VitalCore Health Strategies, LLC (VitalCore) which
subcontracts with a licensed medical doctor (MD) to serve as the center’s designated health
authority (DHA). The center has a contractual agreement with a licensed physician to serve as
the DHA. The DHA holds an unrestricted license which expires on March 31, 2026, which meets
all requirements for independent and unsupervised practice in the State of Florida. The DHA
has specialty training in internal medicine. The DHA is responsible for performing evaluations,
sick call, reviewing the nursing protocols, as well as establishing policies for providing medical
care to youth in the center. The DHA is on site weekly to meet with youth as required by
contact. A review of the center’s sign-in log confirmed the DHA was on-site weekly, except for
one week due to a hurricane. The DHA reported communicating with the nursing staff regarding
placing practitioner orders when on-site. In addition, the DHA is available by telephone when not
on-site. The DHA confirmed an advanced practice registered nurse (APRN) is the designee
when the DHA is not available. Tele-medicine services were not utilized at the center since the
last annual compliance review. The center utilizes an autonomous APRN, who is on-site once a
week and holds an unrestricted license in the State of Florida, with an expiration date of March
31, 2026. The APRN provided on-site coverage fortwo weeks during the annual compliance
review period. The APRN has Collaborative Practice Protocols in place with the DHA, both
share a collaborative agreement signed on July 16, 2025.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures (FOPs) for all health-related procedures and
treatment protocols utilized at the center. Reviewed documentation confirmed the designated
health authority (DHA) reviewed, signed, and dated the medical protocols, policies, and
procedures on January 22, 2025. The psychiatrist signed the medical protocols, policies, and
procedures on February 27, 2025. The treatment standing procedures and protocols, policies
and procedures were approved, written, and authorized by the DHA. Reviewed documentation
confirmed the superintendent signed and dated the updated medical protocols, policies and
procedures on January 22, 2025. Each registered nurse (RN) signed and dated the FOP cover
page between January and March 2025, indicating the protocols, policies, and procedures have
been reviewed. The psychiatrist reviewed and developed the FOPs and other protocols related
to psychiatric services and psychotropic medication management. The center had one newly
employed healthcare personnel since the last annual compliance review and received a
comprehensive clinical orientation to the Department’s health care policy and procedures,
conducted by a registered nurse (RN) or designee, licensed health care professional.
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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.
A review of seven Individual Healthcare Records (IHCRs) included a valid original or legible
copy of the Authority for Evaluation and Treatment (AET) or Limited Consent for Evaluation and
Treatment in their IHCR. Five of the seven reviewed youth records contained a signed AET
completed by the parent/guardian. One youth had a signed Limited Consent for Evaluation and
Treatment, which was maintained in the youth’s IHCR/Electronic Medical Record (EMR). One
youth was eighteen years of age or older and therefore, did not require an AET. The remaining
five youth obtained an AET prior to receiving medical services. Each AET was also signed by a
Department representative. The nurse interview reported AETs are required prior to providing
medical services and was able to confirm knowledge of how AETs are to be obtained for new or
current AETs. When a youth is eighteen years or older the youth is responsible for authorizing
and releasing health care information.
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.
A review of seven Individual Healthcare Records (IHCRs) for Parental Notification/Consent was
conducted. Two of the seven youth IHCRs included parental notification for over-the-counter
(OTC) medications beyond those covered by the Authority for Evaluation and Treatment (AET).
The parent/guardian provided consent for each youth. A written notification was sent for both
applicable youth utilizing the Departments Parental Notification of Health-Related Care and
General or Parental Notification of Health-Related Care: Medications, or the Acknowledge and
Receipt of Clinical Psychotropic Progress Note (CPPN). Two of the seven youth were taking
psychotropic medication at admission and a staff witnessed all telephone call attempts and
conversations for psychotropic medications for each youth. Each of the seven youth IHCRs
included updated and reviewed vaccination and immunization documentation which was
received within thirty days of admission. The nurse reported vaccines and immunizations are
not administered at the center and documentation is obtained and verified. One of the seven
youth was prescribed new medications after admission. Documentation reflected contact with
the parent/guardian in the progress notes, as well as confirmation the Acknowledge of Receipt
of the CPPN form was sent to the parent/guardian. The parent/guardian verbal consent for the
psychotropic medication was documented on page three of the CPPN as required. A written
Parental Notification/Consent showing an attempt to obtain the signed parent/guardian consent
was located in the youth’s IHCR. The nurse was interviewed and reported parental notification is
made to inform the parent/guardian of significant changes to the youth’s condition and obtain
consent when new medications are ordered, discontinued, or emergency situations occur. For
emergency situations, 9-1-1 is called immediately, and the designated health authority (DHA) is
notified. All IHCRs are reviewed upon the youth admission to the center. When a youth is
exempt from immunization, the parent/guardian must provide a certified document of exemption,
and it is uploaded in the youth’s IHCR.
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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.
A review of seven Individual Healthcare Records (IHCRs) confirmed a Medical and Mental
Health Admission Screening form was completed on the date of admission for each youth. Each
screening was completed by a juvenile justice detention officer (JJDO) or a juvenile justice
detention officer supervisor (JJDOS) and was reviewed within twenty-four hours by a licensed
medical staff. Each IHCR contained documentation of the designated health authority (DHA)
notification. None of the seven IHCRs were applicable for a Rescreening Facility Entry Physical
Health Screening (FEPHS). Three additional IHCRs were requested and received for youth
applicable for a Rescreening FEPHS. Each youth IHCR included a FEPHS rescreening each
time a change in custody occurred. Each screening was completed by a JJDO or JJDOS and
was reviewed within twenty-four hours by a licensed medical staff. Two of the three youth
received a qualitative urine pregnancy screening test with consent, which was documented in
the progress notes. The remaining youth was not applicable. The nurse reported all youth are
first seen on the day of admission. Medical staff are notified of an admission by notification from
the supervisor or master control. The nurse confirmed the JJDO/JJDOS completes the
admission screening and the nurse reviews and signs the form. When a youth changes custody,
the youth is assessed for any changes, and it is documented in the IHCR.
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) outlining orientation to healthcare services.
The FOP included access to medical care, sick call, what constitutes an emergency and when
to notify staff, medication process, the right to refuse care, what to do in the case of a sexual
assault or attempted sexual assault, non-disciplinary role of the healthcare providers, and
general infection control/hygiene. Each of the seven reviewed youth received a general
healthcare orientation upon admission and each were documented on the required form. Each
youth with chronic conditions was educated on their condition.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
A review was conducted of seven Individual Healthcare Records (IHCRs) for designated health
authority (DHA)/designee admission notification. Three of the seven were applicable. Each of
the applicable youth identified had a known or suspected chronic condition, and a referral was
submitted to the DHA and advanced practice registered nurse (APRN). None were identified as
in need of emergency care upon admission. There was documentation in each youth’s IHCR of
the notification to the DHA/designee within twelve hours of admission. Each of the applicable
youth were taking psychotropic medication upon admission and there was documentation in the
IHCR of the psychiatrist being notified. The nurse was interviewed and reported when a youth is
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admitted to the center with serious or chronic conditions, the DHA is notified by the nurse on
duty, and it is documented on the intake log as well as the admission form.
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.
A review of seven Individual Healthcare Records (IHCRs) confirmed a Health-Related History
form was completed for each youth within seven days. The nurse reported nursing staff are
responsible for completing the HRH withing seven days. Each HRH was completed prior to the
Comprehensive Physical Assessment (CPA) as evident by signature and date for each youth.
Each HRH was completed by a licensed nurse or practitioner. The designated health authority
(DHA) reviewed each HRH as evident of chronological progress notes and the HRH form. A
review of each HRH confirmed signatures and dates for the most recent admissions.
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.
A review of seven Individual Healthcare Records (IHCRs) included a completed physical
assessment completed on the Comprehensive Physical Assessment (CPA) as required. Each
youth had a current CPA with the Medical Grade documented, in the IHCR. Six of the seven
youth had a completed CPA in each IHCRs. One youth was discharged prior to the CPA being
completed. Each CPA was completed by a licensed physician. None of the youth had changes
to the CPA; however, the CPA was reviewed, and youth was examined and signed off by the
physician. Each of the IHCRs included a completed focused evaluation for each upon re-
admission and the current CPA was used. Each section CPA was marked with an “O” or an “X”.
None of the youth refused any part of the CPA. A review of the center’s facility operating
procedures (FOPs) included instructions of documenting if a youth refused any part of the
exam. When the CPA was completed the Problem List was updated for each youth. Each CPA
included at least one verified Tuberculosis Skin Test (TST) within the last year. Each youth’s
CPA and Infectious and Communicable Disease (ICD) forms matched. The Healthcare
Admission Wizard included documentation of the Tier I TB screening and confirmed each was
completed within seventy-two hours. None of the youth were applicable for further evaluation.
The center’s FOP included an outline for review for Tuberculosis Screening and rescreening
process. Th nurse reported the CPA is completed within seven days of admission. A new CPA
is needed every two years if the youth’s Medical Grade is “1” and one year if changes are made.
The TST screening is to be completed within seventy-two hours of admission. The nurse
reported gynecological exams are not usually completed.
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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.
A review of seven Individual Healthcare Records (IHCRs) was conducted, and three youth were
applicable for sexually transmitted infection (STI) and human immunodeficiency virus (HIV)
screening. Each of the applicable youth were clinically screened and evaluated for sexually
transmitted infections (STIs). One of the three was referred for further evaluation by the medical
doctor, as required. The remaining two youth were not applicable for further evaluation. The
youth was ordered testing and results were filled in the lab section of the IHCR. The youth
received counseling and testing for HIV. Screening results were documented on the Infectious
Communicable Diseases (ICD) form, excluding HIV results, and filed in the lab section of the
youth’s IHCR. None of the youth were out of the Department’s physical custody or exhibited
symptoms; therefore, a rescreening was not required. An interview was conducted with seven
youth, and each indicated being able to ask for a HIV test. The nurse reported STI screenings
are reviewed by the designated health authority (DHA) and a test is ordered with the youth’s
consent. The test is sent to a lab for testing. Each STI screenings/rescreens, evaluations,
referrals and testing are documented in the IHCR. The nurse reported HIV test results are given
to the youth verbally and documented on the Infectious and Communicable Disease (ICD) form.
Youth are required to read and sign a HIV consent form to indicating whether they consent or
decline to be being tested. The local health department provides HIV pre-test counseling,
testing, and post-test counseling and is documented in the youth’s IHCR.
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.
A review of seven Individual Healthcare Records (IHCRs) was conducted for sick call, and none
were appliable; therefore, the center provided three applicable youth IHCRs for review. Each
applicable youth had sick calls noted on the Sick Call Referral Log, as required. None of the
youth presented with a similar sick call complaint three or more times within a two-week period.
Each youth submitted a Sick Call Request Form, and the nurse completed the form. Each
applicable IHCR included the Sick Call Request form filed in reverse chronological order. None
of the youth were in restricted housing of any kind. Each sick call form or progress note was
documented, as required. Each of the youth’s sick calls were documented on the Sick Call
Index with dates, which correspond with the completed Sick Call forms in each IHCR. The
center has facility operating procedures outlining the process if a youth is placed in room
restriction/confinement. A review of the Department’s Juvenile Justice Information System
(JJIS) confirmed only having three youth applicable for room restriction. The nurse reported the
juvenile justice detention officer (JJDO) notifies the medical department of the sick call in the
Department’s JJIS. The nurse generates the sick call list twice a day and they have twenty-four
house to meet with the youth. The nurse confirmed the nursing staff completes all sick calls
submitted. The designated health authority (DHA) conducts sick call when on-site. Sick calls are
conducted in the medical clinic. Sick calls are conducted 7:00 a.m. to 10:00 p.m., as needed,
and are posted outside of medical and on the youth mods. The nurse confirmed if a sick call
with three or more complaints are submitted, the youth is referred to the DHA. The center has
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procedures whereby the shift supervisor reviews all sick call request as soon as possible and
within four hours after the request is submitted. Seven youth were interviewed, and none had
requested a sick call. Seven staff were interviewed, and each reported the nurse reviews the
sick call. One reported the doctor, one reported staff and one reported the supervisor also
review sick call. Each of the seven staff reported the nurse conducts the sick call. The center did
not have any sick calls during the annual compliance review week.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures (FOPs) outlining the process of episodic/first-aid
and emergency care. A review was conducted of seven Individual Healthcare Records (IHCRs),
and three were applicable. The remaining youth were not applicable. Each of the applicable
youth required on-site first-aid or episodic care. The on-site care was provided by the licensed
healthcare staff and documented either in problem oriented and/or standard narrative charting.
The nature of the complaints, treatment rendered, and findings of rendered care were
documented in each IHCR. One of the three applicable youth was referred to off-site care. The
medical staff provided education/instruction to the youth and plans for follow-up care was
documented in the IHCR. Parental Notification was made and documented. Each episodic was
documented on the Episodic Care Log. One of the youth required a follow-up evaluation. The
nurse reported episodic care is documented in an Episodic Care Progress Note. Seven youth
were interviewed, one youth rated the medical care as fair, two as very good and four reported
not receiving medical services. Each of the seven interviewed staff indicated they are able to
call 9-1-1. The center has eight first-aid kits located in master control, kitchen, education, intake,
and each of the three modules totaling fourteen on-site. In addition, eight first-aid kits are kept in
master control for the vehicles. Three first-aid kits were checked for contents. Two of the three
kits were missing a mask and saline, which was corrected during the annual compliance review.
Each first-aid kit had a list and actual items the designated health authority (DHA) approved.
Each kit was checked by the nurse monthly since the last annual compliance review as
documented on each kit. The nurse reported the first-aid kits are on the modules for the
vehicles, kitchen, master control, mental health, education and intake. The center has two
automated external defibrillators (AED) are located in master control and the medical clinic. The
procedures were located with each AED. An outside provider and the nurse check the AED,
with the last check being October 1, 2024. The nurse checks each AED monthly and documents
the check on the AED Maintenance and Inspection Log form. During the tour, the AED was
observed with a green light indicating the AED is functioning. The AED batteries were last
changed on February 14, 2022, with an expiration of August 11, 2026. The AED pads were
changed on February 15, 2022, with the expiration of September 28, 2026. A review of medical
drills for the past year revealed fourteen of the twenty-three drills included AED, and CPR
techniques, which exceeds the requirement at least annually. Medical drills were completed at
a minimum of quarterly on each shift; however, drills were completed more often, by the center
completing them monthly on each shift with the exception of three months on one shift. The
medical drills are kept in a binder. Emergency numbers are posted in master control and the
medical clinic, accessible for non-licensed and licensed staff and inaccessible to youth. Each of
the two pre-service and seven in-service staff were trained on the administration of the
epinephrine auto-injector, episodic care, first-aid, and emergency care. The nurse confirmed the
center has two AEDs, one in master control and one in medical, each have the procedures in a
binder next the AEDs. The nurse confirmed emergency drills are conducted monthly on each
shift and the emergency numbers are located the medical clinic. The center has FOPs on the
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use, access and inventory of Narcan. The center stores the Narcan in the medical clinic in a
locked medical cart. The nurse conducts an inventory of the Narcan weekly, which includes
counts to confirm the number of Narcan is accurate. Each staff, who have access have been
trained to administer Narcan. Each of the seven interviewed staff reported being able to call 9-1-
1 when it is necessary. Seven youth were interviewed and one rated the center’s medical
services fair, two very good and four reported not receiving medical services.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
A review of seven Individual Healthcare Records (IHCRs) was conducted, and none were
appliable for off-site care or referrals; therefore, the center provided three applicable youth for
review. Each of the three youth had documentation of off-site care. The Summary of Off-Site
Care Consultation Report form was utilized and filed in each IHCR. The off-site emergency care
was documented in the Episodic Care Log for each youth. There was documentation of parental
notification for each youth. The discharge and other appliable documents were in each youth’s
IHCR. Each of the three applicable youth IHCRs had documentation the designated health
authority (DHA) was notified of the emergency event. The DHA reviewed and sign/initial all off-
site care findings, instructions and information for each youth. One of the three youth required
follow-up testing, referrals and/or appointments and was entered on the Sick Call Log and
tracking log. The nurse confirmed when youth are sent off-site for emergency care it is
documented on the Off-Site Care Log in the Electronic Medical Record. One of the three
applicable youth had documentation the referral was tracked, and the youth received
appropriate, timely follow-up care. The nurse reported hospital orders are reviewed with the
DHA, who provides follow up instructions. All off-site care findings, instructions and information
are maintained in a folder reviewed by the DHA when on-site. The nurse reported tracking
follow-up testing, referrals and appointments are documented in a calendar and an email is sent
to staff with required documents.
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.
A review of seven Individual Healthcare Records (IHCRs) was conducted for chronic
conditions/periodic evaluations, and one was appliable; therefore, the center provided two
additional applicable youth IHCRs for review. Each of the applicable youth were identified on the
Medical/Mental Health Screening form with a current chronic condition and placed on the
chronic condition list. Each of the applicable youth are taking prescribed medications on an on-
going basis. Two of the three youth were undergoing treatment for physical health condition and
has a classification on the Medical Grade of two or higher. None of the youth were pregnant or
taking anti-TB medication. Two of the applicable youth have not been in the center long enough
to have a periodic evaluation. The remaining youth had periodic evaluations every ninety days
as required. One youth had an off-site evaluation which was documented on the Summary of
Off-Site Care Form, located in the IHCR, with a progress note documenting review and follow-
up recommendations by the designated health authority (DHA). The Department’s Problem List
was updated with the evaluation, as required. Each of the applicable youth are taking prescribed
medications on an on-going basis. All three youth were undergoing treatment for physical health
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condition and had a classification Medical Grade between two and four. None of the youth were
pregnant or taking anti-TB medication. The nurse reported the center monitors youth chronic
conditions by entering alerts in the Department’s Juvenile Justice Information System (JJIS) and
on the medical tracker. The nurse reported medications are verified with a licensed pharmacy
and confirmed the prescription has a valid order. The DHA reported the nursing staff maintain a
log of youth with chronic conditions and required periodic evaluations.
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.
A review was conducted of seven Individual Healthcare Records (IHCRs) and five youth were
appliable for medication management, the remaining two youth were not applicable. Three of
the five youth entered the center taking psychotropic medication. The IHCRs for each applicable
youth entering the center on medications included documentation in the progress notes showing
the prescriptions were verified, as required. The nurse notified the designated health authority
(DHA) to obtain the order to resume the specified medications prescribed prior to admission for
each youth. Each medication had a current, valid order and administered pursuant to a current
prescription. When current medications were continued, discontinued, changed or new ones
were ordered the DHA placed an order on the Practitioner Order Form for each youth. The
IHCRs for each youth included documentation of prescription verification in the chronological
progress notes, as required. None of the youth were placed in restricted housing. Over the
counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form
were administered according to the Practitioner’s Order for all five youth. All medications
administered for each of the youth were documented on the Department Medication
Administration Record (MAR), which clearly indicated medication start and stop dates. Each
MAR included documentation of side effects being monitored weekly. None of the youth refused
medications. Each MAR included all required elements. A review of applicable youth IHCRs
confirmed there were no standing orders for psychotropic medication, any emergency treatment
orders for psychotropic medications and no pro re nata (PRN) orders for psychotropic
medications. One observation of medication administration was conducted, and the youth’s
verbal consent was obtained prior to administration of medications. The youth was escorted by
the center staff. The medical staff identified themselves and explained the purpose of the visit to
the youth. The same medical staff prepared and administered all medications. The medical staff
verified the youth allergy and alert status. The medical staff and youth initialed the MAR. Both
the medical staff and center’s staff ensured medication was swallowed. Medication delivery was
the sole responsibility of the nurse and the staff’s sole responsibility was escorting the youth
during the time of the administration. None of the medications were pre-poured. The nurse was
interviewed and reported the center utilizes the Department’s MAR form. The nurse confirmed
the supervisors are trained to administer medications. Medication pass is daily at 8:00 a.m.,
12:00 p.m., 5:00p.m. and 7:00 p.m. For female youth, gynecological exams are not done at the
center. The facility has a modified Class II permit. The nurse confirmed inventory is done weekly
and medications are in secured/locked cabinets. The nurse confirmed the center utilizes a
psychiatrist. The nurse reported when disposing/destroying of medication two nurses are
present to witness the destruction. They count the medication and fill out the relevant
information on the medication disposal log, and then pour the medications into a drug disposal
solution. Five of the interviewed staff reported not administering medication to youth, the
remaining two staff are supervisors and administer medications. Seven youth were interviewed,
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and four reported the nurse gives them their medication and three reported not taking
medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has a contract with VitalCore Health Strategies, LLC to provide mental health
services, including the provision of a psychiatrist to provide psychiatric services to youth at the
center. The psychiatrist holds a clear and active license with the State of Florida with a specialty
in child and adolescent psychiatry, which expires January 31, 2026. The back-up psychiatrist
holds a clear and active license with the State of Florida with a specialty in child and adolescent
psychiatry, which expires March 31, 2026. The center does not have a psychiatric advanced
practice registered nurse. The designated mental health clinician authority (DMHCA) reported
the psychiatrist is on-site weekly for two hours. The DMHCA communicates with the psychiatrist
while on-site and the psychiatrist provides telepsychiatry one day a week to discuss youth
receiving psychiatric services. A review of seven Individual Healthcare Records (IHCRs) was
conducted, and three youth were appliable for psychiatric services. The remaining four youth
were not applicable. Each of the three applicable youth entered the center on psychotropic
medication. Each applicable youth received an initial diagnostic interview within fourteen days of
admission. Each of the three youth’s mental health records included a completed Clinical
Psychotropic Progress Note (CPPN) page three as a result of either new psychotropic
medication being prescribed or changes were made to the existing prescriptions. Each initial
psychiatric interview included the reason for referral, medical, mental health and substance
abuse history, Mental Status Examination, Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition diagnosis, treatment recommendations, prescribed medication,
frequency of medication monitoring/management, medication name, and explanation of the
need for psychotropic medication. Each youth was applicable for an in-depth psychiatric
evaluation within thirty days and. each received one. Each evaluation included all required
elements and each included the signature of the psychiatrist and was clearly identified as the
psychiatric evaluation. When psychotropic mediation was prescribed, dispensed, or
administered by the psychiatrist all required information was documented, including required
signatures. Each youth’s IHCR documented monitoring for Tardive Dyskinesia on a monthly
basis and was documented on each youth’s CPPN. Each youth’s IHCR documented required
consents. None of the applicable youth were under the supervision of the Department of
Children and Families or eighteen years of age. Each of the three youth had a signed Authority
for Evaluation and Treatment in their mental health record.
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4.17 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 (FOP) outlining the process of inventory and
storing medication/sharps. Medical equipment classified as sharps were secured and
inventoried utilizing a routine perpetual inventory descending count as each sharp was utilized
and disposed. Medications were identified and secured in a locked area designated for storage
of medications. The medication cart was clean/organized with stock items separate from youth
specific medications. The controlled substances had a perpetual inventory and were stored
separately from other medications. All medications were stored in a separate, secured area
inaccessible to youth. Narcotics and other controlled medications were stored behind two locks.
Oral medications were not stored with injectable or topical medications. Medications requiring
refrigeration were stored in a secured refrigerator which was being used for medication only. All
sharps and stock over-the-counter (OTC) medications had perpetual and weekly counts. There
was documentation of shift-to-shift inventory count of all controlled substances which was
documented on the youths individualized Controlled Medication Inventory Record, as required.
Non-health care staff were trained by a registered nurse in delivery and oversite of medication
self-administration who may have perform these duties.
During the annual compliance review, observations of the nurse completing counts on three
controlled medications, three OTC medications, and three sharps were conducted. All counts
match the ending inventory numbers. The center has a FOP regarding inventory discrepancies,
disposal and destruction of expired and/or discontinued medications. The nurse confirmed the
process of disposal and destruction of medications. The nurse confirmed how controlled
substances are stored. The nurse confirmed the center has an agreement/contract with a
consultant pharmacist and a copy of the license is on-site.
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.
A review of seven Individual Healthcare Records (IHCRs) for infection control exposure and
education was conducted. Each of the youth received the required health education for infection
control within seven days of admission to the center, which included all required elements. The
center has an exposure control plan, as required. The exposure control plan includes the list of
job classifications which have potential for occupational exposure and a list of tasks or
procedures, which could cause the staff in the job classification to have occupational exposure.
The exposure plan includes methods of compliance and procedures in place include prevention,
containment, treatment, and reporting requirements related to infectious diseases, according to
the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control
and Prevention guidelines. The center’s infection control procedures include all required
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elements. The center has a process for needle stick post-exposure evaluation. The Hepatitis B
immunization is available for staff and staff have access to protective equipment. The center did
not have any instances in which infectious diseases and sexually transmitted infections (STIs)
were reported to the local health department since the last annual compliance review. The
nurse confirmed this information during interview; however, the center does have a process in
place on maintaining documentation if this should occur. A review of two pre-service and seven
in-service training confirmed staff were trained on the Exposure Control Plan. The nurse
confirmed the exposure plan is located in the medical binder. The registered nurse (RN)
manager conducts the infection control training for staff and youth. The nurse reported youth are
trained on infection control upon admission to the center.
4.19 Prenatal Care/Education [Contract Provider] Non-Applicable
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 not had any pregnant youth throughout the annual compliance review period;
therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures (FOPs) to ensure youth are actively supervised by
staff. During the annual compliance review week, youth supervision such as school and meals
were observed each day. Observations during the annual compliance review confirmed all youth
movements were called into master control and documented in both housing area and master
control logbooks. Observations of the center were conducted the week of the annual
compliance review, during the center tour, and staff were observed following the daily activity
schedule. Youth were observed attending class as scheduled, nine youth were in classroom C,
seven youth in classroom B, and eleven youth in classroom A. All classrooms were staffed with
two staff and one teacher facilitating the class. Observations were completed each day during
the remainder of the annual compliance review week, and all youth were actively being
supervised by the appropriate number of staff. Positive interactions between staff and youth
were observed during all four days of the annual compliance review. Staff maintained constant
supervision of all youth in their assigned area. All line movements were controlled by staff and
the staff were all well positioned inside the classrooms as well as the dining hall; staff ratio and
interaction were in accordance with policy. Seven staff were interviewed, and three stated the
facility was short staffed, and four believed there are enough staff to provide for the safety and
security of the youth and staff.
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5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) detailing the behavior management system
(BMS) to ensure the safety and security of youth and staff. During the annual compliance review
week, BMS posters were observed throughout the center which were accessible for the youth.
The posters provide clear, specified rules and expectations. The center provides a BMS which
includes incentives for positive behavior and consequences for inappropriate behavior. The
center’s BMS includes the use of a three-tiered level system where all newly admitted youth are
placed in level two and are given the opportunity to level up by following the rules and meeting
required expectations. A review of the FOPs for BMS ensured compliance with the components
outlined in the center’s FOPs. The center uses point cards to document youth progress, and a
review of the point cards confirmed youth receive their rewards and are being held accountable
for their actions daily. The FOPs prohibit the use of group punishment and there were no
indications or instances of inappropriate use of restrictions or group punishment displayed
during the annual compliance review. Seven staff were interviewed, and one staff stated the
new BMS is confusing. The remaining staff were able to explain the BMS, which included youth
being told of their expectations every morning, and the rewards for level three youth are an
extra telephone call and extra minutes, they are allowed to remain out of their room later and
weekly canteen, and a Saturday night snack. All staff gave examples of rewards the center
grants, and how youth are able to get these rewards. All seven staff stated they believe the
center's behavior management system is effective, and they all speak to the youth to discuss
the consequences for not following the center rules, and they afford the youth an opportunity to
explain their behavior. All seven staff stated they speak with the youth about alternative
acceptable behaviors. Two of the seven interviewed staff were supervisors; one stated they
receive feedback on the night shift, and the other supervisor receives feedback as needed. Four
staff stated supervisors provide feedback to staff regarding the implementation of the BMS, and
one stated they never provide feedback. All seven staff stated levels can be taken away as a
consequence and six stated points would be taken. All seven staff stated they have never
witnessed detention staff take meals, snacks, clothing, education, or medical care from a youth
because they were acting out, and they all stated they have never observed another staff
encourage a youth to beat up another youth. The superintendent was interviewed and stated
the new behavior management system which is currently in place consists of four levels. The
youth are on level one for seven days, level two for seven days, level three for seven days and
the highest level they can achieve is ambassador level, level four. Seven youth were
interviewed, and two said the BMS was very good, four said it was good, and one said it was
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fair. All were able to explain the difference between each level. All were able to provide
examples of incentives, such as extra snacks, extra telephone calls, staying up later, and
receiving canteen. All seven youth stated the staff use the BMS system fairly. All interviewed
youth stated they never witnessed handcuffs or leg irons being used on out of control youth to
prevent them from hurting themselves or hurting others. Three youth stated they were never
stopped from reporting abuse to the abuse hotline since they have been at the center and four
said they never had to report abuse. All youth said youth are not allowed to punish other youth.
The youth were asked if they have ever been sent to their room as punishment, and all said no.
Two youth said they have received consequences, and both said the consequences were fair.
Both youth had a level reduction as a result of the consequence. The remaining five youth have
not received consequences. All seven-youth stated staff were respectful when speaking to all
the youth and none of them ever heard staff used profanity with speaking to any youth, nor have
they ever heard staff threaten any youth.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures (FOPs) requiring ten-minute checks to be
conducted when youth are secured in their rooms. The center has sixty-four surveillance
cameras, and sixty-two were operational during the week of the annual compliance review. The
center’s video surveillance system can store video recordings up to thirty days. The electronic
wand system is used in the center to document and collect data of the ten-minute visual checks.
The staff use an electronic wand with sensors on the outside of every room during sleeping
hours, and the designee uploads the collected data and downloads it to a wand report which is
reviewed on a weekly basis. During the annual compliance review week, a video review of nine
samples of video over nine different days including samples from each living module, revealed
staff conducted ten-minute checks as required; a discrepancy of four minutes past the ten-
minutes was observed on one occasion. These video reviews were compared with the wand
reports, and confirmed to be accurate. Seven staff were interviewed, and all stated room checks
are conducted every ten minutes when a youth (non-suicidal) is placed in their room for sleeping
or non-punishment reasons. The superintendent was interviewed and stated when a youth is
placed in a room, whether for sleeping or other reasons, officers shall conduct visual
observations to ensure safety and security. Pre-printed times are prohibited, and the electronic
wand check system is used.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures (FOPs) ensuring staff always know the exact
number and location of all youth under their supervision. During the annual compliance review
week, staff were observed conducting counts before and after every movement. Counts were
also observed during youth transitions from the classrooms to the dining hall for meals and from
the dining hall to their assigned housing areas. Seven staff were interviewed, and all staff stated
counts are conducted in the beginning and at the end of each shift, and three stated counts are
conducted before and after school and two stated before and after meals. All seven staff stated
emergency counts are conducted if a youth is believed to be missing, when visibility is hindered,
such as an electrical outage, and after a major disturbance. A sample of one full day of
logbooks was reviewed for each month during the annual compliance review period. The
logbook entries contained all head counts, counts at the beginning of each shift, following an
emergency, counts following a population change, and youth movement.
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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 only
has a separate logbook for housing modules and master control. All logbooks were bound with
numbered pages, with the date documented on the top of each page. All entries included the
times of events in a.m./p.m. format, name of the staff and youth involved, a brief description of
the events, and the initials of the staff making the entry. All entries involving safety and security,
to include medical and special needs alerts were highlighted. Logbook reviews included
superintendent reviews, juvenile justice detention officer supervisor (JJDOS) reviews, and
superintendent or staff in charge of the center’s daily tour of youth living areas. Master control
logbooks were reviewed from August 31, 2024, through July 2025. All contained emergency
situations, incidents which included notification of the Department’s Central Communications
Center (CCC) and Florida Abuse Hotline, right interaction (RI) incidents, drills, receipt of medica/
or mental health care, population counts at the beginning and end of each shift, population
counts as center counts changed, counts following emergency situations, group movement,
admissions and releases, searches, and names of youth in confinement or precautionary
observation with times they began and ended. Seven vehicle logbooks were reviewed, and all
included the vehicle number, driver and passenger names, number of youth being transported,
time and date of departure and arrival, and destination. The superintendent was interviewed and
stated the superintendent or designee shall review all logbooks (excluding the visitor’s logbook)
at a minimum of weekly and review the entries for the last seventy-two hours.
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5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) describing the center’s key control process,
issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys,
and reporting and replacement of damaged keys. Observations during the annual compliance
review confirmed when detention staff enter the center, their personal keys are secured on the
non-secure side of the center or given to master control prior to being issued a key set by the
master control operator. Visitors and contracted staff secure personal keys in a locker outside of
master control. A review of the key inventory verified the key rings on the inventory matched the
actual key rings in use. The key storage box is opened by the on-duty supervisor whenever
keys are being issued or when staff return keys. Observation of key issuance logs confirmed all
restricted keys are only issued to authorized staff. All facility keys were confirmed to have been
maintained on a tamper-resistant ring. The emergency key rings are located in a secured red
box in master control. Only the superintendent or their designee has access to the emergency
key box. The master key inventory includes the key ring number, number of keys on each ring,
what doors the keys access, and who the key ring is issued to. All facility key rings are color-
coded, depending on what area they access. Shift reports were reviewed and all included the
date and time key rings were issued, the name of the staff issuing the key ring and the staff
receiving the key ring, and the time the key ring was returned. During the annual compliance
review, staff were observed carrying issued keys on their person and in their pockets at all
times. Staff did not allow youth to handle keys, and were not allowed to remove keys from the
facility without authorization. During the annual compliance review period, there were no
instances of any lost keys or any key control issues. A sampling of three random key rings was
conducted and compared with the key check-out log. All sets of keys were present on the key
log, matched the number of keys listed on the key ring tag, and matched the number of keys on
the inventory. Three staff were informally interviewed during the annual compliance review, and
all knew the number of keys on their rings as well as the function of each key. An informal
interview was also conducted with the master control operator, who was able to explain the
process of restricting the use of certain keys, such as medical, youth records, and youth
property, only to staff assigned to those areas. Seven staff were interviewed, and all stated staff
keys are given to master control upon entry, which is when center keys are assigned to staff.
Staff also identified which keys were restricted. The superintendent was interviewed and
advised each staff receives key training and are issued keys while on shift. There is a secured
box located in the administrative hallway where the supervisor secures keys. Keys for
maintenance, superintendent and assistant superintendent are secured in each respective
office.
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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 maintains facility operating procedures (FOPs) for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of eight vans
utilized to transport youth. One of the vans was undergoing service at the repair shop for service
at the time of the annual compliance review. The seven available vans were inspected to ensure
they were locked when not in use, and all were secured. The maintenance mechanic provided
documentation of an annual inspection for each van which was completed by a certified
mechanic. Monthly inspections consisting of checking the vehicle’s water coolant, lights, oil,
emergency equipment, brakes, horn, interior, exterior, and cleanliness of the vehicle, were
conducted by the maintenance mechanic and were documented on SharePoint. The inspections
also included review of the tires, batteries, windshields, wipers, windows, mirrors, and a
thorough check for damages to the vehicles. An additional physical inspection of all the vehicles
was conducted to ensure each vehicle contained the appropriate number of seatbelts, a seatbelt
cutter, window punch, current fire extinguisher, and a first-aid kit. Each vehicle was equipped
with a transport logbook to document all youth transports. The logbook included documentation
of the vehicle being checked for contraband, d required equipment, the van’s destination, the
number of youth, youth and staff names, start time and end time of transports. No transports
were scheduled during the time of the annual compliance review for observation. Seven youth
were interviewed, and six stated they felt staff are driving safely when transporting youth; one
stated they have never been transported. All youth reported they have never witnessed anyone
place contraband in a transport 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 (FOPs) ensuring all tools and equipment
related to maintenance and the kitchen are properly maintained, stored, and inventoried. The
FOP also prohibits youth from having access to any tools, including kitchen and/or medical
equipment. According to the center’s FOP, youth are allowed to use cleaning items such as
mops, brooms, and other common household items when completing general cleaning under
staff supervision. During the annual compliance review week, observation of youth utilizing
cleaning tools was unable to be conducted. Observations were made of the tool room,
maintenance shed, and kitchen. Kitchen staff were observed utilizing sharps in the kitchen as a
food service worker was using a knife to cut salad. Sharps in the kitchen are secured in a locked
cabinet when not in use. A review of the monthly inventory sheets since the last annual
compliance review confirmed no maintenance or kitchen tools were missing. The food service
director maintains an itemized inventory of kitchen tools. All items, including knives, are
inventoried daily upon kitchen staff reporting for duty. Seven staff were interviewed and were
asked what the center’s practice for damaged or missing tools is, and one staff stated they are
to report the missing item to supervisors and search for it, one staff stated they are to search all
the rooms, put the youth on lockdown until it is located, one staff stated they are not allowed to
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have any tools, and if something is missing, it is reported to the supervisor, one staff stated to
document in the logbook, inform a supervisor and then look for the broomstick/missing item.
One staff stated they do not have access to tools, only maintenance does. One staff stated they
are to report it to the supervisors and conduct a search to find the missing item, and one staff
stated they would notify the supervisor of the missing tool and stop movement and find the
missing tool. Six staff said youth can use mops, brooms, and scrub brushes, and one staff said
youth cannot use any type of tools. An informal interview with the maintenance mechanic
indicated all service vendors and technicians are searched prior to entering the secure area of
the center and are always accompanied either by the maintenance mechanic, or by staff. If
youth are in the area to be serviced, all youth are removed from the area, and the area is placed
out of service, and the youth are not allowed back until work in the area is complete and cleared
by staff. The vendor will ensure they exit the work area with the tools they entered with. A
review of the sign-out sheet of the inventory used to document the issuance and return of
maintenance tools found no discrepancies. A sample of ten tools to confirm accurate inventory
was reviewed and all tools were accounted for; all tools were secured and had marking for easy
identification. Seven youth were interviewed, and all stated the only tools they use are mops
and brooms. The superintendent was interviewed and stated the maintenance mechanic and
administration have access to facility tools. During an informal interview with the maintenance
staff and kitchen staff, the maintenance mechanic stated all tools are accounted for and if ever
there is a missing tool, it gets reported immediately. Kitchen staff said youth are not permitted to
use any kitchen equipment, and they are not allowed into the back of the kitchen area.
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 maintains facility operating procedures (FOPs) ensuring the proper use, storage,
disposal, and inventory of all chemicals including poisonous, flammable, and toxic materials.
The policy also ensures limited access to flammable, toxic, caustic, and poisonous items. Only
authorized staff are permitted access or use flammable, toxic, caustic, and poisonous items.
Youth are strictly prohibited from handling or using hazardous chemicals under any
circumstances. During the annual compliance review week, the center’s Safety Plan was
reviewed, which followed the center’s FOPs. No toxic materials were observed in any area
accessible to youth during the week of the annual compliance review. Documentation of five
inventoried flammables, toxic, caustic, and poisonous items in the center were reviewed for the
annual compliance review period, and it revealed the center maintained an accurate inventory.
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Only authorized personnel are permitted access to this area. Seven youth were interviewed,
and asked if they handle chemicals or have access to chemicals, and all said no, and they did
not have access to flammable, toxic, caustic, or poisonous items. Seven staff were interviewed,
and all stated youth are not permitted to clean with substances which are toxic, flammable, or
poisonous. Five chemical samples were selected, and each with a corresponding safety data
sheet (SDS)located nearby , and the inventory was confimed accurate.
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 maintains facility operating procedures (FOPs) ensuring the proper disposal of
hazardous items and toxic materials in accordance with Occupational Safety and Health
Administration (OSHA)standards . No chemical spills or disposal of flammable, toxic, caustic, or
poisonous material were reported during the annual compliance review period. Kitchen staff
reported the grease used for cooking is disposed of by an outside contractor. The maintenance
mechanic was informally interviewed and confirmed the center is equipped with a grease trap,
and it is properly disposed of by an outside contractor. The maintenance mechanic verified all
hazardous materials are disposed appropriately.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures (FOPs) to govern the use of confinement for youth.
There was a total of 199 youth placed in confinement under twenty-four-hours for the annual
compliance review period, and fifteen were reviewed. All fifteen showed a supervisor conducted
an initial confinement review within one hour of placement. Thirteen of the fifteen confinement
reports were fully completed before the end of their shift. A supervisor conducted additional
reviews with the youth at a minimum of three hours and documented the reviews in the
Department’s Facility Management System (FMS). All fifteen reflected the supervisor/staff
continuously counseled the youth and considered removing the youth from confinement as soon
as possible. None of the fifteen youth were applicable for requested/needed access to mental
health care. Four of the fifteen confinements were during regularly scheduled daily showers and
afforded a shower; the remaining eleven records were not applicable due to the confinement
occurring during sleep hours or during classroom time. All youth in confinement were afforded
three meals a day plus school and evening snack, if they were confined during those times. All
youth confined during school hours were provided education materials with the exception of one
youth. All fifteen records contained documentation showing all youth had clean clothing and a
mattress/bedding while they were in in confinement. All fifteen records confirmed the youth’s
right to grieve a confinement placement. All fifteen records contained supervisor approval prior
to each confinement, and each youth was placed in a confinement room alone. All fifteen
records stated the room was searched prior to the youth being placed in it and documented in
FMS. All fifteen records had fully completed Visual Observation Reports (VORs) for the entire
confinement, to include five-minute checks for the first hour and behavior codes for observations
made of youth. Two of the fifteen records did not have date or time out on the confinement
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reports. None of the fifteen records were applicable for observed physical injury; therefore, they
did not need referrals. All fifteen records contained documentation the reason for confinement
was explained to the youth. None of the fifteen confinements interfered with scheduled
visitation. All fifteen confinement reports were reviewed within the required forty-eight hours by
the superintendent or designee. The center did not have any pregnant youth in confinement
during the annual compliance review period. All windows and cameras were free of
obstructions/scratches, so the youth may be visually observed. The superintendent was
interviewed and stated the center ensures the appropriate use of confinements are tracked and
reviewed by regional detention management every thirty to sixty days. The superintendent also
advised the use and appropriateness of confinement is tracked through confinement reports,
supervisor reviews, and administrative reviews of confinement. Seven staff were interviewed,
and all confirmed youth in confinement are provided education materials if the confinement
occurs during school hours. All seven staff are familiar with the step-by-step process of placing
a youth in confinement, to include completing the confinement report, five and ten-minute
checks, and searching the confinement room.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures (FOP) which require they conduct and document
Continuity of Operations Plan (COOP) drills at a minimum, twice a year, with one drill being
completed prior to the start of hurricane season. A review of the center’s drill binder confirmed
they conducted COOP drills within the required time frames; one on September 24, 2024, and
one on May 15, 2025. Both drills simulated the evacuation of the center in response to an
impending storm scenario.. Each drill contained all of the required elements, to include the type
of drill, date, start and end time, shift, detailed information of the drill, recommendations for
improved emergency response, and review. The drill packet also included a completed
emergency checklist, actions taken, maps with evacuation routes, supplies, and a youth census.
The superintendent was interviewed and confirmed the center’s comprehensive
safety/emergency center drill is the COOP plan.
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5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures (FOPs) to address escape drills and escape
prevention. Quarterly escape drills were conducted on each shift, as required, and documented
in the center’s logbook. Seven in-service training records were reviewed, and each staff
completed training in security and escape prevention annually. Seven staff were interviewed,
and all confirmed completing escape drills annually.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention, and evacuation plan addressing fire prevention
and safety in the center. The center conducted monthly fire drills on each shift, as required, with
one exception. The center did not conduct fire drills in October 2024 because the center was
evacuated due to a hurricane on the same day the fire drills were scheduled. The center is
running on twelve-hour shifts and all twenty-one drills were conducted and documented in the
logbook. Fire evacuation plans were posted throughout the center. identifying the primary and
secondary exit routes and locations of fire extinguishers, and first-aid kits. All fire extinguishers
received complete annual inspection, as required. Seven staff were interviewed, and all
confirmed fire drills occur at least monthly. Seven youth were interviewed regrading fire safety
instruction. Six reported they had been instructed on fire procedures, and one youth who had
been in the center for four days stated no.
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5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) which address illegal contraband,
prohibited items, and how to reduce the introduction of contraband into the center. A review of
the center’s policy and observations during the annual compliance review week verified
contraband attestation forms are available in the lobby as part of the visitor’s log, and visitors
were electronically searched when entering the secure area of the center. Only clear bags are
permitted on the secure floor, and all bags, cases, jacket pockets, and shoes were searched. All
personal keys, personal cellular telephones, and other contraband items were prohibited in the
secure areas of the center. On the second day of the annual compliance review, a member of
the review team was not searched prior to entering the secure floor for the detention review
meeting. On the final day of the review, a review team member observed a staff entering the
facility with a non-clear bag, after which both staff and bag were searched. The bag was
immediately taken back to the non-secure area of the facility.
An observation of a new admission into the center was conducted, and verified staff wore
gloves during the search, which was conducted individually in a private area by the same
gender staff, and not in a group setting. Youth room searches are documented on the shift
reports and are uploaded electronically into the Department’s Facility Management System
(FMS). Youth rooms are searched upon a youth’s release and prior to placing a new youth in
the room. A review of random shift reports for one day for each month of the annual compliance
review period verified youth room searches were documented and completed during each
awake shift as required. A review of the Department’s Central Communications Center (CCC)
reports since the last annual compliance review confirmed there were five instances of
contraband found at the center. The contraband and the call to the CCC were documented in
the master control logbook. Documentation verified incident reports were completed identifying
findings and disposition of the contraband found. Confiscated items were secured, and hand
delivered to the supervisor. Two of these five incidents involved illegal contraband, and
documentation revealed the shift supervisor documented the chain of custody for the
contraband items and local law enforcement was contacted for the items considered illegal as
defined by Florida Statute. A review of five newly hired staff records revealed all contained
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contraband attestation forms. The superintendent was interviewed and stated if a youth or staff
is found with contraband, the contraband is confiscated, reported, an internal investigation is
conducted, which may lead to an external investigation as well, to include law enforcement if
needed, and staff may receive disciplinary action. The superintendent also stated additional
measures the center has implemented to prevent the introduction of contraband is searching
using the electronic wand on all staff and visitors entering the building, and removal of shoes
every time they enter the building, in addition to all bags and lunch boxes being checked.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 57

source: DJJ

report_type: QI Detention