summary: QI Detention - FY25-26 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Brevard Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
5225 Dewitt Avenue
Cocoa, Florida 32927
Review Date(s): August 26-29, 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:
Heather Molinario, Office of Accountability and Program Support, Lead Reviewer (Standard 1 &
4)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 4)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Nick Johnson, Office of Education, Deputy Director of Education (Standard 2)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 3 & 4)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Interviews
& Standard 1)
April Walker, Office of Detention Services, Senior Management Analyst II (Standard 2)
Program Name: Brevard Juvenile Detention Center MQI Program Code: 244
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Brevard County / Circuit 18 Number of Beds: 40
Review Date(s): August 26- 29, 2025 Lead Reviewer Code: 197
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
Limited Ratings Failed Ratings
4.19 Sick Call Process - Visits/Encounters
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 62
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 62
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a tis fa c to
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a tis fa c to
S ta ff C o d e o f C o n d u c t S a tis fa c to
In c id e n t R e p o rtin g (C C C ) * S a tis fa c to
R ig h t In te ra c tio n s (R I) S a tis fa c to
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a tis fa c to
In -S e rv ic e T ra in in g S a tis fa c to
G rie v a n c e s S a tis fa c to
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a tis fa c to
D a ta T re n d A n a ly s is S a tis fa c to
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 62
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
S ta n d a r d 2 - Y o u th M a n a g e m e n t
A d m is s io n 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 re s e n ta tiv e 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 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
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 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 62
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
* T h e D
b e lo w D
re s u lt in
e p a
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ro g
e n t h a s id e n tifie d c e rta in
e n t s ta n d a rd s . A p ro g ra m
ra m a le rt fo rm b e in g c o m
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 ) S a
L ic e n s e d M H /S A C lin ic a l S ta ff * S a
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff S a
M H /S A A d m is s io n S c re e n in g S a
M H /S A E v a lu a tio n S a
T re a tm e n t a n d D is c h a rg e P la n n in g S a
M H /S A T re a tm e n t S a
S u ic id e P re v e n tio n P la n * S a
S u ic id e P re v e n tio n S e rv ic e s * S a
S e c u re O b s e rv a tio n * S a
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 a
S u ic id e P re v e n tio n T ra in in g * S a
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 * S a
E m e rg e n c y C a re P la n * S a
C ris is A s s e s s m e n ts * S a
B a k e r a n d M a rc h m a n A c ts * S a
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 u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to d o
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 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 62
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p a rtm
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 to ry
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c to ry
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 to ry
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c to ry
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 to ry
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 to ry
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 to ry
H e a lth -R e la te d H is to ry S a tis fa c to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g S a tis fa c to ry
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g S a tis fa c to ry
S ic k C a ll P ro c e s s S a tis fa c to ry
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 to ry
O ff-S ite C a re /R e fe rra ls S a tis fa c to ry
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 to ry
M e d ic a tio n M a n a g e m e n t S a tis fa c to ry
P s y c h ia tric S e rv ic e s * S a tis fa c to ry
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 to ry
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 to ry
P re n a ta l C a re /E d u c a tio n L im ite d
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to d
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
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth* Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Limited
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 62
Program Overview
The Brevard Juvenile Detention Center is a state-owned detention facility, operated by the
Department, located in Cocoa, Florida. The center serves youth in Brevard County in Circuit 18.
The center is co-located with the Brevard Juvenile Assessment Center. Male and female youth
who are detained pending adjudication, disposition, or placement in a residential commitment
program are housed in the forty-bed center. Youth are provided with 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
Brevard County School Board. The center’s management team includes the superintendent, two
assistant superintendents, two administrative assistants, one facility training coordinator, one
food support director, two food support workers, 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. Mental health services are provided by one
licensed mental health counselor (LMHC) who is the designated mental health clinician authority
(DMHCA), one part-time licensed clinical social worker (LCSW), one pro re nata (PRN) LMHC,
and one psychiatrist. 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, one advanced practice registered nurse, one
registered nurse manager, three full-time registered nurses, two part-time registered nurses,
and one medical records clerk. The medical clinic maintains nursing coverage twenty-four hours
a day, seven days a week. Food services are provided by Department staff and include menus,
meal planning, meal schedules, special diets, nutritional analysis, daily allowance, food
preparation, health certifications, food product standards, sanitation, and cleaning. Staff are
responsible for the custody and control of youth in their care, providing youth supervision
twenty-four hours a day, seven days a week. The center has four living modules which are
divided by male and female. There are fifty-eight security cameras at the center, of which fifty-
four were operational. At the time of the annual compliance review, the center had ten
vacancies, which included one full-time licensed clinical staff, one food support worker, one
juvenile justice detention officer (JJDO) supervisor, and seven JJDOs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 62
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 to ensure all newly hired staff, volunteers, and
contracted provider staff receive a background screening prior to being hired; and to ensure all
volunteers, mentors and interns working with youth less than ten hours a month have the
required sight and sound supervision while on-site. The center submitted an Annual Affidavit of
Compliance with Level 2 Screening Standards to the Department on January 31, 2025, and the
local school board submitted an Annual Affidavit of Compliance with Level 2 Screening
Standards to the Department on January 21, 2025, as required. The center had fourteen new
staff, one new volunteer, and five new contracted staff during the annual compliance review
period. All twenty background screenings received an eligible rating prior to the date of hire, and
each background screening included a criminal history review. Twelve of the fourteen newly
hired staff received a passing score on the pre-employment assessment, the remaining two
were not applicable as their positions do not require the assessment; contracted staff and
volunteers are not applicable for the assessment. All five contracted staff were added to the
Clearinghouse roster as required.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all eligible staff receive a five-year
background rescreening. The center had eight applicable staff for a five-year background
rescreening. Each rescreening was completed within the required timeframe and returned with
an eligible rating.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 62
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 to ensure all staff adhere to a staff code of
conduct. Five staff personnel records were reviewed for a sample of disciplinary action and
commendations. Two records had commendations, two records had disciplinary action
documented, and the final record had both discipline and commendation. Each reviewed staff
personnel record contained a signed code of conduct at the time of hire. Each of the three
disciplinary actions within the reviewed records documented the date and nature of the
infraction, and date and type of the management response. Each of the three commendations
were documented in the record with the date and nature of the commendation.
Seven staff were interviewed regarding staff conduct. Four of seven interviewed staff stated
coworkers are occasionally observed using profanity when speaking to youth; two staff reported
a single incident observed; and the remaining staff stated this had not been observed. The staff
indicating to have observed staff utilizing profanity with youth stated it occurred in a situational
manner. None of the seven interviewed staff had observed staff using threats, humiliation, or
intimidation when interacting with youth. Three of the seven interviewed staff reported the
working conditions at the center over the past year have been very good; three stated good; and
the remaining staff reported fair working conditions. Six of seven staff confirmed youth are
allowed to call the Florida Abuse Hotline or the Department’s Central Communications Center
(CCC) if needed to report abuse; four of the seven staff indicated supervisory staff is notified
when a youth makes a request to call; and one staff confirmed staff are allowed to call if
needed.
Seven youth were interviewed, and each confirmed they did not need to request a call to the
Florida Abuse Hotline or the Department’s CCC. Six of the seven interviewed youth stated staff
are respectful when speaking to youth; the remaining youth stated staff are not. Three of seven
interviewed youth stated staff are occasionally using profanity when speaking to youth; three
youth reported a single incident observed; and the remaining youth stated this had not been
observed. The youth who indicated to have observed staff utilizing profanity when interacting
with youth stated it occurred in a situational manner. Six of the seven interviewed youth had
never observed staff using threats, humiliation, or intimidation when interacting with youth; the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 62
remaining youth reported observing a single incident. This incident was reported to have been a
staff making a verbal threat to disclose youth-specific information; however, the staff did not act
on the threat. The center did not provide any additional information regarding this alleged
incident. Six of the seven interviewed youth reported feeling safe at the center; the remaining
youth stated they did not feel safe due to the other youth’s behavior and stated staff do make
the youth feel safe. All seven youth confirmed they have never exchanged personal information
to include social media contacts, telephone numbers, or emails.
The superintendent interview confirmed the center’s code of conduct, policy, and processes.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures to ensure all reportable incidents are called into the
Department’s Central Communications Center (CCC) within the required two-hour time frame of
staff becoming aware of the incident. The center had a total of fifty-seven reported incidents
during the annual compliance review period. A sample of six incidents were reviewed. The
reviewed documentation for each of the six incidents confirmed all incidents were reported
within the required time frame and were documented in the logbook and each shift report.
During youth interviews, one youth reported seeing a staff vaping while the transport vehicle
was stopped at a convenience store during transport from another center. The center was
notified and called in the incident to the CCC within the required timeframe. The incident was
accepted by the CCC.
The superintendent interview confirmed the center’s policy and procedures for reporting
incidents to the CCC and how the center conducts an internal investigation for each incident.
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 to ensure the center utilizes approved physical
interventions, Right Interactions (RI), and maintains all required documentation. The center had
a total of 204 RI incidents during the annual compliance review period. A sample of nine RI
incidents were reviewed. Eight of the nine reviewed RI reports were completed by each involved
staff by the end of the workday; the remaining report did not have all the involved staff
statements completed by the end of the workday. All nine reports contained a statement from all
involved staff, and each report was reviewed by the supervisor and/or RI instructor. None of the
reviewed incidents involved serious injury of a youth or staff nor youth allegations of abuse;
therefore, not requiring a call to the Department’s Center Communications Center (CCC) or the
Florida Abuse Hotline. Eight of the nine reviewed RI reports contained documentation of a post-
RI interview between the youth and a designated administrator within thirty minutes; the
remaining report confirmed this interview was conducted past the required thirty-minute
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 62
timeframe. The post-RI interview confirmed none of the reviewed incidents required medical
attention for the youth involved. None of the reviewed incidents involved mechanical restraints.
Three of the nine reviewed RI reports contained documentation of the
superintendent/designee’s review within seventy-two hours; the remaining six had
superintendent/designee reviews after the required time frame. The center reported the delay
was a direct result of playback issues with the camera system; documentation to support the on-
going problem was provided to the review team. No additional RI incidents which should have
had a report completed were located during the annual compliance review. The center’s RI rate
during the previous quarter was 26.79, which is above the standard Detention RI rate of 12.59.
Seven staff were interviewed, and each staff confirmed staff attempts to talk with youth prior to
the use of physical or mechanical restraints.
The superintendent was interviewed regarding documentation of physical and mechanical
restraint usage, and it was confirmed the center ensures documentation is maintained as
required by Florida Administrative Code and policy. The superintendent confirmed the center
follows the policy and procedures of monitoring RI incidents and use of force.
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 to ensure all newly hired staff receive the required
pre-service/certification training. Seven pre-service staff training records were reviewed, and
each record contained documentation of the completion of all required trainings. All newly hired
staff received a new staff orientation within thirty days of hire. Each staff received the proper
certification within the required 180-days of hire.
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 to ensure all staff receive the required annual in-
service training. Seven in-service staff training records were reviewed. Six of the seven staff
training records contained documentation of all required trainings being completed; the
remaining record did not have documentation of completion for three required trainings. The
center provided documentation of disciplinary action issued to this staff. Three of the seven
reviewed records were supervisory staff. Two of the three supervisory staff completed all
required supervisor in-service training; the remaining supervisor was promoted during the
annual compliance review period and is current with required supervisory training. A registered
nurse provides in-service education on girls’ healthcare annually to direct-care staff. The girls’
healthcare education includes monitoring, observation, and emergency care of pregnant youth.
The center maintains an annual in-service training calendar, which is updated as needed. The
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superintendent, assistant secretary of Detention, and the director of the Department’s Office of
Talent, Leadership, and Culture (TLC) approved the calendar, as evidenced by their signatures.
The superintendent interview confirmed all required management and staff training
requirements as outlined in the center’s policy and training calendar.
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 to ensure each youth can grieve any violation of
their rights, and to ensure youth are treated with respect, fairness, and without discrimination.
Youth have access to the center’s grievance forms throughout the center. The center did not
have any grievances for the annual compliance review period.
The superintendent interview confirmed the center’s policy and procedures for the grievance
process. The center maintains grievances by uploading the written documentation into the
Department’s Juvenile Justice Information System (JJIS) under Facility Management System.
Seven staff were interviewed, and each staff was able to articulate the center’s grievance
process.
Seven youth were interviewed regarding the grievance process, and each confirmed they can
ask for a grievance form, if needed. None of the interviewed youth had needed to submit a
grievance form.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures to ensure all critical and special youth alerts are
entered into the Department’s Juvenile Justice Information System (JJIS), and all staff have
access to this information. The center reviews and makes applicable updates to youth alerts
daily, as needed. A review of seven youth records was conducted. Six of seven reviewed
records had correlating youth alerts for each required issue documented in the case
management record; the remaining record had one alert open in JJIS which should have been
closed according to documentation in the youth record. All required youth alerts were observed
to be maintained in the logbook, reviewed during each shift debrief, and accessible for staff to
review. The JJIS alert report is reviewed by supervisors and administration daily, and shift
debriefing minutes and agendas confirmed alerts are being reviewed with staff as required. A
shift briefing was observed during the annual compliance review week and observation
confirmed alerts are reviewed in detail. The center conducts a daily review of the JJIS Alert
report, and the alerts are updated as needed by designated staff and at each admission.
The superintendent interview confirmed the center’s policy and procedures for maintaining
current and active youth alerts, as well as how and when staff is provided youth alert
information.
Seven staff were interviewed, and each staff confirmed youth alert information is reviewed at
shift debriefings; three staff also indicated they review JJIS for updates. Other methods of alert
information delivery mentioned were emails, directly from medical or kitchen staff, and the
printed alert list. Two of the seven interviewed staff stated the delivery methods are very good;
four stated they are good; and the remaining staff indicated the delivery is fair.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center utilizes the Department’s quarterly report card to review and analyze data trends
within the center. The report card includes an impact plan to address any improvement needs or
problems which are discussed at meetings with supervisors and regional staff. Data trend
analysis information is shared monthly at supervisor’s meetings and Juvenile Assessment
Center advisory board meetings. The documentation provided for review confirmed the center’s
practices.
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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 to ensure each youth admission is completed
properly. Seven youth records were reviewed to determine compliance with established
procedures. Documentation in the Department’s Juvenile Justice Information System (JJIS)
Admission Wizard confirmed each youth had a completed arrest affidavit or custody order, a
Detention Risk Assessment Instrument, and a Suicide Risk Screening Instrument, as applicable.
The review also verified all seven youth received a full-body and/or electronic search conducted
by a staff of the same gender. Admission records showed six of the seven youth received a
telephone call to their parent/guardian upon admission, and all seven youth were provided a
meal. Additionally, documentation verified a medical and mental health/substance abuse
screening was completed for each youth at the time of admission. No admissions occurred
during the annual compliance review week while the team was on-site; therefore, a youth
admission could not be observed.
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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 to ensure each youth receives an orientation upon
admission. Seven reviewed youth records confirmed each youth received an orientation within
twenty-four hours of admission and signed an orientation acknowledgment form. Documentation
confirmed each orientation was delivered both verbally and in writing by a juvenile justice
detention officer. The orientation materials, including a brochure, cover all required topics and
are consistent with the center’s established procedures. Youth were informed of the center’s
rules and regulations, grievance procedures, visitation hours, telephone usage, access to
medical, mental health and substance abuse services, the Florida Abuse Hotline, and the
Department’s Central Communications Center (CCC). Additionally, each orientation addressed
behavior expectations and consequences, potential new law violations, youth rights, and
information related to the Prison Rape Elimination Act (PREA). Although no admission occurred
during the review week, informal interviews with staff and youth confirmed all youth consistently
receive the required orientation within twenty-four hours of admission.
Seven youth were interviewed. Six youth confirmed receiving an orientation upon admission to
the center. The remaining youth stated they tried to read all the paperwork at admission;
however, the youth alleged he was rushed through the paperwork and had to sign quickly.
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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 to ensure all youth admitted are classified by a
juvenile justice detention officer (JJDO) to maintain the highest standards of safety and security,
according to required criteria. The center’s classification procedure outlines all required
components. Seven youth case management records confirmed each record included
classification documentation detailing the youth’s background and status. This information was
used to guide appropriate room assignments, considering factors such as physical
characteristics, level of aggression, mental health concerns, intellectual or physical disabilities,
history of violent behavior, gang involvement, criminal history, history of sexual offenses,
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening results,
medical and suicide risk indicators, and potential escape or security risks. In accordance with
policy, youth with a history of sexual offenses or those identified as victims of sexual abuse are
not housed with other youth. All seven records documented youth were assigned rooms based
on their classification, with reclassification completed when changes in behavior or status were
observed. Three of the seven youth were identified as gang members, which was considered
when classifying each youth. The center’s juvenile probation officer (JPO) detention coordinator
ensured alerts were entered into the Department’s Juvenile Justice Information System (JJIS)
and notifications were sent to the assigned JPOs and local law enforcement agencies for each
youth identified with gang affiliation. The superintendent is informed of alerts through JJIS
alerts, Detention Reviews, email notifications, and the gang liaison.
The superintendent interview confirmed the center’s policy and procedures for youth
classification.
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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 established facility operating procedures to ensure each newly admitted youth is
screened for gang members or affiliation. A review of seven youth records confirmed three
youth were identified as having gang involvement. The center’s juvenile probation officer (JPO)
detention coordinator serves as the designated gang representative and is responsible for
communicating all suspected gang activity to local law enforcement and the assigned JPO by
email. The reviewed documentation confirmed all required email notifications were sent.
Additionally, the center shares information related to suspected gang affiliation with the circuit
gang representative during weekly Detention Review meetings. The JPO detention coordinator
also communicates suspected gang behavior to the assigned JPO and the chief probation
officer. Gang alert information is entered into the Department’s Juvenile Justice Information
System (JJIS), and all three applicable records reviewed had documentation of the required
gang alerts. The center’s gang representative was informally interviewed and demonstrated a
clear understanding of the gang notification procedures.
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 to ensure each youth’s personal property is
inventoried, securely stored, and documented upon admission. A review of seven youth records
confirmed in each record, the admitting juvenile justice detention officer (JJDO) inventoried the
youth’s property and entered the information into the Department’s Juvenile Justice Information
System (JJIS). A Property Receipt form was printed and signed by both the youth and the JJDO
in all seven records. Each youth record included a signed letter of acknowledgment regarding
unclaimed property.
One of the seven reviewed youth records had documentation of valuable property; the
remaining six were not applicable. Valuable items are placed in clear, tamper-proof bags
labeled with each youth’s name, JJIS identification number, and an itemized list of the contents.
The bags are secured in a safe drop which is under continuous video surveillance. A property
log is maintained to document all items placed in the safe, to include the date, time, youth’s
name, the name of the staff securing the property, and the staff’s initials. No youth refusals to
sign the Property Receipt Form were observed. All other personal property was placed in
assigned storage bags, as documented, and the signed forms were filed in the respective youth
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records. There were no admissions while the team was on-site during the annual compliance
review week. A review of the Department’s Central Communications Center (CCC) reports
confirmed there were no incidents regarding youth property valued at over fifty dollars needing
to be reported to the CCC during the annual compliance review period.
The superintendent interview confirmed the center’s policy and procedures for youth property.
Access to the drop safe is limited to supervisors and administrative staff. Non-valuable items are
also logged into JJIS and stored in secured mesh bags until each youth is released.
Six of seven interviewed youth confirmed staff inventoried their personal property during
admission and each signed a form verifying the accuracy of the listed items; the remaining
youth was transported from another center and did not have property.
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 governing the release of youth from secure
detention to ensure accuracy, safety, and compliance with legal requirements. A review of three
closed youth case management records confirmed each had a completed Detention Release
Form, which documented a supervisor reviewed all necessary paperwork, including court-
related documents, prior to release. In all three records, the youth’s identity was verified, and
the parent or guardian’s identification was also confirmed, with photocopies of the identification
cards filed in the respective records.
None of the reviewed records indicated any youth were classified as endangered persons. Each
youth and the individual receiving the youth received a reminder of upcoming court dates and
signed the appropriate release forms. The admission and release dates documented in each
youth record matched the dates recorded in the Department’s Juvenile Justice Information
System (JJIS). Additionally, all required signatures were present on the applicable forms in each
record.
During the annual compliance review week, two youth releases were observed. In both
instances, staff adhered to the center’s established policies and procedures, ensuring a
compliant release process.
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2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures to ensure all personal property, to include
medication, is accounted for and properly released. Three closed youth case management
records were reviewed, and each youth and parent/guardian signed a Property Receipt Form
upon release. There was documentation verifying each youth was released to an appropriate
person with a copy of their identification maintained in the youth’s record. None of the youth
were released with medication. Each youth and person they were released to were reminded of
any health or welfare issues, including, medical, mental health, and/or substance abuse needs
and any pending appointments. An example of properties held for more than thirty days during
the annual compliance review period was reviewed and confirmed the center was following their
disposal process. During the annual compliance review week, two youth releases were
observed. Both youth were released to authorized individuals, verified through photocopies of
identification. Neither youth was released with medication. Property Receipt Forms were signed
by each youth and their parents/guardian to acknowledge the return of personal belongings.
One youth received property which had been securely stored in the drop safe. Additionally,
both youth and their parents/guardian were provided information regarding future court dates.
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 to ensure weekly Detention Review meetings are
conducted as required. The superintendent designates the Detention Review specialist to
oversee and coordinate the meetings. During the annual compliance review week, a Detention
Review meeting was observed, and the detention secure log was reviewed. Documentation
confirmed all required participants were present, either in person, by telephone, or through
virtual conferencing. Documentation supported completion of required elements for the meeting.
A review of Detention Review documentation from the annual compliance review period was
conducted and confirmed Detention Review meetings were held weekly as required.
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2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures addressing the daily activity schedule. The center’s
daily activity schedule includes daily expectations in accordance with the behavior management
system, education, mealtimes, visitation, indoor and outdoor recreation, shift changes,
bedtimes, groups, and open center time. The center provides and maintains weekday,
weekend, and holiday schedules. Observations during the annual compliance review week
confirmed schedules were posted throughout the center along with a monthly activity calendar.
Visitations are held twice a week. During the morning and early afternoon hours, youth are
participating in education. Reviewed documentation reflected activities included behavior
management incentive parties and a variety of recreational activities. A review of the center’s
logbook and observations of education and other daily activities confirmed the center adheres to
the daily activity schedule.
Seven youth and seven staff were interviewed, and each reported the center has a daily
schedule which 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 is provided. The
center integrates education into the daily schedule with the required minimum instruction time
distributed over twelve months. The district-approved calendar and daily school schedule were
reviewed, which incorporated the required 250 days of instruction, with ten days used for
teacher planning, and a minimum of twenty-five hours of weekly instruction. The school
approved bell schedule has a start time of 8:00 a.m. and ends at 2:00 p.m. on Monday through
Thursday. On Friday, there is a start time of 8:00 a.m. and an end time of 1:45 p.m. The center’s
video system was experiencing perpetual issues with the playback feature; therefore, no video
was able to be reviewed during the annual compliance week. A sample of logbook entries were
reviewed. School started in accordance with the approved school district schedule on all
reviewed days.
Seven youth were interviewed, and six indicated they attend school Monday through Friday; the
remaining youth indicated school was not attended daily. Three of the seven youth indicated
education, and vocational services are preparing them very well; two youth said good; and the
remaining two youth reported not well. Youth with negative responses indicated the work is not
challenging and the education is not engaging.
Seven interviewed staff confirmed there is minimal interference with educational instruction.
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The superintendent interview also confirmed there is minimal interference in educational
instruction.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to ensure career education is provided. Career
educational services are provided through the local school board. The center provides
vocational competency development programs for all youth to include communication,
interpersonal, and decision-making skills. Youth are enrolled in academic courses through the
local school board.
Seven youth were interviewed. Five youth confirmed they receive career choices, math,
science, and reading; four youth confirmed receiving life skills and history; and one youth
confirmed receiving social studies and general education diploma preparation.
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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 designated a single licensed mental health counselor (LMHC) as the designated
mental health clinician authority (DMHCA). The DMHCA is on-site for forty hours a week to
coordinate and implement the mental health and substance abuse services in the center, as
indicated by the job description, and as contractually required. The DMHCA’s license expires on
March 31, 2027. No other DMHCA was utilized during the annual compliance review period.
The back-up DMHCA is also a licensed mental health counselor, whose license expires on
March 31, 2027.
The DMHCA was interviewed and stated all mental health professionals are employed by an
outside provider; however, are oriented to the Department’s facility operating procedures,
practice standards, and they receive regular supervision from the DMHCA. The DMHCA and the
superintendent are responsible for overseeing and consistently implementing mental health
services to youth in detention. The DMHCA provides consistent monitoring of the services
provided and the Department’s senior behavioral analyst provides center audits to ensure
appropriate delivery of services. Clinical staff offer crisis management, individual counseling,
group counseling, and family counseling as needed and requested, and the DMHCA provides
daily, weekly, and as needed communication with clinical staff.
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 designated mental health clinician authority (DMHCA) ensures all licensed clinical staff
working under their supervision are performing services they are qualified to provide based on
education, training, and experience. All licensed clinical staff were licensed under the
appropriate Florida Statutes chapter and copies of the licenses were available on-site. The
center has one licensed mental health counselor (LMHC) who is the DMHCA, one part-time
licensed clinical social worker (LCSW), and one Pro Re Nata (PRN) LMHC. The DMHCA works
forty hours a week at the center and the LCSW works forty hours a week splitting the hours
between this and another center. All three licensed clinical staff have licenses expiring on March
31, 2027. The contract requires two full-time licensed staff to be at the center as well as two
traveling PRN licensed staff a region for back-up to the DMHCA. At the time of the annual
compliance review the center was missing one full-time licensed clinical staff. The staff had
terminated employment on August 20, 2025, the week prior to the annual compliance review.
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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 provider’s contract does not require any non-licensed clinical staff, and they did not have
any non-licensed clinical staff during the annual compliance review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
Seven reviewed electronic medical records (EMR) indicated six of the seven youth were
transferred from another detention center, and one was a newly admitted youth. In all seven
EMRs the staff reviewed the Massachusetts Youth Screening Instrument-Second Version
(MAYSI-2) and the Suicide Risk Screening Instrument (SRSI). In all seven EMRs the SRSI was
completed in the Department’s Juvenile Justice Information System (JJIS) upon intake. One of
seven had a MAYSI-2 completed in JJIS, the remaining six youth were transferred from another
center and did not require a new MAYSI-2. In all seven EMRs the nurse and mental health staff
completed the required sections of each SRSI and included an accurate referral selection in the
“Screening Results” section. Five of the seven youth had positive responses on the SRSI and
were placed on suicide precautions, and a mental health referral was completed, which
documented each youth's need for an Assessment of Suicide Risk (ASR). One of the remaining
two youth was also placed on suicide precautions and a had a mental health referral completed,
which documented a need for an ASR. The center indicated the staff did not mark the youth’s
prior suicide alerts on the Suicide Risk Screening. The remaining youth did not have any hits for
suicide. Five youth SRSI screenings included a “yes” response when youth had any open or
closed suicide risk alerts in JJIS, as prompted within the JJIS SRSI navigation screen in red
font. One of the remaining two was not marked correctly on the SRSI and should have had “yes”
responses. The remaining youth did not have any “yes” responses. One of the seven youth had
all negative responses, and the screening was marked as “invalid”, and the youth was referred
for a comprehensive assessment on the MAYSI-2 referral section. The six remaining youth did
not receive a MAYSI-2 screening due to being transferred from another center. In all seven
EMRs the results of the SRSI and/or MAYSI-2 indicated a need for further assessment, a
referral was made to the center’s clinical staff, and the superintendent/designee was notified. In
the one applicable EMR the youth’s MAYSI-2 indicated an elevated suicide risk subscale, the
youth was placed on suicide precautions and referred for an ASR.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Seven electronic medical records (EMR) were reviewed. All seven youth were identified after
admission as requiring a mental health and substance abuse evaluation, and each was referred
to the center’s provider. Five of the seven youth had not been at the center long enough to
receive an evaluation; therefore, one more example was provided by the center. All three
reviewed applicable EMRs contained an updated mental health and substance abuse
evaluation completed within thirty-one days of admission. In all three records, the treatment
recommendations were made, which corresponded to all diagnosed mental health or
substance-related disorders. None of the evaluations were completed by a community provider.
During the interview, the designated mental health clinician authority (DMHCA) stated the intake
screener refers any youth who has areas indicating further need for assessment, as well as
overrides on the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2), to the
assigned juvenile probation officer (JPO). The JPO is responsible for ensuring the
comprehensive assessment is completed. The DMHCA attends biweekly audit meetings, and
once the assessments are received, is responsible for providing them to the clinical team. The
DMHCA said during the length of stay a youth's behavior may warrant the need for an
assessment or additional information may have been acquired addressing the need for further
mental health or substance abuse evaluation. Information may be gathered from detention staff,
medical staff, education staff, parents/guardians, youth, or a mental health professional.
Detention audits provide the opportunity to share this type of information and address the need
for a youth to have a comprehensive assessment. JPOs will then make a referral for the youth
to receive an assessment, and clinical staff will file each assessment upon receipt. In cases
where there is an immediate need, clinical staff complete a new comprehensive assessment
where they are required to incorporate information obtained from all collateral sources, as well
as an interview with the youth.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
Seven electronic medical records (EMR) were reviewed, and four youth received a mental
health orientation within fourteen days of admission. The remaining three youth had not been at
the center long enough. Three of the seven youth required an Initial Treatment Plan, which was
completed within seven days of the onset of treatment. All three plans were developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form and included the
reason for referral for treatment, the initial Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnosis/symptoms, initial treatment goals, and the initial
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treatment methods encompassing counseling and frequency. One of the three youth required
psychiatric services including psychotropic medication and frequency of monitoring, which was
part of the Initial Treatment Plan; however, the plan was missing the medication the youth was
admitted with to the center. All three plans were signed by a mental health and substance abuse
professional, and each youth. All three applicable youth were assigned to a mini-treatment team
and all members were involved in the development of the Initial Treatment Plan. Two of the
three youth had been at the center long enough to require an Individualized Treatment Plan;
therefore, one more example was requested. All three applicable youth had an Individualized
Treatment Plan developed by the thirty-first day of their admission, which included the DSM-5
diagnosis, symptoms which were treatment-focused, treatment goals addressing mental health
and/or substance abuse services, and strength and needs. Two of the three youth were taking
psychotropic medications and in one the psychotropic medications listed in the Initial Treatment
Plan matched the psychotropic medications the youth was prescribed at the time the
Individualized Treatment Plan was developed. The other youth’s Initial Treatment Plan did not
include the psychotropic medications the youth was admitted with; therefore, could not be
compared. All three reviewed EMRs had progress notes validating each youth was receiving
treatment services as stipulated on the treatment plan. All three Individualized Treatment Plans
were signed and dated by youth, mental health and substance abuse professional, and
treatment team members. Two plans stated the parent/guardian was involved; however, they
did not sign. The third youth was eighteen years old. One of the three youth had been at the
center long enough to receive treatment plan reviews; therefore, two more examples were
requested. In all three applicable EMRs the Individualized Treatment Plan was reviewed every
thirty days by the treatment team and modifications were documented on the review form. Each
Individualized Treatment Plan review was signed and dated by clinical staff/licensed mental
health professional and youth. Two of the three documented parent/guardian involvement in the
reviews; however, none were signed. The third youth was eighteen years old. Two of the three
plans included treatment and services provided by a licensed psychiatrist; the third youth did not
require those services. None of the youth were an alleged victim of a Prison Rape Elimination
Act (PREA) event.
Three closed EMRs were reviewed. All three discharge plans were documented on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form and
completed upon each youth’s transition/discharge. A copy of the Mental Health/Substance
Abuse Treatment Discharge Summary was provided to each youth, parent/guardian, and
juvenile probation officer (JPO). All documentation practices were adhered to, including
completion on the day of service, signed by a licensed mental health professional, and any
additional documentation was uploaded within fourteen days.
A mini-treatment team meeting could not be observed during the annual compliance review
week due to treatment team meetings being conducted on Friday afternoon when the team was
no longer on-site.
An interview with the designated mental health clinician authority (DMHCA) stated the DMHCA
is responsible for working in conjunction with administration to ensure the provision of services.
The DMHCA and superintendent have an open-door policy and meet as needed. The DMHCA
oversees services provided by the mental health team and reviews documentation, as well as
consults with the team prior to removing any youth from precautionary observation or
transitioning from close to standard supervision. The DMHCA attends department head
meetings weekly, as well as detention audits, which offer opportunities to address any concerns
with administration in reference to mental health services. The DMHCA also consults with the
provider’s clinical director to address quality of services and service provision, as well as the
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Department’s senior behavioral analyst, who performs quarterly on-site reviews of services by
auditing charts. The Individualized Treatment Plan is reviewed with each youth during treatment
team every thirty days to identify progress made or not made, and to explore the need for
updated or new goals to their treatment plan.
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 electronic medical records (EMR) were reviewed. Two of the seven youth required
treatment. One more example was provided. All three applicable youth required treatment and
were assigned to a mini-treatment team. Each mini-treatment team consisted of the required
members. All three youth required mental health treatment and received individual, group, or
family counseling provided according to the frequency of their treatment plan. All plans included
individual, group, and/or family therapy prescribed at least weekly, as well as substance abuse
treatment, and all youth received the counseling according to frequency required by each plan.
Two of the three youth had an Authority for Evaluation and Treatment, and the third youth had a
court order maintained in the EMR. All three had the proper consent obtained for substance
abuse treatment through the signed Department form. Two of three records required and had
signed consent for release of information. All three EMRs contained treatment notes
documented on the Department’s Counseling/Therapy Progress Notes.
Video Observation could not be conducted due to the center’s video system being non-
operational during the annual compliance review week. Mental health staff have adequate
access to youth and confidential space to provide treatment services, and a review of records
confirmed group therapy was limited to fifteen or fewer youth.
Seven youth were interviewed. One rated the mental health and substance abuse services at
the center as fair, two as good, two as very good, and two stated they had never received any
services. Two youth mentioned the center was better than other centers, and one stated staff
are consistent and helpful. One youth stated it was hard to get a hold of the mental health staff,
but the therapist does sit down and talk to youth, which is nice.
The designated mental health clinician authority (DMHCA) interview stated the individualized
mental health treatment planning begins with reviewing and collecting data, including
information from each youth's record, comprehensive assessment, current Clinical Psychotropic
Progress Notes (CPPN), parent/guardian, and youth input. Treatment of mental health issues is
multi-disciplinary in nature and can include individual counseling, crisis intervention, and psycho
pharmacological intervention. After data is collected, the DMHCA and each youth discuss the
Individualized Mental Health Treatment Plan, and the youth is given an opportunity to add,
change, or delete items in the plan. Signatures from each youth and parent/guardian are
obtained, if available. Substance abuse treatment planning includes identifying the type of
substance, frequency, and duration of use, as well as age of onset of use. Concerns of
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detoxification are discussed with the nurses, when applicable. The sources used to develop
each treatment plan include data obtained from the substance abuse evaluation, collected from
the parent/guardian, and youth input. Treatment may target any present denial, relapse
prevention, and exploring the need for more formal substance abuse treatment. The center
provides crisis management, individual counseling, group counseling, and family counseling, as
needed and/or requested.
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 facility operating procedures addressing a Suicide Prevention Plan. The plan
details suicide prevention procedures and was reviewed and signed by the designated mental
health clinician authority and superintendent annually. The plan includes identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
referral, communication, notification, documentation, immediate staff response, and a review
process as referenced. The center has an established review process for every serious suicide
attempt or serious self-inflicted injury and conducts a mortality review for any completed suicide.
The multidisciplinary review includes circumstances surrounding the event, center procedures
relevant to the incident, all relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, and recommendations.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Six of seven reviewed electronic medical records (EMR) were applicable for suicide
precautions. The remaining one youth was not applicable. All six applicable youth were
determined to be at risk during the admission screening process. One of the six youth was also
identified at risk while at the center. Two of the six youth had two events to place them on
precautionary observation (PO). All six youth received an Assessment of Suicide Risk (ASR)
which documented an assessment of the youth on the day of service. In six of the eight events
the Suicide Precautions Observation Logs were completed in their entirety. One youth was not
on PO long enough to document on the log. The other youth was on PO and close supervision
for fifteen days and was missing ten thirty-minute checks. All eight events involved a mental
health professional, and staff documented a consultation with the designated mental health
clinician authority (DMHCA) or licensed mental health professional on the Mental
Health/Substance Abuse Referral Summary for each. None of the youth were released prior to
receiving an ASR. In all eight events the superintendent or designee was immediately notified of
each youth’s suicide risk, and an ASR was completed within twenty-four hours. One of the
seven youth required a follow-up ASR on multiple occasions. The youth received a follow-up
ASR prior to removal from PO and the discontinuation of close supervision was documented in
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accordance with the center’s Suicide Prevention Plan. In all seven EMRs documentation
indicated a conference was held by the superintendent and licensed mental health professional
to reduce level of supervision. All ASRs were completed by a licensed mental health
professional and included the recommendations for supervision and follow-up. Each event had
evidence in the center’s logbook and on the ASR showing administration or supervisory staff
provided specific instructions related to the ASR findings and suicide precaution decisions,
when applicable. A review of the Department’s Juvenile Justice Information System (JJIS)
determined alerts were appropriately entered and removed following youth removal from PO for
each youth. A review of the logbooks determined beginning and ending times were documented
for youth placed on precautions.
The interviewed DMHCA stated screeners from the Department complete the initial sections of
each Suicide Risk Screening Instrument (SRSI). Each SRSI is then passed on to the intake
officers and on-duty supervisor for their review and recommendation. One copy is given to
mental health who then completes the final section of the SRSI and proceeds with any
recommendations or requirements as appropriate. Screeners also complete the Massachusetts
Youth Screening Instrument-Second Version (MAYSI-2) with each youth at intake, which is also
passed on to intake staff and on-duty supervisors, and then to mental health to review and
proceed with any recommendations or requirements as needed. Mental health staff also review
each youth’s Community Assessment Tool (CAT) for indications of suicide risk. When suicide
risk is indicated mental health staff will complete an ASR. The DMHCA stated staff are trained
on signs and symptoms of at-risk behavior for suicide. If any youth exhibits any of these
signs/symptoms, or present with at risk "hits" on the screening instruments, staff increase the
youth’s supervision level and informs the shift supervisor. A referral is made to the mental health
professional, and youth status is noted in the logbook and on the population board. The DMHCA
is on-call twenty-four hours a day seven days a week and can be contacted by telephone for
further instructions including an increase in supervision level or even Baker Act, as needed.
Mental health staff are notified through JJIS when a SRSI/MAYSI-2 indicates any hits. If a youth
exhibits suicide risk behaviors or is identified at intake as a potential suicide risk, the youth is
placed on PO until an ASR is completed. Detention staff are notified in writing through logbook
entries, receiving precautionary/secure observation log forms, through briefings, and by the
previous staff on the module. Communication of supervision levels is documented in the
logbook, as well as the ASR and EMR. The youth’s parent/guardian and juvenile probation
officer (JPO) are contacted anytime a youth’s supervision level is raised during their stay at the
center. If a potentially suicidal youth is scheduled for either release or transfer, it is the
responsibility of the juvenile justice detention officer supervisor to inform the parent/guardian or
receiving facility of the youth's status and any current mental health concerns. These
notifications are documented in the youth’s record. The DMHCA or licensed clinician meets
weekly with the psychiatrist. The psychiatrist is on-call twenty-four hours a day and seven days
a week for any emergent needs.
Seven youth were interviewed. Five stated they had been placed on suicide watch while at the
center and said they were always supervised. Two stated they had not been placed on suicide
watch.
Seven staff were interviewed. All stated if a youth expresses suicidal thoughts staff have to
notify the DMHCA, five also stated they are required to document supervision and provide
constant sight and sound supervision, and three also mentioned they speak to the youth about
what is bothering them.
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3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
One of seven reviewed electronic medical records (EMR) were applicable. Two more were
requested. In the three applicable EMRs each youth placement in secure observation was
authorized by the superintendent and designated mental health clinician authority (DMHCA) and
the secure room was designated in writing. In two of the three EMRs the Health Status Checklist
was done prior to placement in secure observation and the Suicide Precautions Observation
Logs were completed in their entirety. In the remaining one EMR the Health Status Checklist
was not completed, and the Suicide Precautions Observation Logs were done; however, one
log was missing one check, and one check was missing staff initials. In all three EMRs a new
Assessment of Suicide Risk (ASR) was completed within eight hours of placement or the next
morning. Two of the three EMRs documented a parent/guardian was notified of a youth’s
potential suicide risk as indicated by an ASR and this was documented on the ASR. The
remaining youth was eighteen years old. In all three applicable EMRs a juvenile probation
officer (JPO) was notified of a youth’s potential suicide risk as indicated by the ASR and
documented on the ASR. In one of the three EMRs the youth remained on secure observation
beyond twenty-four hours, and a mental health professional provided written support for
continuation. In all three EMRs mental health staff provided supportive counseling services
during secure observation status, the level was reduced only after conference with the
superintendent/licensed mental health professional, and the discontinuation of secure
observation and step-down to close supervision was documented in the center’s logbook and in
each youth’s EMR by a mental health clinical staff.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Six of seven reviewed electronic medical records (EMR) were applicable. In five of the six
applicable EMRs the Suicide Precautions Observation Logs were maintained for the duration
each youth was on suicide precautions, and the appropriate level of supervision and
observations of each youth’s behavior was documented in real time and not exceeding thirty-
minute intervals. The remaining youth was on precautionary observation (PO) for fifteen days
and was missing ten checks. All applicable EMRs documented when warning signs were
observed, notification was made to the superintendent/designee and mental health clinical staff
and documented on the Suicide Precautions Observation Logs, as well as all logs being
reviewed and signed by each shift supervisor and mental health clinical staff. All logs
documented safe housing requirements.
Video observation could not be conducted during the annual compliance review week due to the
video system being out of order.
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3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures to ensure all staff have suicide prevention training.
A review of seven pre-service and seven in-service staff training records indicated training
included suicide drills held quarterly on each shift. The center had six suicide response kits co-
located with first-aid kits. The kits were located in master control, training room, emergency
medical bag in the clinic, and one in each of the three modules. Video review of suicide drills
could not be conducted due to the video system not working during the annual compliance
review week.
The center conducted mock suicide drills held no less than quarterly on each shift, for all staff
who come in contact with youth. The mock mental health drills were in response to a suicide
attempt and/or incident of serious self-injury and no youth were used in the simulations. The
center provided semi-annual training on emergency response procedures which included mock
training in emergency response to a suicide attempt or incident of serious self-inflicted injury
and included the use of cardiopulmonary resuscitation (CPR). Staff who are not present during
a quarterly drill have the opportunity to review each drill scenario and procedures in an effort to
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or incident of serious self-inflicted injury in the center. Seven staff were interviewed and
stated the suicide response kits are located in master control, five also said in the sub control
room, three in medical, one in shift supervisor office, one in modules, and one in training room.
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 including notification and alert system, means of referral, as well as self-referral,
communication, supervision, and documentation and review.
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3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures (FOP) regarding the process for emergency mental
health and substance abuse services. The center’s Emergency Care Plan includes immediate
staff response, notifications, communication, supervision, authorization to transport for
emergency mental health or substance abuse services, transport for Baker Act or Marchman
Act, documentation, training, and review. The plan was approved and last updated on August
13, 2025. The plan is located in the FOPs in the training room, in master control, administration
offices, supervisor office, and the K-drive on the computer. All staff receive training on the plan
during pre-service training and then twice a year during all-staff meetings. The plan is available
to staff at all times.
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 youth in crisis are provided proper
services. None of the seven reviewed electronic medical records (EMR) were applicable. The
center had only one example during the annual compliance review period. In the one applicable
EMR the Crisis Assessment included reason for assessment, mental status examination and
interview, determination of danger to self/others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up or further
evaluation, and notification to parent/guardian of follow-up treatment. A mental health alert was
entered into the Department’s Juvenile Justice Information System (JJIS) when the youth was
placed on precautions after completion of the Crisis Assessment. The youth was identified by
direct care staff or clinical staff as having acute emotional or behavioral problems, or acute
psychological distress. The Crisis Assessment was conducted by a licensed mental health
professional within twenty-four hours based on the needs of the youth. The youth was not an
alleged victim in a Prison Rape Elimination Act (PREA) event.
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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 facility operating procedures to ensure immediate services are provided for
youth in imminent danger of self-harm or harm to others. None of the seven reviewed electronic
medical records (EMR) were applicable. The center had only one example during the annual
compliance review period. In the one EMR, while pending off-site transport, a suicide risk alert
was opened, and the youth was placed on one-to-one supervision. The supervision was
documented on a precautionary observation (PO) log until the youth’s authorized release. The
youth was placed on suicide precautions upon readmission from the Baker Act and a mental
health referral was completed for a mental status examination (MSE). The MSE was completed
by a licensed mental health professional and the youth was maintained on a minimum of
constant supervision until properly transitioned to a lower level of supervision. In the one EMR
the youth’s supervision level was maintained until an appropriate assessment was conducted
and licensed mental health staff conferred with the superintendent or designee. The youth had a
suicide risk alert entered in the Department’s Juvenile Justice Information System (JJIS) and the
discontinuation of the alert and precautions were based upon an Assessment of Suicide Risk
(ASR).
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures (FOP) ensuring there is a contract agreement with
a licensed physician to serve as the designated health authority (DHA). The center maintains a
contract with VitalCore Health Strategies, LLC., (VitalCore) which subcontracts with a medical
doctor (MD) to serve as the center’s DHA. The DHA ensures all medical and mental health
policies and protocols are reviewed and signed annually, and ensures all appropriate medical
staff receive training on all medical policies. The DHA holds an unrestricted license which
expires on January 31, 2027, and meets all requirements for independent and unsupervised
practice in the State of Florida. The DHA has specialty training in family practice. The DHA is
clinically responsible for the medical care of all youth. A review of the center’s sign-in logs for
the DHA for the past twelve months during the annual compliance review period found the DHA
was on-site once a week as contracted. The center utilizes an autonomous advanced practice
registered nurse (APRN), who holds an unrestricted license in the state of Florida, with an
expiration date of July 21, 2026. The APRN has Collaborative Practice Protocols in place with
the DHA, and copies are maintained on-site. The DHA and APRN signed the collaborative
agreement on June 24, 2025. The APRN was utilized for two weeks during the annual
compliance review period. The center’s APRN serves as the DHA designee for clinical services
and provides additional clinical services to youth at the center. The DHA has both verbal and
written communication with medical and non-medical staff at the center and is available twenty-
four hours a day, seven days a week. While on-site the DHA provides medical services such as
reviewing and signing medical FOPs and completing admission assessments, periodic
evaluations, and sick calls if needed. The center does not utilize a physician assistant. The
center has a back-up DHA through their contract with the medical provider, who holds an
unrestricted license in the state of Florida, with an expiration date of January 31, 2027. The
back-up DHA provides coverage when the DHA is on scheduled absences or vacation and was
utilized three weeks throughout the annual compliance review period. The center maintains a
tele-medicine policy; however, there were no instances of tele-medicine utilized during the
annual compliance review period. The DHA interview confirmed their role in providing youth with
comprehensive physical assessments (CPA), sick call care, episodic care, and periodic
evaluations. The DHA confirmed being on-site one day each week and being available to staff
twenty-four hours a day and seven days each week. The DHA explained how off-site care is
entered in electronic medical records (EMR) and instruction and information is reviewed by a
designee. The DHA reported communication with staff regarding medical needs is done through
telephone calls, email, and EMRs. The DHA described the formalized procedure in place to
review medical issues pertaining to youth and explained how coverage is arranged by VitalCore
while they are on vacation or scheduled absences. The DHA did not have any concerns with the
healthcare at the center.
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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 (FOP) for all utilized health related procedures and
protocols. The designated health authority (DHA) documented their review with a signature and
date on the medical FOP on July 9, 2025. The center’s contracted psychiatrist documented their
review with a signature and date on the medical FOPs and other protocols related to psychiatric
services and psychotropic medication management on July 25, 2025. Reviewed documentation
supported the superintendent signed and dated the updated medical FOPs and treatment
protocols on August 26, 2025, during the week of the annual compliance review. Reviewed
documentation validated the registered nurse (RN) manager and three full-time RNs
documented their review of the center’s healthcare FOPs and protocols on a cover page on July
22, 2025 and July 9, 2025. Two part-time RNs had not signed the FOPs and protocols. The
program indicated the two part-times RNs would sign the FOPs and protocols on their next
scheduled shifts. All newly employed healthcare personnel received a comprehensive clinical
orientation to the Department’s healthcare policies and procedures, given by a RN. The
approval of treatment protocols or standing procedures were written and authorized by the DHA.
Each new nurse received a comprehensive clinical orientation to the Department’s healthcare
policies and procedures. Any time there were changes to the policy and procedures each nurse
reviewed the update and signed the signature page apart from the two part-times RNs.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures ensuring parents/guardians are afforded the right to
give or withhold consent regarding the healthcare provided to youth while at the center. A
review of seven youth Individual Healthcare Records (IHCRs) found six were applicable for
requiring a signed Authority for Evaluation and Treatment (AET). The remaining youth was over
the age of eighteen at admission to the center and an AET was not required, as the youth is
responsible for authorizing their healthcare and authorizing release of their healthcare
information. All six AETs were valid and had the word “copy” stamped on them. The six
applicable AETs were signed by a parent/guardian and a Department representative. None of
the youth were in the custody of the Department of Children and Families. Each applicable
youth’s AET was obtained prior to providing medical services to the youth. The interviewed
nurse indicated three attempts are made to contact a parent/guardian to sign an AET, if needed,
if there is no response an email is sent to the juvenile probation officer (JPO) to contact a
parent/guardian to obtain a new AET. If Department custody has ended for a youth, a new AET
is required. The nurse stated if a youth is eighteen years of age or older, the youth is
responsible for authorizing their healthcare and authorizing release of their healthcare
information. In addition, the youth can give verbal consent and sign for treatment and/or
medications.
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4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures which require notification to be made toa
parent/guardian when there are any significant changes in a youth’s condition and to obtain
consent when new medication or treatments are prescribed. A review of seven youth Individual
Healthcare Records (IHCRs) found five youth were applicable for parent/guardian notifications,
as one youth was eighteen years of age, and the remaining youth did not receive any
medications while at the center. Four youth were applicable for prescribed over the counter
(OTC) medications not covered by the Authority for Evaluation and Treatment (AET). Three of
the four IHCRs included documentation showing a parent/guardian was notified of OTC
medications beyond those covered by the AET being prescribed, and consent was given for
each. In the remaining IHCR there was no documentation of parent/guardian notification or
consent. Three of the five applicable IHCRs contained documentation showing parent/guardian
notifications were sent using the required Department forms with a request to obtain signed
parent/guardian consent. One youth has not been ordered any new medications since
admission, and the remaining youth’s parent/guardian was not notified in writing of OTC
medication beyond those covered on the AET. Two of the five applicable youth were taking
psychotropic medications at admission. Both IHCRs included documentation indicating a staff
witnessed all telephone call attempts and conversations for psychotropic medications. None of
the reviewed youth were applicable for parent/guardian notifications for vaccinations or
immunizations. Four of the five applicable IHCRs had new medication ordered and there was
documentation of attempted contact to the parent/guardian in the progress notes for three. The
was no documentation of attempted parent/guardian contact for the remaining youth. None of
the youth were applicable for having a new psychotropic medication being prescribed or
discontinues, or the drug dosage being significantly changed. None of the youth were in the
care of the Department of Children and Families, where there was a termination of
parent/guardian rights.
Seven IHCRs were reviewed for vaccine verification. Six of the seven youth’s vaccines were
verified within thirty days of their admission; the remaining youth had not been at the program
for thirty days. None of the youth were applicable for being administered a vaccination or a
religious exemption for vaccinations. An interview with the nurse indicated parent/guardian
notification is made upon arrival to facility, in the event of emergency and when being sent out
for off-site care, when OTC medications are prescribed in nursing protocol not covered in the
AET, changes in condition or chronic health, vaccines/immunization, significant changes to
existing conditions, discontinuation of medication, surgical procedures, and dental services
other than evaluations. The nurse stated notifications are made as soon as possible, as soon as
the medication is prescribed by the doctor, or in the case of injury in the facility, as soon as the
youth is stabilized, they contact the parent/guardian. Within twenty-four hours, nurses make all
necessary attempts to contact a parent/guardian if a notification is required. The nurse was able
to explain the procedures regarding informing a parent/guardian whenever a new psychotropic
medication is prescribed, dosage is significantly changed, or is discontinued. The nurse was
able to explain the procedures staff are to follow when a medical emergency arises.
Immunization records are obtained and verified through the Florida Shots website and are
reviewed upon a youth’s admission. When a parent/guardian presents a certified documentation
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of exemption from immunization, nursing staff and the designated health authority (DHA) will
review and upload the document in the youth’s Electronic Medical Record (EMR).
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures which require each youth, at the time of admission,
to receive a medical and mental health admission screening on the Department’s Medical and
Mental Health Admission Screening Form in the Department’s Juvenile Justice Information
System (JJIS). A review of seven youth Individual Healthcare Records (IHCRs) found each
contained a screening form completed on the date of admission by a juvenile justice detention
officer (JJDO). All seven forms were reviewed with the youth by a licensed medical staff within
twenty-four hours, as required. In all seven IHCRs a notification to the designated health
authority (DHA) was documented. One reviewed youth was applicable for requiring a
rescreening, so two additional records were requested. The center completed a Healthcare
Admission Rescreening Form each time a change of custody occurred for all three youth. Two
of the three rescreens were completed by a JJDO and both were reviewed with the youth by a
licensed medical staff within twenty-four hours, as required. None of the three youth were
applicable for a qualitative urine pregnancy screening test. An interview with nursing staff
confirmed youth are seen shortly after the intake process occurs: each youth showers and is
then sent to the medical clinic within twenty-four hours. The nurse indicated nursing staff are
notified of a youth admission by an intake packet being sent to the medical clinic and checked
upon medical staff arrival. Intake staff complete each initial admission screening, and a nurse
signs, prints, dates, and times all screening forms while youth are present for accuracy.
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, including all required topics, requiring all youth to
be oriented to the general healthcare delivery services at the center. A review of seven youth
Individual Healthcare Records (IHCRs) supported each contained a completed Department
Health Education Form documenting the youth’s orientation to the center’s healthcare services.
Each youth received a general healthcare orientation on the day of admission to the center.
Reviewed documentation supported each youth’s orientation included all required elements
including chronic medical condition education. Additionally, youth are oriented on the non-
disciplinary role of the healthcare providers, the list of availability of healthcare staff, dental
hygiene, sexually transmitted infections, personal hygiene, immunizations, infection control,
nutrition, self-examinations, and a review of healthcare contacts.
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4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures which require notification to the designated health
authority (DHA) of all youth admitted with chronic health conditions or youth in need of
emergency care. A review of seven Individual Healthcare Records (IHCRs) indicated there were
no youth h identified with a suspected chronic medical condition upon admission. There were no
youth identified as in need of emergency care upon admission. Each of the seven youth records
documented the DHA/designee was notified of the youth’s admission and the notification was
documented on the nursing admission chronological notes in each IHCR. Three youth were
taking psychotropic medications at the time of admission and the psychiatrist was notified for
each. An interview with nursing staff reported when a youth is admitted with a serious or chronic
condition, the nurse contacts the DHA by telephone within twenty-four hours, and the
information is documented on the intake log.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures requiring completion or review and updating of the
Department’s standard Health-Related History (HRH) form for each youth upon admission. A
review of seven youth Individual Healthcare Records (IHCRs) confirmed an HRH form was
updated/completed for each youth within seven days of admission. Two of the seven HRH
forms were completed prior to the Comprehensive Physical Assessment (CPA) being
completed/updated. The remaining five youth were not applicable for CPA completion/updates
as they were transferred from another facility. Each HRH was completed or updated by a
licensed nurse or practitioner. All seven HRH forms were reviewed by the designated health
authority (DHA) or advanced practice registered nurse (APRN) and were maintained in each
youth’s IHCR. The nursing interview confirmed each HRH is completed by licensed healthcare
staff within twenty-four hours.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures requiring a Comprehensive Physical Assessment
(CPA) form to be completed or updated for all applicable youth admitted to the physical custody
of the center to determine the health and well-being of each youth. A review of seven youth
Individual Healthcare Records (IHCRs) found one youth had a CPA completed within seven
days of admission. One youth had a current CPA on file, the current CPA was reviewed as the
youth was examined, as evidenced by the designated health authority (DHA) signature, and a
focused evaluation was completed. The remaining five youth had a current CPA on file;
however, they did not require an update, as they were transferred from a different facility where
their CPA was completed/reviewed. Each of the CPAs were completed in full and included all
required elements. None of the applicable youth refused any portion of the examination. The
Department’s Problem List was updated as needed for each youth. A review of seven youth
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IHCRs validated each youth had a tuberculosis (TB) screening completed within the last year.
There were no applicable youth with any symptoms of active TB in the center at the time of the
annual compliance review. The results of each TB test were documented on each youth’s CPA
and Infectious and Communicable Diseases (ICD) form. During the interview with nursing staff,
it was reported the designated health authority (DHA) completes a new CPA annually, up to
every two years. The nurse was able to describe the process and timeframe for TB screening.
The nurse indicated gynecological exams are not routinely completed for female youth.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures requiring all youth to be evaluated and treated, if
necessary, for sexually transmitted infections (STIs). A review of seven youth Individual
Healthcare Records (IHCRs) indicated two youth were applicable and were screened for STIs.
The remaining five youth were not applicable due to transferring from another program and the
screening not required to be completed. An additional record was requested to meet the
minimum sample of three. Two of three applicable youth required further evaluation, and both
were referred. Each youth’s referral was documented on their STI Form. Both referred youth
were ordered for STI testing. One of the two applicable records contained testing results, clinical
evaluations, and diagnosis which was documented on their ICD form and filed in the lab section
of their IHCR, the remaining record did not contain screening results documented on the ICD
form in the IHCR. None of the youth were applicable for gynecological exam. None of the youth
were out of the Department’s physical custody and/or had symptoms; therefore, a rescreen was
not required for any.
Documentation confirmed two of seven reviewed youth were offered counseling, testing, and
treatment/referral for human immunodeficiency virus (HIV). The remaining five youth were not
applicable due to transferring from another facility. An additional record was requested to meet
the minimum sample size. None of the reviewed records indicated youth received HIV testing.
Seven youth were interviewed, and each stated they can ask for a HIV test. The interview with
nursing staff confirmed STI screenings, evaluations, referrals, and tests are documented on the
Department’s Juvenile Justice System (JJIS) Electronic Medical Record (EMR). All STI
screening are filed in the ICD section, physician evaluations are documented in the
chronological progress notes section, referrals are documented in the physician’s order section,
and testing is documented in the laboratory section. The interviewed nurse indicated additional
rescreening measures are taken when youth have been out of the Department's physical
custody for more than thirty days and/or symptoms present. The nurse reported HIV test results
are filed in the laboratory section of the IHCR.
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4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures regarding the sick call process and sick call
requests. A review of seven youth Individual Healthcare Records (IHCRs) indicated five youth
had submitted sick call requests and each was documented on the center’s Sick Call Referral
Log. None of the applicable youth presented with similar sick call complaints three or more
times within a two-week period. Documentation in each of the five IHCRs indicated each sick
call was conducted by a registered nurse (RN) within twenty-four hours. Each Sick Call Request
form was in the youth’s IHCR in reverse chronological order for each youth. Each form was
completed by a nurse. Three youth were in restricted housing and were applicable for daily sick
call/health complaints checks and these were completed and documented in each IHCR while
each youth was in restricted housing for medical confinement or secure observation. All
applicable sick call events were documented on the Sick Call Index and dates correlated with
each sick call form. Sick call forms documented the nature of the complaint, assessment, and
plan to include subjective; objective, assessment, and plan (SOAP) note format and in
accordance with Florida Administrative Code. The center conducts sick call seven days a week
to respond to youth medical illnesses or injuries of a non-emergent nature by a healthcare
professional. Postings throughout the center indicate sick call takes place seven days a week
from 8:00 a.m. to 10:00 a.m. Shift supervisors and authorized staff are trained by a RN on the
center’s sick call procedures and are to review all sick call requests in the absence of healthcare
staff. Youth who require a sick call will inform staff of their complaint and staff will generate a
sick call request in the Department’s Juvenile Justice Information System (JJIS). When the level
of need for a youth cannot be determined, the on-call practitioner/designated health authority
(DHA) shall be contacted for guidance and referral to the emergency room or off-site emergency
care. The interviewed nurse reported youth notify staff of medical complaints and staff enter a
sick call in JJIS. A nurse checks the sick call list twice a day and then has twenty-four hours to
see a youth. RNs complete sick calls. The DHA will conduct sick calls when on-site. All sick
calls are conducted in the nurse’s clinic daily from 8:00 a.m. to 10:00 a.m., and as needed.
When a youth presents with a similar sick call complaint three or more times within a two-week
period, the youth is referred to the DHA or advanced practice registered nurse (APRN). The
nurse reported the DHA has approved the treatment protocols. A sick call observation was
conducted during the annual compliance review week. The youth was escorted by direct care
staff to the clinic. The RN identified themselves and discussed the nature of the sick call with the
youth. The youth was seen in the medical clinic for privacy which contains an examination table
and equipment to perform sick calls and was examined by the nurse. The direct care staff
always remained in sight of the youth. Seven staff were interviewed, and all staff indicated a
nurse reviews sick calls and conducts sick call. Seven youth were interviewed, three youth
reported they can be seen immediately once they make a sick call request, two reported within
one day, and the remaining two youth stated they never requested a sick call.
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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 (FOP) regarding a comprehensive process of
episodic care, first-aid treatment, and emergency care. Seven youth Individual Healthcare
Records (IHCRs) were reviewed, three were applicable for episodic or first-aid care events.
Each applicable IHCR documented problem-oriented elements which were used to capture
pertinent information pertaining to the nature of each youth’s ailment including identification of
subjective, objective, assessment, and plan (SOAP) elements to address the complaint for each
incident. A review of each applicable youth IHCR indicated the center had no applicable
episodic care events conducted by non-healthcare staff. Each reviewed applicable record had a
documented progress note containing all required elements. None of the three applicable
IHCRs contained an off-site care referral. Two of the three applicable IHCRs contained follow-
up plans for future care, and all three IHCRs had parent/guardian notifications. None of the
applicable youth were required to be placed on the alert list. All three youth received episodic or
first-aid care and licensed healthcare staff documented the care on the Episodic Care Log for
each youth.
The center has nineteen total first-aid kits: one on each of the three dormitories, one in the
supervisor’s office, one in classroom one and one in classroom three, one in the intake office,
one in the staff lounge, one in the training room, one in master control, one in the kitchen, one in
maintenance, and eight kits for transportation. Three of the nineteen kits were opened and
reviewed. Two of the three viewed kits were observed to contain each item from the approved
designated health authority (DHA) list with future expiration dates; the remaining one was
missing one required item and the current approved DHA list. First-aid kits are monitored by
nursing staff, and documentation of monthly checks confirmed this practice.
The center has two automated external defibrillators (AED) located in medical and master
control. Each AED is stored in a cabinet and AED procedures are stored with both devices.
Nursing staff conduct monthly checks for each AED’s batteries and pads. The expiration dates
are recorded and monitored during these checks. Each AED was observed with a green battery
indicator and pads with future expiration dates. Nursing staff conducted a self-test during the
annual compliance review week, and both devices appeared to be working as designed. All
AED batteries and pads were changed during the annual compliance review period.
A review of thirty-two medical drills from the annual compliance review period was conducted.
Due to the center’s video equipment not functioning during the annual compliance review week
no drill stimulations were able to be reviewed. The center conducts medical drills monthly, on
each of the three shifts, to ensure all staff have the opportunity to participate in emergency drills.
A list of emergency numbers was posted for non-licensed and licensed staff, and inaccessible to
youth. The center has staff authorized to administer the epinephrine auto-injector and
documented training by a registered nurse (RN) was reviewed. Fourteen staff training records
were reviewed, and each contained required trainings regarding episodic and first-aid care, as
well as cardiopulmonary resuscitation (CPR).
The center has a policy for the use, access, and inventory of Narcan. There is one box with two
doses of Narcan kept in the medication cart separate from youth medication within a locked
drawer. An additional four boxes, a total of eight doses, is stored in the locked medical closet.
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Each staff with access to Narcan has the required training documented in their staff training
record.
During an interview, nursing staff confirmed the number and location of the center’s first-aid kits
and AEDs. The nurse indicated AED procedures are located with each AED and nursing staff
complete monthly checks to ensure both AEDs are operable. The nurse stated all AED pads
expire August 28, 2025, all AED pads were last changed in August 2024, and the last date both
AED’s batteries were changed was in February 2021. The nurse was able to explain the
process for documenting on-site episodic care which includes entering information into the
youth’s Electronic Medical Record (EMR) in an episodic care progress note. Non-healthcare
staff document first-aid/emergency care utilizing the Report of On-site Health Care by Non-
Healthcare Staff Form. The nurse indicated off-site emergency care is tracked and documented
in the EMR and the Episodic Care Log. The nurse indicated the center’s FOP defines regular
basis for emergency drills with the CPR technique being demonstrated at least once annually.
Medical drill scenarios are dictated by the Department’s Office of Health Services (OHS) and
drills are conducted monthly on each shift. The nurse stated emergency numbers are posted in
the medical office and in master control. Seven staff were interviewed. All seven staff indicated
they can call 9-1-1 if they feel it is necessary. Seven youth were interviewed. Six of the seven
interviewed youth reported the center’s medical services are good and one youth 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.
The center has facility operating procedures to ensure youth identified with chronic conditions
receive regularly scheduled evaluations and necessary follow-up care. A review of seven
Electronic Medical Records (EMR) indicated none were applicable for off-site care. An
additional three records were requested to meet the minimum sample of three. The applicable
three reviewed EMRs indicated each youth required off-site care. In two of the three IHCRs a
Summary of Off-Site Care Consultation Report form was utilized and uploaded in both EMRs.
The remaining one youth did not have a Summary of Off-Site Care Consultation Report form for
the off-site visit. The off-site emergency care was documented on the Episodic Care Log for all
three applicable youth. The three EMRs had parent/guardian notification efforts documented, as
well as the discharge and other applicable documents. In all three there was documentation the
designated health authority (DHA) was notified of the emergency event. In two EMRs the DHA
or designee reviewed and signed/initialed all off-site care findings, instructions, and information.
In the remaining one EMR record the incident occurred a few days prior to the annual
compliance review and the DHA had not been able to review the documentation yet. One of the
three youth required follow-up appointments and those were tracked with the youth receiving
appropriate, timely follow-up care, as needed. The nurse was interviewed and stated youth who
are sent off-site for emergency or first-aid care are documented on the Episodic Care Log.
Hospital orders are reviewed by a nurse and discussed with the physician upon the youth’s
return to the center, they are placed in the DHA binder, and signed by the physician when next
on-site. Nurses track follow-up testing, referrals, and appointments on the appointment
calendar.
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4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures to ensure youth who have chronic conditions
receive regularly scheduled evaluations and necessary follow-up care. A review of seven youth
Individual Healthcare Records (IHCRs) indicated none were identified with a chronic condition
during admission. An additional three records were requested to meet the minimum sample of
three. An informal interview with the registered nurse (RN) manager confirmed the center did
not have any applicable youth with chronic conditions since the last annual compliance review
period. The frequency of periodic evaluations is determined by each youth’s condition, clinical
needs, and clinically appropriate medical standards. Youth are screened during the intake
process for medical conditions warranting periodic evaluations and follow-up care, which no
youth could be identified. The nurse interview stated youth with chronic medical conditions are
seen by the designated health authority (DHA) at least once every ninety days. Youth with
chronic medical conditions are tracked using a medical tracker to ensure youth remain in
compliance with the ninety-day time frame. The DHA reported periodic evaluations for youth
with chronic conditions are tracked every ninety days and nursing staff keep a list.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures to ensure medication is received, stored,
inventoried, and provided in a safe and effective manner. A review of seven youth Individual
Healthcare Records (IHCRs) identified four youth who were taking prescribed medication upon
admission. Documentation located in each youth’s Electronic Medical Record (EMR) found all
medications for each youth admitted to the center with medication were verified.) In each
instance, the designated health authority (DHA) was contacted to obtain an order to resume the
medication.
Six youth were applicable for taking prescribed medication while at the center. Each youth’s
medication had a current, valid order and was administered pursuant to a current prescription.
Anytime a current medication was continued, discontinued, changed, or new ones were ordered
for each youth, the DHA or designee placed an order on the Practitioner Order Form. Two youth
were in restricted housing, and both received daily visits from nursing staff and received all
prescribed medication, as ordered and on time. Five youth were applicable for over the counter
(OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form and all
were administered according to the Practitioner’s Order.
Each reviewed youth was applicable for receiving OTC medications or prescribed medications
while at the center. All medications administered for each youth were documented on the
Department’s Medication Administration Record (MAR), which clearly indicated medication start
and stop dates. Trained non-healthcare staff administered medication only when licensed staff
were not on-site. Youth and staff initials were present on each MAR each time non-healthcare
staff assisted with medication administration. There were no undocumented explanations for
lapses or errors in administered medication for any youth. One of seven reviewed IHCRs did not
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include weekly side effect monitoring documented by nursing staff on MARs. One youth refused
medication, and it was clearly documented on the youth’s MAR, and the youth signed a Refusal
of Treatment Form indicating the refusal. Each youth’s MAR contained all required elements,
with the exception of weekly side effect monitoring for one youth. None of the reviewed youth
required parenteral medication.
A review of youth IHCRs confirmed there were no standing orders for psychotropic medication,
no emergency treatment orders for psychotropic medications, and no pro re nata (PRN) orders
for psychotropic medications. One observation of medication administration was conducted
during the annual compliance review week, and the youth’s verbal consent was obtained prior to
administration of medications. The licensed healthcare staff administered the medication. The
youth was escorted by direct care staff. The medical staff identified themselves and stated why
the youth was there. The same medical staff prepared and administered the medications. None
of the medication was pre-poured from the original packaging or placed in another container for
subsequent administration. The medical staff verified the youth allergy and alert status. Both the
medical staff and youth initialed the MAR, and the medical staff and center’s direct care staff
ensured the medication was swallowed. The interviewed nurse was able to explain the regimen
when a youth is admitted with medication to include medications shall have a current and valid
order. The nurse indicated non-healthcare staff do provide medications and there is a
Department training curriculum which is utilized. The nurse reported morning medication pass is
at 8:00 a.m. and evening medication pass is at 5:00 p.m. Monday through Sunday. Seven staff
were interviewed, three staff indicated they give youth medication, and the four remaining staff
indicated they do not administer medication. Seven youth were interviewed. Six of the seven
youth reported the nurse administers medication and the remaining youth reported not taking
medication.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has a contract with VitalCore Health Strategies, LLC to provide psychiatric services
to include psychiatric evaluations, psychiatric consultations, medication management, and
medical supportive counseling to youth with a diagnosed mental disorder and/or substance-
related disorder. 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, 2027. The center does
have an advanced practice registered nurse (APRN) who works under the clinical supervision of
a psychiatrist who holds a clear and active license with the State of Florida, which expires July
21, 2026. The center utilizes a back-up psychiatrist who holds a clear and active license under
Florida Status 459, which expires March 31, 2026. The center has a facility operating procedure
for tele-psychiatry for medication management but has not utilized it during the annual
compliance review period. A review of seven youth Individual Healthcare Records (IHCRs) was
conducted, and three youth were applicable for psychiatric services. Three youth entered the
center on psychotropic medication and were referred for a psychiatric interview. Each applicable
youth received an initial diagnostic psychiatric interview within fourteen days of admission. 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 (DSM-5), treatment recommendations, prescribed
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medication, frequency of medication monitoring/management, medication name, and
explanation of the need for psychotropic medication All three youth were applicable for an in-
depth psychiatric evaluation within thirty days, and each evaluation was completed within thirty
days and included all required elements. There were no changes to medication for any of the
applicable youth. None of the applicable youth were under the supervision of the Department of
Children and Families. Each of the three youth had documentation of consent for psychotropic
medication as two records included a signed Authority for Evaluation and Treatment, and the
remaining youth was eighteen years of age. The designated mental health clinician authority
(DMHCA) indicated in an interview they met with the psychiatrist weekly and the psychiatrist is
on call twenty-four hours a day for any emergency needs.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center has facility operating procedures to ensure all medication and sharps are securely
stored and routine perpetual inventories are maintained. All medications were observed to be
stored in a designated and locked area, by type of medication (injectable, topical, drops and
liquids). The medication cart was observed to be well-maintained and organized with youth-
specific medication stored separately from stock items. Controlled medication is stored in the
medical cart within a separate drawer inside a locked box. The medication cart is inaccessible to
youth. The center has a refrigerator designated for the storage of medication in the clinic and it
has a lock on the door. The perpetual and monthly inventories were observed to be maintained
of all sharps and stock over the counter (OTC) medications. A shift-to-shift inventory is
conducted for all controlled medications and documented on each youth’s individualized
Controlled Medication Inventory Record as required. Non-healthcare supervisory staff have
received training by a registered nurse (RN) to provide delivery and oversight of medication.
This is only utilized when nursing staff are not on-site. An inventory sample of controlled
substances, OTC medications and sharps was conducted. All three OTC medications and
sharps inventories were observed to be accurate. The center only had two controlled
medications on-site during the annual compliance review week, and both inventories were
observed to be accurate. When an inventory discrepancy is encountered a second count is
immediately conducted, and should the amount remain incorrect administration is immediately
notified and if applicable the Department’s Central Communications Center (CCC) is also
contacted. Expired or discontinued medications are destroyed utilizing drug buster liquid, which
is stored in the secured medical closet, and a log of destroyed medication is maintained in the
medical office.
An interview with nursing staff confirmed the center’s medication inventory, disposal process,
and controlled medication storage. The center has a current agreement with a consultant
pharmacist and a copy of the license is available on-site.
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4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures for infection and exposure control. A review of
seven youth Individual Healthcare Records (IHCRs) was conducted, and each youth’s health
education record verified each received all required trainings at admission. The center’s
Exposure Control Plan was written in accordance with the Office of Safety and Health
Administration (OSHA) guidelines to include all elements of risk assessment and method of
compliance. The infection control procedures include prevention, containment, treatment,
reporting requirements, and all required elements. The center’s process for needle stick post-
exposure is an on-site episodic evaluation and they refer off-site if necessary. Hepatitis B
vaccines are available to staff on-site. Staff have access to protective equipment. Each positive
test result is forwarded to the local health department if applicable. The center reported there
were no reportable incidents to report to the health department this annual compliance review
period. The superintendent confirmed the center has not had any incidents of staff exposure.
The fourteen reviewed staff training records confirmed each staff received training on the
center’s specific Exposure Control Plan.
The nursing staff interview confirmed staff has access to the center’s Exposure Control Plan,
and nursing staff provides the exposure control and infection control training to staff. Each youth
admitted to the center receives infection control training by a nurse. The health department
routinely offer immunizations and human immunodeficiency virus (HIV) testing.
4.19 Prenatal Care/Education [Contract Provider] Limited Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures and nursing protocols for providing prenatal care
and education to female youth who are pregnant while in custody. A review of seven youth
Individual Healthcare Records (IHCRs) was conducted and found none were applicable for
prenatal services. The center provided three additional IHCRs which were applicable during the
annual compliance review period. Two of the three applicable youth had prenatal services start
immediately after their pregnancy status was determined and services were provided at the
recommended intervals; the remaining youth did not have services as required. One of the three
youth had all required thirty-day focused medical evaluations as required; one was not
applicable due to the length of time within the center; and the remaining youth did not receive
the required evaluations. All three youth had the required medical alert in the Department’s
Juvenile Justice Information System (JJIS), and none of the youth had complained of pregnancy
related issues. Each youth has daily monitoring for danger signs of pregnancy complications
documented in their IHCR. Two of the three youth were not applicable for post-birth
psychological and physical care plans; the remaining youth was applicable and did not have a
plan created. Each IHCR confirmed the youth received training on all required topics for
pregnant youth; however, not all training was documented on each youth’s health education
record. One of the three IHCRs contained documentation the youth was routinely monitored for
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nutritional and weight status during the pregnancy while in custody; the remaining two IHCRs
did not have monitoring documentation. All annual girls’ health education was provided by a
licensed nurse to non-healthcare staff as documented in fourteen reviewed staff training
records.
The nursing staff interview confirmed the services provided for pregnant youth at the center.
Each youth receives a specified diet, education, monitoring, and testing as required. Non-
licensed staff girls’ health training is conducted annually by a registered nurse (RN).
Seven youth were interviewed about female healthcare services. Five of the seven were not
applicable; and the remaining two youth confirmed they had received prenatal, obstetrical, or
gynecological services when needed.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center maintains facility operating procedures (FOP) which govern the supervision of youth.
These FOPs require staff to be aware of the location of youth who they are assigned to
supervise, at all times. Observations of active supervision of youth were conducted each day of
the annual compliance review week. Staff were observed supervising youth in class while
attending school, in the dining hall during the lunch meal, while being escorted to and from the
restroom during school breaks, and on the recreation field. Staff were asked if they knew the
number of youth they were supervising, and all staff were aware of the total number of youth
under their supervision, in addition to any youth who were currently at other places. During the
week of the annual compliance review, positive interactions between staff and youth were
observed each day. Staff were stationed strategically to properly supervise all youth. All
movements were heard announced and authorized by master control, and these
announcements included the housing module, number of youth being moved, the location of
travel, and a conclusion of the movement. The team was unable to view recorded video due to
the center's camera system malfunctioning. This has been reported several times by work
orders prior to the annual compliance review, and an additional two work orders were submitted
during the annual compliance review week. Seven staff were interviewed, and six said they
believed there was enough staff to provide for the safety and security of youth and staff, while
one said no. This staff said they felt the center did not have enough staff because staff are held
over often for overtime, and sometimes newly hired staff leave right away.
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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 (FOP) requiring a behavior management system
(BMS). The BMS is a system consisting of rewards and privileges for positive behaviors and
actions, and consequences for negative behaviors and actions, which are designed to motivate
youth to meet and exceed the center’s expectations and learn from any negative actions. During
the tour at the beginning of the annual compliance review week, postings of the BMS were
observed in all living areas, the dayroom, and the dining hall. The postings explained what
behaviors were considered appropriate and inappropriate, rules, and expectations for all youth.
All rewards and consequences observed were in accordance with the BMS postings. A review
of the FOPs confirmed the center prohibits the use of group punishment. There were no
instances of inappropriate use of restrictions or group punishment observed or reported during
the annual compliance review period. Seven staff were interviewed and were able to articulate
and explain the BMS. Each staff was able to give examples of rewards provided to youth
advancing through their levels. Six staff said they believed the BMS was effective, and one said
it was not because it was hard to come up with rewards as an incentive for the youth. Each
staff said they speak with youth about consequences being imposed, allow youth an opportunity
to explain their behavior, and discuss alternative acceptable behaviors. Each staff said they
receive regular feedback regarding the implementation of the BMS from their supervisors. All
staff knew what could be taken away from youth because of bad behavior, such as points and
levels, and knew what could not be taken from a youth because they are acting out. Each staff
said they have never seen a coworker take meals, snacks, clothing, education, or medical care
from a youth because they were acting out, and they have never observed staff encourage
youth to harm another youth. Seven youth were interviewed and asked how they felt about the
BMS, and six said it was good or fair, while one said it was very poor. Each youth was able to
explain the different levels of progression with the BMS and provided different examples of
rewards and punishments. Each youth said staff use rewards in the same manner and said
youth are not allowed to punish other youth. Three youth said they had been sent to their room
for fighting; however, these were for confinement or safety purposes. Each of the three youth
said they received consequences in the form of a level drop because of their actions. Each
youth said their room door was locked during confinement, and one youth said a staff was
always with them because the youth was placed on secure observation. Each of the three
youth said the consequences they received were fair. None of the youth interviewed said they
have ever seen handcuffs or leg irons used on out-of-control youth to prevent them from hurting
themselves or others. The superintendent was interviewed and advised the BMS system tracks
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youth on a three-level system. Each youth enter the facility at a level one and can level up
during the first week of their stay. Level one youth earn the basic rights. Level two youth earn
the basic rights and extra privileges. Youth may reach level three during the second week and
earn additional privileges. Youth levels may be reduced for displaying negative behavior or
being placed into confinement.
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 which require staff to visually observe youth
standard supervision at least every ten minutes while they are in their rooms. The center has a
total of fifty-eight cameras, and at the time of the annual compliance review, fifty-four were
operational. The inoperable cameras were located in the vehicle sally port, shackle storage
room, supervisor's hallway, and the loading dock. Video recordings are stored for thirty days;
however, center staff were unable to view recorded video during the annual compliance review
week, due to a malfunction with the recording system. Work orders have been submitted for
repairs prior to the annual compliance review week, in addition to two work orders being
submitted during the annual compliance review week. A review of ten-minute check logs for
thirty-minute increments from each shift and each housing module from October 2024 through
August 2025 was conducted and compared with the corresponding ten-minute check wand
reports. Out of a total of 232 checks reviewed, all but twenty were completed within ten minutes,
with those twenty being less than two minutes late. Seven staff were interviewed, and all said
checks are to be conducted every ten minutes when youth are in their room for non-punishment
reasons. The superintendent was interviewed and confirmed officers assigned to housing
modules conduct visual sight and sound checks of youth assigned to their modules every ten
minutes. The superintendent also said weekly reviews of management oversight are conducted.
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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 (FOP) governing census, counts, and tracking.
These FOPs require staff to always know the exact number and location of all youth under their
supervision at all times. An informal count was called and observed from master control during
the week of the annual compliance review. When count was conducted, all staff assigned to
supervise youth, contacted master control by radio, and provided a count of the number of youth
they were supervising. Staff also provided master control the number of youth who were at court
or medical, and not under their direct supervision at the time the informal count was called.
Once master control received all the counts, the center count was reconciled and verified. Staff
were aware of the total number of youth assigned to them and the actual number of youth
present. Seven staff were interviewed, and they all knew the different times when count is
conducted at the center, and what steps to take in the event a count is not correct, as well as
when emergency counts are conducted. A review of one full day of logbook entries from each
month from the time of the last annual compliance review was conducted. Counts were
consistently conducted at the beginning and end of each shift, prior to and following group
movement, as well as anytime a population change occurred. Counts were also called randomly
at least once on each shift.
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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 requiring they maintain a chronological record of
events, incidents, and activities in logbooks. Logbooks are maintained in master control, in each
transport vehicle, and in each housing module. A review was conducted of master control
logbooks for one full day each month from the time of the last annual compliance review. This
review revealed logbooks were bound with numbered pages and displayed the date at the top of
each page. All entries had the times of each event displayed in a.m./p.m. format, as well as the
name of each staff and youth involved, and a brief description of each event. Each entry also
contained the initials of the staff who made the entry. Entries which may have an impact on the
safety and security of the center were highlighted. This review confirmed all emergency
situations, incidents, drills, receipt of medication and mental healthcare, population counts at the
beginning and end of each shift, counts, group movements, admissions and releases, presence
of law enforcement, searches, and youth on precautionary or suicide observation, with the
beginning and ending times, were consistently documented. All errors found were struck
through with a single line and included the staff’s initials. The superintendent conducted logbook
reviews weekly, and a juvenile justice detention officer supervisor (JJDOS) conducted reviews
when assuming center responsibility. A JJDOS conducted daily review of logbooks maintained
in each living area and a juvenile justice detention officer (JJDO) conducted a review of the
living area logbook they were assigned to when beginning their shift. The superintendent was
interviewed and confirmed they review all logbooks at a minimum of weekly and review any
entries for the last seventy-two hours. The superintendent also advised a JJDOS must review
the master control logbook as well, going back seventy-two hours and documenting their
presence in each living area logbook every shift.
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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 (FOP) governing key control. These FOPs require
the center to be responsible for maintaining inventory and control of all center keys. The FOP
includes key assignments and usage, restrictions on usage, inventory and daily tracking of keys,
secure storage of keys, procedures to follow when keys are missing or lost, and the reporting
and replacement of lost or damaged keys. A review was conducted of the key storage area in
master control. The key storage box in master control was locked when it was inspected during
the week of the annual compliance review and only opened by the master control operator to
issue and to return keys. An observation was also conducted of staff during shift change and
staff were observed to turn in personal keys and receive a tag so they can retrieve their
personal keys at the end of their workday. This was also the case with the annual compliance
review team for each day of the review. Certain staff are authorized to check out specific keys to
the areas they are assigned to work in. These are restricted keys. There is a reference log
which has the name of the staff authorized to check out the key ring. All center keys were found
to be maintained on a tamper-resistant ring. The emergency key ring is located in the secured
server room adjacent to the training office. The maintenance mechanic, assistant
superintendents, and the superintendent are the only ones with access to these keys. The
master key inventory was reviewed and included each key ring number, number of keys on
each ring, which lock each key accesses, and who each key ring was issued to. All facility key
rings contained a color-coded marker which coincided with each department. Documentation of
each key issuance included the date and time of issue, name of staff issuing the key ring, name
of staff who the key ring was issued to, and the time the key ring was returned. Staff carrying
keys were observed to always carry their keys on their person and in their pockets. Staff did not
allow youth to handle facility keys. During the annual compliance review period, there were no
incidents reported to the Department’s Central Communications Center (CCC) related to lost
keys or any key control issues. A sample of five key rings were observed and compared to the
inventory and key log. All key rings matched the key ring inventory. Three staff were informally
interviewed about the number of keys on their key rings and the function of each key, and all
were aware of how many keys were on their key rings and which doors each key accessed.
Each of the staff were issued keys which they kept in their pocket. An inspection of each key
ring confirmed staff were aware of the number of keys on their issued key ring. An informal
interview was conducted with the master control operator, who advised they only issue keys to
certain areas such as medical, property room, and records office to staff who are authorized and
working in those areas. Juvenile Justice detention officer (JJDO) keys are exchanged during
shift briefing by a shift supervisor. Staff must turn in their personal keys to check out a key ring.
Key rings are color coded which allows master control to identify who can check out certain
keys. Seven staff were interviewed, and all were able to explain which keys were restricted and
were aware of the center’s key control policy. The superintendent was interviewed and advised
they have a binder detailing which key is being issued to center staff for permanent keys.
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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 has facility operating procedures to ensure any vehicle used to transport youth is
properly maintained. The center is required to maintain documentation on the use and
maintenance of each vehicle. During the annual compliance review week, center staff advised
they had six transport vehicles. Of the six transport vehicles, one was at the hospital with a
youth, and one was at the shop for repairs during the annual compliance review week. The
maintenance mechanic maintains a binder which confirmed all transport vehicles had a current,
annual inspection conducted by a certified mechanic. A review of documentation revealed the
maintenance mechanic conducts monthly visual checks of all transport vehicles, which include
tires, battery, fluid levels, interior/exterior, cleanliness, windows, mirrors, damage, and
windshield wipers. Each transport vehicle was found to have the appropriate number of
functioning seatbelts, a seatbelt cutter/window punch tool, and a current fire extinguisher. The
center has first-aid kits for each transport vehicle, which are checked out whenever staff go on a
transport. Each transport vehicle has a corresponding logbook. Each logbook was reviewed and
contained confirmation the vehicle was checked for contraband and required equipment prior to
and after each transport, the destination of the transport, number of youth and staff names,
name of the officer riding in the back of the van, and the time the transport began and ended. A
transport of two youth going to court was observed during the annual compliance review week.
Transport staff inspected the vehicle for contraband, ensured the vehicle had sufficient fuel,
verified the equipment to include the seatbelts were present and functioning, ensured they had
the proper documentation and logs for the transport, ensured they had a cellular telephone for
the transport, and documented the vehicle inspection in the logbook. Transportation staff
searched each youth prior to the youth being placed in the vehicle and ensured both youth were
secured with a seatbelt prior to departing. The four center vehicles present were inspected, and
all were locked when not in use. Seven youth were interviewed, and six said they have never
seen staff place contraband in a transport vehicle. One youth said they saw staff vape outside of
a transport vehicle when they were being transferred to the center from another center. The
youth did not know who the staff was. This was reported to the superintendent and a report was
also made to the Department’s Central Communications Center (CCC). Two of seven youth
said staff drive safely when driving in transport vehicles, and other five said they have not been
on a transport.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOP) requiring all tools and equipment used for
maintenance and in the kitchen are always properly maintained and accounted for. The FOP
states maintenance staff will have a shadow board of all tools and a master inventory reflecting
what is on the shadow board. The maintenance staff shall conduct a monthly inventory of all
tools and provide the inventory to the superintendent for review. Maintenance shall ensure the
monthly tool inspection is uploaded into the tool inspection section of each facility's
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Department’s SharePoint page. When it is necessary to take tools onto the secure floor for a
repair or project, each tool shall be documented in a tool logbook. It is the maintenance staff’s
responsibility to ensure they maintain control over any tools they are using. Tools shall be
stored in a locked area when not in use. Kitchen knives and other hazardous kitchen sharps
shall be stored in a locked sharps/knife cabinet. Inventory of the sharps/knife cabinet shall be
completed on the daily inventory sheet in the morning, mid-day, and in the evening, and
documented on a daily inventory sheet. Any missing knife or sharps shall be reported
immediately to the superintendent and noted on the daily inventory sheet. There will also be a
shadow board in each kitchen which lists all cooking utensils, and a written weekly inventory
shall be maintained. An inspection was conducted of the tool room and kitchen area where tools
are stored, which revealed all tools were properly stored and there were no tools missing. A
review of documentation confirmed kitchen staff conduct an itemized inventory of all equipment,
including knives, daily. An informal interview was conducted with the maintenance mechanic
which confirmed service vendors are accompanied by center staff when they are in a secure
part of the center. The maintenance mechanic also advised if a tool is lost or missing, the facility
is locked down and a search is conducted to find the tool. If a tool is lost or damaged, a report is
submitted, and a replacement tool is ordered. Once the replacement is received, it is marked
and added to the active inventory. The superintendent was interviewed and advised the only
staff with access to class A tools are the maintenance mechanic, kitchen staff, and
administration. Seven staff were interviewed, and all were aware of the center’s practice for
damaged or missing tools. All staff were aware of youth being limited to using mops and
brooms. Seven youth were interviewed, and all said they could use mops and brooms. A
sample of five tools from the kitchen and five tools from the maintenance tool area were
inspected. All ten tools had proper markings for easy identification, had an accurate inventory,
and the inventory was signed by the superintendent/designee. All tools were secured at the time
of the inspection.
5.09 Inventory of and Access to all Flammable, Toxic, Caustic,
Limited Compliance
and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has facility operating procedures governing inventory and access to flammable,
toxic, caustic, and poisonous items. The superintendent is named as the person responsible for
the implementation of a safety plan addressing proper use, storage, and disposal of chemicals,
including flammable, toxic, caustic, and poisonous items. A review was conducted of the
center’s Safety Plan which requires flammable, toxic, caustic, and poisonous fluids, and other
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dangerous substances to only be drawn or acquired by authorized personnel. Youth shall not be
permitted to use, handle, 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.
All flammable, toxic, caustic, and poisonous materials shall be stored in secure areas which are
inaccessible to youth. Safety Data Sheet (SDS) must also be located where any chemicals are
stored. During a tour during the annual compliance review week, one gallon of bleach was
found in an unsecured fire extinguisher storage closet in the B-2 modular unit, which was
accessible to twelve youth who were housed in this modular unit during the week of the annual
compliance review. Bleach is considered a toxic item. Seven youth were interviewed and said
they are allowed to clean with items if staff spray the solution. All youth said they do not have
access to any flammable, toxic, caustic, or poisonous items. Seven staff were interviewed and
said youth are not allowed to handle flammable, toxic, caustic, and poisonous items. Staff also
said they can spray items with cleaning solution and youth can wipe them down. An inspection
of three chemicals from the maintenance shop and two from the chemical shed was conducted.
All five chemicals had accurate inventories which matched the amount stated on hand. All had
the appropriate SDS sheets in a binder where the chemical was stored.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOP) designating the maintenance mechanic as
the person responsible for diluting, handling, and disposing of hazardous items and toxic
materials in accordance with Occupational Safety and Health Administration (OSHA) standards.
The FOPs state the maintenance mechanic or other trained staff who have 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 OSHA standards. The
disposal of all hazardous waste must be by either compaction, evaporation, flushing,
incineration, or bio-hazardous waste contractor. Hazardous liquid waste shall be disposed of in
accordance with the manufacturers' materials Safety Data Sheet (SDS). Designated containers
for hazardous liquid waste shall be kept in the hazardous materials storage area. Liquid waste
not resulting from work details, such as dirty mop water or unused beverages, shall be disposed
of in the plumbing area of each housing unit. Liquid waste resulting from work details shall be
disposed of in sinks located in mop storage areas. Kitchen liquid waste, except for grease, shall
be disposed of in the kitchen drain. Grease shall be placed in a separate container for disposal.
During an informal interview, the maintenance mechanic advised any flammable, toxic, caustic,
and poisonous items not used are taken to an approved facility for disposal, should the need
arise to dispose of such items. The maintenance mechanic advised there has not been an
instance to dispose of these items from the time of the last annual compliance review and
advised there have been no instances of chemical spills during this time as well. The
maintenance mechanic advised a vendor is used monthly to remove kitchen grease from the
appropriate storage area.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 62
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 outlining the requirements for behavioral
confinement for less than twenty-four hours. The center had 379 instances of youth placed in
confinement for less than twenty-four hours from the time of the last annual compliance review.
A sample size of fifteen confinements under twenty-four hours were reviewed. All confinements
were found to be documented in the Department’s Facility Management System (FMS).
Documentation confirmed all fifteen youth had access to mental healthcare as needed. All youth
received notice of their right to grieve a confinement placement. Thirteen youth were applicable
for receiving meals and/or snacks based on the amount of time in confinement, and all received
their required meals and snacks. Nine youth were applicable for being afforded a daily shower,
based on the time they were placed and released from confinement, and all received their daily
shower. Three youth were applicable for needing education materials based on the time they
were placed and released from confinement, and one received educational materials. Two did
not. All confinements were approved by a supervisor prior to the youth being placed in
confinement, and only one youth was placed in a confinement room at any given time.
Documentation confirmed each room was searched prior to placing a youth in confinement, and
this search was entered into FMS. Each youth reviewed for confinement under twenty-four
hours contained a Visual Observation Report (VOR) which documented visual supervision at a
minimum of every five minutes. None of the youth had a physical injury; therefore, assessments
and treatment were not needed. All youth were explained the reason for confinement. A
supervisor conducted an initial confinement review for all youth within one hour of the incident
occurring, and each report was completed before the end of the shift. FMS contained
documentation which verified a supervisor conducted additional reviews at a minimum of every
three hours for any youth remaining in confinement longer than three hours. Two of the
confinements interfered with visitation and notifications for potential visitors were documented.
All confinement reports were reviewed by the superintendent within forty-eight hours of
placement. The superintendent was interviewed and said behavioral confinement is an
immediate, short-term, crisis management strategy for use during situations in which the
behavior of one or more youth imminently and substantially threatens the physical safety of
others or compromises security. The superintendent also confirmed all confinement reports are
reviewed within forty-eight hours, excluding weekends and holidays, and it is determined
whether each confinement was appropriate or not. Seven staff were interviewed, and all knew
the process for placing a youth in confinement, and said youth placed in confinement are
provided education materials.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 59 of 62
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) in place governing the establishment of a
Continuity of Operations Plan (COOP). This FOP requires COOP drills to be conducted at a
minimum of twice a year. The center conducted two drills from the time of the last annual
compliance review, with one being completed prior to hurricane season, as required. A review of
documentation determined both drills contained the type of drill, date and time, participants,
brief scenario, findings, and recommendations. The superintendent was interviewed and
confirmed the center’s comprehensive safety/emergency policy is the COOP, which is designed
to ensure each facility has a planned and comprehensive approach to effectively manage
emergencies and disaster events, including those requiring the facility to relocate its youth and
staff while maintaining operations, safety, and security.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures requiring the development and implementation of
an escape prevention plan. The center is required to conduct escape drills at least quarterly on
each shift. Escape drills were reviewed from the time of the last annual compliance review
which revealed the center conducted monthly escape drills on each shift. A review of seven staff
training records was conducted and confirmed all staff were trained in escape prevention
annually. A review of logbooks was conducted and confirmed the documentation of each drill.
Seven staff were interviewed, and all said they have participated in at least one escape drill
from the time of the last annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 60 of 62
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 facility operating procedures governing the implementation of a disaster
preparedness fire prevention plan. The center is required to conduct monthly fire drills on each
shift. The plan was reviewed and approved by the local fire official who also conducted an
annual inspection of all fire extinguishers on February 5, 2025. A review of fire drill
documentation from the time of the last annual compliance review was conducted. The center
conducted drills monthly on each shift, from the time of the last annual compliance review.
Logbooks were reviewed and all the drills were properly documented. Seven staff were
interviewed, and all said the center conducts fire drills every month on each shift. Seven youth
were interviewed, and four said they have been instructed on what to do in the case of a fire,
while three said they have not.
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 (FOP) requiring they address illegal contraband
and prohibited items. The FOPs are designed to stop illegal contraband and prohibited items
from entering the facility. This includes identifying which items are considered contraband and
providing youth and staff with this list. The center must also have a policy on contraband and
searches and establish systems to prevent the introduction of contraband through searches of
the physical plant, facility grounds, staff, youth, and visitors. The FOPs require any contraband
confiscated and disposed of to be documented. This documentation is to include the
confiscation and disposition of any illegal contraband and the manner of disposition. The center
must complete an incident report identifying findings for all recovered illegal contraband, notify
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 61 of 62
the regional director, and report these to the Department’s Central Communications Center
(CCC) within two hours. The center must turn over any illegal contraband to local law
enforcement and a criminal report must be filed. A review of the Department’s Facility
Management System (FMS) revealed searches are being documented electronically and
documented in center logbooks. During the annual compliance review week, a transport of two
youth going to court was observed. Frisk and metal detector searches were conducted on both
youth prior to restraints being applied. Room searches were not observed during the annual
compliance review. From the time of the last annual compliance review, there were no reported
strip searches, other than during admission. During the annual compliance review week,
electronic searches were conducted anytime a staff, visitor, or volunteer entered the secure part
of the facility. All personal keys and cellular telephones are prohibited from entering the secure
area of the facility. A review of logbooks from the time of the last annual compliance review
confirmed room searches are conducted on each shift when youth are awake, prior to placing a
youth in a room, and whenever a youth is released. From the time of the last annual compliance
review, there have been no instances which may have compromised the safety or security of
the center. All visitors entering the facility are required to complete a contraband attestation
statement. Seven staff records were reviewed, and all contained contraband attestations. A
review of fourteen newly hired staff records was conducted, and all contained a signed
contraband attestation. Four instances of contraband entering the center were reported from the
time of the last annual compliance review. The confiscation of contraband and notification to the
CCC was documented in the logbook. A review of FMS confirmed all incident reports regarding
contraband were entered into the system. Confiscated items were handed to the on-duty
supervisor. One of the contraband incidents required law enforcement to be contacted for illegal
contraband entering the center, and this notification was documented. The superintendent was
interviewed and advised searches are conducted to control contraband and to ensure safety.
The results of any search are documented in the logbook and electronically. Staff are to prepare
youth prior to the initial frisk search or any strip search by explaining the purpose and procedure
of the search while assuring youth of his/her safety. All searches are required to follow the Right
Interaction (RI) curriculum and FOPs. Throughout each search, staff shall continue to treat the
youth with dignity and respect to reduce the youth’s potential feelings of embarrassment. An
electronic search consists of the use of an electronic walk-through or hand-held wand device to
locate metal objects. This search is to be conducted during admission and following any
transport. The superintendent also advised if a youth or staff is found with contraband, a
supervisor will take control of the contraband, contact local law enforcement if required, and
contact the CCC within two hours.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 62 of 62

report_type: QI Detention

program_name_raw: Brevard Regional Juvenile Detention Center

rule: Indicator 4.19

rating: Limited Compliance

rule: Indicator 5.09