facility_name: Southwest Florida Regional Juvenile Detention Center

summary: QI Detention - FY24-25 - 3 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Southwest Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated )
2525 Ortiz Avenue
Fort Myers,, Florida 33905
Review Date(s): December 10-13, 2024
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:
Rosa Flores, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Interviews)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Alphonza Gates, Palm Beach Regional Juvenile Detention Center, Operations
Analyst/Statewide Trainer, Detention Headquarters (Standard 5)
Tonya Gittens, Office of Accountability and Program Support, South Region Deputy Supervisor
(Standard 2)
LeAnn Gruentzel, Office of Accountability and Program Support, North Region Deputy
Supervisor (Standard 3)
Evan Hald, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Program Name: Southwest Regional Juvenile Detention Center MQI Program Code: 1046
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Lee County / Circuit 20 Number of Beds: 50
Review Date(s): December 10-13, 2024 Lead Reviewer Code: 182
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
2.10 Educational Access*
4.04 Parental Notification/Consent
4.12 Episodic/First Aid Care/Emergency Care
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 56 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 56 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 56 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Limited
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Limited
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 56 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours 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 56 (Revised July 2023)
Program Overview
The Southwest Regional Juvenile Detention Center is a state-owned detention center, operated
by the Department, located in Fort Myers, Florida. The center serves youth in Lee, Hendry,
Glades, and Charlotte counties in Circuit 20. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Lee County School District. The
center’s management team includes the superintendent, two assistant superintendents, two
administrative assistant IIs, eight juvenile justice detention officer supervisors (JJDOSs),
eighteen juvenile justice detention officer IIs (JJDOIIs), twenty-one juvenile justice detention
officer Is (JJDOIs), one training coordinator, one maintenance mechanic, a food service director,
and four food service workers. Mental health and healthcare services are provided through the
contracted provider, VitalCore Health Strategies, LLC. Mental health services are provided by a
licensed mental health counselor (LMHC) who serves as the designated mental health clinician
authority (DMHCA). In addition to the DMHCA, the center has one regional licensed supervisor,
and the center has four licensed full-time therapists on-site. A licensed psychiatrist provides
psychiatric services for applicable youth in the center. Clinical services provided by the center
include mental health and substance abuse evaluations, mental health treatment planning,
individual, group, and family therapy, mental health crisis intervention services, on-site
psychiatric services, and availability for substance abuse services for youth with co-occurring
disorders. Medical services are provided by one medical doctor (MD) who serves as the
designated health authority (DHA), one advanced practice registered nurse (APRN), eight
registered nurses (RNs), and one licensed practical nurse (LPN). The medical clinic maintains
nursing coverage Monday through Sunday from 9:00 a.m. to 5:00 p.m. Food services are
provided by Department staff and include menus, meal planning, meal schedules, special diets,
nutritional analysis, daily allowance, food preparation, health certifications, food product
standards, sanitation, and cleaning. Staff are responsible for the custody and control of youth in
their care, providing youth supervision twenty-four hours a day, seven days a week. The center
has two living modules which are divided by male and female. There are fifty-six security
cameras at the center, and eight additional cameras are pending repair and will be added to the
center. A tour of the center was conducted during the annual compliance review week and
observations found it to be clean, the exterior was free from debris, the grass was maintained
and manicured, and the center was free from insect infestation. The observed lobby area was
clean and had no broken furniture. The youth living areas and bathrooms were observed to be
clean and the bathrooms were functional. There was no graffiti observed at the center. The
classrooms, kitchen, and dining area were found to be clean and well organized. At the time of
the annual compliance review, the center had four vacancies which included four JJDOIs and
one chaplain.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures ensuring initial background screenings are
conducted on all newly hired staff, contracted providers, mentors, interns, and volunteers. The
Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the
Department’s Background Screening Unit (BSU)/Clearinghouse on January 30, 2024, meeting
the annual requirement. The Annual Affidavit of Compliance with Level 2 Screening Standards
for school district teachers was submitted to the BSU/Clearinghouse on January 26, 2024. A
review of the initial background screenings for twenty-four newly hired staff, revealed the center
received background screening results from the Department’s BSU/Clearinghouse prior to each
staff’s date of hire. At the time of the annual compliance review, there were five new volunteers
and five contracted staff applicable for background screenings. All required documentation was
reviewed prior to hire for each staff and volunteer. Each staff and volunteer had a completed
background screening prior to working with the center. None of the reviewed staff were
applicable for a break in service. Four of the twenty-four staff were applicable for a background
screening exemption, which was obtained as required. The center utilizes ergometric (ERGO),
which is a pre-employment assessment tool, for all direct care applicants. Twenty-two
applicants were applicable for being a direct care staff, and each record included a copy of the
pre-employment assessment passing score, which was maintained in accordance with policy.
Two staff were not direct care staff and did not require a pre-employment assessment.
Reviewed documentation validated the center added all applicable staff to the Clearinghouse
employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all staff, volunteers, and contracted
providers with access to youth undergo a criminal history background rescreening every five
years from the initial date of employment. A review of the staff roster found the center had five
direct care staff eligible for a five-year rescreening. The center had no contracted staff or
volunteers eligible for rescreening. Reviewed documentation confirmed each applicable staff’s
rescreening was completed and submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse within the required time frames.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 56 (Revised July 2023)
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 staff adhere to the center’s code of
conduct. Staff are required to adhere to the code of conduct which prohibits any type of abuse,
profanity, threats, harassment, intimidation, horseplay, or personal relationships with youth. A
review of five staff personnel records revealed the staff signed a code of conduct. The code of
conduct addressed officer professionalism, poor performance, negligence, insubordination,
conduct unbecoming of a public employee, and misconduct. Each of the reviewed personnel
records contained disciplinary actions for violations of the code of conduct. A review of the five
code of conduct violations indicated two staff received a written reprimand, two staff received an
oral reprimand, and one received a memorandum requiring re-training. In each instance,
management took immediate corrective action to address conduct when staff violated policies
and procedures. One of the reviewed staff received a commendation/promotion. Five youth
were interviewed, and each youth reported they never had to report abuse. Five youth were
interviewed, four youth reported staff are respectful when talking with them, and one youth
stated one staff has used profanity toward the youth as well as towards another youth. Two
youth reported they have never heard staff use profanity when speaking to them or other youth,
two youth reported they have heard profanity used at least once or occasionally, and one youth
indicated having heard a staff often use profanity. Three youth reported they have never been
threatened or heard staff threaten other youth and two reported having heard it on at least on
one occasion. Four of the five interviewed youth indicated they feel safe in the center, and one
youth reported not feeling safe at the center, indicating they have received threats from the
other youth at the center. This information was provided to the superintendent and
administrative staff. Five youth reported they have never exchanged emails, telephone
numbers, or social media contact information with staff. Five interviewed staff were able to
explain the process for allowing staff and youth to call the Florida Abuse Hotline or the
Department's Central Communication Center (CCC) to report suspected abuse. Two of the five
interviewed staff indicated they have never observed a co-worker using profanity when speaking
to youth, and three staff indicated they have heard a staff using profanity on only one occasion.
All five staff indicated they have never observed a co-worker using threats, intimidation, or
humiliation when interacting with the youth. Four staff reported working conditions were good at
the center, and one indicated the conditions at the center were very good. An interview with the
superintendent confirmed staff must act in a manner which is professional to the youth and
peers, staff’s behavior shall be respectful towards others, and staff are expected to be role
models for the youth. Additionally, the superintendent indicated any form of abuse is prohibited,
and suspicion or knowledge shall be reported to the Florida Abuse Hotline and the CCC.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56 (Revised July 2023)
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 when a reportable incident occurs the
center notifies the Department’s Central Communications Center (CCC) within two hours of
becoming aware of the incident. The center had 112 reportable incidents during the annual
compliance review period. A review of eleven incidents showed all were reported to the CCC
within two hours of the incident or when staff became aware of the incident. Each of the
reviewed incident reports showed they were documented in the center’s logbook. A review of
the center’s internal incident/grievance reports revealed there were no additional incidents
which should have been reported to the CCC. An interview with the superintendent indicated
staff are to report all incidents immediately to their supervisors and all reportable incidents must
be called in to the Florida Abuse Hotline and/or the CCC within two hours of gaining knowledge
of the incident, as required.
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 pertaining to the use of the Right Interactions (RI)
model, in accordance with Florida Administrative Code. The center had a total of 115 RI
incidents since the last annual compliance review. A review of nine RI incident reports
confirmed each of the nine reviewed RI Reports were completed by the end of the staff’s
workday. Each of the reviewed reports contained statements from all the staff involved. None of
the incidents resulted in serious injury to the youth or staff or needed to be reported to the
Florida Abuse Hotline. All nine RI Reports were reviewed and processed by a supervisor or an
RI instructor. Each of the RI Reports confirmed a post-RI interview was conducted with the
youth by the center’s administration within thirty minutes after the incident. None of the youth
were applicable for a post-RI medical review. None of the incidents required the use of
mechanical restraints. A review of internal incident/grievance reports and logbooks for the
compliance review period confirmed there were no additional RI incidents which did not have a
report. Each of the reviewed RI Reports were reviewed by the superintendent or designee within
seventy-two hours. The center’s RI rate during the previous quarter was 8.90, which is below
the statewide Detention RI rate of 9.79. Five interviewed staff reported staff try to talk to youth
prior to using RI or mechanical restraints. An interview with the superintendent indicated in the
event physical or mechanical restraints are utilized, all detention staff must complete a Physical
and Mechanical Restraints Log and conduct ten-minute checks. Additionally, the superintendent
and/or designee monitors RI incidents, reviews the RI video footage within twenty-four hours,
and all RI Reports are reviewed within seventy-two hours from the incident.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 56 (Revised July 2023)
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 addressing the training and certification
requirements for all new staff. Phase One training consists of instructor-led and web-based
courses. Phase Two consists of 120 hours of academy instructor-led training. A review of five
staff training records for pre-service training indicated four of the five staff completed all required
trainings within 180-days of hire; however, one staff’s record was missing a two-hour suicide
training. An informal interview with the training coordinator indicated the missing two-hour
training was completed as part of the training prerequisites; however, this was not documented
in the Department’s Learning Management System (SkillPro). An informal interview with the
training coordinator confirmed the applicable staff’s training had not been added to SkillPro due
to Department-wide system outages. Reviewed documentation confirmed the applicable staff
completed the trainings required by the Department; however, not all trainings were
documented in SkillPro due to the system outages.
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 which require staff to complete twenty-four hours of
in-service training each calendar year after completion of pre-service certification training. The
policy requires supervisors to complete eight hours of supervisory training in addition to the
twenty-four hours of in-service training. The center provides in-service training to staff through a
combination of the Department’s Learning Management System (SkillPro) and instructor-led
classes. Five staff training records were reviewed for in-service trainings, which included two
supervisory staff and three direct care staff. Four of the five reviewed staff records confirmed
each staff completed the required twenty-four hours of the mandatory training topics which are
to be completed annually, and one staff was missing the two-hour suicide prevention training.
The policy requires supervisory staff to complete eight hours of supervisory training annually.
Two staff were applicable for a minimum of eight hours of supervisory training and each staff
completed the required minimum hours. All trainings were documented in SkillPro, with the
exception of the two-hour suicide prevention training. Reviewed documentation confirmed the
center has a registered nurse (RN) who provides in-service training annually for the education
on girls’ healthcare to all non-healthcare staff involved in the supervision or treatment of girls.
The center has an annual in-service training calendar which is updated as changes occur. The
in-service training plan was approved by the Department’s assistant secretary for Detention
Services on November 17, 2023, and by the director of the Department’s Office of Talent,
Leadership, and Culture (TLC) on December 1, 2023. An interview with the superintendent
confirmed the center’s practices for training and development.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 56 (Revised July 2023)
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 in place related to youth grievances to ensure each
youth has the right to grieve and ensure all youth are treated fairly, respectfully, without
discrimination, and their rights are protected. The grievance process is posted throughout each
living module and is explained to each youth during the admission and orientation process. The
center keeps blank grievance forms on the youth living modules which are available for youth
upon request. The center’s staff will then input the grievance into the Department’s Facility
Management System (FMS) in the Department’s Juvenile Justice Information System (JJIS).
The process includes an informal phase, formal phase, and the appeal phase. During the time
of the annual compliance review, the center had no documented grievances for the annual
compliance review period. An interview with the superintendent confirmed the center’s
grievance process, indicating the process has an informal and a formal phase. Additionally, the
superintendent indicated youth are provided with grievance forms to complete, and staff are to
submit the grievance in FMS, on behalf of the youth. Supervisors shall provide a response
within twenty-four hours, and the completed grievance form shall be provided to the
superintendent or designee. Four of the five interviewed youth were able to explain the
grievance process, and one indicated being unaware of the process; however, believes they
were informed of the process during intake. Three of the five youth reported never having filed a
grievance, one youth rated the grievance process as very good, and one youth rated it as very
poor. Five staff were interviewed, and all staff were knowledgeable and could explain the
center’s grievance process.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 56 (Revised July 2023)
The center has facility operating procedures outlining the process of entering and sharing alerts.
The center’s practice is to appropriately enter, downgrade, or discontinue alerts in the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been previously identified prior to the youth’s admission. A review of five youth
records confirmed alerts were documented in accordance with the center’s policy. The reviewed
youth were applicable for twenty-one separate alerts. Each reviewed youth record documented
alert types, and the name/title of the staff removing/updating alerts. Each alert was documented
in the logbook. Documented alerts were accurately entered and matched the alerts in JJIS. All
applicable alerts were downgraded and removed by the medical staff and/or the mental health
staff, as applicable. A copy of the alerts is provided to the supervisors and detention staff at the
start of each shift, and the alerts are reviewed with staff during each shift briefing. A copy of the
alerts is maintained with the logbook and is accessible to all staff. Reviewed documentation
confirmed the alerts are discussed during shift briefings. An observation of a shift briefing
meeting during the annual compliance review week validated the center’s practice. An interview
with the superintendent confirmed the center’s practice for review and documentation of medical
alerts. Five staff were interviewed and reported they are informed of security, safety, medical,
and mental health alerts which are specific to youth through shift briefings, the alert forms, JJIS,
alert board, logbooks, and other types of communication. Five staff were interviewed, and each
staff reported management informs staff about issues within the center through shift briefings,
alerts, logbooks, meetings, emails, and other forms of communication. Four of five interviewed
staff indicated the process for communicating information within the center is very good and one
indicated it was good.
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 has a practice in place regarding data trend analysis. The center uses data to
decrease confinements, use of Right Interactions (RI), and incidents. The center utilizes the
Department’s visual analytics platform and the Department’s Juvenile Justice Information
System (JJIS) to identify the areas which are needing improvement, and the information is
shared with the center’s administrative staff. The center conducts monthly meetings to ensure
all staff are made aware of imperative information regarding the center. Additionally, the
information is shared and discussed with staff through several methods of communication.
Reviewed documentation validated the center’s practices. The center conducts weekly
Detention Review meetings where information is provided to the juvenile probation officers
(JPOs), medical staff, mental health staff, and lead teachers. The center shares information with
providers and stakeholders on a quarterly basis. The information is shared at meetings, as well
as through email communication.
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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 for admitting youth into secure detention. The
center's policy requires the center to complete admissions in the Department's Juvenile Justice
Information System (JJIS). During the annual compliance review week, a total of five youth
records were reviewed. Each of the records contained the arrest affidavit/custody order,
Detention Risk Assessment Instrument (DRAI), and the Suicide Risk Screening Instrument
(SRSI). A review of the documented admission forms indicated a full-body search and/or
electronic search was completed for all five youth. The admission form confirmed all five of the
youth received a meal, telephone call, and a medical, mental health, and substance abuse
screening. An observation of an admission was conducted during the annual compliance review
week. Observations confirmed the admission procedures were followed, and the youth was
provided a telephone call to their parent/guardian and a meal.
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 advise youth of center rules and regulations,
expectations for behavior and related consequences for failing to meet those expectations, and
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youth rights within twenty-four hours of a youth being admitted into the center. A review of five
youth case management records confirmed an orientation was completed within twenty-four
hours of admission. All five youth signed an orientation acknowledgement document. The
elements included in the orientation, both written and verbally, included the rules and
regulations, grievance procedures, visitation, telephone calls, access to medical, mental health
and sexual abuse services, access to the Florida Abuse Hotline/Department's Central
Communications Center (CCC), behavior expectations, youth rights, possible new law violations
for destruction of property, and Prison Rape Elimination Act (PREA) related information. A youth
admission which included an orientation was observed during the annual compliance review
week. Observations confirmed the youth was advised of the rules and regulations, youth rights,
daily schedule, visitation, and behavior management system during the admission process. The
youth received a telephone call to their parent/guardian. Staff additionally informed the youth of
the PREA-related information and how to get access to staff for medical and mental health
matters. Five interviewed youth confirmed all youth were advised of the rules and regulations,
daily schedule, visitation, and behavior management system during the admission process.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security. 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 requiring all youth admitted to the detention center
to be classified for safety and security. The center’s policy requires classification to be
conducted for the highest level of safety and security for each youth. A review of five youth
records indicated a review of information concerning the youth’s history and status. All youth
records confirmed the classification process included the consideration of youth’s mental illness,
intellectual/physical disabilities, history of violent and/or criminal behavior, gang affiliation,
history of sexual offenses, the results of the Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) screening, medical, suicide risk, escape, security, and history of
human trafficking. The classification process was completed and documented in all five youth
records. Each classification form contained all the required elements when making room
assignments, including the gender of the youth, height, weight, age, and level of aggression.
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The center’s practice is to enter all suspected gang affiliation alerts into the Department’s
Juvenile Justice Information System (JJIS) and notify the youth’s juvenile probation officer
(JPO) by email. The center’s superintendent reported being notified of any related gang
information by email by the direct care staff and JPO. An interview with the center’s
superintendent indicated the JJIS alert system is utilized to document a single room only youth
classification for youth with a history of committing sexual offenses, a history of being a victim of
a sexual offense and/or abuse, or youth determined to be physically or sexually aggressive. In
addition, a review of the VSAB results confirmed they are documented by the person making a
youth room assignment. This is documented and completed by signing and dating page three of
the VSAB. Any youth whose VSAB results specify the youth as vulnerable to victimization
and/or sexually aggressive shall be placed on single room only status, an alert to indicate single
room only status must be entered into JJIS, and a mental health referral shall be completed.
Room assignments will not be made prior to the review of the VSAB.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity. A referral for youth with suspected
gang involvement shall be shared, by e-mail, with the circuit gang representative, indicating
suspicions of gang activity such as youth flashing gang signs, gang tattoos, gang-related
drawings, or related activity. Center staff should include in the e-mail pictures (when
appropriate), copies of written statements, drawings, graffiti, and a description of what gang
signs the youth was “flashing.”
The center has facility operating procedures on the screening process for youth newly admitted
into the center to determine if the youth is a gang member or gang affiliated. The policy requires
the center to share suspected gang related information by email. A review of five youth case
management records found none were applicable for suspected gang affiliation. A review of the
alerts in the Department's Juvenile Justice Information System (JJIS) confirmed the center did
not have any youth documented as a suspected gang member during the annual compliance
review period. The center’s administrative staff enter all suspected gang affiliation alerts into
JJIS, when applicable. An email communication is sent to the juvenile probation officer (JPO)
with pictures and documentation of all suspected gang related activities. An informal interview
with the superintendent confirmed there is currently no gang liaison for the center; however, the
administration staff is responsible for sharing the gang related information to the JPO.
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 on admissions and the storage of youth’s personal
property. The center’s policy requires all youth personal property to be inventoried and returned
upon release. A review of five youth itemized Personal Property Receipt forms and Valuable
Property Receipt forms included the youth and staff signature and letter of acknowledgement
regarding unclaimed property. One of the five youth had money and personal items of value
which were verified and secured in a clear tamper-proof property bag. During the annual
compliance review week an observation was made, where the youth’s valuable property bag
was placed in the safe. The youth’s valuable property bag was initially located in the youth’s
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personal property bag containing clothing. The secured bag included the youth’s name, date
and Department identification number (DJJID) along with the list of items inside the bag. The
valuable property bag was placed in a property secured safe and documented in the safe bound
logbook with the date, time, youth’s name, DJJID, and the name and initials of the officer who
secured the property. A review of five property receipts confirmed one youth did not sign the
property sheet. During the annual compliance review week, the youth signed the property sheet,
and the property sheet was placed in the youth’s active record. All the Property Receipt forms
confirmed the youth’s personal property, including clothing, was documented and a copy of the
form was placed in the youth’s active record along with the Valuable Property Receipt form.
Three youth valuable and personal property samples were observed. Each of the three personal
property bags contained a completed inventory form for the youth’s personal property.
Documentation in the center’s safe logbook indicated the youth’s valuable property was
documented and stored in a clear tamper-proof bag. An observation was conducted during the
annual compliance review week and validated the process of how youth property is secured and
documented in two logbooks at the center. One logbook is for documenting personal property
during the intake process. The other logbook is kept in master control in the location of the
youth’s personal property bag storage area. Both logbooks are reviewed and signed by an
administrator. The center has two drop-safes. One is in the intake room and the other is in
master control. Both safes are under video surveillance and only accessible to designated staff.
Documentation reviewed of the Department's Central Communications Center (CCC) confirmed
one property incident was reported during the annual compliance review period. An interview
with the superintendent indicated the youth’s personal property is secured in a clear tamper-
proof bag and placed in a secure safe, under surveillance. The superintendent indicated the
facility’s administrators have access to the valuable property safes located in intake and the
master control room. Additionally, the superintendent stated in the event there is any property
not picked up within thirty days, the property will be considered abandoned. After thirty days, a
Notice of Impending Disposal of Property shall be mailed to the last known address. Five
interviewed youth stated staff checked their personal property and they signed the form stating
their personal property was correct.
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 for releasing youth from secure detention. The
center’s policy requires the court order to be verified prior to release. Five youth case
management records were reviewed, and two were applicable for release procedures. One
additional closed record was requested and reviewed for release. A review of three closed youth
release records indicated the on-duty supervisor reviewed all related paperwork prior to the
youth’s release. All three closed youth case management records included documentation the
juvenile justice detention officer supervisor (JJDOS) reviewed the release paperwork received
from the court, and the youth’s identification was verified prior to release. All three youth were
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released to a parent/guardian. A copy of the parent/guardian identification was present in each
of the records. None of the youth had an endangered person alert. Documentation reviewed of
the three closed youth records confirmed the youth and parent/guardian were notified of the
future court dates, and all parties signed all applicable release forms. A review of the
Department's Juvenile Justice Information System (JJIS) confirmed all youth had the date of
admission and release documented, which coincided with case records. During the annual
compliance review week, there was an observation of a release conducted. The staff conducting
the release made a copy of the parent’s/guardian’s identification card and placed it in the
record. The personal property sheet indicated the youth had valuable property in the safe. The
personal property was removed from the safe in master control for the release. The staff
completed the Release Wizard and property sheet in JJIS. The youth was retrieved, searched,
and taken to the area for release processing. The youth and parent/guardian signed the release
documentation and were provided with a copy of the youth’s court documentation.
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 each youth's personal property is
maintained securely and returned to the youth in a timely manner upon their release. The
center’s policy outlines procedures regarding release of youth with prescription medications.
Three closed youth case management records were reviewed. All three closed youth records
confirmed the youth and parent/guardian signed the Property Receipt form upon release. Each
reviewed record contained a copy of the parent/guardian identification card confirming the youth
was released to the appropriate person. Two of the three closed youth records were applicable
and supported the receipt of medications was signed by the person receiving the youth using
the Department’s Health Discharge Summary Transfer Note form. Reviewed documentation
confirmed both the youth and parent/guardian were reminded of any health or welfare issues
including any medical, mental health, and/or substance abuse needs. During the annual
compliance review period the center had one example of youth property held for more than
thirty days. The youth was released in April and the valuable property was still located in the
safe at the center. The Department's Juvenile Justice Information System (JJIS) confirmed the
youth’s current placement is in the county jail. An informal interview with the superintendent
indicated there were no documented attempts for property retrieval nor was a notification sent to
the parent/guardian or juvenile probation officer. The center provided a sample for a notification
of property; however, it was outside of the annual compliance review period. Observations of a
youth property release during the annual compliance review week confirmed the youth and
parent/guardian received the youth’s property and signed the receipt of property form.
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 ensuring Detention Reviews are conducted weekly
for securely detained youth and to ensure proper management of youth and the sharing of
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information. Detention Review meetings are held at the center on Thursdays. During the annual
compliance review week, an observation of a Detention Review meeting was conducted. All
parties were present from all required departments. The meeting contained staff who were
present in person, including the center’s superintendent, medical, and mental health staff.
Participating virtually were the education representative, the juvenile probation officers (JPOs),
and the detention services south regional chief. During the Detention Review meeting the
participants discussed any upcoming appointments, population, medical needs, court
appearances, and behavioral changes while in detention. A review of documentation in the
Department’s Facility Management Systems confirmed the required participants were in
attendance, contained a sign-in attendance sheet, alerts of the youth, and Detention Review
notes. Reviewed documentation supported Detention Review meetings were held weekly at the
center. An interview with the superintendent confirmed the weekly Detention Review meetings
are held on Thursdays at noon and are held in the center’s conference room. Topics discussed
are questionable court orders, youth detention status, behavior, medical and/or mental health
updates, and any other special or critical cases needing immediate resolution.
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 to address the daily activity schedule. The center’s
policy requires the daily activity schedule to outline the days and times of youth activities. The
daily activity schedule was observed during the center tour posted in the living areas. The
activity schedule contained wake-up/personal hygiene, mealtimes, visitation, recreation and
physical activities, and indoor activities which promote education and life skills. The daily
schedule included bedtimes, groups, and open program time including games and reading.
Observations of youth engaged in various activities throughout the week were conducted which
included youth searches, educational programming, lunch times, indoor recreation times, and
open programming times. Observed activities coincided with the schedule. Five interviewed
youth confirmed the center has a daily activity schedule. Four of the five interviewed youth
indicated the daily scheduled is followed and one youth stated no, further indicating female
youth do not get the same outdoor recreation time as the male youth. Five interviewed staff all
agreed the center’s daily schedule is followed.
2.10 Educational Access (Critical) Limited Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center provides
education services through the Lee County School District. The daily school schedule reflects
five hours of instruction each day, which meets the required minimum of 300 minutes of
instruction each day. The school district approves the 250-day calendar, which incorporates ten
days of teacher planning and/or training. A review of the daily school schedule revealed the
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center provides five sixty-minute class periods daily, fulfilling the weekly requirement of twenty-
five hours of instructional time. The school schedule, which was reviewed, coincides with the
provided daily activity schedule. A review of twelve randomly chosen dates, to include one each
month from January through December 2024, demonstrated the daily class schedule was not
consistently adhered to, and classes were not facilitated as scheduled. The youth were between
ten to 124 minutes late to class during eleven of the twelve monts reviewed. The youth were
transitioned from education classes on time for five out of the twelve reviewed months. A review
of video from three random dates on November 18, 2024, November 20, 2024, and November
22, 2024, confirmed inconsistencies in adhering to the daily school schedule. Youth arriving to
classes varied from six to forty-three minutes late. Five youth were interviewed, and all five
reported they attend school Monday through Friday. Three youth felt the school was preparing
them well for a high school equivalency diploma (GED), high school diploma, vocational,
employment, and/or college, while two stated not well. Five staff were interviewed, and all felt
there was minimal interference in educational services. The interview with the superintendent
reported there is minimal interference with educational services.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has established facility operating procedures to deliver career education to youth,
offering a Type 1 program which includes communication, interpersonal, and decision-making
skills. The center provides career education programming which meets the requirements of a
Type 1 program and incorporates communication, interpersonal, and decision-making skills, as
well as life skills and activities through the personal career and social development class. Five
youth were interviewed, and all five reported they were taking core classes such as math,
science, history, reading, social studies, career choices, and life skills.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures requiring a single licensed mental health
professional working as the designated mental health clinician authority (DMHCA) to be on-site
forty hours each week to ensure the appropriate coordination and implementation of mental
health and substance abuse services taking place. The Department maintains a contract with
VitalCore Health Strategies, LLC to provide mental health and substance abuse services to all
applicable youth in the center. The DMHCA is a licensed mental health counselor with a clear
and active license in the State of Florida expiring March 31, 2025. The DMHCA is a full-time
staff and scheduled to be on-site forty hours each week and is available twenty-four hours a
day. A review of the mental health sign-in logbook during the annual compliance review period
confirmed the DMHCA was on-site, as required. The center had a previous DMHCA during the
annual compliance review period who had a clear and active license expiring March 31, 2025.
The center has not needed to utilize a back-up DMHCA during the annual compliance review
period. Copies of the DMHCA’s agreement and position description were reviewed and
confirmed the weekly hours are covered, as required. The DMHCA stated they ensure the
compliance metrics are being met as well as providing mental health services for the youth in
the program through individual sessions utilizing Cognitive Behavioral Therapy (CBT) and
motivational interviewing. The DMHCA is on-site forty hours a week, is available twenty-four-
hours a day seven days a week for any notifications, and communicates with staff daily.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. The center requires
mental health and substance abuse services to be provided by individuals with appropriate
qualifications. The clinical supervisor ensures the licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. The licensed mental health professional is licensed under the appropriate
Florida Statute chapter and copies of the licenses are available on-site. The center has four full-
time licensed mental health staff, in addition to the designated mental health clinician authority
(DMHCA). Licenses of all four licensed mental health professionals expire on March 31, 2025,
and staffing was in accordance with the provider’s contract.
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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 Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. All mental health
services are being provided by a licensed mental health professional. There are no non-licensed
mental health staff providing services at the center. The center does not have a Chapter 397
license and all substance abuse services are being provided by licensed mental health
professionals. The reviewed contract confirms the center is not required to hire any non-
licensed clinical staff.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure the mental health and substance abuse
needs of youth are identified through a comprehensive screening process. The center’s policy
requires referrals to be made when youth are identified with mental health and/or substance
abuse needs or are identified as a possible suicide risk in accordance with Florida
Administrative Code. Five reviewed youth records had a completed Suicide Risk Screening
Instrument (SRSI) in the Department’s Juvenile Justice Information System (JJIS). Only one
record had a completed Massachusetts Youth Screening Instrument, Second Version (MAYSI-
2) in JJIS. The other four records were transferred from another center and were not required to
complete a new MAYSI-2. The trained nurse and/or mental health staff completed the required
sections in each of the SRSIs, with accurate referral selection entries in the “Screening Results”
sections. All five youth had positive responses on the SRSI, including a “yes” response when
the youth had any open or closed suicide risk alerts in JJIS, were placed on suicide precautions,
and a mental health referral was completed documenting the youth's need for an Assessment of
Suicide Risk (ASR). All five SRSIs and one MAYSI-2 result indicated a need for further
assessment. The one applicable MAYSI-2 was not determined to be “invalid” and did not
indicate an elevated suicide risk subscale; however, indicated a need for a comprehensive
assessment due to an elevated score above the cut-off. A referral was made for an assessment
to be completed. Each reviewed SRSI and MAYSI-2 indicated the superintendent or designee
was notified of the referrals made for assessments.
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.
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The center has facility operating procedures outlining the process to identify the mental health
and substance abuse needs of youth through a comprehensive screening. Five youth records
were reviewed for a mental health and substance abuse assessments. Three of the five youth
were applicable for new or updated assessments completed by the detention provider. One
youth was transferred prior to assessment completion and the other youth received an
assessment in another center weeks prior to being transferred to this center. All three applicable
assessments were completed on-site within the required time frame. All treatment
recommendations made corresponded to all diagnosed mental health or substance abuse
disorders in all three records. None of the youth were applicable for receiving a new
comprehensive assessment from a community provider. The designated mental health clinician
authority (DMHCA) reported they obtain the comprehensive mental health and/or substance
abuse assessment. Both the initial screening and the assessment based on the youth’s
behavior are uploaded and retrieved from the Department’s Juvenile Justice Information (JJIS).
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center. All youth who receive mental health and/or substance abuse
treatment while in at the center shall have a discharge summary completed documenting the
focus and course of the youth's treatment and recommendations for mental health and/or
substance abuse services upon youth's release from the center.
The center has facility operating procedures for mental health and substance abuse treatment
and discharge planning. The provider’s contract requires the superintendent and designated
mental health clinician authority (DMHCA), or mental health/substance abuse clinical staff to
ensure the development and review of an initial and/or individualized treatment plan (ITP) for
each youth receiving mental health/substance abuse treatment in the center. Five records were
reviewed for treatment and discharge planning and only three were applicable for treatment.
Two youth were already being provided treatment through a community provider who was
delivering treatment services. Two of the youth were applicable for having an initial treatment
plan. One youth had a treatment plan in place within seven days of admission and treatment,
therefore, an initial plan was not needed. The two applicable records documented an initial
treatment plan was completed within seven days of the onset of treatment and developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each initial treatment
plan included the reason for referral for treatment, initial Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis/symptoms, initial treatment methods including
counseling and frequency, initial treatment goals, psychiatric services including psychotropic
medications and frequency of monitoring, and the medication the youth was admitted with. Each
initial treatment plan was signed by both the licensed mental health professional and the youth.
Both youth were assigned a mini-treatment team, and members of the treatment team were
involved in the development of the initial treatment plan. Each of the three applicable youth
received an ITP and were receiving mental health and/or substance abuse services. Two plans
were developed by the thirty-first day of the youth’s admission. One completed ITP was
developed thirteen days late. Each plan included the youth’s DSM-5 diagnosis, symptoms which
were treatment focused, treatment goals, strengths and needs, and psychiatric services
including psychotropic medication with frequency of monitoring, if applicable. Two youth were
applicable for psychotropic medications and the medications listed in the initial treatment plan
matched the psychotropic medications when the ITP was developed. Documentation reflected
each ITP was signed and dated by the youth, mental health/substance abuse professionals, and
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treatment team members. An attempt was made to obtain the signature of the parent/guardian
in each instance. A review of progress notes validated each youth received treatment services
as stipulated on their ITP. Only one reviewed record was applicable for ITP reviews. Two
additional records were reviewed. Each record confirmed the ITPs were reviewed every thirty-
days, as required, by the youth, mental health staff, and treatment team members, and were
documented on the Department’s Individualized Mental Health/Substance Abuse Plan Review
form. Modifications were documented on the review form and clearly identified as such. A
review of the documentation reflected the ITP reviews were signed and dated by required
parties. In the one applicable record, the reviews included the treatment and services provided
by the licensed psychiatrist. None of the youth were an alleged victim of a Prison Rape
Elimination Act (PREA) event. Three closed records were reviewed for mental health/substance
abuse treatment discharge. The discharge plan was documented on the Department’s Mental
Health/Substance Treatment Discharge Summary form and completed upon the youth’s
transition/discharge in each record. A copy of the summary was provided to the youth’s juvenile
probation officer (JPO) in all three records. Only in one closed record was the summary
provided to the youth and parent/guardian. The remaining two youth were transferred to
commitment placement. A mini-treatment team was observed during the annual compliance
review week and contained all the required elements. The mini-treatment team consisted of
mental health, medical, youth, direct care staff, and the therapist. An interview with the
designated mental health clinician authority (DMHCA) explained the process of creating,
reviewing, and updating the youth’s individualized treatment plan. The DMHCA stated staff meet
with the youth to ensure the youth receive the services they need. The DMHCA conducts
compliance checks to ensure services are being provided. The DMHCA stated the process for
reviewing and updating ITPs is to gather information from the treatment team meetings as well
as from observations on the youth’s behavior. The youth’s progress and behaviors are
discussed with the youth at least once every thirty days with the youth, to ensure they are
receiving the necessary services.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. Each youth determined to need mental
health treatment, including treatment with psychotropic medication, or substance abuse
treatment while in at the center, must be assigned to a mini-treatment team.
The center has facility operating procedures in place for mental health and substance abuse
treatment planning to focus on treatment provisions to reduce or alleviate youth’s symptoms of
mental disorder or substance abuse impairment and enable youth to function adequately in the
juvenile justice setting. Five youth records were reviewed for mental health and substance
abuse treatment and three were applicable for treatment. Two youth were not applicable and
were already receiving treatment through another provider. Each of the three applicable youth
were assigned to a mini-treatment team which consisted of mental health clinical staff, one staff
from a different service area, the youth, and the parent/guardian when possible. Each youth
required mental health treatment as well as substance abuse treatment and received weekly
individual and/or family counseling according to the frequency required by the treatment plan.
Each record contained a signed Authorization for Evaluation and Treatment (AET) and the
Department’s Youth Consent for Substance Abuse Treatment form, giving consent for
treatment. None of the records were released requiring a signed authorization of release form.
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Treatment notes were documented on the Department’s Counseling/Therapy Progress Notes
form in each record. Video footage of groups was not available for observation during the
annual compliance review week. The clinical director indicated the center had not been able to
provide groups due to vacancies. Sign-in sheets were reviewed for when the center was
providing groups, which was from December of 2023 to March of 2024. The facilitator was
verified, and groups were conducted for the required group time and length. Mental health staff
have adequate access to youth and confidential space to provide treatment services. A review
of sign-in sheets confirmed group therapy was limited to ten or fewer youth with mental health
diagnoses for mental health treatment groups and fifteen or fewer youth with substance abuse
diagnoses for substance abuse treatment groups. The clinical director indicated groups will be
restarting once the center’s vacancies are filled. Five interviewed youth rated the mental health
and substance abuse services. One youth said services were very poor, one youth said they
were fair, two said they were very good, and one youth stated they were not receiving services.
The designated mental health clinician authority (DMHCA) stated the process for individualized
mental health and substance abuse planning is conducted by reviewing current and historical
assessments, interviewing the youth and direct care staff, and conducting treatment team
meetings, which include the JPO. In addition to mental health services, youth with substance
abuse diagnoses meet individually with the certified addictions professional.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures summarizing the provision of psychiatric services to
youth in need, to include psychiatric evaluation, consultation, medication management, and
medical supportive counseling. Psychiatric services are provided by a physician licensed
pursuant to Chapter 458, Florida Statute, who is board certified in child and adolescent
psychiatry with a clear and active license in the State of Florida expiring January 31, 2026.
Services are not provided by an advanced practice registered nurse. If the psychiatrist is not
available, the center will use a back-up psychiatrist with equal education to the psychiatrist, who
is pulled from a pool of psychiatrists contracted through the provider. A back-up psychiatrist was
not utilized during the annual compliance review period. The center does utilize tele-psychiatry
which is the equivalent as rendering services in-person. Each youth agreed to the use of tele-
psychiatry; however, the provider does not obtain permission from the parent/guardian. The
Department’s Office of Health Services was consulted and stated the provider can obtain verbal
consent and document this on a progress note or on a tracker. The designated mental health
clinician authority (DMHCA) stated they meet weekly with the psychiatrist. Five youth records
were reviewed for psychiatric services and three were applicable for entering the center on
psychotropic medication and received an Initial Psychiatric Diagnostic Interview within fourteen
days of the youth’s admission to the center. All three initial psychiatric interviews included the
reason for referral, youth’s history, Mental Status Examination, Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition (DSM-5) diagnosis, treatment recommendations
specific to mental health and/or substance abuse diagnosis, and prescribed medication. Each
initial psychiatric interview documented the medication name, explanation of the need for
psychotropic medication, and frequency of monitoring. An in-depth psychiatric evaluation was
conducted on all three referred youth within thirty days of referral/admission which stated the
reasons and factors leading to the referrals. Each clearly identified evaluation included all the
required elements of an in-depth psychiatric evaluation, and page three of the Clinical
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Psychotropic Progress Note (CPPN) when the medication was prescribed or changes were
made to the existing prescription. When psychotropic medication was prescribed/dispensed the
identifying data, diagnosis, target symptoms of each medication, evaluation, and description of
the effect of medications on the target symptoms were recorded for all four youth. Each
prescribed psychotropic medication included all required elements the name of dosage and
quantity of the medication, normal dosage range, ordered dosage, frequency and route of
administration, reasons for changes in medication and/or dosage, as well as side effects,
youth’s adherence to the medication regime, height, weight, blood pressure, and most recent
drug serum levels, as appropriate. None of the reviewed records noted telephone contact with
the parent/guardian. Each of the three evaluations were signed and dated by the psychiatrist.
None of the youth needed monitoring for Tardive Dyskinesia. The consent for psychotropic
medication included a signed Authority for Evaluation and Treatment (AET) by the
parent/guardian. One youth was applicable and was in the care of the Department of Children
and Families (DCF) with termination of parental rights. Review of the applicable record
contained all consent requirements.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures detailing suicide prevention procedures, which are
reviewed and signed by the designated mental health clinician authority (DMHCA) and the
superintendent annually. The plan included all required elements of identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
referrals, communication, notification, documentation, immediate staff response, and review
process. The center has an established review process for every serious suicide attempt or
serious self-inflicted injury and a mortality review for a completed suicide. The multidisciplinary
review included all required elements of 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, if any, for policy changes, training, physical plant, medical or mental health
services, and/or operational procedures.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. 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).
Five youth records were reviewed for suicide prevention services and four were applicable for
suicide risk. Two were applicable during admission screening and two due to staff observation.
An alert in the Department’s Juvenile Justice Information System (JJIS) was initiated for all four
youth when placed on precautionary observation (PO) with constant supervision, and a suicide
risk assessment referral was made on the required form. An Assessment of Suicide Risk (ASR)
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was completed on the required Department form within twenty-four hours in three reviewed
records. One youth was Baker Acted prior to receiving an ASR, which the parent/guardian was
notified of on the required form. Each record contained Suicide Precautions Observation Logs
completed in their entirety with required signatures by the qualified mental health professional,
with three documenting safe housing areas and one which did not. Each reviewed record
documented the staff documented a consultation with the designated mental health clinician
authority (DMHCA) or licensed mental health professional on the Mental Health/Substance
Abuse Referral Summary and the superintendent or designee was notified immediately of the
suicide risk. The ASR or Follow-Up ASR was completed prior to the removal of each youth from
PO, and there was documentation of a conference held by the superintendent and DMHCA to
reduce the level of supervision. The discontinuation of close supervision was documented in
accordance with the center’s Suicide Prevention Plan. Each suicide risk assessment was
completed by a licensed mental health professional and results of the assessments included
recommendations for supervision follow-up. Three of the four reviewed records as well as the
center logbooks evidenced suicide risk assessment instructions related to the suicide risk
assessment findings and suicide precaution decisions. A review of JJIS determined all alerts
were appropriately entered and removed following youth removal from PO. A review of logbooks
determined the beginning and ending times for PO were documented for youth in three of four
youth records. One reviewed youth had the ending time; however, did not have the beginning
time recorded in the logbooks. Five youth were interviewed, and one youth stated they have
been placed on suicide observation and was watched by staff the entire time. The remaining
youth stated they have not been on suicide watch while at the center. Five interviewed staff
reported once a youth expresses suicidal thoughts the staff notifies the mental health staff and
the administration/supervisor, search the youth and room, document placement of youth on
constant sight and sound supervision, and place the youth in a locked room. The DMHCA
stated all licensed staff conduct suicide risk screenings utilizing the ASR form. Once a youth is
placed on PO, youth are reassessed daily until standard supervision is appropriate. Prior to
revising a youth’s supervision level, it is noted on the ASR regarding the meeting with
administration staff. Usually, mental health staff are notified of youth on PO through JJIS, email,
and/or daily meetings with detention staff. Administration staff, juvenile probation officers, and/or
parents/guardians are notified of suicidal youth by telephone and/or emails. The interviewed
superintendent confirmed the center does not utilize secure observation for potentially suicidal
youth.
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures regarding secure observation. The policy requires
youth placed on suicide precautions to remain under secure observation if less restrictive
methods are not effective. Five youth records were reviewed, and none of the reviewed youth
records were applicable for secure observation. The center provided the only two applicable
records for review during the annual compliance review period. Each of the youth’s placements
in secure observation were authorized by the superintendent and the designated mental health
clinician authority (DMHCA). Each of the secure observation rooms were designated in writing.
The Department’s Health Status Checklist form was completed prior to placement in secure
observation and the Suicide Precautions Observation Logs were completed in their entirety for
both youth. Reviewed documentation confirmed a new Assessment of Suicide Risk (ASR) was
completed within eight hours for each applicable youth placement into secure observation. The
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youth’s parent/guardian and juvenile probation officer (JPO) were notified of the youth’s
potential suicide risk for both youth. Neither youth remained in secure observation beyond
twenty-four hours. Reviewed documentation in both youth records verified the mental health
staff provided supportive counseling services and the observation log documented supervision
while each youth was in secure observation. Each youth’s level of supervision was reduced
after a conference with the superintendent and a licensed mental health professional. The
discontinuation of secure observation and step-down to close supervision was documented in
the center’s logbook and in each youth’s mental health record by mental health clinical staff.
3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures for the process to safely screen, refer, assess,
monitor, and protect youth with an elevated suicide risk in the least restrictive means possible.
Five reviewed youth records found four were applicable for suicide precaution observation.
Each youth’s Suicide Precautions Observation Log was maintained for the duration the youth
was on suicide precautions and the appropriate level of supervision and observations of the
youth’s behavior were documented in real time, not exceeding thirty-minute intervals in each
reviewed record. Two youth records were applicable for warning signs and notification to the
superintendent or designee and mental health clinical staff was documented on the log. Each
log was reviewed and signed by each shift supervisor and signed by the designated mental
health clinician authority (DMHCA). Three of the four logs documented safe housing
requirements and one did not have this notated. A review of video footage and corresponding
documentation of three youth on precautionary observation (PO) confirmed proper supervision
was maintained for each youth placed on PO.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures to address suicide prevention training. The policy
requires all staff who work with youth to be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions. Five in-
service and five pre-service staff training records were reviewed. Each reviewed staff record
documented staff completed suicide awareness and prevention trainings, with the exception of
one in-service and one pre-service record, which did not have the two-hour online suicide
prevention training documented in the Department’s Learning Management System (SkillPro).
Reviewed drill documentation confirmed suicide drills were conducted no less than quarterly on
each shift for all direct care staff, and each drill was simulated. The center conducted trainings
for suicide attempts or incidents of serious self-inflicted injury at least semi-annually. The mock
mental health drills in response to a suicide attempt and/or incident of serious self-injury were
simulated and did not include any center youth. The center has five suicide response kits, which
included a knife-for-life, wire cutters, and needle nose pliers. Kits were located in master control,
both sub-control rooms, medical, and the supervisor’s office. Suicide response kits are co-
located with first-aid kits. Reviewed documentation found at least one mock drill which included
the use of cardiopulmonary resuscitation (CPR) annually. Staff who were not present during a
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quarterly drill had the opportunity to review each drill scenario, procedures, and critique 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. Five interviewed staff stated suicide response
kits are kept in master control, each sub-control room, medical, and the supervisor’s office.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures for mental health services which includes a
notification and alerts system, means of completing referrals including self-referrals,
communication, supervision, documentation, and reviews.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures to address the Emergency Services Plan which
stipulates the response procedures for youth in crisis. A review of the center’s Emergency
Services Plan confirmed it included immediate staff response, notification, communication,
supervision, authorization to transport for emergency mental health or substance abuse
services, transport for emergency mental health evaluation and treatment under Chapter 349 for
a Baker Act, transport for emergency substance abuse assessment and treatment under
Chapter 397 for a Marchman Act, documentation, training, and review. The plan was approved
July 24, 2024, and last updated on August 10, 2024. A copy of the approved plan is maintained
in the designated mental health clinician authority’s (DMHCA’s) office.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
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The center has facility operating procedures regarding Crisis Assessments. The policy requires
a Crisis Assessment for any youth demonstrating acute psychological distress. Five youth
records were reviewed for Crisis Assessments; however, none were applicable. Only one youth
was applicable for having a Crisis Assessment during the annual compliance review period. The
reviewed Crisis Assessment included the reason for the Crisis Assessment, a Mental Status
Examination and interview, determination of danger to self, initial clinical impressions,
supervision recommendations, recommendations for follow-up or further evaluation, and
notification to the 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 the completion of a Crisis Assessment. The Crisis Assessment was completed
from a Prison Rape Elimination Act (PREA) event at another center prior to being transferred to
this center. The Crisis Assessment was completed by a licensed mental health professional
within twenty-four hours based on the needs of the youth and becoming aware of the incident.
Due to the youth being an alleged victim of a PREA event the youth was offered ongoing mental
health treatment, as required.
3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures for Baker and Marchman Acts. The policy requires
youth 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. Five youth records were reviewed for Baker Acts and Marchman Acts and three were
applicable for being Baker Acted. An interview with the designated mental health clinician
authority (DMHCA) indicated there were no youth transferred under the Marchman Act since the
last annual compliance review. All three reviewed records verified a suicide alert was opened
pending off-site transport and each youth was placed on one-to-one supervision with
documentation being noted on precautionary logs until released. One youth did not return to the
center after being transported off-site for the Baker Act. Upon re-admission from Baker Act, the
two applicable youth were placed on suicide precautions and a mental health referral was
completed for a Mental Status Examination (MSE). The MSE was completed by a licensed
mental health professional in each record. Both youth’s supervision level was not lowered until
an appropriate assessment was conducted and a mental health staff conferred with the licensed
supervisor and superintendent or designee. Each applicable youth’s supervision levels were
maintained based upon the Assessment of Suicide Risk (ASR), and discontinuation of the
mental health alerts was completed in the Department's Juvenile Justice Information System
(JJIS) when applicable.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures requiring a contractual agreement with a licensed
physician to serve as the designated health authority (DHA). The center maintains a contract
with VitalCore Health Strategies, LLC which subcontracts with an osteopathic physician (DO) to
serve as the center’s DHA. The DHA holds an unrestricted, clear, and active license which
meets all requirements for independent and unsupervised practice in the State of Florida which
expires March 31, 2026. The center utilizes a part-time advanced practice registered nurse
(APRN) whose license expires April 30, 2025. The APRN and the DHA both signed the
Collaborative Practice Protocol agreement in August 2023. The center’s DHA is contracted to
be on-site at least once a week, with a week defined as the seven-day period beginning on
Sunday and ending on Saturday; however, at no time are more than nine days to pass between
on-site visits. The contract stipulates the number of hours the DHA is to be on-site is dependent
upon the size and population of the center. The DHA is on-call twenty-four hours a day, seven
days a week, and on-site for at least two-hours a week. A review of the center’s healthcare staff
sign-in sheets during the compliance review period showed the DHA was on-site each week, as
required. An interview with the DHA revealed they are on-site at least once every nine days to
provide clinical services, and are available by telephone twenty-four hours a day, seven days a
week for acute medical concerns, emergency medicine, and coordination of off-site care. The
interviewed DHA reported the specific duty of the DHA is to perform Comprehensive Physical
Assessments (CPAs) and CPA updates, provide consultation and advise the nursing staff with
sick call, urgent matters, medication questions, medical condition questions, follow-up on urgent
and acute issues with detained youth, provide oversight to the APRN, and develop and/or
review and make recommended changes to policy and procedures. The center did not utilize
tele-medicine during the annual compliance review period.
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 for all utilized health-related procedures and
protocols. Reviewed documentation reflected the designated health authority (DHA) reviewed,
signed, and dated, on May 17, 2024, and the superintendent signed on May 10, 2024. The
psychiatrist last reviewed the protocols related to psychiatric services on April 4, 2023, and had
not reviewed the relevant policy and procedures in the previous year; however, the center
obtained the psychiatrist’s signature on the first day of the annual compliance review week. The
DHA conducted an annual review of the center’s medical protocols on May 13, 2024. Reviewed
documentation validated the advanced practice registered nurse (APRN) and each of the
program’s nurses reviewed, and respectively signed and dated the cover page treatment
protocols during the week of May 10-17, 2024. VitalCore Health Strategies, LLC has an
established comprehensive clinical orientation for all newly employed healthcare staff, which
includes the Department’s healthcare policy and procedures, and is provided by a registered
nurse (RN).
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures requiring parents/guardians to be afforded the right
to give or withhold consent regarding the healthcare provided to the youth. A review of five
youth Individual Healthcare Records (IHCRs) revealed each record had a valid Authority for
Evaluation and Treatment (AET) which was signed by the parent/guardian and a Department
representative. Each AET was obtained prior to providing medical services for each youth. None
of the five reviewed records were for youth applicable for being under the care and custody of
the Department of Children and Families (DCF). An interview with the clinical nurse manager
indicated the nursing staff obtain a valid AET upon each youth’s admission into secure detention
which may include contacting the assigned juvenile probation officer (JPO) to assist in obtaining
the parent/guardian signature. When a youth reaches eighteen years of age, the youth will
provide verbal consent at the point of contact for healthcare.
4.04 Parental Notification/Consent [Contract Provider] Limited 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 requiring notification to be made to each youth’s
parent/guardian for consent from the parent/guardian for treatment, when new medications and
treatments are prescribed, when there are significant changes in the youth’s condition, and
when the youth is sent for off-site care. A review of five youth Individual Healthcare Records
(IHCRs) showed none received any over-the-counter (OTC) medication beyond those covered
by the Authority for Evaluation and Treatment (AET). Three youth records were applicable for
having a new prescribed medication ordered after the youth’s admission to the center. Two of
the three records documented attempted contact to the parent/guardian in the progress notes,
as required, and one did not. One of the three applicable records included documentation a
written notice was sent to the parent/guardian, as required, and two did not. One record was
applicable for a newly prescribed psychotropic medication and significantly changed
psychotropic dosages; however, parental/guardian verbal consent was not documented on page
three of the Clinical Psychotropic Progress Note (CPPN), or on a chronological progress note.
One youth’s IHCR was applicable for the youth having been admitted while taking psychotropic
medications; however, there was no documentation of a staff witnessing attempted telephone
calls to or conversations with the parent/guardian related to psychotropic medication. Five youth
IHCRs were reviewed for vaccination status, and four contained a vaccination record from
Florida Shots, all of which were reviewed by medical staff within thirty days of each youth’s
admission. An interview with the nursing staff confirmed immunization records are obtained and
reviewed once the youth is admitted to the center. One youth record was for a youth transferred
from another detention center where the youth’s vaccination status had already been verified.
The clinical nurse manager was interviewed and indicated parental/guardian notifications are to
be made when starting new medication and the medical staff will contact the parent/guardian in
order to ensure notifications are made; however, an informal follow-up interview with the clinical
nurse manager revealed they were unaware written notifications were required. The nursing
staff indicated the procedures to obtain consent for youth with new psychotropic medications or
adjustments are conducted by the psychiatrist who will make contact with the youth’s
parents/guardians.
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4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures requiring each youth, at the time of admission, to
receive a Facility Entry Physical Health Screening utilizing the Department’s Medical and Mental
Health Admission Screening form. A review of five youth Individual Healthcare Records (IHCRs)
found each had a Medical and Mental Health Admission Screening form completed on the date
of admission. Each reviewed form was completed on the date of admission by a juvenile justice
detention officer (JJDO), and each indicated the screening was reviewed by a licensed medical
staff within twenty-four hours. Each youth’s screening form was completed in the Department’s
Juvenile Justice Information System (JJIS), as required. Reviewed documentation validated the
designated health authority (DHA) was notified of each youth’s admission. The center reported
there were no youth applicable for a change in physical custody during the annual compliance
review period; however, two records documented previous admissions to the center and a
healthcare admission rescreening was completed upon each admission for each youth. Two of
the five reviewed records were for youth who received a qualitative urine pregnancy screening
test; however, chronological progress notes did not document verbal or written consent. An
informal interview with the clinical nurse manager revealed although consent was not
documented, the youth taking a pregnancy test indicates the youth consented to the test. An
interview with the nursing staff confirmed the admission screening process. Additionally,
indicated when there is a change in the youth’s physical custody, the center has a process for
rescreening upon re-entering the center.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures requiring all youth to be oriented to the general
healthcare delivery services at the center. A review of five youth Individual Healthcare Records
(IHCRs) validated each youth received a general healthcare orientation on the day of admission
to the center. Each reviewed record contained a completed Department Health Education
Record form documenting youth orientation to the center’s healthcare services within twenty-
four hours of admission to the center. Each youth orientation included topics addressing access
to medical care, sick call, instances which constitute an emergency and when to notify staff, the
medication process and side-effect monitoring, the youth’s right to refuse care and how refusals
are documented, what to do in the case of a sexual assault or attempted sexual assault, and the
non-disciplinary role of the healthcare providers.
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 in need of emergency
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care. A review of five Individual Healthcare Records (IHCRs), reflected two youth were
applicable for a known or suspected chronic health condition at the time of their admission. An
interview with the clinical nurse manager indicated the DHA is notified at the time of intake
whenever a youth is admitted and identified with an emergency or chronic condition. When the
DHA is notified by the nursing staff, it is to be documented in the healthcare record on the
admission chronological progress note. It is the center’s practice to notify the DHA of all new
admissions regardless of medical condition and the notification is documented in the
chronological admission progress note. All five reviewed records supported the DHA was
notified of each youth’s admission to the center. Two youth records were applicable for youth
having been admitted with current prescriptions for psychotropic medication and the psychiatrist
was notified of the youth’s admission, as well. An interview with the nursing staff confirmed the
centers practice for youth admitted with serious chronic conditions.
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 a review and update of the
Department’s standard Health-Related History (HRH) form at each youth admission. The center
utilizes the HRH form for all youth admitted into the center’s physical custody. A review of five
youth Individual Healthcare Records (IHCRs) found each contained a new HRH form which was
completed by a licensed nurse within seven days of the youth’s admission and subsequently
reviewed by the designated health authority (DHA) or advanced practice registered nurse
(APRN). The HRH form was completed prior to or at the same time as the Comprehensive
Physical Assessment (CPA) for each youth and reflected each youth’s most current admission.
An interview with the clinical nurse manager indicated it is the program’s practice to complete
the HRH form within seven days of the youth’s admission to the center.
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) to be completed or updated for all youth admitted to the center to determine the health
and wellbeing of each youth. A review of five Individual Healthcare Records (IHCRs) was
conducted and two contained a current CPA on file at the time of admission and three records
required a new CPA. Each CPA was completed or reviewed within seven days of the youth’s
admission and signed by the designated health authority (DHA) or the advanced practice
registered nurse (APRN). Each CPA was completed in full to include the Medical Grade, Tanner
Stage, cardiovascular elements, body mass index, visual acuity field, and most recent
Tuberculosis Skin Test (TST). All five records had all sections of the CPA completed or noted by
the DHA or APRN as not being medically indicated. The Department’s Problem List was
updated in each reviewed instance, as required. The center’s policy and procedures for
tuberculosis (TB) control and screening require the routine screening of all youth for latent and
active TB and outline environmental controls in the case of a youth with suspected active TB.
Each of the reviewed records documented a TST had been completed within the last year and
none of the reviewed youth required further evaluation prior to entering general population. An
interview with the clinical nurse manager indicated the DHA completes the CPA every one to
two years, as needed. Nursing staff indicated TB screenings are provided to youth at the time of
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intake to the center unless the youth does not have an Authority for Evaluation and Treatment
(AET).
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). After the screening, sexually active youth
are referred to the designated health authority (DHA) or advanced practice registered nurse
(APRN) to determine if further testing is indicated. A review of five Individual Healthcare
Records (IHCRs) indicated each youth was clinically screened and evaluated for STIs. Three
youth records indicated no further evaluation was required. Two youth records included referrals
and one had testing ordered which the youth declined as the youth had been tested the month
before at another detention center prior to being transferred to this center. The second referred
youth indicated they had not been sexually active since becoming pregnant and had negative
STD testing completed at the center in September at the time of the pregnancy diagnosis. STI
screenings, evaluations, and referrals were documented and maintained in each youth’s IHCR.
There were no youth applicable for being out of the Department’s custody for thirty days or more
needing a rescreening during the annual compliance review period. All five reviewed records
validated each youth was offered counseling and testing for human immunodeficiency virus
(HIV). Three of the five youth declined consent for HIV testing, while one had recently
completed testing at another center. One youth consented to testing and was provided pre- and
post-test counseling which was documented in the youth’s Health Education Record. An
interview with the clinical nurse manager indicated the STI screenings, evaluations, referrals,
and testing are documented on the youth’s confidential Infectious and Communicable Disease
form. HIV results were not included on the center’s internal alerts. Additionally, the medical staff
provide youth with the HIV pre and post counseling. Five youth were interviewed, and all five-
youth reported being able to request a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures regarding the center’s sick call process and
requests. The center conducts sick call seven days a week for a healthcare professional to
respond to youth’s medical illnesses or injuries of a non-emergent nature. Postings throughout
the center indicated sick call takes place daily from 9:00 a.m. to 10:00 a.m., and 4:00 p.m. to
5:00 p.m., when youth are securely detained at the center; however, the clinical nurse manager
indicated it is typically the center’s practice to provide a “flexible sick call” by responding to
requests as episodic care. Shift supervisors are trained in the center’s sick call procedures and
are required to review the sick call requests in the absence of the healthcare professionals as
soon as possible and within four hours of the submission of a sick call request. A review of five
Individual Healthcare Records (IHCRs) indicated three were applicable for having submitted a
Sick Call Request form. Each of the reviewed sick calls were completed by the nurse in
accordance with Florida Administrative Code and maintained in each youth’s Electronic Medical
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Record (EMR) in the Department’s Juvenile Justice Information System (JJIS). There were no
instances of a youth presenting with a similar sick call complaint three or more times in a two-
week period nor any youth complaints of severe pain in which staff were unfamiliar. Sick calls
were conducted by a licensed nurse either immediately or within twenty-four hours of the sick
call request submission and documented on the Sick Call Referral Log for each youth.
Observations of a sick call could not be completed as no youth requested a sick call during the
week of the annual compliance review. An interview with the clinical nurse manager confirmed
sick calls are conducted by a nurse or the designated health authority (DHA); however, if a sick
call is conducted by a licensed practical nurse (LPN) on the weekend, then the registered nurse
(RN) will review and approve the forms in the EMR. One of the reviewed sick calls was
applicable for having been completed by an LPN, and the RN reviewed the sick call forms
sixteen days later, on December 9, 2024. The center maintains treatment protocols appropriate
to the level of the provider conducting sick call, which were approved by the designated health
authority (DHA). Five staff were interviewed, and all five indicated nurses review all sick calls,
and two staff indicated other staff review the sick calls. Five youth were interviewed. One
interviewed youth indicated they could be seen immediately when submitting a sick call, and
four stated they could be seen within one day. Five youth were interviewed, and each indicated
nursing staff conduct sick calls and one indicated staff conduct sick calls.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Limited Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures detailing a comprehensive process for the provision
of episodic care, first-aid treatment, and emergency care. The center utilizes an Episodic Care
Log to document episodic care and first-aid treatment. A review of five youth Individual
Healthcare Records (IHCRs) showed four youth were applicable for having had episodic or
emergency care. In each instance the nature of the complaint was documented, and the
findings of the healthcare staff rendering care were included. None of the reviewed instances of
episodic care required referral to off-site care. Each reviewed instance documented the
education/instruction which was provided to the youth and an entry in the Episodic Care Log
was completed. None of the reviewed instances required any follow-up. The center maintains a
total of eighteen first-aid kits which are located in master control, in each of four classrooms, in
each of the two sub-controls, the maintenance shed, intake/transport, the education office, the
supervisor’s office, and two in the kitchen. There is one kit for each of five transport vehicles,
which are stored in the intake office. The center’s first-aid kits are sealed with breakaway tabs.
When a kit has been opened, as indicated by the snap tag having been broken, the shift
supervisor must bring the opened kit to the nurse manager for inspection, restocking of the kit,
and resealing the kit. The nurses check all eighteen first-aid kits monthly, in addition to
restocking any open kits which are brought to medical. One sealed first-aid kit in the master
control was opened and contained all items approved by the DHA, as required. The center
maintains two automated external defibrillators (AEDs). The center’s AEDs are located in wall-
mounted AED boxes in the medical clinic and master control. The AED procedures are stored
with the AED, and each AED provides audible instructions when utilized. Nursing staff check the
AEDs weekly to ensure the AED is operational and the checks are documented. A review of the
center’s AED tracking sheets during the annual compliance review period validated the center’s
practice. The batteries in the AEDs, which were last changed on April 8, 2021, were observed to
be fully charged as determined by the light on the front of each device showing green. The AED
pads were last changed in March 2024, and expire March 28, 2026. AED maintenance was last
conducted by an outside medical equipment company on September 10, 2024. All non-
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healthcare staff and nursing staff are required to maintain certification and a review of five in-
service staff training records found each was trained and held current certification in
cardiopulmonary resuscitation (CPR), first-aid, and AED. CPR/AED demonstration is to be
practiced on a regular basis, at least annually. A review of the thirty-one emergency medical
and suicide drills conducted by center administration during the annual compliance review
period validated drills were run at least quarterly on each shift; however, only one drill on alpha
shift in December 2023 documented the mock demonstration of CPR/AED. Observations
confirmed emergency contact telephone numbers were posted out of the view of youth. Only
healthcare and trained supervisory non-healthcare staff can administer the epinephrine auto
injector for youth requiring administration, when indicated. A review of five training records
supported each staff received the required training on the center’s Emergency Care Plan and
the designated supervisory staff received training on epinephrine auto injector. Reviewed
documentation supported the designated health authority (DHA), the advanced practice
registered nurse (APRN), and all nursing staff maintained current certifications in CPR and
AED. The center’s medical policy and procedures document the requirements for the use,
access, and inventory of medication for the emergency treatment of an opioid overdose. The
center maintains NARCAN® in the locked medication cart which is accessed only by the
licensed nurses and shift supervisors who have completed training on medication
administration. The center maintains a perpetual and weekly inventory of the NARCAN®. An
informal interview with the clinical nursing manager indicated the center has not utilized
NARCAN® during the annual compliance review period. An interview with the nursing staff,
confirmed the location of the first-aid kits and AEDs. Additionally, the nursing staff indicated the
process for documenting on-site episodic care and how a youth’s off-site emergency care is
tracked. Five youth were interviewed, and one rated the medical care at the center as very
good, three rated it as good, and one stated the care was fair. Five staff were interviewed, and
each indicated they are allowed to call 9-1-1, if needed.
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 requiring the provision of referrals and coordination
of medical services to ensure youth have timely access to off-site care services. A review of five
youth Individual Healthcare Records (IHCRs) found three youth were applicable for off-site care.
All three records contained a completed Summary of Off-Site Care form for the youth which was
signed by the designated health authority (DHA). None of the reviewed instances of off-site care
were applicable for discharge paperwork; however, progress notes documented the related
notification made to each parent/guardian and the DHA and noted any needed follow-up care,
when required. The clinical nurse manager reported the center receives the discharge
paperwork, which is reviewed and signed-off by the designated health authority (DHA). The
hospital records are then maintained in the youth’s record and in the Department’s Juvenile
Justice Information System (JJIS) Electronic Medical Record (EMR), under the tab for off-site
care. The clinical nurse manager ensures the DHA reviews and initials all off-site care findings,
instructions, and information by putting the information in the DHA folder, which is reviewed and
signed when the DHA is on-site and then returned to the nurses.
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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 which require youth identified with chronic
conditions to receive regularly scheduled evaluations and necessary follow-up care. A review of
five youth Individual Healthcare Records (IHCRs) found four were applicable for the existence of
a chronic condition. Three youth were taking prescribed medication on an ongoing basis, one
was undergoing treatment for a physical health condition related to a body mass index (BMI)
over thirty, and one youth was pregnant. The four youth were placed on the chronic list;
however, one did not remain in secure detention long enough for a periodic evaluation. One
youth on the chronic list was prescribed medication for an on-going condition the week prior to
the annual compliance review. The problem list for each youth was updated to indicate each
youth’s chronic condition upon completion of the Comprehensive Physical Assessment (CPA).
There were no youth applicable for taking anti-tuberculosis medication. An interview with the
clinical nurse manager explained the center utilizes a report sheet to track periodic evaluations.
An interview with the designated health authority (DHA) indicated periodic evaluations will be
addressed and reviewed every thirty days or may be evaluated more frequently depending on
the number of chronic conditions and the Medical Grade of the youth. If a youth is a Medical
Grade five, they will be evaluated at least every thirty days or more often depending upon
whether their condition is stable or not. An interview with the clinical nurse manager indicated all
youth who have chronic conditions are maintained on the report sheet and are followed-up with
as needed.
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 requiring all medication and pharmaceutical
products to be procured, dispensed, administered, and stored safely, accurately, and in
accordance with state, federal, and industry standards. The center’s practice is for nursing staff
to verify each medication has a current, valid order, and is given according to a current
prescription or practitioner’s order. Nursing staff verify medication with the parent/guardian when
they deliver the medication to the center. A Medication Receipt, Transfer, and/or Disposition
form is used to document medication received in the original packaging from another center or a
licensed pharmacy with a current, legible, patient-specific label affixed. There were no youth
applicable for restricted housing while taking prescribed medications during the annual
compliance review period. The center utilizes a local pharmacy as a back-up for emergency
purposes. All medication is delivered to the center in blister packs. A review of five Individual
Healthcare Records (IHCRs) showed there were two youth taking medication upon admission;
therefore, one additional applicable record was selected for review. A review of the three
applicable records indicated the designated health authority (DHA), or when applicable the
psychiatrist, was contacted to at the time of admission. The medication for two of the three
reviewed youth each had a current, valid order, and were administered pursuant to the current
prescription; however, one of the three youth was admitted on September 18, 2024, with
psychotropic medication, which was received by the center, but the youth had not been taking
the medication for the two weeks prior to admission. The psychiatrist was notified of the youth’s
admission with psychotropics; however, the youth was not referred to the psychiatrist and no
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medication order had been issued by the psychiatrist to hold, continue, or discontinue the
medication. When current medications were continued, discontinued, or changed the reviewed
records indicated the DHA placed an order on the Practitioner Order form, as required. Two
reviewed records for youth transferred from another center had the completed Medication
Receipt Transfer Disposition form in the IHCRs. None of the reviewed records were applicable
for over-the-counter (OTC) medications not listed on the Authority for Evaluation and Treatment
(AET) form. The center utilizes the standard Department Medication Administration Record
(MAR) for each youth receiving either prescription medications on a routine basis or OTC
medications. The center maintains a policy and procedures requiring the use of the MAR by
licensed healthcare staff and non-licensed staff. A review of the standardized MAR form showed
each included the youth’s name, Department identification number (DJJID), date of birth, youth
allergies, precautions, Medical Grade, medical alerts, and a current picture of the youth. Five
youth records were reviewed and three were applicable for having MARs documenting
administered medications. Two of the three reviewed MARs documented side effect monitoring
by the nursing staff at each medication administration. The November 2024 MAR for one youth
did not document any side effect monitoring by the nursing staff from November 20 to
November 30, 2024. Two reviewed records validated the youth initialed each medication entry,
as required. The MAR for one youth clearly documented several instances of the youth refusing
the medication and the youth’s IHCR contained a signed Refusal of Treatment Form for each
instance. No youth records were applicable for trained non-healthcare staff assisting in the
delivery of medications when licensed healthcare staff were not on-site and there were no
undocumented explanations for lapses or errors in medication administration. The center did not
have any standing orders for psychotropic medication, pro re nata (PRN) orders for
psychotropic medication, or emergency treatment orders for psychotropic medication. Two of
five reviewed records were applicable for youth entering the center while on prescribed
psychotropic medication. In both instances the psychiatrist was notified upon the youth’s
admission; however, the psychiatrist conducted an Initial Diagnostic Psychiatric Interview for
only one of the youth within fourteen days of admission. The other youth had not been seen by
the psychiatrist since their admission to the center on September 18, 2024. An informal
interview with the clinical nurse manager indicated the youth had been seen by mental health
staff; however, was not referred to the psychiatrist due to the youth having refused to take the
prescribed psychotropic medication for the two weeks prior to admission to the center.
Observations of a medication pass were conducted during the week of the annual compliance
review. Medication delivery was the sole responsibility of the nurse at the time of administration.
The youth was escorted to the medication administration area by a direct care staff. The youth
approached the nurse administering medication individually and the same staff prepared and
administered each medication. The nurse observed the youth’s open mouth after the medication
was administered to ensure the medication was swallowed. The nurse and youth initialed the
MAR. Additionally, the center has non-healthcare supervisory staff who are trained by medical
staff to provide OTC medication to youth. An interview with five staff regarding medication
administration was conducted, and all five non-supervisory staff stated they do not give
medication to youth. Five youth were interviewed and two indicated the nurse administers their
medication and two indicated they did not take medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
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The center has facility operating procedures detailing the requirements for the storage and
inventory of medication and sharps and requiring all medication be inaccessible to youth at the
program. Observations found all medications in the medical clinic were inaccessible to youth.
The locked medication cart, which is kept in the locked medical clinic, was clean and organized,
with stock items maintained separately from youth specific medication. Narcotics and other
controlled medications were securely stored and double-locked within the medication cart. The
center had no medication requiring refrigeration during the annual compliance review week;
however, the center has a refrigerator which is used only for medication, if needed. Perpetual
inventories with running balances are maintained on all controlled substances with a shift-to-
shift inventory conducted by the nurses. A count of three controlled medications was observed,
and the reviewed inventory was found to be accurate. A review of three over-the-counter (OTC)
medications was conducted, two of which validated the respective inventories were accurate,
while observations showed one medication had three tablets beyond the count noted on the
inventory. Healthcare staff reviewed the medication orders at the time of the observation to
determine whether, or how many, youth were prescribed the missing medication; however,
neither nurse knew what the procedure was when inventory discrepancies were identified or
what the reporting requirements were. The cause of the inaccurate count could not be
determined, and the clinical nurse manager reported the error to the Department’s Central
Communications Center (CCC) within the required time frame. Syringes and sharps are counted
through a perpetual inventory and are verified weekly. Observations of a count of three sharps
was conducted with the registered nurse (RN) which validated the counts of the three sharps on
the perpetual inventory. An interview with the clinical nurse manager indicated the center utilizes
a chemical pharmaceutical drug disposal system to dispose of expired medication in the
presence of the consultant pharmacist.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures requiring proper procedures to be followed to
prevent the spread of infectious diseases or illnesses and to educate staff on the appropriate
prevention, containment, treatment, and reporting requirements of infectious diseases. A review
of five youth Individual Healthcare Records (IHCRs) was conducted. Reviewed documentation
indicated each youth received infection control training within seven days of admission. The
infection control training included hand-washing techniques, universal/standard precautions,
prevention/transmission of communicable diseases, vaccinations, and the Centers for Disease
Control and Prevention (CDC) guidelines for infection control. A review of the center’s Exposure
Control Plan/Infection Control Plan showed the plan was written in accordance with
Occupational Safety and Health Administration (OSHA) guidelines to include risk assessment
and methods of compliance. The plan addressed common childhood infectious diseases, self-
limiting, episodic contagious illnesses, viral and bacterial infectious diseases, tuberculosis,
Hepatitis A, B, and C, human immunodeficiency virus (HIV), blood-borne pathogens, other
outbreaks and epidemics, and outbreaks of pediculosis. In addition, the plan included Methicillin
Resistant Staphylococcus Aureus (MRSA) and other antibiotic-resistant micro-organisms, food-
borne illnesses, bioterrorism agents, chemical exposures in the workplace, and protocols for
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needlestick post-exposure intervention and treatment. The center’s post-exposure process for
evaluating needle sticks includes reporting the stick to the immediate supervisor, documenting
the circumstances, route of exposure, and the source individual and their status. Results of
testing are to be made available to the exposed staff, as well as providing appropriate
counseling, and a referral to the nearest medical center/hospital or Department of Health for
post-exposure evaluation through worker’s compensation. The center ensures Hepatitis B
immunizations are available for staff and staff have access to protective equipment as needed.
There were no incidents for which the local county health department, CDC, or the
Department’s Central Communications Center (CCC) were notified relating to an infectious
disease during the annual compliance review period. A review of five staff training records
confirmed each staff completed Exposure Control Plan/Infection Control Plan training. An
interview with the clinical nursing manager indicated youth are provided with the infection
control training upon admission, and nursing staff are responsible to provide staff with training
on the center’s Exposure Control Plan. Additionally, nursing staff validated the process for
securing and conducting inventory and indicated all medication is maintained in a locked
medication cabinet.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. The clinical nurse manager
indicated the center did not have any nursing protocols specific to pregnancy; however, the
policy entitled Medical Services, which addresses pregnancy, was obtained from the regional
nursing manager during the week of the annual compliance review. The center had one
pregnant youth admitted during the annual compliance review period. Prenatal care began
immediately upon determination the youth was pregnant during the annual compliance review
period in September 2024, which continued through the youth’s previous discharge and
readmission to the center on November 30, 2024. The designated health authority (DHA) and/or
advanced practice registered nurse (APRN) provided a routine focused medical evaluation of
the youth’s pregnancy every thirty days or sooner. A review of the applicable record indicated
prenatal care was provided at recommended intervals while the youth was in the center and the
youth was placed on the center’s internal alert system for the provision of prenatal nutrition and
staff health awareness. The healthcare staff had not provided routine monitoring of the pregnant
youth’s nutritional and weight status as the DHA had not ordered routine monitoring of the
youth’s weight status. There was no documentation indicating the youth was monitored daily for
signs of pregnancy complications; however, the youth was prescribed prenatal vitamins which
were administered daily by the nurse. Reviewed healthcare education information showed the
applicable pregnant youth completed prenatal education including the topics of alcohol and drug
use, smoking cessation, nutrition, sexually transmitted infections (STIs), contraception, prenatal
care, birthing process, postpartum care, basic baby care, child/infant development, and
parenting skills. All youth education was documented in the youth’s Individual Healthcare
Record (IHCR). The youth did not yet have a documented plan for post-birth psychological and
physical care and the clinical nursing manager indicated the youth was not due to give birth until
March 2025. A review of five staff training records validated each staff received training specific
to working with pregnant youth. Reviewed staff training documentation reflected training was
provided by the nurses, as needed. An interview with the clinical nurse manager indicated the
center's process for routine monitoring of pregnant youth includes the youth to be seen weekly
by the DHA or APRN and seen by the nurses as needed. All pregnant youth are to have off-site
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obstetrical appointments and are to be provided with 300 additional calories in the second and
third trimester to meet caloric intake for pregnancy.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures regarding the supervision of youth. Observations
were conducted each day of the annual compliance review week of staff supervising youth.
Observations revealed all youth were always in sight and sound supervision of staff. Youth and
staff observations were made on the living modules, in the classrooms, in the cafeteria, in the
booking area, and during line movements throughout the center. Staff were observed
supervising youth by controlling line movements, positioning themselves appropriately, and
giving clear directions throughout the week in which the annual compliance review team was
on-site. There was proper supervision during each of these observations and staff were aware
the number of youth they were supervising. The staff used the radio to call the youth movement
throughout the center and to communicate between officers and master control. The center’s
logbooks were reviewed, and counts were consistently documented throughout the shifts. The
center conducts a shift briefing prior to the beginning of each shift. Five staff were interviewed,
and four staff indicated there are enough staff to safely provide supervision to the youth. One
staff interviewed stated there are a lot of troubled youth, which could be a hazard if there is a
limited number of staff available for both the male and female youth.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
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The center has facility operating procedures addressing the behavior management system
(BMS) to ensure the safety and security of youth and staff, which offers rewards, privileges, and
consequences for youth behaviors. A standardized behavior management system (BMS) shall
enhance safety and security as it relates to youth’s behavior and promote the health and well-
being of youth by providing an environment which fosters social, emotional, intellectual, and
physical development. Corporal punishment shall not be used in detention centers. The BMS
shall be explained to all youth during the admission and orientation process and be posted in all
common areas. Youth shall be provided an orientation brochure at the time of admission, which
clearly describes the BMS. The BMS is a three-tiered level system. Each youth enters at level
“2.1” when admitted, and the level may increase or decrease, depending on the youth’s
behavior in the center. The center has an incentive calendar outlining the daily incentives for the
month. Incentives available for every youth earning level three status include later bedtimes,
extra telephone calls, extra visitation outside of the allotted visitation time, participation in
special events, and canteen food items. Reward calendars were posted alerting the youth of
rewards and privileges which can be earned. Observations conducted during the annual
compliance review week revealed the center had the BMS posted in each of the living modules.
The postings describe appropriate behaviors and rewards for such behavior, and inappropriate
behavior and consequences for such behavior. Staff maintain a BMS data sheet for each youth
to capture youth behavior throughout the day. A review of five youth’s level sheets and logbooks
confirmed the center’s practice. Five youth were interviewed regarding the BMS. One youth
stated the BMS is very good, and one youth stated the BMS is good. One youth stated the BMS
is fair, and two youth stated the BMS is poor. All five youth were able to articulate the difference
between each level and how youth are rewarded in the center. Three of the five youth confirmed
all staff use the rewards the same way and two youth indicated they feel staff are not always
fair. Each youth stated youth are never allowed to punish other youth. Two of five interviewed
youth indicated they’ve never been sent to their room, and three youth indicated they were sent
to their room behind a locked door due to code violations or negative behaviors. Three of five
interviewed youth indicated when receiving consequences, they felt it was fair, and two youth
stated they have never received consequences. Three of the five interviewed youth indicated
when consequences are given, they have their level or points taken away. Five interviewed
youth indicated they have never seen staff place out of control youth in handcuffs or leg irons to
prevent them from hurting themselves or others. Five staff were interviewed regarding the BMS.
All five staff were able to explain the center’s BMS. All five staff stated youth who earned their
level receive extra telephone calls, snacks incentives, participate in movie nights, and/or other
incentive parties. Five interviewed staff indicated they believe the center’s BMS is effective.
Each staff stated youth are given an opportunity to discuss and explain their behavior, and staff
can speak to the youth about their behavior, consequences, and alternate behavior. Five
interviewed staff indicated supervisors provide feedback to staff daily, during their briefing
meetings. Five interviewed staff stated co-workers are not allowed to take meals, snacks,
clothing, education, or medical care from a youth as part of a consequence and only the youth’s
points or level can be taken away. Five staff were interviewed, and each indicated, they have
not observed any staff encouraging a youth to beat up another youth. An interview with the
superintendent validated the center’s practice in the utilization of the standardized BMS.
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
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conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks to ensure ten-minute
checks are conducted when youth are in their rooms for sleeping purposes, shift change, and
confinement. The center has a total of fifty-six cameras with a recording capacity of thirty days.
Eight of the cameras were not operational at the time of the annual compliance review. The
observation by a staff member assigned to monitor a youth shall occur at intervals not to exceed
ten-minutes throughout the youth’s stay in their room and/or sleeping areas. Visual checks must
be made of the youth’s condition, such as outward appearance, behavior, and position in the
room, at intervals not to exceed ten-minutes. A Visual Observation Report (VOR) must be used
to document the checks as completed. The center uses written observation report logs to
document ten-minute checks. When conducting room checks, staff must pause at each room
door and look inside the room to ensure there are no issues with the youth. The center utilizes
VORs, which is a written report to document room checks. A review of ten-minute check log
samples for each month for the last twelve months, reflected checks were consistently
conducted at intervals of no more than ten-minutes. A review of the documentation and
surveillance coverage was conducted for nine randomly selected dates during the thirty days
prior to the annual compliance review, across three shifts, and on two different youth modules.
The review confirmed the ten-minute checks were being conducted at intervals of ten-minutes
or less. Five staff were interviewed, and each staff was knowledgeable on the requirements and
policy for ten-minute checks and room checks. Each staff stated checks are conducted every
ten-minutes or less. An interview with the superintendent reported anytime a youth is placed in
their room, staff are assigned to monitor the youth at intervals not to exceed ten-minutes. A
VOR must be used to document the checks as completed.
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 in place to ensure staff always know the exact
number and location of all youth under their supervision. A review of one full day from each
month since the last annual compliance review confirmed counts were being conducted and
documented as required. A review of the master control logbooks confirmed the census counts
of youth are written at the beginning and at the end of each shift. Master control authorizes all
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movement of youth prior to and following routine group movements. Random head counts are
conducted and documented, at a minimum, one additional time randomly each shift. Counts
were documented in the logbooks following emergencies, disturbances, and drills. Census
counts were documented upon any change of population in the logbooks and updated in the
Department’s Juvenile Justice Information System (JJIS) census. Living module counts were
documented in the assigned module logbooks. An observation of counts was completed during
the week of the annual compliance review, and staff were observed conducting counts before
and after each movement. Five staff were interviewed, and each staff stated emergency counts
are conducted when a youth is believed to be missing, when visibility is hindered, or after a
major disturbance. Additionally, four of the five staff indicated emergency counts are conducted
following any code call indicating a potential escape, disturbance, and/or medical/mental health
emergency. Five interviewed staff indicated youth counts are conducted during every shift,
before school, before and after meals, as well as throughout the day. Additionally, in the event
counts are not correct, movement within the center stops and staff will continue counts and will
call in their findings into master control. Once the count is verified, movement within the center
continues.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures regarding logbooks. The center maintains separate
logbooks in master control for transportation, each living module, as well as one for visitors, and
one for contracted staff. A review of logbooks for the last twelve months revealed each logbook
was bound with numbered pages. All entries included the date and time of the event or incident
with the name of the staff and youth involved, with a brief description of the event and the initials
of the staff making the entry. All reviewed entries revealed safety and security of the center,
including medical, special needs, and mental health alerts, were highlighted. The master control
reviewed logbooks revealed emergency situations, incidents, fire and escape drills, population
counts at the beginning and end of each shift, group movements, admissions and releases,
presence of law enforcement, and name of youth placed in confinement, the time confinement
began and the time confinement ended, name of youth placed on precautionary/secure
observation, the time precautionary/secure observation began, and the time
precautionary/secure observation was discontinued. Reviewed logbooks reflected all errors
were struck through with a single line and voided and initialed by the person correcting the error.
The juvenile justice detention officer (JJDO) assigned to the modules reviewed the logbook
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upon accepting the shift. The superintendent or designee reviewed all logbooks at a minimum of
weekly and reviewed the entries for the last seventy-two hours and documented their presence
in the living area logbooks every shift. An interview with the superintendent validated the
center’s practice.
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 detailing the requirements of the center’s key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or
lost keys, and reporting and replacement of damaged keys. All keys are secured on a color-
coded tamper-resistant ring which inhibits the removal of keys, with a tag identifying the ring
number and the number of keys on the ring. The center’s keys are stored and secured inside
the supervisor’s office. The key box is only accessible by the shift supervisor, assistant
superintendent, and superintendent. All restricted keys are secured in the supervisor’s key box.
Emergency keys providing egress through exterior doors are stored in master control and the
supervisor’s office. A key inventory for each key is maintained in the supervisor’s office and
superintendent’s office. The inventory identifies the ring number, number of keys assigned to
the ring, the location assigned to the keys, and the staff assigned to the keys. A review of the
Key Control Log and observations of the distribution and collection of keys confirmed keys are
distributed after shift briefing by the shift supervisor. The issued keys were documented on the
Key Control Log on each shift with the date and time of issue, name of the staff issuing the key,
name of staff receiving the key ring, and the time each was returned. Key issuing and return of
keys were documented on the daily shift reports. A review of the master key control inventory
confirmed the inventory report matched the actual key rings in use. During the annual
compliance review week, staff were observed carrying the keys on their person and youth did
not have access to center keys. The center keys carried by three staff were examined and were
confirmed to have the correct number of keys on the ring, as well as the correct assigned key
ring number documented for the shift. Informal interviews conducted with three staff confirmed
all staff knew about the number of keys on their key ring and the function of each key. A review
of the Department’s Central Communications Center (CCC) reports for the last twelve months
found there were no reported incidents of missing keys. Five interviewed staff reported medical
records keys, case management keys, mental health keys, and kitchen keys are restricted. All
five interviewed staff were knowledgeable on the center’s key control process and were able to
explain the process for reporting missing or damaged keys as outlined in the policy. An
interview with the superintendent indicated there are no permanent keys assigned to staff.
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.
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The center has facility operating procedures in place for transportation and operation of
Department vehicles. The center has four vehicles used to transport youth and two vehicles
which are not in service. All vehicles have the appropriate number of seatbelts, a seatbelt cutter,
a window punch, and a fire extinguisher. First-aid kits, with approved items are stored inside the
transportation office to prevent heat damage. Officers place emergency kits inside the vehicles
prior to the start of a youth transport. The center’s vehicles are locked when not in use.
Reviewed documentation verified the center’s maintenance staff conducted monthly visual
checks for all transportation vehicles. During the monthly maintenance checks staff visually
checked the vehicle’s water coolant, lights, oil, emergency equipment, brakes, horn,
interior/exterior, and cleanliness. The inspections were documented on the Monthly Inspection
forms which were maintained by the maintenance staff. Documentation supported the
maintenance mechanic’s completion of weekly and monthly vehicle checks. A review of the
vehicle maintenance invoices revealed all vehicles received an annual inspection during the
annual compliance review period. Reviewed documentation confirmed each vehicle was
inspected prior to transport. An observation of a youth transport was conducted. The vehicle
was searched by staff prior to the transport. Staff searched the youth prior to placing the youth
in the van. Staff assisted the youth in securing the seatbelt. The transport staff were in
possession of the vehicle logbook and a binder containing the Vehicle Log, gas credit card, and
vehicle registration. Staff ensured youth were searched upon return to the center. Observations
confirmed the transport staff ensured the vehicle was searched for contraband and locked to
prevent the introduction of contraband. The center’s vehicles are to be securely locked when not
in use. A check of three vehicles found all to be securely locked when not in use. Five youth
were interviewed and asked if they felt staff are driving safely when transporting youth. Four
youth stated yes, they do feel safe, and one youth stated they do not feel safe. Five youth stated
they have not seen anyone placing contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures to ensure all tool inventories are properly
maintained, stored, and inventoried. All tools were secured in the locked and secured
maintenance workshop which is accessible to the maintenance staff and administrators. The
center maintains an inventory of tools. A review of the inventory logs confirmed they included
documentation of the issuance and return of tools. Kitchen tools included knives and other
sharps which were stored in a locked box in the kitchen area. An inventory of kitchen tools was
maintained, and counts were documented. A permanent inventory of kitchen tools is
maintained, and counts are documented at the beginning of the day, midday, and at the end of
the day. Tools are stored on shadow boards and are marked with a number to identify them as
property of the Department. The center maintains a permanent inventory of tools. All tools are
checked out prior to use and checked in after they are returned. Only administration,
maintenance staff, and kitchen staff have access to this area. When tools are in use, a Tool
Tracking form is used indicating the date the tool is being used and has the signature of the
person using the tool. A review of ten tools and the tool inventory lists was conducted. Ten tools
were randomly selected, and each tool was secured, marked for easy identification, inventoried
accurately, and the inventory was signed by the superintendent/designee. There were no tools
missing or documented as being missing from the center, and there were no tools in the center
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not listed on the inventory. An informal interview with the maintenance staff confirmed only
administrative staff, kitchen staff, and the superintendent have access to tools. Five interviewed
staff had knowledge of the center's practice for damaged and/or missing tools. Five staff
indicated youth are allowed to use mops and brooms with staff supervision. Five youth were
interviewed and stated they were only allowed to use mops and brooms. An interview with the
superintendent indicated only the maintenance mechanic and administrative staff have access
to the center’s tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has facility operating procedures which state flammable, toxic, caustic, and
poisonous fluids and other dangerous substances may only be drawn or acquired by authorized
staff and prohibit youth from using or handling these items. A review of the flammable, toxic,
caustic, and poisonous materials storage area confirmed the area is inaccessible to youth.
Inventories of flammable, toxic, caustic, and poisonous items are maintained by the
maintenance mechanic. Safety Data Sheet (SDS) logbooks are in the same location as the
center’s stored chemicals. The center maintains an inventory of all chemicals which includes the
quantity of each chemical. Monthly inventories of flammable, toxic, caustic, and poisonous items
are maintained by the maintenance staff and reviewed and signed by the superintendent or
designee. The inventories were compared to the items on-site and were found to be accurate
and complete. A review of five SDSs and corresponding items was completed, and all five
chemicals were properly accounted for and stored in a secure place. Five youth were
interviewed, and all indicated they did not have access to flammable, toxic, caustic, and
poisonous items. Four interviewed youth indicated they do not clean with any type of cleaning
agent at the center, and one youth indicated having cleaned only after the staff sprayed the
cleaning agent. Five staff were interviewed, and all five stated no youth is allowed to have
access or clean with flammable, toxic, caustic, and poisonous items.
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).
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The center has facility operating procedures to ensure all flammable, toxic, caustic, and
poisonous items are disposed of according to the manufacturers Safety Data Sheet (SDS). An
observation of the flammable, toxic, caustic, and poisonous materials storage area confirmed
the area is inaccessible to youth. All items are secured and away from youth and staff. All listed
items are transported by authorized staff to a local hazardous waste authority. No toxic spills
were reported during the annual compliance review period. An interview with the maintenance
mechanic stated all chemicals have been used and the center has not had any disposals for any
chemicals during the annual compliance review period.
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 to address requirements for behavioral
confinement for less than twenty-four hours. The procedure requires staff to 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. Fourteen youth confinement records were reviewed. Each of
the fourteen reviewed youth confinement records contained documentation which ensured each
youth had the right to have three meals a day, plus evening snack, access to mental health care
as needed and requested, daily showers, clean clothing, mattress/bedding, education materials
during school hours, and the right to grieve a confinement placement. The center documents
confinements under twenty-four hours in the Facility Management System (FMS) within the
Department’s Juvenile Justice Information System (JJIS). Documentation verified the supervisor
approved the confinements, staff placed only one youth in the confinement room, the room was
searched, and documentation of the search was entered in FMS prior to placing a youth in
confinement for all fourteen reviewed records. Nine of the fourteen reports had the initial
confinement reviewed by the juvenile justice detention officer supervisor (JJDOS) within two
hours to determine the appropriateness of the use of confinement. Five were completed
between fifteen to sixty minutes late. Documentation indicated the fourteen youth were
supervised while in confinement with the supervision documented on the Visual Observation
Report (VOR) Log at least every five minutes. Fourteen reviewed confinements documented a
review was conducted by the supervisor at least every three hours, including the reason for
continued confinement based on severity of rule infraction, past disciplinary history, or behavior
confinement. All fourteen reports were reviewed by the superintendent or designee. An
interview with the superintendent indicated confinements are entered, tracked, and monitored in
JJIS. Additionally, the superintendent indicated, the use of confinement, lockdowns and
restraints are reviewed with management on a weekly basis. Five interviewed staff indicated
staff must complete a confinement report, search the room, notify the youth, inform the
supervisor, conduct, and document ten-minute room checks when a youth is placed in
confinement. Two of the five interviewed staff indicated when youth are placed in temporary
confinement educational materials are provided, and three staff indicated none are provided.
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.
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Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures to manage various emergencies and disaster
events. The center’s Continuity of Operations Plan (COOP) was approved by the regional
director. Reviewed documentation showed there were two COOP drills conducted during the
annual compliance review period. Documentation confirmed the center conducted a hurricane
drill on April 30, 2024, prior to the beginning of hurricane season, and July 31, 2024. Each
reviewed drill had documentation containing the type of drill, time and date, participants, a brief
scenario, findings, recommendations, critique forms, and emails used to document the drills.
Additionally, drills are reviewed during monthly management meetings and during shift briefings.
An interview with the superintendent confirmed the center’s safety and emergency plan.
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 regarding implementing and maintaining an Escape
Prevention Plan. The centers policy requires the center to conduct escape drills at least
quarterly. A review of the center’s Escape Prevention Plan confirmed it included the
Department’s established policies and procedures regarding escapes. A review of the center’s
drills confirmed escape drills were conducted quarterly during the annual compliance review
period. The center completed quarterly escape drills on January 10, 2024, April 20, 2024,
August 21, 2024, and October 24, 2024. The Emergency Drill Reporting form included
scenarios, a synopsis of the incident, start and end date and time of drill, detailed information of
problems and concerns during the drill, and a staff sign-in attendance roster. A review of
logbooks revealed each mock escape drill was documented in the logbooks, as required. A
review of five staff training records confirmed the staff were trained in escape prevention
annually. Five staff were interviewed, and all staff reported they participated in fire, weather,
major disturbances, chemical spills, flooding, hostage, terrorism, bomb threat, medical, and
escape drills during the annual compliance review period.
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.
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The center has facility operating procedures regarding fire drills. The fire prevention procedures
have been approved by the Division of State Fire Marshal and an annual inspection was
completed. The center maintains a Fire Prevention Plan and a Disaster Preparedness Plan
approved by the local fire department. A review of the center’s monthly drills was reviewed and
documented in the master control logbooks. Reviewed documentation supported the center was
conducting fire drills monthly, on each shift, and drills were documented on the fire drill report;
however, the center’s Charlie shift was missing three fire drills. Observations confirmed the
annual inspection of fire extinguishers was completed as reported. In an informal interview with
the superintendent, they confirmed there were scheduled fire drills scheduled in December
2024. Five interviewed staff reported participating in a fire drill at least once every month. Five
youth were interviewed, and four youth stated they were instructed on what to do in the case of
a fire and one youth stated they were not instructed on the center’s fire emergency procedures.
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 which address illegal contraband, prohibited items,
and how to reduce the introduction of contraband into the center. A review of the center’s policy
and observations during the annual compliance review week confirmed prior to admission, an
electronic search is completed for anyone entering the secure area of the center. Searches are
conducted by the shift supervisor when there is a reasonable suspicion a youth is harboring
contraband, and during center-wide initiatives to reduce the introduction of contraband. An
observation of a new admission into the center verified staff wore gloves during the search.
There were two same-gender staff present when the search was conducted. The observation
verified the search was conducted individually in a private area and not in a group setting. A
review of the center’s policy and observations verified staff and visitors were electronically
searched when entering the secure area of the center. All bags, cases, jacket pockets, and
shoes were searched. All personal keys, personal cellular telephones, and other contraband
items were prohibited in the secure area of the center. Youth room searches are documented
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 56 (Revised July 2023)
on the shift reports and are uploaded electronically. A review of random shift reports for one day
for each month of the annual compliance review period verified youth room searches were
documented and completed during each awake shift as required. A review of the Department’s
Central Communications Center (CCC) reports during the annual compliance review period
found there was one instance of contraband found at the center. The contraband and the call to
the CCC were documented in the master control logbook. Documentation verified incident
reports were completed identifying findings and disposition of the contraband found. The
confiscated item was secured and delivered to the supervisor. Reviewed documentation
showed the shift supervisor documented the chain of custody for the contraband and the
regional director was notified. Local law enforcement was contacted for the items considered
illegal as defined by Florida Statute. There were no instances which may have compromised the
safety or security of the center throughout the annual compliance review period. The center’s
visitor log does not contain a contraband attestation statement; however, the center does have
separate visitor contraband attestation forms. A review of the attestation forms and visitors’ log
revealed no discrepancies. Five staff records were reviewed, and all contained a contraband
attestation form. An interview with the superintendent indicated the center’s search procedures
shall be in accordance with the policy and staff shall be diligent in their efforts to prevent the
introduction of contraband into the center and all searches are conducted as necessary to
control contraband and to ensure safety. In the event contraband is located on a youth or staff,
all contraband will be confiscated, documented, and law enforcement will be contacted, along
with the CCC and the regional director.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 56 (Revised July 2023)

report_type: QI Detention

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 4.04

rule: Indicator 4.12