state: FL

facility_name: Brevard Juvenile Detention Center

summary: QI Detention - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Brevard Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
5225 Dewitt Avenue
Cocoa, Florida 32927
Review Date(s): September 24-27, 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:
Paula Friedrich, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Dennis Brown, West Palm Beach Regional Juvenile Detention Center, Juvenile Detention
Officer Supervisor (Standard 5)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Interviews &
Standard 1)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Cindy Jones, Office of Education, Deputy Education Supervisor (Standard 2)
Nissia Moore, Detention Services, South Region, Operations Analyst (Standard 5)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Brevard Regional Juvenile Detention Center MQI Program Code: 244
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Brevard County / Circuit 18 Number of Beds: 40
Review Date(s): September 24-27, 2024 Lead Reviewer Code: 137
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures) and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 60 (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 60 (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* Satisfactory
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 60 (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 60 (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 Satisfactory
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 Satisfactory
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 Non-Applicable
* 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 60 (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 Satisfactory
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 60 (Revised July 2023)
Program Overview
The Brevard Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Cocoa, Florida. The center serves youth in Brevard County in Circuit
18. The center is co-located with the Juvenile Assessment Center. Male and female youth who
are detained pending adjudication, disposition, or placement in a residential commitment
program are housed in the forty-bed center. Youth are provided services which include youth
orientation, behavior management, safety and emergency procedures, transportation, mental
health, and healthcare services. The center’s educational services are provided by the Brevard
County School District. The center’s management team includes the superintendent, two
assistant superintendents, two administrative assistants, one field training coordinator, and
seven juvenile justice detention officer (JJDO) supervisors. Mental health and healthcare
services are provided through a contracted provider, VitalCore Health Strategies, LLC. Mental
health services are provided by one designated mental health clinician authority (DMHCA), four
licensed mental health professionals, and one psychiatrist. Clinical services provided by the
center include mental health and substance abuse evaluations, mental health treatment
planning, individual, group and family therapy, mental health crisis intervention services, on-site
psychiatric services, and availability of substance abuse services for youth with co-occurring
disorders. Medical services are provided by a medical doctor (MD) who is the designated health
authority (DHA), one advanced practice registered nurse (APRN), one registered nurse (RN)
manager, three RNs, and one licensed practical nurse (LPN). 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,
through the provision of youth supervision twenty-four hours a day, seven days a week. The
center has three gender specific living units, which include two for males and one for females.
There are fifty-eight security cameras at the center, of which fifty-six were operational. A tour of
the center was conducted during the annual compliance review week, and observations verified
the center was clean and maintained. The lobby has new flooring, guest bathrooms are dated;
however, they were clean and functional. The exterior of the building appears new and has
been repainted. The air conditioning unit has been replaced; however, thermostat controls were
not installed within the interior of the center and require staff to climb a ladder to the roof and
retrieve the thermostats from the return air vent shafts to reset the thermostats after each power
surge or outage. The center’s roof has been replaced, and new fencing has been installed. The
toilet in one sleeping room was not functional at the time of the annual compliance review;
however, a work order had already been submitted on September 23, 2024. The outside
landscaping was well maintained. The youth living units and sleeping rooms had peeling paint
and there was some graffiti on the walls. Plexi-glass windows in the youth sleeping room doors
had varying degrees of scratches. Bathrooms in the living units were very dated, some still with
porcelain toilets and sinks; however, the bathrooms were clean. There was no indication of any
insect infestation. At the time of the annual compliance review, the center had fourteen vacant
positions, which included one assistant superintendent position, one JJDO supervisor position,
four JJDO I positions, six JJDO II positions, one administrative assistant, and one chaplain
position.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 60 (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 maintains a written policy and procedures to address compliance with the
Department’s background screening requirements. The Annual Affidavit of Compliance with
Level 2 Screening Standards was submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse on January 25, 2024, meeting the annual requirement. The Annual
Affidavit of Compliance with Level 2 Screening Standards for school board teachers was
submitted to the BSU on January 4, 2024. A review of the initial background screenings for
eleven newly hired staff, three new contracted staff, and one new volunteer showed the center
received background screening results from the BSU/Clearinghouse prior to each
staff’s/volunteer’s start date and a criminal history report was reviewed for twelve applicable
records. None of the reviewed staff, contractors, or volunteers were applicable for a background
screening exemption or a break in service. The center utilizes an ergometric pre-employment
assessment tool for all direct care applicants. A review of the ten applicable direct care staff
records indicated each staff completed a pre-employment assessment tool and received a
passing score. A copy of the pre-employment assessment was maintained within each staff’s
record.
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 maintains a written policy and procedures to ensure all staff, contracted providers,
and volunteers with access to youth undergo a criminal history background check every five
years. The center had three staff applicable for a five-year rescreening since the last annual
compliance review. Each staff’s rescreening was completed and submitted to the Department’s
Background Screening Unit (BSU)/Clearinghouse within the required time frames. There were
no volunteers or contracted staff applicable for a five-year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 60 (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 maintains a written policy and procedures outlining the staff code of conduct. Staff
are required to adhere to the code of conduct which prohibits abuse, profanity, threats,
harassment, intimidation, horseplay, or personal relationships with youth. It is the center’s
practice for each staff personnel record to include a copy of the signed code of conduct
prohibiting any form of abuse, profanity, threats, harassment, or intimidation. The code of
conduct addresses officer professionalism, poor performance, negligence, insubordination,
conduct unbecoming of a public employee, and misconduct. Right Interactions (RI) Reports and
the Department’s Central Communications Center (CCC) reports were reviewed for violations
related to code of conduct; however, none were applicable. The center provided documentation
for two staff who received disciplinary actions for violations of code of conduct, and one staff
who was issued a certificate of commendation since the last annual compliance review. Five
youth were interviewed, and each stated they had never been stopped from reporting abuse
while at the center. Each interviewed youth indicated staff are respectful when talking to youth
and stated they have never heard staff threaten youth at the center. Three interviewed youth
reported never hearing staff use profanity, while two youth indicated hearing staff use profanity
which was not directed at, or about any youth. All five interviewed youth stated they feel safe at
the center. Each youth asserted they had never exchanged emails, telephone numbers, or
social media contact information with staff. Five staff were interviewed, and each confirmed they
allow youth to make a telephone call to the Florida Abuse Hotline or the CCC if the youth wish
to make an abuse call. Four staff indicated they would notify the supervisor and the youth would
be allowed to make the call, and one staff stated they would inform the superintendent. Three of
the five staff stated they had never heard a co-worker using profanity when speaking with youth,
and two indicated they had heard a co-worker using profanity once. Both staff clarified the
profanity was not threatening or directed at a youth, rather it was a slip in conversation. All five
staff stated they had never observed a co-worker using threats, intimidation, and humiliation
when interacting with youth. Five staff were interviewed about the working conditions at the
center, four indicated the conditions were good, and one stated working conditions were very
good. An interview with the superintendent indicated staff are to communicate and interact with
youth in a manner which models socially accepted behaviors and display behavior which is
respectful of others and reflect desired behaviors for youth. Youth are afforded an opportunity to
use the telephone for the purposes of reporting verbal abuse, physical abuse, sexual abuse,
and sexual harassment to the Florida Abuse Hotline or a local advocacy center, and staff are to
remain at a distance to allow the youth privacy during the call.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 60 (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 maintains a written policy and procedures which require the center to notify the
Department’s Central Communications Center (CCC) of reportable incidents within two hours of
the incident or within two hours of becoming aware of the incident. The center had forty-four
reportable incidents since the last annual compliance review. A review of five incidents found
four incidents were reported to the CCC within two hours of the incident. One incident was
called into the CCC twenty-six minutes late. The center indicated a voicemail message was left
for the CCC within two hours as required; however, the call was not documented anywhere. The
center maintains a logbook specifically for documenting calls to the CCC. Four of the five
reviewed incidents were documented in the center’s CCC logbook, and one was not. A review
of the center’s internal incidents and youth records found there were no additional incidents
which should have been reported to the CCC and were not. An interview with the center’s
superintendent indicated reportable incidents are to be communicated to the CCC within two
hours of the event or within two hours of gaining knowledge of the incident.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center maintains a written policy and procedures specifying the use of physical intervention
techniques is to be in accordance with Florida Administrative Code. Any time staff use a
physical intervention technique, including countermoves, control techniques, takedowns, or
application of mechanical restraints, other than during regular transports, a Right Interactions
(RI) Report is to be completed. The center had a total of sixty-one RI incidents since the last
annual compliance review. A review of nine RI Reports validated all involved staff completed
appropriate statements by the end of their shift. None of the reviewed RI Reports indicated the
physical intervention resulted in serious injury of youth or staff and none required a RI medical
review. None of the nine reviewed reports showed the youth alleged abuse, which would require
the Florida Abuse Hotline to be contacted immediately. Each RI Report was reviewed by a
supervisor or a RI certified instructor and each documented a post-RI interview was conducted
with the youth by the center’s administration within thirty minutes after the incident. None of the
reviewed reports were applicable for the use of mechanical restraints. The superintendent or
designee reviewed eight of the nine RI Reports and made comments when needed within
seventy-two hours; however, one was reviewed fifty-one days late. A review of internal incident
reports and logbooks indicated there were no additional RI incidents which did not have a
report. The center’s RI rate during the previous quarter was 32.20, which is above the statewide
Detention RI rate of 16.29. Five staff were interviewed, and each reported they use verbal
interventions with youth prior to using RI. A program tour confirmed RI mechanical restraints are
stored in a secure area which was designated by the superintendent. The interviewed
superintendent stated all RI incidents are monitored and tracked through the RI Reports. A
report is to be generated any time an officer places their hands on a youth, apart from the sole
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 60 (Revised July 2023)
use of the straight arm, close, or extended escort. In the event a RI technique is not able to be
used due to the rapid escalation of dangerous behavior, a detailed description of the use of
physical intervention is to be documented on the RI Report with subsequent entries reflecting
the appropriate level of RI used.
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 maintains a written policy and procedures requiring staff to complete pre-service
training in accordance with Florida Administrative Code. Detention staff are to satisfy pre-
service/certification requirements specified by Florida Administrative Code within 180 days of
hire. Phase One training consists of instructor-led and web-based courses. Phase Two training
consists of 120 hours of academy instructor-led training. A review of seven staff training records
for pre-service training indicated four staff completed all required trainings within 180-days of
hire and new staff orientation was completed within thirty days of hire. Three reviewed staff
records were for staff attending the academy at the time of the annual compliance review week.
The remaining four staff records were reviewed, and documentation confirmed each applicable
staff completed all trainings required by the Department prior to having contact with youth. All
completed pre-service trainings were documented in the Department’s Learning Management
System (SkillPro). The center did not have any returning direct care staff applicable for the
specified training when returning less than one year from separation.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training. Supervisory staff must complete eight hours of training (in addition to the twenty-four
hours of in-service training) in the areas specified in Florida Administrative Code.
The center maintains a written policy and 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 additionally complete eight hours of supervisory
training annually. The center provides in-service training to staff through a combination of the
Department’s Learning Management System (SkillPro) and instructor-led classes. Seven staff
training records were reviewed for in-service trainings which included four direct care staff and
three supervisory staff. All seven staff records reflected staff completed all mandatory training
topics. Three staff were applicable for a minimum of eight hours of supervisory training, and
each completed more than the required eight hours of supervisory training. All trainings were
entered into SkillPro. A licensed nurse provided in-service education on girls’ healthcare
annually to all non-healthcare staff involved in the supervision or treatment of female youth. The
center has an annual in-service training calendar which is updated as changes occur. The in-
service training calendar was approved by the center’s highest ranking official, the assistant
secretary of Detention Services, and the director of Talent, Leadership, and Culture. An
interview was conducted with the center’s superintendent who indicated being trained in
Certified Public Management (CPM), leadership and development, quality customer service,
communication, and the delivery of constructive criticism. In addition, staff receive training on
Right Interactions (RI), cardiopulmonary resuscitation (CPR), suicide prevention,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 60 (Revised July 2023)
professionalism, universal precautions, fire safety, and cyber safety along with additional
trainings.
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 maintains a written policy and procedures which provide each youth the right to file a
grievance and requires all youth to be treated fairly, respectfully, without discrimination, with
their rights protected. The grievance process is posted in each living unit and explained to each
youth during the admission and orientation process. The grievance process consists of an
informal phase, wherein the juvenile justice detention officer (JJDO) attempts to resolve the
complaint or condition with the youth using effective communication skills. The formal phase is
when the youth submit a written grievance which results in a response from a JJDO supervisor.
Next, the appeal phase requires a response from the superintendent or designee. The center
did not have any formal grievances submitted since the last annual compliance review.
Grievance forms are accessible to youth on each living unit of the center. An interview with the
superintendent indicated youth are not to be denied the opportunity to file a grievance, and
youth are not punished for filing a grievance, whether it is substantiated or unsubstantiated.
Special needs youth are provided access to the same grievance procedures as other youth.
Staff verbally explain the process and can help youth complete the grievance form, if needed.
Five youth were interviewed regarding the grievance process and each youth stated there are
grievance forms available on the living unit for youth to fill out then give to the staff. All five youth
reported they never filed a grievance. Five staff were interviewed and were able to explain the
center’s grievance process. Each staff stated they allow the youth to fill out the form and then
turn in the form to the supervisor. An interview with the superintendent indicated the youth sign
a hard copy of the grievance form which is maintained in a separate grievance file and uploaded
into the FMS module of the Department’s Juvenile Justice Information System (JJIS.)
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 60 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately. Upon completion of the Admission Wizard, the officer shall ensure all critical
and special alerts are listed in JJIS. The JJIS alert report shall be reviewed daily by
supervisors and administrators to ensure it correctly reflects the status of youth. If the
electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately. Medical and mental health staff shall
review alerts to ensure each alert is correctly tracked and managed. The responses and
updates by medical, mental health, and other staff should be documented in JJIS alerts as
they pertain to the specific alert. JJDOSs shall inform staff of alerts during shift briefing. When
a JJDOS receives changes to the alert list, he/she shall notify the staff affected by changes
and add the information to the shift briefing for the oncoming shift upon receipt of the
information.
The center maintains a written policy and procedures requiring critical and special alerts to be
reviewed and responded to appropriately and entered into 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. The JJIS alerts are verified by medical staff, juvenile
justice detention officer (JJDO) supervisors, or mental health staff, as applicable. Five youth
records were reviewed for medical, mental health, and medication alerts. Each reviewed youth
record documented all alerts were accurately entered into JJIS. The five reviewed youth were
applicable for fourteen separate alerts. All applicable alerts were downgraded and removed by
the medical staff and/or the mental health staff, as applicable. The JJIS alerts are printed daily
by the on-duty supervisor, copies are provided to all staff during their shift briefing, and all staff
have access to the alert system. Reviewed documentation and observations of a shift briefing
validated alerts were discussed during shift briefings. During the center tour, observations
verified the kitchen staff have access to the alert list and alerts were posted on a white board in
the kitchen. The interviewed superintendent stated staff enter alerts at admission based upon
information provided by the youth, the parent/guardian, the law enforcement officer, the Juvenile
Assessment Center officer, and healthcare staff. Healthcare staff review the alerts and ensure
they are up to date. Medical alerts include all routine prescribed medications, allergies/allergic
reactions, medication interactions, head trauma/injury, pregnancy, chronic medical conditions,
activity limitations or precautions, and medication side effects. Medical alerts are updated in
accordance with information obtained during admissions, upon return from off-site medical
appointments, and anytime new information is received. Five staff were interviewed, each staff
reported receiving youth alert information during shift briefings, and four also indicated they
received JJIS alert forms. Three of five interviewed staff reported the center’s process for
communicating information is good and two stated it was very good.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 60 (Revised July 2023)
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 structured method for reviewing and analyzing data in decision-making
practices. The Department prepares a quarterly Detention Services Report Card which is a
comprehensive review of policy compliance conducted through site visit observations and
desktop audits. Department headquarters staff work with centers to identify strengths and areas
which need improvement. The report card includes information based on drills, center
inspections, center meetings, and operations. The report card assigns a grade for the center
with recommendations for improvement. The information is then shared with center staff through
monthly management meetings and daily shift briefings. A review of report cards, surveys, and
meeting agendas confirmed the center’s practices. The center also reported participation in the
Juvenile Assessment Center advisory board meetings, where information is shared with
stakeholders at least quarterly; however, documentation was not maintained by the center’s
previous administration.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 60 (Revised July 2023)
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 maintains a written policy and procedures regarding youth admission in accordance
with Florida Administrative Code. Five youth case management records were reviewed for
admission requirements. Reviewed documentation revealed the Department’s Juvenile Justice
Information System (JJIS) Admission Wizard documented the arrest affidavit/custody order, a
Detention Risk Assessment Instrument (DRAI), and Suicide Risk Screening Instrument (SRSI)
were completed for each youth. Reviewed documentation confirmed all five youth were either
full-body and/or electronically searched by an officer of the same gender. The Admission
Wizards documented each youth received a telephone call to their parent/guardian and was
provided a meal upon admission. Reviewed documentation validated a medical and mental
health/substance abuse screening was completed upon each youth’s admission. There were no
youth admissions during the annual compliance review week; however, an observation of the
youth admission process was conducted through review of recorded surveillance video footage
of a recent admission. The video footage validated all required procedures of the admission
process were followed, the youth was afforded the opportunity to make a telephone call to their
parent/guardian, and a bag meal was provided.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 60 (Revised July 2023)
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 maintains a written policy and procedures requiring each youth admitted to the
center to receive an orientation within twenty-four hours of admission. Five youth case
management records were reviewed which validated each youth was provided an orientation
within twenty-four hours of admission and signed an acknowledgement of the orientation topics
discussed. There were no youth admissions during the annual compliance review week;
however, an observation of the youth admission process was conducted through review of
recorded surveillance video footage of a recent admission. Observations and reviewed
documentation validated all youth orientation procedures were followed and were consistent
with the center’s operating procedures. The youth was informed of the center’s rules and
regulations, grievance procedures, visitation hours, telephone calls, how to access mental
health and medical services, access to the Florida Abuse Hotline/Department’s Central
Communications Center (CCC), behavior expectations and consequences, possible new law
violations, youth rights, and Prison Rape Elimination Act (PREA) related information.
Observations confirmed the required orientation video including PREA guidelines was played for
the youth. Five youth were interviewed, and each youth reported their orientation process
included an explanation of the center rules and regulations, daily schedule, education services,
visitation, abuse reporting, and the behavior management system (BMS).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 60 (Revised July 2023)
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 maintains a written policy and procedures to ensure all youth are classified upon
admission to provide the highest level of safety and security. The center’s classification process
addressed mental illness, intellectual disabilities, physical disabilities, history of violent behavior,
gang affiliation, criminal behavior, history of sexual offenses, Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) screening results, medical, identified suicide risk, escape,
security, and history of human trafficking in each of the five youth records reviewed. One record
was applicable for gang affiliation, criminal behavior, and suicide risk. Four of the five youth
were classified for criminal behavior. Each youth’s gender, height, weight, and level of
aggressiveness were considered prior to sleeping room assignment. Each youth was assigned
to a room based upon the classification procedures. The superintendent was interviewed and
indicated each youth is assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. The center’s practice is for no more than two youth
to occupy a sleeping room and any exceptions to this must be approved in writing by the
regional director. Youth with a history of committing sexual offenses, a history of sexual offense
or abuse victimization, or determined to be physically or sexually aggressive are not to be
placed in a room with any other youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 60 (Revised July 2023)
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 maintains a written policy and procedures requiring each youth to be screened to
determine if the youth is affiliated or identified as a gang member and requiring the juvenile
probation officer (JPO) designated as the circuit gang representative to be notified about
suspected gang activity. A review of five youth case management records showed only one was
applicable for gang involvement; therefore, two additional applicable records were requested for
review. Each of the three reviewed youth case management records had a referral for
suspected gang involvement which was shared by email with the circuit gang representative,
including pictures in each email and copies of written statements, drawings, or graffiti, when
applicable. The center’s assistant superintendent serves as the gang representative to
communicate all suspected gang activity to local law enforcement and the assigned JPO. The
assistant superintendent shares suspected gang behavior of youth with the JPO and the chief
probation officer (CPO) during the weekly Detention Review meeting. The center maintains a
gang unit tracking log which was reviewed and confirmed the center’s practice of documenting
identified gang members. The alert information is entered into the Department’s Juvenile Justice
Information System (JJIS). The center’s gang liaison was interviewed and was knowledgeable
of the center’s gang notification procedures.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center maintains a written policy and procedures outlining the proper, safe, and secure
handling of each youth’s personal property and valuables which are to be collected and secured
at the time of a youth’s admission. Five youth records were reviewed. Each record contained a
Personal Property Receipt form which was signed by the youth and staff. All five youth case
management records contained a letter of acknowledgment regarding unclaimed property
signed by each youth. Each youth’s clothing and other non-valuable property are also logged
into the Department’s Juvenile Justice Information System (JJIS) and stored in a secured mesh
bag until the youth is released. The personal property was placed in an assigned mesh bag, as
documented on the Personal Property Receipt form, and the forms were placed in all five youth
reviewed records. Only one of five reviewed records was applicable for admission with valuable
property; therefore, two additional applicable records were requested. The three applicable
records documented the youth’s property was inventoried by the admitting juvenile justice
detention officer (JJDO) and entered in JJIS. Each record contained a Valuable Property
Receipt form which was signed by the youth and staff. All three youth case management
records contained a letter of acknowledgment regarding unclaimed property signed by each
youth. Currency and other personal items of value are to be placed in a clear tamper-proof
property bag and placed in a drop safe, which is under camera surveillance. The tamper-proof
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Office of Accountability and Program Support Page 20 of 60 (Revised July 2023)
bags are to be labeled with the youth’s name, Department identification number, and a listing of
the items in the bag. A bound drop safe logbook is maintained to document items placed in the
safe and includes the date, time, youth’s name, name of the officer who secured the property,
and the officer’s initials. A review of the drop safe logbook confirmed the center’s practice.
Reviewed records indicated none of the youth refused to sign the Property Receipt form. An
observation of three youth property bags validated each contained a completed inventory form
for the enclosed personal property. Valuable property for three reviewed youth was documented
in the safe logbook and each youth’s valuable property was stored in a clear tamper-proof bag.
The center had no new admissions during the week of the annual compliance review; therefore,
an observation of the center receiving youth’s personal property could not be conducted. A
review of the Department’s Central Communications Center (CCC) incident reports since the
last annual compliance review indicated there were no reported incidents regarding youth
property valued over fifty dollars since the last annual compliance review. Five youth were
interviewed, and each reported having signed forms for their property and were aware of how
their personal property was secured. One youth further stated a cellular telephone and other
personal property was given to their parent/guardian, and one youth indicated they knew the
number of the property bag in which their property was stored. An interview with the
superintendent confirmed personal property is stored in the intake office, within camera view, to
which only supervisors and administrators have access and valuable property is to be placed in
a clear tamper-proof bag and placed in the drop safe.
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 maintains a written policy and procedures requiring review of all youth record
information and the court’s authorization to release each youth from secure detention to prevent
the negligent release of a youth. Three closed youth case management records were reviewed.
Each record included a copy of the Department’s Detention Release form, which documented
the on-duty supervisor’s review of all related paperwork and court documents prior to the
youth’s release. All three reviewed records showed each youth’s identification was verified prior
to release. The identification of each parent/guardian was verified prior to release of each youth
and a photocopy of the parent’s/guardian’s identification was placed in the youth’s record. None
of the three reviewed case management records identified the youth as an endangered person.
Reviewed records reflected each youth, and the person to whom the youth was released, were
reminded of future court dates and all required parties signed the release forms. The date of
admission and the date of release documented in each youth’s record correlated with the dates
documented in the Department’s Juvenile Justice Information System (JJIS). During the annual
compliance review week, the release of a youth with property was observed to be completed in
accordance with policy.
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Office of Accountability and Program Support Page 21 of 60 (Revised July 2023)
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 maintains a written policy and procedures to address youth releases from detention
including retrieval of personal property, medication, and aftercare instructions. Three closed
youth case management records were reviewed. Each record contained documentation
verifying the youth was released to an appropriate person and included a photocopy of the
parent/guardian’s identification. Each record contained a Property Receipt form signed by the
youth and parent/guardian at the time of release. None of the three reviewed case management
records were for a youth with prescribed medication. Documentation validated the person to
whom each youth was released was made aware of any existing health or welfare issues
including medical, mental health, and/or substance abuse needs as well as any pending
appointments. The center provided three examples of property abandoned during the annual
compliance review period where neither the youth nor parent/guardian were able to be located.
Reviewed documentation validated the center’s disposal process was followed with the property
being donated to a local charity on the thirty-first day after release and a receipt being obtained
showing all items were accounted for. The release of a youth with property was observed during
the annual compliance review week, validating the center’s practices.
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 maintains a written policy and procedures requiring Detention Review meetings to
be conducted on a weekly basis for the proper management of youth in secure detention and for
the appropriate sharing of information. An informal interview was conducted with the center’s
assistant superintendent, who is designated as the detention review specialist, and who stated
the weekly meeting is held virtually each Thursday morning. Each week, all youth in the center
are discussed during the Detention Review meeting with mental health, medical, education, the
chief probation officer, the commitment manager, and juvenile probation officers (JPOs). A
review of the center’s Detention Review uploads to a shared network drive confirmed the center
conducted the meetings on a weekly basis with all the required participants since the last annual
compliance review. An interview with the superintendent confirmed Detention Review meetings
are conducted by the review specialist on a weekly basis and all required staff participate in the
meetings. During the week of the annual compliance review an observation was made of the
Detention Review meeting, and all required participants were in attendance.
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Office of Accountability and Program Support Page 22 of 60 (Revised July 2023)
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 maintains a written policy and procedures addressing the daily activity schedule.
Youth are provided the opportunity to participate in constructive activities benefiting the youth in
the center. A copy of the daily schedule was provided by the center for review, which listed the
days, times, and all required elements outlined by the Department’s policy. During the annual
compliance review week, a center tour was conducted, and the daily activity schedule was
posted in each youth living unit. Youth were also observed attending school, lunch, and sick call
at the times indicated on the posted schedule. A review of the center’s logbook confirmed
activities such as wake-up/personal hygiene, mealtimes, visitation, recreation, education, shift
change, bedtime, and groups were conducted, as scheduled. Five youth were interviewed,
four youth stated the schedule is followed, and one youth stated sometimes showers are
completed early. Five staff were interviewed, and each staff reported the center adheres to the
daily activity schedule.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center maintains a written policy and procedures for the integration of academic, career,
and technical education instruction for youth. The Brevard County School District provides the
center’s educational services and approves the 250-day calendar, which incorporates twenty
days of teacher planning and/or training. The school’s daily bell schedule allows for two one-
hundred-minute blocks and one seventy-five-minute block, which exceeds the required twenty-
five hours of weekly instruction. The center’s activity schedule included the school’s bell
schedule. All youth have an opportunity to earn education credits upon course completion.
Seven randomly selected logbook entries were reviewed covering the previous seven months
which showed the daily school schedule was followed with little deviation, as youth were taken
to school and released according to the daily schedule. A review of video surveillance
recordings of three weekdays validated the youth were provided educational access according
to the daily bell schedule. Five youth were interviewed about how well the center was preparing
them for high school, their high school equivalency diploma (GED), vocational school,
employment, and/or college. One youth stated the center was preparing them very well and one
stated the center was preparing them well. Three of five youth indicated they were not being
well prepared and commented the work is too easy as it is for younger youth or lower grades,
and education is more like group preparation. One youth who indicated the program did not
prepare them well reported having already received a GED at a previous program. One youth
commented they are just given worksheets and youth may choose to either work on the
computer or worksheet packets. Each youth reported they attend school Monday through
Friday. An interview with the lead educator confirmed packets are part of the instructional
lessons at times. The lead educator indicated educational classes are provided according to the
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Office of Accountability and Program Support Page 23 of 60 (Revised July 2023)
written schedule, which was confirmed in interviews with both the superintendent and five center
staff.
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 provides career education competency development programming meeting the
requirements of a Type 1 program which incorporates communication, interpersonal and
decision-making skills, and life skills and activities through career-related instruction in class.
Four of the five interviewed youth stated they were taking math, science, history, and reading.
Three youth stated they were taking life skills and career choices, and one indicated they were
taking a social studies class.
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Office of Accountability and Program Support Page 24 of 60 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains a written policy and procedures requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services. The Department maintains a contract with VitalCore Health Strategies, LLC.
(VitalCore) to provide mental health and substance abuse services to all applicable youth in the
center. The DMHCA is a licensed mental health counselor (LMHC) who holds a clear and active
license in the State of Florida, with an expiration date of March 31, 2025. The DMHCA is a full-
time staff and scheduled to be on-site forty hours each week, Tuesday through Friday, between
the hours of 9:00 a.m. to 5:00 p.m. and Saturdays from 7:00 a.m. to 3:00 p.m. A review of the
mental health sign-in logbook since the last annual compliance review confirmed the DMHCA
was on-site, as required. The DMHCA is available seven days a week, twenty-four hours a day,
by way of telephone for consultation. A review of the VitalCore job description found the
DMHCA oversees all clinical and administrative operations ensuring clinical integrity, quality,
and contract compliance. The center has a back-up DMHCA in the event of scheduled leave
and/or absences, which is one of the full-time clinical staff. The back-up DMHCA is a licensed
clinical social worker (LCSW), who holds a clear and active license in the State of Florida, with
an expiration date of March 31, 2025. An interview with the DMHCA indicated the mental health
staff are oriented to the center’s facility operating procedures, practice standards, and receive
regular supervision from the DMHCA. The DMHCA and the superintendent are responsible for
overseeing consistent implementation of mental health services to youth in detention. The
DMHCA provides consistent monitoring of service provisions. The mental health staff provide
crisis management, individual counseling, group counseling, and family counseling as needed
or requested. The DMHCA communicates with the mental health staff daily, weekly, and as
needed.
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. (VitalCore) to
provide mental health and substance abuse services to all applicable youth in the center. The
licensed contractual positions, in addition to the designated mental health clinician authority
(DMHCA), included three licensed mental health staff. Copies of all licenses were posted in the
DMHCA’s office. A review of the licensed clinicians’ credentials indicated all three held a clear
and active license in the State of Florida, with an expiration date of March 31, 2025. The
contract with VitalCore provides for a full-time regional clinical mental health director, in addition
to the DMHCA, to serve as a senior manager responsible for all operations of all central region
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Office of Accountability and Program Support Page 25 of 60 (Revised July 2023)
detention centers. The regional clinical mental health director provides detention center-specific
technical assistance. The regional clinical mental health director is a licensed clinical social
worker (LCSW), licensed in the State of Florida, with an expiration date of March 31, 2025. The
regional clinical mental health director and the DMHCA are responsible for ensuring all mental
health staff are qualified based on education, training, and experience.
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 provided by licensed mental health professionals and the center does not have any
non-licensed mental health clinical staff. The mental health department was operating without
the Chapter 397 license at the time of the annual compliance review. Reviewed documentation
indicated only the licensed mental health counselors were facilitating all substance abuse
treatment and groups. In an informal interview, the designated mental health clinician authority
(DMHCA) stated all mental health staff are licensed; therefore, a Chapter 397 license was not
needed. There were no reported vacancies for clinical services during the annual compliance
review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center maintains a written policy and procedures to ensure the mental health and
substance abuse needs of youth are identified through a comprehensive screening process in
which referrals are 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. A review of five youth mental health and substance abuse records indicated each youth
was processed in the Juvenile Assessment Center (JAC). During the intake process the juvenile
probation officer (JPO) completed the mental health, substance abuse, and suicide risk
screenings utilizing the Suicide Risk Screening Instrument (SRSI) and the Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) in the Department’s Juvenile Justice
Information System (JJIS). Reviewed documentation supported the center’s staff reviewed all
prior documentation completed by the JPO when each youth was admitted to the center. The
juvenile justice detention officer (JJDO) reviewed each youth’s MAYSI-2 results, face sheet, and
alerts upon admission. The JJDO completed their assigned section of the SRSI for all five
youth. All five SRSIs were reviewed by a licensed mental health professional with their
documented recommendation. Each of the five SRSIs had completed entries, which included an
accurate referral selection in the “Screening Results” sections. Four of the five reviewed youth
records had a positive “YES” response on the SRSI. Each applicable youth was placed on
suicide precautions and a mental health referral was completed, which documented the youth’s
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Office of Accountability and Program Support Page 26 of 60 (Revised July 2023)
need for an Assessment of Suicide Risk (ASR). Each of the four youth applicable for suicide
precautions placement had a suicide risk alerts in JJIS. All five reviewed records documented a
need for further assessment and each youth was referred for further clinical assessments.
Documentation showed the superintendent or designee was notified a further assessment was
required for each youth. Three of the five reviewed MAYSI-2s had all negative responses and
were marked as an invalid screening. All three youth were referred for a comprehensive
assessment on the MAYSI-2 referral section. Four of the five reviewed youth were identified
with having a positive suicide ideation subscale on the MAYSI-2 and were placed on suicide
precautions and referred for an ASR. All five youth reviewed were applicable for a
comprehensive assessment. Documentation supported each youth was referred for a
comprehensive assessment by the licensed mental health staff.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center maintains a written policy and procedures outlining the process for identifying the
mental health and substance abuse needs of youth through a comprehensive screening. Youth
with identified needs are referred for a further in-depth mental health and/or substance abuse
evaluation. The center utilizes the Department’s Mental Health and Substance Abuse Referral
Summary form. Five reviewed youth records were not applicable for having a Substance Abuse
Mental Health (SAMH) assessment completed by the center’s provider. Three additional youth
records were reviewed. Each reviewed youth was identified after admission and was referred to
the center’s provider for a SAMH assessment. One of the three reviewed youth received a new
SAMH assessment, and two youth received an updated SAMH assessment on the thirty-first
day of being in the center. All three reviewed SAMH assessments included treatment
recommendations for any applicable diagnosed mental health or substance abuse disorder. All
three SAMH assessments were maintained in the Department’s Electronic Medical Record
(EMR). None of the reviewed records were applicable for the mental health/substance abuse
evaluation having been completed by a community provider. An interview with the designated
mental health clinician authority (DMHCA) confirmed the intake screener refers any youth who
have areas of review indicating further need for assessment indicated by the MAYSI-2. In
addition, if there are no areas indicating further need for assessment, the intake officer can write
an override narrative indicating a need for further assessment and refer the youth to the juvenile
probation officer (JPO). The JPO is responsible for ensuring the comprehensive assessment is
completed by the community provider. If the community provider does not complete the
assessment, the center’s mental health provider will then complete the assessment. A youth’s
behavior may indicate the need for an assessment or additional information may have been
acquired addressing the need for further mental health or substance abuse evaluation.
Information may be gathered from detention staff, medical staff, education staff,
parent/guardian, youth, or a mental health professional. Detention Reviews provide the
opportunity to share this type of information and address the need for a youth to have a
comprehensive assessment. The JPO will then make the referral for the youth to receive the
assessment. Mental health staff would record receipt of the assessment on the tracking log and
file the assessment. In cases where an immediate assessment is needed the mental health
team may complete their own comprehensive assessment incorporating information obtained
from collateral sources as well as an interview with the youth.
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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 maintains a written policy and procedures detailing a process 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 for each youth receiving mental health/substance abuse treatment
in the center. Five youth mental health and substance abuse records were reviewed, and one
was applicable for mental health and substance abuse treatment services; therefore, two
additional youth records were reviewed. All three reviewed youth records included
documentation of a mental health orientation which was held within fourteen days of admission
to the center. All three youth records had an initial treatment plan in place within seven days of
initiation of treatment which was developed on the Department’s Initial Mental Health/Substance
Abuse Treatment Plan form. Each of the three initial treatment plans contained the reason for
treatment referral, the initial Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnosis, initial treatment methods, and goals. Two of the three reviewed youth
records were applicable for receiving psychiatric services and included the required medication
information. All three of the plans were signed by the youth and the DMHCA. Documentation
verified each youth was assigned to a mini-treatment team which was involved in the
development of the youth’s initial treatment plan. All three reviewed records were applicable for
individualized treatment plans (ITPs). All three youth had an ITP developed within thirty-one
days of the youth’s admission, on the Department’s form, and including all required elements.
Each youth’s ITP documented a DSM-5 diagnosis, treatment-focused symptoms, treatment
goals, and strengths/needs. Two of the records were applicable for pharmacological
interventions. Documentation showed the psychotropic medication listed in the ITP matched the
medication each youth was prescribed at the time the treatment plan was developed. Each ITP
was signed and dated by the youth and mini-treatment team members. None of the reviewed
youth records were applicable for a thirty-day ITP review as each was not yet due at the time of
the annual compliance review. None of the reviewed youth records were applicable for having
been an alleged victim of a Prison Rape Elimination Act (PREA) incident. Three closed youth
mental health and substance abuse records were reviewed for a mental health/substance abuse
treatment discharge summary, and each documented the Department’s Mental
Health/Substance Treatment Discharge Summary form was completed. Documentation
supported a copy was provided to each youth, parent/guardian, and emailed to each youth’s
assigned juvenile probation officer (JPO). A mini-treatment team meeting was observed during
the annual compliance review week. The DMHCA, center staff, and the youth participated in the
treatment team meeting. The objectives of the ITP and the youth’s progress towards goal
achievement were discussed. An interview with the DMHCA confirmed the ITP is reviewed with
the youth during treatment team every thirty days to identify progress made and explore the
need for updated or new goals to be added to the treatment plan.
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3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. Each youth determined to need mental
health treatment, including treatment with psychotropic medication, or substance abuse
treatment while in at the center, must be assigned to a mini-treatment team.
The provider’s contract requires mental health and substance abuse treatment planning to focus
on treatment provision 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 mental health and substance abuse records were reviewed, and none were applicable for
mental health and substance abuse treatment services; therefore, three additional applicable
youth records were requested for review. All three reviewed youth records included
documentation the youth required treatment, and each was assigned to a mini-treatment team.
Each youth’s mini-treatment team consisted of clinical mental health staff, one staff from a
different service area, the youth, and the youth’s parent/guardian. Each reviewed youth record
was applicable for treatment with individual therapy, group, and/or supportive counseling
sessions. Reviewed chronological progress notes validated youth were receiving treatment
services as stipulated on the treatment plans. All three youth were applicable for inclusion of
substance abuse treatment. Documentation supported the youth were receiving individual
substance abuse treatment services. Reviewed records supported each youth had an Authority
for Evaluation and Treatment (AET) and proper consent forms for substance abuse treatment
and information release. Each youth’s record contained progress notes documented on the
Department’s Counseling/Therapy Progress Notes form. A review of three separate days of
mental health groups on the center’s video footage for mental health groups confirmed licensed
therapists conducted group sessions with the youth as required. The observed groups were
conducted as scheduled and matched the group sign-in sheets. A review of mental
health/substance abuse group sign-in sheets and observations made during the annual
compliance review period verified mental health staff had adequate access to youth and had a
confidential space to provide treatment services. In addition, sign-in sheets validated mental
health groups were limited to ten or fewer youth and substance abuse treatment groups were
limited to no more than fifteen youth. An interview with the designated mental health clinician
authority (DMHCA) confirmed the process used for individualized mental health treatment
planning begins with reviewing and collecting data. Data collection may include information from
the youth's record, comprehensive assessment, current Clinical Psychotropic Progress Note
(CPPN), parent/guardian input, and youth input. Typically, treatment of mental health issues is
multi-disciplinary in nature and can include individual counseling, crisis intervention, and
psychopharmacological intervention. After the data is collected the DMHCA or licensed clinician
and the youth discuss the individualized mental health treatment plan. The youth is given an
opportunity to add, change, or delete items in the treatment plan. If there are no changes to be
made the DMHCA attempts to obtain signatures from the youth and the youth's parent/guardian.
The DMHCA was interviewed and stated the process used for individual substance abuse
treatment planning is to identify the type of substance use, frequency and duration, and age at
onset of use. Concerns of detoxification are discussed with medical staff, when applicable.
Sources used to develop the treatment plan would include data obtained from the substance
abuse evaluation, data collected from the parent/guardian, and youth input. Treatment may
target any presented denial, relapse prevention, and exploration of the need for more formal
substance abuse treatment. Five youth were interviewed regarding their rating of the center’s
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mental health and substance abuse services. Two youth rated services as very good and three
youth rated services as good.
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 maintains a written policy and procedures outlining the provision of psychiatric
services to youth in need, to include psychiatric evaluation, consultation, medication
management, and medical supportive counseling. Psychiatric services are provided to youth
determined to need services, as indicated by symptoms of a mental disorder or substance-
related disorder, or to youth who are treated with psychotropic medication after their admission
to the center. The center maintains a contract with VitalCore Health Strategies, LLC. (VitalCore)
for the provision of a licensed psychiatrist to provide psychiatric services for applicable youth in
the center. VitalCore has an independent contract for psychiatric services with a medical doctor
to serve as the center’s psychiatrist. The psychiatrist is a medical doctor who maintains a clear
and active license in the State of Florida, which expires on January 31, 2025. VitalCore has an
independent contract for psychiatric services with an osteopathic physician (DO) to serve as the
back-up psychiatrist in the event the psychiatrist is on scheduled leave or not at the center due
to an illness. The back-up psychiatrist maintains a clear and active Florida license, under
Chapter 459, which expires on March 31, 2026. The back-up psychiatrist was not utilized during
the annual compliance review period. The center does not utilize a psychiatric advanced
practice registered nurse (APRN). The psychiatrist is available for consultation, twenty-four
hours a day, seven days a week. Reviewed documentation and entries in the medical and
mental health sign-in logbook, during the annual compliance review period, validated the
psychiatrist provided services for two hours every week. The designated mental health clinician
authority (DMHCA) indicated they meet with the psychiatrist weekly and the psychiatrist is on
call twenty-four hours a day for any emergency needs. A review of five mental health and
substance abuse records indicated all were applicable for receipt of psychiatric services. Three
of the five reviewed youth records were applicable for receiving an initial psychiatric interview,
and two youth had the initial psychiatric interview completed at a different center. The three
applicable youth were admitted with prescribed psychotropic medications and each youth
received an initial diagnostic interview, which was documented on the Department’s Clinical
Psychotropic Progress Note (CPPN) form and completed within fourteen days of admission. All
three youth had an initial psychiatric interview which included the reason for referral, history,
mental status examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnosis, treatment recommendations, continuation of prescribed medications,
explanation for the need for psychotropic medications, frequency of medication
monitoring/management, and the psychiatrist’s signature. Each reviewed evaluation included
page three of the CPPN outlining medication target symptoms, side effect descriptions,
medication name, dosage, and frequency. Each youth record documented the in-depth
psychiatric evaluation was conducted within thirty days of the youth’s referral/admission. All
reviewed mental health and substance abuse documentation was completed utilizing the
required Department forms. All three youth records required the monitoring of Tardive
Dyskinesia which was conducted monthly. All three applicable youth records had a current
Authority for Evaluation and Treatment (AET) consenting for the continuation of the
psychotropic medication. The contract was reviewed and confirmed the inclusion of tele-
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psychiatry; however, none of the reviewed records were for youth receiving tele-psychiatry
services.
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 maintains a written policy and procedures requiring a Suicide Prevention Plan which
details processes to safely screen, refer, assess, monitor, and protect youth with elevated risk of
suicide in the least restrictive means possible. The plan details all required suicide prevention
procedures and was reviewed and signed by the designated mental health clinician authority
(DMHCA) and the superintendent. The plan addresses identification and assessment of youth
at-risk of suicide, staff training of at least six hours annually on suicide precautions, levels of
supervision, the referral process, communication, notification, documentation, immediate staff
response, and a review process as required by Florida Administrative Code. The center’s plan
includes an established review process for every serious suicide attempt or serious self-inflicted
injury and a mortality review for a completed suicide which includes circumstances surrounding
the event, center procedures relevant to the incident, all relevant staff training, pertinent medical
and mental health services involving the victim, possible precipitating factors, and any
recommendations as needed.
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).
The center maintains a written policy and procedures requiring suicide prevention services to
safely screen, refer, assess, monitor, and protect youth with an elevated risk of suicide in the
least restrictive means possible. A review of five youth mental health and substance abuse
records showed all five youth were applicable for having been placed on precautionary
observation (PO) at the time of admission until an Assessment of Suicide Risk (ASR) was
completed. All five youth were identified as at-risk based on the admission screenings.
Reviewed documentation showed all five youth records had a new suicide alert placed in the
Department’s Juvenile Justice Information System (JJIS). Documentation showed the ASR was
completed for each youth within twenty-four hours by a licensed therapist, using the
Department’s form. Each youth began on constant supervision based upon the Suicide Risk
Screening Instrument (SRSI), and after the completion of the ASR or Follow-Up ASR, all five
youth were placed on standard supervision. A review of all five youth’s Suicide Precautions
Observation Logs confirmed each was completed in its entirety to include documented safe
housing areas and all required signatures. Documentation supported the mental health
professionals were involved in the process for each youth. None of the five youth were released
from the center prior to receiving an ASR. The staff completed a mental health and substance
abuse referral for each youth due to the youth being identified as having a suicide risk. The
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superintendent and designated mental health clinician authority (DMHCA) were notified for each
youth. Two of the five records were applicable for a Follow-Up ASR prior to the removal of youth
from PO. Each ASR included recommendations for supervision and follow-up services. Each
ASR documented a conference was held between the licensed mental health professional and
the superintendent pertaining to reducing the level of supervision. A review of the center’s
logbooks revealed the starting and ending time of each youth’s precaution period was
documented in the logbook. The staff entered into JJIS the date and time each youth was
placed on and discontinued from PO. Documentation supported the DMHCA, and the
superintendent were consulted prior to each youth being stepped down from PO. The
interviewed DMHCA stated if it is determined a youth indicates suicide risk at intake, the youth
is placed on PO status at which time the administrator, supervisors, and other appropriate
individuals are notified through the JJIS system which automatically sends out an email. If
during length of stay a youth is determined to have become suicidal or attempts suicide, the
DMHCA and center administrators are contacted and, if necessary, emergency procedures are
implemented. The on duty mental health staff or the juvenile justice detention officer supervisor
(JJDOS) contact the youth's parents/guardian and juvenile probation officer (JPO) any time a
youth's supervision level is raised during their stay in secure detention. If a potentially suicidal
youth is scheduled for either release or transfer from the center, it is the responsibility of the
center staff to inform the parent/guardian or receiving program of the youth's status and any
current mental health concerns. Suicide attempts are documented in the youth’s record. If
necessary, a call to the Department’s Central Communications Center (CCC) and a report will
be completed, and emails and telephone calls will be used to notify the DMHCA,
superintendent, JPO, and necessary parents/guardians. A mental health referral will be placed
in the youth’s Electronic Medical Record (EMR) by detention staff. The DMHCA stated
communication of a youth’s supervision level is documented in the living unit logbook and the
master control logbook and indicated by signature of the superintendent/designee on the ASR
and in the EMR. Interviews with five youth were conducted, two youth stated they had been
placed on suicide precautions while at the center, and both youth confirmed staff always
watched them. The remaining three youth reported never having been placed on PO at the
center. Five staff were interviewed, and each staff reported they are responsible for notifying
mental health staff if a youth has suicidal thoughts. Four stated they would document
supervision and place the youth on constant sight and sound supervision. Three stated they
would search the youth and their room for any sharp objects. The interviewed superintendent
stated the center uses secure observation for potentially suicidal youth. Secure observation is a
suicide precaution method which provides for the use of a secure observation room for the
placement of youth demonstrating at risk or suicide risk behaviors and either one to one
supervision or constant supervision of the youth in the secure observation room.
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 maintains a written policy and procedures regarding secure observation (SO). Youth
placed on suicide precautions may remain under SO if less restrictive methods are not effective.
Five youth records were reviewed, and none were applicable for placement in SO. The center
provided three additional applicable youth records whereby youth were placed on SO.
Reviewed records supported each youth placement was authorized by a supervisor and the
designated mental health clinician authority (DMHCA). The secure room was designated in
writing and the Department’s Health Status Checklist was completed, as required. Staff
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completed the Suicide Precautions Observation Logs in their entirety and in real time. A new
Assessment of Suicide Risk (ASR) was completed when each youth was placed in SO, and a
Follow-Up ASR was completed within eight hours of placement. Documentation supported each
youth’s parent/guardian and juvenile probation officer (JPO) were notified of the placement.
None of the youth were maintained on SO beyond twenty-four hours. The mental health staff
provided supportive counseling while each youth was in SO. Documentation supported a
conference was held with the superintendent and the licensed mental health counselor prior to
the reduction of supervision level for each youth. A review of the center’s logbooks validated the
beginning and ending times of youth placed on precautions were documented. In addition,
discontinuation of SO and the step down to close supervision was documented in the center’s
logbook and the youth’s mental health record by mental health 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 maintains a written policy and procedures detailing the process to safely screen,
refer, assess, monitor, and protect youth with elevated suicide risk in the least restrictive means
possible. A review of five youth mental health and substance abuse records verified each youth
was applicable for having been placed on suicide precautions and each had a Suicide
Precautions Observation Log maintained. Each youth’s log was documented in real time and
was maintained for the duration the youth was on suicide precautions. The review of the Suicide
Precautions Observation Logs for all five youth found the staff were documenting the youth’s
behavior at thirty-minute intervals or less. When warning signs were observed for three youth,
staff notified the superintendent and mental health staff, and documented the signs on the
Suicide Precautions Observation Log. All five youth’s Suicide Precautions Observation Logs
included the signature of the mental health staff and the center’s shift supervisors. Observations
of video surveillance footage for three dates and corresponding documentation of youth placed
on precautionary observation (PO) confirmed each youth was placed on constant supervision,
the youth slept on a portable bed in the living unit activity area, and staff were positioned to
monitor the youth. A review of surveillance video footage confirmed staff were always present
while the youth were 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 maintains a written policy and procedures to address suicide prevention training. 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. A review of five in-
service and five pre-service training records verified each staff participated in suicide prevention
training. A review of the center’s suicide training policy verified it includes suicide drills are to be
held no less then quarterly on each shift. An informal interview with the superintendent and
observations verified the center has six suicide response kits located in the training room,
master control, one in each living unit, and one in the medical clinic. The suicide response kits
are co-located with the first-aid kits. A review of mock suicide drills during the annual
compliance review period verified drills were held no less than quarterly on each shift and all
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staff who come into contact with youth participated or were briefed on the suicide drill scenario.
A review of the mock mental health drills confirmed they were in response to a suicide attempt
and/or a simulated serious injury. Reviewed documentation and an informal interview with the
superintendent confirmed youth did not participate in the simulated suicide drills. Documentation
verified the center provided semi-annual training on emergency response procedures which
included mock training in emergency response to a suicide or incident of self-inflicted injury.
Observations and an informal interview with the superintendent verified staff who were not
present during the quarterly drills had the opportunity to review the scenario and procedures 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 staff were interviewed, and each stated
the suicide response kits are in master control and there is one in each living unit. A review of
surveillance video footage of three mock suicide drills was conducted, to include one on each
shift. On the first two scenarios medical, mental health, and center staff responded to a mock
suicide attempt and/or a simulated serious injury. Staff brought the suicide response kits and
first-aid kit when responding to the scenario. The third reviewed drill showed the staff who acted
as the victim in the scenario brought the suicide rescue kit, a first-aid kit, and a flashlight. The
staff enacted the drill scenario in front of one staff and the staff responded to the simulated
injury. Master control called 9-1-1 and documented the drill in the logbook. Two other staff
signed the scenario sign-in sheet; however, they did not participate. Reviewed video footage
showed the two staff were briefed on the scenario by the supervisor.
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 maintains a written policy and procedures regarding crisis intervention services and
a Combined Emergency Services Plan. The center’s staff 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 center. The center staff must be able to differentiate a youth who has
an acute emotional problem or serious psychological distress from one who requires emergency
services. In an informal interview the designated mental health clinician authority (DMHCA)
stated the center uses a Combined Emergency Services Plan. The Combined Emergency
Services Plan includes a notification and alert system, a means of referral for mental health
services including self-referral, communication, supervision, documentation, and review of any
crisis a youth may have.
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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 maintains a written policy and procedures to address the Emergency Care Plan
which stipulates the response procedures for youth in crisis. Youth determined to be an
imminent danger to themselves or others due to mental health or substance abuse emergencies
occurring in the center require emergency care provided in accordance with the center’s
Emergency Care Plan. The Crisis Intervention Plan and Emergency Care Plan were combined
into an integrated Crisis Intervention and Emergency Services Plan. A review of the Emergency
Care Plan verified it was approved by the superintendent on August 26, 2024. In an informal
interview, the assistant superintendent verified a copy of the plan is in master control and all
staff have access to the plan. The Emergency Care Plan includes immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health and substance abuse services, transport for a Baker Act, transport for a Marchman Act,
documentation, training, and review.
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.
The center maintains a written policy and procedures regarding Crisis Assessments which are a
detailed evaluation of a youth demonstrating acute psychological distress. Five youth records
were reviewed, and none were applicable for a Crisis Assessment. The center provided three
additional applicable youth records which included the need for a Crisis Assessment to be
completed. A review of three youth Crisis Assessments found each assessment included the
date, the reason for the assessment, a Mental Status Examination and interview, a
determination of danger to self or others, initial clinical impressions, supervision
recommendations, treatment recommendations, and recommendations for follow-up or further
evaluations. One reviewed Crisis Assessment was applicable for and documented notification to
the parent/guardian for follow-up treatment, as required. Two of the three reviewed Crisis
Assessments required a mental health alert to be entered in the Department’s Juvenile Justice
Information System (JJIS). All three Crisis Assessments included documentation the center staff
and/or the mental health staff identified the youth as having acute emotional or behavioral
problems, or acute psychological distress. All three reviewed Crisis Assessments were
conducted by licensed mental health staff. Each Crisis Assessment was conducted immediately
or within two hours of the emergency, or within twenty-four hours based upon the youth’s needs.
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Each of the three reviewed Crisis Assessments involved a Prison Rape Elimination Act (PREA)
event. Documentation showed each youth was offered on-going mental health treatment
services.
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 maintains a written policy and procedures which specify the mental health and
substance abuse emergency procedures for youth who are believed to be an imminent danger
to themselves or others because of mental illness or substance abuse impairment. Three Baker
Act incidents were reviewed. Documentation validated suicide risk alerts were entered into the
Department’s Juvenile Justice Information System (JJIS) while pending off-site transportation.
Each youth was placed on one-to-one supervision, and supervision was documented on the
precautionary observation (PO) log until the time of the youth’s authorized release.
Documentation verified each youth was placed on suicide precautions upon readmission to the
center from the Baker Act facility. Each reviewed record indicated a Mental Status Examination
(MSE) was conducted within the administration of the Assessment of Suicide Risk (ASR).
Documentation verified each MSE was completed by a licensed mental health staff, as required.
Each youth was maintained on constant supervision until properly transitioned to a lower level of
supervision. Each youth’s supervision level was maintained until an appropriate assessment
was conducted and the licensed mental health staff conferred with the superintendent or
designee. A review of JJIS alerts verified each suicide risk alert was discontinued based on the
completion of the ASR.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains a written policy and 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 (VitalCore) which subcontracts with a medical
doctor (MD) to serve as the center’s DHA. The DHA holds an unrestricted license which expires
on January 31, 2025, which meets all requirements for independent and unsupervised practice
in the State of Florida. The DHA has specialty training in family medicine. The DHA ensures all
medical and mental health policies and protocols are reviewed and signed annually, and
ensures all appropriate medical staff receive training on all medical policies. The MD serves as
the center’s DHA and is clinically responsible for the medical care of all youth. A review of the
contract with VitalCore, effective March 17, 2022, indicated the DHA is required to be on-site
each week, in accordance with Florida Administrative Code. A week is defined as the seven-day
period beginning on Sunday and ending on Saturday. There is to be no more than nine days
between on-site visits. The DHA is responsible for conducting periodic evaluations,
Comprehensive Physical Assessments (CPAs), sick call referrals, and administrative duties.
The DHA is responsible for communication with the center and the medical staff regarding all
youth medical needs. The DHA is available on-call twenty-four hours a day, seven days a week
for consultation. The DHA is typically on-site weekly on Tuesdays. Reviewed attendance logs
since the last annual compliance review, supported the DHA was on-site weekly as required.
The center utilizes an advanced practice registered nurse (APRN), who is on-site once a week
and holds an unrestricted license in the State of Florida, with an expiration date of April 20,
2025. The APRN has Collaborative Practice Protocols in place with the DHA. The APRN and
DHA had a collaborative agreement which was signed on September 17, 2024. VitalCore
provides a back-up DHA for coverage when the center’s DHA is on scheduled absences or
vacation; however, no back-up DHA was utilized during the annual compliance review period.
Tele-health services were not utilized at the center since the last annual compliance review. An
interview with the DHA confirmed they provide youth with CPAs, sick call care, episodic care,
and periodic evaluations. The DHA confirmed being on-site at least one day each week and
being available to staff twenty-four hours a day and seven days each week. Communication
with the center’s staff regarding medical needs is conducted through weekly medical team
meetings. The DHA reported off-site care is reviewed with the center’s nursing staff and
documented in a chronological progress note, with new orders given as needed. Any youth with
active/acute medical conditions are reviewed and discussed during DHA clinic visits.
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 maintains a written policy and procedures for all utilized health-related procedures
and protocols. Reviewed documentation reflected the designated health authority (DHA)
reviewed, signed, and dated the medical facility operating procedures (FOPs) on September 3,
2024. Reviewed documentation confirmed the superintendent signed and dated the updated
FOPs on August 26, 2024. The four registered nurses signed the FOP cover page between
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 60 (Revised July 2023)
February 13, 2023, and May 29, 2024. The psychiatrist signed the healthcare protocols,
policies, and procedures on April 26, 2024. The center’s treatment protocols and standing
procedures were signed and dated by the new DHA on September 25, 2024, and by the
center’s psychiatrist on April 26, 2024. The center’s non-healthcare staff protocols were signed
and dated by the DHA on September 10, 2024. Nursing services are available at the center
Monday through Friday from 7:00 a.m. to 7:00 p.m. and on weekends from 7:00 a.m. to 5:00
p.m. VitalCore has an established comprehensive clinical orientation for all newly employed
healthcare staff which includes the Department’s healthcare policies and procedures. A review
of each medical staff’s training records verified each newly employed medical staff received a
clinical orientation conducted by a registered nurse (RN).
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 a written policy and procedures requiring 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. Five youth records were reviewed
and all five had an original AET with dated parent/guardian signatures executed prior to the
provision of medical services. Each AET was valid, was signed by a Department representative,
and filed in the youth’s Individual Healthcare Record (IHCR). All five youth were under the age
of eighteen, and none were applicable for a Limited Consent for Evaluation and Treatment, and
none of the youth were in the care of the Department of Children and Families (DCF) where
there had been a termination of parental/guardian rights.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains a written policy and procedures which require notification to be made to
the parent/guardian of any significant changes in a youth’s condition and to obtain consent
when new medication or treatments are prescribed. A review of five Individual Healthcare
Records (IHCRs) showed one record was applicable for a required parental/guardian
notification; therefore, two additional applicable records were requested for review to reach the
minimum required sample size. A review of three applicable records included parental/guardian
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET) with consent provided by the parent/guardian in each instance.
One youth was admitted with psychotropic medication; however, there were no significant
changes or a discontinuation of the medication while the youth was in secure detention. None of
the youth were applicable for newly ordered medication, or for newly prescribed or discontinued
psychotropic medication. One youth received off-site care and another youth required an off-site
examination and written parental/guardian notification was sent in each instance. The center’s
healthcare staff verified each youth’s immunizations within thirty days of admission on the
Florida Shots website. An interview was conducted with the registered nurse (RN) who indicated
the center has a policy requiring immunization records to be obtained and reviewed from the
Florida Shots website, and consent is to be obtained from the parent/guardian prior to
administering any vaccination/immunization.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 38 of 60 (Revised July 2023)
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 maintains a written policy and procedures requiring each youth to be screened for
healthcare concerns in the Department’s Juvenile Justice Information System (JJIS) at the time
of admission. A review of five youth Individual Healthcare Records (IHCRs) found each
contained a Facility Entry Physical Health Screening (FEPHS) form and Medical and Mental
Health Admission Screening (MMHS) completed on each youth’s date of admission. Four of five
youth had their FEPHS completed by a registered nurse (RN), and one was completed by a
juvenile justice detention officer (JJDO), which was reviewed by the medical staff within twenty-
four hours, as required. None of the youth at the center were applicable for having had a
change in physical custody. An interview was completed with the RN who stated the center's
medical staff are responsible for updating the healthcare admission screening and re-screening
form.
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 program has a policy and procedures requiring all youth to be oriented to the center’s
healthcare services. A review of five youth healthcare records indicated each received
orientation at admission which addressed access to medical care, the sick call process, what
constitutes an emergency and when to notify staff, the medication process and side effect
monitoring, the right to refuse care and how refusals are documented, what to do in the case of
a sexual assault or attempted assault, the non-disciplinary role of the healthcare providers, and
standard universal precautions. Each youth record contained a signed orientation sheet to
acknowledge the youth’s completion of the orientation. The program utilizes an
education/orientation binder to ensure all required orientation topics are covered with each
youth. Each youth’s record documented completion of health education on the topics of seatbelt
usage, alcohol and drug related problems, sexually transmitted diseases and infections, tobacco
products and smoking cessation, dental hygiene and care, basic personal hygiene,
immunizations, infection control, prevention of sexual and physical violence, nutrition, physical
fitness, breast and testicular self-examinations, parenting skills, and prenatal, postpartum, and
parenting education. All five youth records indicated each youth successfully completed the
health education topics.
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 a written policy and procedures which require the designated health authority
(DHA) to be notified when a youth is admitted with a chronic condition or needs emergency
care. Five youth records were reviewed. None of the five youth were identified as needing
emergency care at admission. Two of five youth had chronic conditions and one youth was
admitted taking psychotropic medications. Each Individual Healthcare Record (IHCR)
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Office of Accountability and Program Support Page 39 of 60 (Revised July 2023)
documented the DHA/designee was notified within twelve hours of admission, and a referral
was made to the DHA. One of five reviewed records was for a youth with prescribed
psychotropic medication at the time of admission and the psychiatrist was notified at admission.
An interview was conducted with the registered nurse. The nurse indicated the DHA is
contacted by telephone as soon as each admitted youth is seen at the clinic and the
notifications to the DHA are documented on the intake log as well as the youth’s admission
progress note.
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 maintains a written policy and procedures requiring the completion or review and
updating of the Department’s standard Health-Related History (HRH) form. A review of five
youth Individual Healthcare Records (IHCR) found each contained an HRH form completed by a
licensed nurse within seven days or less of the youth’s admission to the center. All five of the
HRH forms were reviewed by the designated health authority (DHA) or advanced practice
registered nurse (APRN) and were maintained in the youth’s IHCR. Each of the applicable
HRHs were completed before the Comprehensive Physical Assessment (CPA) and reflected the
most current admission into detention. The nursing interview confirmed the HRH is completed
by the medical staff within seven days of a youth’s admission.
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 maintains a written policy and procedures requiring a Comprehensive Physical
Assessment (CPA) to be completed or updated for all youth admitted determining the health
and wellbeing of each youth. Five Individual Healthcare Records (IHCRs) were reviewed, two
had a current CPA on record at admission, and three youth had a new CPA which was
completed by the designated health authority (DHA) within seven calendar days of admission.
Four youth had a focused CPA completed by the advanced practice registered nurse (APRN)
and one by the DHA. Each new CPA was completed within seven days of the youth’s admission
and signed by the APRN or the DHA. Each CPA was completed in full to include the Medical
Grade, Tanner Stage, cardiovascular, body mass index, visual acuity, and most recent
Tuberculosis Skin Test (TST). All sections of each CPA were marked with an “O”. One of the
five reviewed records documented the youth’s refusal on a part of the exam and the youth
signed a refusal form which reflected the refused portion of the exam. The Department’s
Problem List was updated in each record, as required. An interview with the nursing staff
indicated the DHA or APRN completes the CPA at the time of admission and yearly for youth
who have not been out of the Department’s custody or unless there’s a change on the youth’s
Medical Grade. The center’s policy and procedures for tuberculosis (TB) control and screening
requiring the routine screening of all youth for latent and active TB and outlining environmental
controls in the case of a youth with suspected active TB. Each reviewed youth record
documented a Tier 1 TB screening was completed on the Medical and Mental Health Admission
Screening form. Each reviewed record documented a TST was completed within the last year.
None of the reviewed youth required further evaluation prior to entering the general population.
Nursing staff indicated TB screenings are provided to youth within seventy-two hours of
admission to the center if required, and results are documented in the youth’s CPA and in the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 60 (Revised July 2023)
youths IHCR. Additionally, for female youth, gynecological examinations are not routinely
completed.
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 maintains a written policy and procedures requiring all youth to be evaluated and
treated, if necessary, for sexually transmitted infections (STIs). All sexually active youth are to
be clinically screened and evaluated for STIs. After the screening, 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 (IHCR) confirmed
none of the five youth were sexually active and did not require STI testing; therefore, three
additional applicable records were requested and reviewed. Each of the three youth records
indicated further evaluation was required. The center’s practice is to obtain counseling and
testing orders at the direction of the DHA or APRN. Each of the reviewed applicable youth
records included documentation for ordered testing and results. STI screenings, evaluations,
and referrals are documented and maintained in each youth’s IHCR. There were no youth
applicable for having been out of the Department’s custody for thirty days or more needing a
rescreening since the last annual compliance review. All three reviewed records documented
each youth was offered counseling and testing for human immunodeficiency virus (HIV). Two
reviewed records indicated the youth consented to HIV testing, and one declined testing. It is
the center’s practice for HIV results to be provided to the youth verbally by the DHA or APRN
and results are to be maintained in a confidentially marked, sealed envelope, in the youth’s
IHCR. The two applicable youth records indicated the results and post-test education discussion
with the youth were pending. In an informal interview, the registered nurse (RN) indicated the
results were received and scheduled for the APRN or DHA to review, discuss the results with
the youth, and complete the youth’s post-test education during the week of the annual
compliance review. An interview with the nursing staff indicated youth are screened for STIs, the
DHA or the APRN review and complete the STI screening form with the youth, and if testing is
required, the youth can consent for screening for STI or HIV testing. Interviewed nursing staff
indicated STI and HIV screenings are documented on the youth’s Infectious and Communicable
Disease form as well as in the progress notes; however, an informal interview with the nursing
staff confirmed only STI screening results are documented, and only the HIV testing date is
listed, not the results. Nursing staff indicated the center maintains a tracking log for
documenting all the youth requesting to be tested. The APRN is responsible for HIV pre and
post-test counseling, and the county’s Department of Health (DOH) completes the testing.
Pre/post-test counseling is documented in the IHCR form. Five interviewed youth reported being
able to request an HIV test.
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Office of Accountability and Program Support Page 41 of 60 (Revised July 2023)
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 maintains a written policy and procedures detailing the process for sick call. The
center conducts sick call seven days a week to respond to youth medical illnesses or injuries of
a non-emergent nature by a healthcare professional. The center maintains treatment protocols
appropriate to the level of the provider conducting sick call, which were approved and signed by
the designated health authority (DHA) on May 28, 2024. Postings throughout the center
indicated sick call takes place seven days a week on Monday through Sunday from 8:00 a.m. to
10:00 a.m., when youth are securely detained at the center. The nurse conducts sick calls in the
medical office. Sick calls are entered by staff in the Department’s Juvenile Justice Information
System (JJIS) and can be conducted any time medical staff is on-site. The designated health
authority (DHA) or the advanced practice registered nurse (APRN) conduct sick calls if sick call
is scheduled when the DHA or APRN are on-site. Youth are provided the opportunity to request
sick calls in a private manner. Shift supervisors are trained in the center’s sick call procedures
and, in the absence of healthcare professionals, are to review submitted sick call requests. A
review of five Individual Healthcare Records (IHCRs) indicated there were two applicable
records for having submitted a sick call; therefore, one additional applicable record was
requested. Sick calls were conducted by the nursing staff within twenty-four hours. There were
no instances of a youth with three or more similar sick call complaints within a two-week period.
Each reviewed record indicated a Sick Call Request form was completed by the youth and the
sick call was conducted by a registered nurse (RN). Reviewed documentation confirmed each
youth sick call was included on the Sick Call Index, were documented in each youth’s
chronological progress notes, and the Sick Call Request forms were filed in the youth’s IHCR.
The center’s policy and procedures require youth in confinement to be questioned daily for
medical complaints, which is to be documented in the IHCR. A review of documentation
revealed the center did not have any instances of sick calls for youth in confinement or secure
observation. An observation of a sick call was conducted during the annual compliance review
week which confirmed the center’s practice. An interview with the nursing staff confirmed the
sick call would be conducted by the nursing staff as soon as they are available, and not to
exceed twenty-four hours. Sick call is conducted in the medical clinic daily, by either a RN or a
licensed practical nurse (LPN). Sick calls conducted by an LPN must be reviewed by a RN
within twenty-four hours. The DHA is able to conduct sick calls if the sick call is scheduled while
the DHA is on-site. An interview with the RN confirmed the center’s practice for referring youth
with repeated sick call complaints and the process for assessing youth in restricted
housing/confinement. An interview with five staff was conducted and all five stated sick calls are
reviewed by the nursing staff and by the detention staff. Four of five staff indicated both the
nursing staff and detention staff conduct sick call, and one staff indicated the nursing staff
conduct sick call. Five youth were interviewed, and three youth stated they are seen within
twenty-four hours after submitting a sick call, and two youth stated they are immediately seen
after submitting a sick call. All five youth indicated the nursing staff conduct the sick calls.
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Office of Accountability and Program Support Page 42 of 60 (Revised July 2023)
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center maintains a written policy and 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. The log is used to
document the date, name of youth, the youth’s Department identification number, the nature of
the illness or injury, the treatment rendered, staff initials, nurse initials, verification of who
provided episodic care, and whether the youth was recommended for off-site care. A review of
five youth Individual Healthcare Records (IHCR) showed there were three youth applicable for
episodic or emergency care. In each applicable record, the youth received episodic or first-aid
care by a licensed healthcare staff, the nature of the complaint was documented, and the
findings of the healthcare staff rendering care were included. Each reviewed instance for
episodic care documented the education/instruction provided to the youth, and an entry in the
Episodic Care Log was completed. There was one instance of episodic care which required a
referral to off-site care. The youth required a follow-up evaluation, and the record maintained the
documentation for the required follow-up, the parental/guardian notifications as required, and
the youth received a follow-up evaluation by a licensed healthcare staff. The center maintains
thirteen first-aid kits which are located on each of the youth living units, master control, intake,
dining room, the medical office and one kit for each of the center’s five transport vehicles. The
first-aid kits for the transport vehicles are stored within master control. The center requires the
first-aid kits to be sealed with breakaway tabs and inspected and restocked monthly.
Observations of three first-aid kits during the annual compliance review week validated the kits
were sealed and stocked with the designated health authority (DHA) approved contents. A
review of first-aid kit inventory checks found the nurse conducts monthly checks of first-aid kits
to ensure all contents are in the kits. An informal interview with the nursing staff indicated
nursing staff are responsible for monthly first-aid kit inventory checks and monthly check logs
are maintained. The center has two automated external defibrillators (AEDs) on-site. One in
master control and one in the medical office. The AED procedures and instructions were located
with the AED. The center has an outside vendor who conducts battery and pad checks for the
AEDs. The provider last serviced the AEDs on July 28, 2023. Nursing staff check the AED
batteries and pads monthly to ensure the AED is operational and document their review on the
AED maintenance and inspection log. A review of the center’s AED maintenance and inspection
logs since the last annual compliance review validated the center’s practice. The AEDs were
self-tested in front of the annual compliance reviewer to ensure they were operational. The
batteries in both AEDs expire on August 28, 2025, and the pads expire on July 28, 2025, and on
August 28, 2025. The center’s policy and procedures indicated emergency drills are to be
conducted for each shift on a quarterly basis at minimum, and AED/cardiopulmonary
resuscitation (CPR) must be demonstrated at least annually. A review of quarterly emergency
drills since the last annual compliance review indicated drills were being conducted on each
shift, as required. Observations were made of surveillance video recordings of drills conducted
in the previous thirty days which confirmed drills for episodic care, first-aid, and/or AED/CPR
included the simulation of techniques, as required. Additionally, the center reported, all drills are
also discussed with staff during the staff briefings. All drills documented the type of simulated
medical event, the time the drill/event occurred, the time 9-1-1 was called, if applicable, the
name of the juvenile justice detention officer supervisor or healthcare provider in charge, the
healthcare provider response time, type of medical care rendered, time the event concluded,
clinical manager/medical staff review, and a critique. The center maintains a list of emergency
numbers, including the Poison Control Center, in the medical office and in master control, which
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Office of Accountability and Program Support Page 43 of 60 (Revised July 2023)
are available to all staff and inaccessible to youth. A review of five in-service and five pre-
service staff training records documented the staff were trained in CPR, first-aid, and AED. All
non-healthcare staff and nursing staff are required to maintain current CPR and AED
certifications. Only healthcare and trained supervisory non-healthcare staff may 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 supervisory staff received training on the epinephrine auto injector.
Reviewed documentation supported the DHA, the advanced practice registered nurse (APRN),
and all nursing staff maintained current certifications in CPR and AED. The center has a policy
and procedures regarding the use of NARCAN®. The center’s nursing staff are responsible for
conducting staff training on NARCAN® as a stand-alone, instructor-led class for the supervisors
trained and approved for medication administration. The center maintains NARCAN® in the
locked medication cart which is accessed only by the licensed nurses and staff who have
completed training on medication administration. The center maintains a perpetual and weekly
inventory of the NARCAN®. An interview with the nursing staff indicated all emergency and
medical drills are held monthly. Nursing staff confirmed the location of the center’s AEDs, first-
aid kits, including the kits for the transportation vehicles, and indicated nursing staff are
responsible for maintaining inventory logs and completing monthly checks. Medical staff are
responsible for documenting and tracking all instances of episodic care, first-aid, emergency
care, and off-site referrals. Five staff were interviewed to determine if they can call 9-1-1 if
necessary, and each staff indicated they could. An interview was conducted with five youth,
three of whom rated the center’s medical care as good, one youth rated the center’s medical
care as very good, and one youth indicated they had not received any medical care at the
center.
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 a written policy and procedures requiring timely referrals and coordination of
care for access to off-site medical services. A review of five youth Individual Healthcare Records
(IHCRs) found there was one applicable youth for off-site care; therefore, two additional records
were requested. The reviewed applicable records included the discharge paperwork. Each
youth’s Summary of Off-Site Care Consultation Report form was reviewed and signed-off by the
designated health authority (DHA) or advanced practice registered nurse (APRN) and were
maintained in the youth’s record and in the Department’s Juvenile Justice Information System
(JJIS) Electronic Medical Record (EMR). Progress notes recorded the related notification to the
DHA and notification efforts made to each parent/guardian, and the DHA documented needed
follow-up care, as required. One youth required follow-up care, and all referrals were
documented on the center’s Off-Site Care Log, Sick Call Log, and/or the referral tracking log. An
interview with the nursing staff indicated the Off-Site Care Log and/or Episodic/Medical Tracking
Log is utilized for youth receiving off-site care. Nursing staff review all medical orders with the
DHA and ensure all hospital orders are followed.
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Office of Accountability and Program Support Page 44 of 60 (Revised July 2023)
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 a policy in place to ensure youth with chronic conditions receive regularly
scheduled evaluations and necessary follow-up. Three youth records were reviewed and were
identified on the Medical/Mental Health Screening form with a current chronic condition. Each of
the three youth were placed on the chronic conditions list and seen by the designated health
authority (DHA). Progress notes were reviewed of each completed periodic evaluation. The
dates of the periodic evaluations for the three youth were March 10, 2024, March 22, 2024, and
March 19, 2024. The Department’s Problem List was updated, as required. None of the three
youth were applicable for any lapse in care or missed periodic evaluations. None of the youth
were in secure detention long enough to have another periodic evaluation for their chronic
condition. None of the three youth had a communicable disease, were taking prescribed
medication on an on-going basis for any reason or were pregnant. All three youth were
classified with a Medical Grade between two and four. None of the three youth were applicable
for taking anti-tuberculosis (TB) medication, for periodic evaluations conducted prior to renewing
a prescription medication which expired, or for off-site care. The DHA and nursing interview
results verified the center’s chronic conditions and periodic evaluations procedures.
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 maintains a written policy and procedures which require 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 all medications have a current, valid order, and are 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
a licensed pharmacy with a current, legible, patient-specific label affixed. The center utilizes a
local pharmacy. All medication is delivered to the center in blister packs. A review of five
Individual Healthcare Records (IHCRs) showed only one youth was taking medication upon
admission; therefore, two additional records were requested. A review of the three applicable
records indicated the designated health authority (DHA), advanced practice registered nurse
(APRN), and/or the psychiatrist were contacted to obtain an order to resume the specified
medication prescribed prior to admission. A review of each youth’s medication record showed
the youth had a current, valid order, and medication was administered pursuant to the current
prescription. When current medications were continued, discontinued, or changed the reviewed
records indicated the DHA placed an order on the Practitioner Order form, as required. Each
reviewed record confirmed prescription verification was completed in the chronological progress
notes in the related IHCRs. A review of the youth records showed there were two youth
applicable for restricted housing while taking prescribed medications, and nursing staff
completed the daily visits and provided all prescribed medications, as required. Each of the
three youth were applicable for over-the-counter (OTC) medications beyond those 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 medication
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Office of Accountability and Program Support Page 45 of 60 (Revised July 2023)
on a routine basis and/or OTC medication which includes all required elements. The center
maintains a written policy and procedures to ensure the usage of the MAR by licensed
healthcare staff and non-licensed staff. A review of the three youth records confirmed they
contained MARs documenting administered medications. There were no records including a
trained non-healthcare staff assisting in the delivery of medication when licensed healthcare
staff were not on-site. There were no undocumented explanations for lapses or errors in
medication administration. The reviewed MARs documented side effect monitoring by the
nursing staff at each medication administration. One of the three applicable MARs documented
a refusal and contained a signed Refusal of Treatment form in the youth’s IHCR. The reviewed
standardized MAR forms 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. There were no youth requiring parenteral medication at the center since the last
annual compliance review. Each of the three reviewed records were applicable for youth
entering the center while on prescribed psychotropic medication. The psychiatrist was notified
upon each youth’s admission and the psychiatrist conducted an initial diagnostic psychiatric
interview within fourteen days of admission, as required. One applicable record indicated the
youth was on psychotropic medication at the center for more than thirty days and confirmed the
center’s practice, which required medication monitoring every thirty days. The center did not
have any standing orders for psychotropic medication, no pro re nata (PRN) orders for
psychotropic medication, or emergency treatment orders for psychotropic medication.
Medication pass is conducted daily at 8:00 a.m., 12:00 p.m., 5:00 p.m., 7:00 p.m., and/or as
required by the medication orders. A medication pass was observed which confirmed the nurse
administers the medication. The youth was escorted by a direct care staff to the medical office
who maintained supervision of the youth. Each youth approached the nurse individually and the
nurse verified the Six Rights of Medication Delivery/Administration. The youth’s allergy and alert
status were verified, and the youth and nurse initialed the MAR. The nurse verified each youth
swallowed all medications. None of the medications were pre-poured. An interview with nursing
staff indicated the center has a process for monitoring and tracking youth with chronic
conditions, and medication upon entering the center. Nursing staff indicated when youth arrive
at the center with medication, the center’s process is to review and verify the medication has a
valid order and contact the DHA, and when applicable the psychiatrist. Additionally, nursing staff
stated medication/prescriptions are inventoried on a weekly basis and maintained in a locked
secure area. The nursing interview confirmed the center has non-healthcare staff who are
trained by medical staff to provide over-the-counter medication to youth. An informal interview
with the center’s nursing staff indicated training for non-healthcare staff on medication self-
administration was completed on March 28, 2024, and April 5, 2024. An interview with five staff
regarding medication administration was conducted. Four of the five staff stated they do not give
medication to youth, and one staff indicated they do. An interview with five youth indicated three
youth did not take medication and two youth stated the nursing staff gives the youth their
medication. An informal interview with the nurse, indicated all controlled medications are
disposed of between a nurse and the pharmacist consultant, and other medications are
disposed of between two nurses. If medication is discontinued it can be returned to the
pharmacy.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 60 (Revised July 2023)
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains a written policy and procedures stipulating the requirements for the
storage and inventory of medication and sharps to ensure all medication is inaccessible to youth
at the center. The dose-by-dose daily administration of medication is documented utilizing a
perpetual inventory process for the daily distribution of non-controlled prescription medication
and over-the-counter (OTC) medication. Documentation of each individual dosage of medication
administered to youth is maintained on the Medication Administration Record (MAR) utilizing a
routine perpetual inventory descending count. An observation of the medical office was
conducted during the annual compliance review week and found the medical office to be
secured and maintained under lock and key. All medication, medical equipment, and sharps
were securely stored within the medical office. The youth’s medication was stored in a locked
medication cart maintained in the locked medical office. The center had three controlled
medications on-site during the week of the annual compliance review. Narcotics and other
controlled medications were securely stored within the double locked medication cart. The
center is required to conduct shift to-shift counts when there are controlled substances on-site.
An informal interview with the nurse indicated the nursing staff maintain perpetual inventories
with running balances on all controlled substances, with required shift-to-shift inventory counts.
Observations of the inventories and controlled medication logs validated the center’s practice. A
count of three OTC medications was observed and the observed counts matched the inventory.
The center maintains an inventory of all sharps and medical equipment classified as sharps, to
include syringes, butterflies, needles, scissors, and suture removal kits. Items designated as
sharps are stored in a designated cabinet, locked in the medical office which is inaccessible to
youth. Syringes and sharps are counted through a perpetual inventory and are verified weekly.
An observed count of three sharps verified each matched the inventory log. Reviewed
documentation confirmed all perpetual and weekly inventories were conducted on stock OTC
medications, and sharps. The center had no medication requiring refrigeration during the annual
compliance review week; however, the center has a refrigerator which is maintained only for the
storage of medication. The center has a process for the destruction, disposal or return of
expired or discontinued medication through the pharmacy the center utilizes. An interview with
the nursing staff validated the center’s process for disposal of discontinued or expired
medication, with all controlled medications disposed between the nurse and the pharmacist
consultant, and other medications disposed by two nurses. The center utilizes a pharmaceutical
vendor and maintains a copy of their pharmacy consultant license on-site at the center. The
interviewed nursing staff confirmed the center’s practice is to securely store all medication, and
any narcotic/controlled medication must be maintained behind double locks. The center has a
list of non-healthcare staff trained by the registered nurse to administer medication.
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Office of Accountability and Program Support Page 47 of 60 (Revised July 2023)
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 maintains a written policy and procedures to prevent the spread of infectious
diseases or illnesses and provide staff with the knowledge of 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 education within seven days of admission. The
infection control education 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 including risk assessment
and methods of compliance. The plan addressed common childhood infectious diseases, self-
limiting, episodic contagious illnesses, viral or 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
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.
The center did not have any incidents or illnesses which required a report to the local health
department or the Department’s Central Communications Center or required quarantining of
youth during the annual compliance review period. The nursing staff are responsible for
providing detention staff with training on Infection Control and the Exposure Control Plan.
Examination of five staff pre-service and five staff in-service training records found each staff
completed Exposure/Infection Control Plan training. An interview with the nurse indicated
infection control education is provided to all youth at admission. The nursing staff indicated the
Exposure Control Plan is available to staff and a copy of the plan is located within the medical
office. The center utilizes the local county health department for services including
immunizations, HIV testing, and/or any routine gynecological care.
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 maintains a written policy and procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. Five Individual Healthcare
Records (IHCRs) were reviewed and none of the youth were applicable for prenatal care. An
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Office of Accountability and Program Support Page 48 of 60 (Revised July 2023)
informal interview with the nursing staff confirmed the center had no pregnant youth admitted
since the last annual compliance review. An interview with the registered nurse indicated the
center provides youth with the required services once it is determined a youth is pregnant. The
center maintains prenatal healthcare education information for pregnant youth to receive, which
includes education on alcohol and drug use, smoking, nutrition, sexually transmitted infections,
contraception, prenatal care, the birthing process, postpartum care, basic baby care, child/infant
development, and parenting skills.
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Office of Accountability and Program Support Page 49 of 60 (Revised July 2023)
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 a written policy and procedures to address staff supervision of youth. During the
week of the annual compliance review, observations confirmed youth were actively supervised
during all daily activities including educational classes, recreation, medication pass, and meals.
All observed movements were reported to master control and approved by the master control
operator prior to the movement occurring. A random review of the center’s logbooks for the
previous six months indicated youth counts were consistently conducted. Daily counts are
tracked in shift meetings, living unit logbooks, the master control logbook, and the Department's
Juvenile Justice Information System (JJIS). A review of surveillance video footage was
conducted of three days of educational classes and three mental health and substance abuse
groups, with no discrepancies noted. Five staff were interviewed, and four of five staff stated
there were enough staff to provide proper and safe supervision of 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.
The center has written policies and procedures detailing the center’s behavior management
system (BMS) to include rewards, privileges, and consequences to encourage youth to meet the
center’s behavioral expectations. The policy also outlines restrictions and punishments for
behaviors which are prohibited. A copy of the BMS was provided and was verified as the
statewide BMS which was approved by the Department. Observations and a tour of the center
were conducted, and postings were found throughout the center detailing the BMS
expectations. In addition, a calendar was posted throughout the center outlining the scheduled
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Office of Accountability and Program Support Page 50 of 60 (Revised July 2023)
monthly rewards available for the youth. Positive interactions between staff and youth were
observed during school, recreation, meals, and free time on the living unit. A review of the
center’s policy in comparison with BMS documentation found the center is compliant with the
requirements of the BMS and assignment of positive and negative consequences. A review of
five youth case management records, the Department’s Central Communications Center (CCC)
reports, and internal incident reports found there was no indication the center utilized prohibited
restrictions or group punishment. An interview with the superintendent confirmed the BMS is a
level system which allows youth to advance through the levels to achieve positive rewards. Five
youth were interviewed, and three youth rated the BMS as good, and two youth rated the BMS
as very good. Each youth was able to explain the difference in levels and the type of rewards
provided. All five youth reported staff consistently apply rewards in the same manner and stated
youth are not allowed to punish other youth in the center. Four of five youth reported having
never been sent to their room for punishment while one stated they were placed in their
assigned sleeping room due to room confinement. Four youth reported the consequences they
received were fair and levels were taken away and one youth reported never receiving
consequences. Five youth reported they never witnessed any incident where mechanical
restraints were used. Five staff were interviewed and were knowledgeable about the center’s
BMS. Each staff was able to identify the types of rewards provided by the center and indicated
points and the youth’s level are allowed to be taken away as a consequence of their behavior.
One staff stated when youth are in confinement school materials are provided to them. All five
staff reported the BMS is effective, they speak with youth to discuss consequences being
imposed, and youth are allowed an opportunity to explain their behavior. Five staff also reported
they receive feedback on the implementation of the BMS as needed.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains a written policy and procedures requiring ten-minute checks to be
conducted when youth are in their rooms for sleeping purposes. The center has a total of fifty-
eight cameras with a recording capacity of thirty days and two cameras were not operational at
the time of the annual compliance review. The center utilizes an electronic wand system to
conduct ten-minute checks which electronically records each conducted check and generates a
report. A review of nine reports, to include three from each shift, was conducted and compared
to the corresponding surveillance video footage. Each of the checks were conducted within the
required time frames and conducted with fidelity with each staff observed pausing at the window
of each room to ensure the safety of each youth. A review of twenty-one wand reports was
conducted, one from each shift from each month since the last annual compliance review, with
each of the center’s three living units selected randomly. The wand reports indicated checks
were conducted with fidelity in each instance with the exception of one check being five minutes
late. Reviewed documentation confirmed there were weekly reviews and management oversight
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Office of Accountability and Program Support Page 51 of 60 (Revised July 2023)
of the ten-minute checks. An interview with the superintendent confirmed the center’s practice.
Five interviewed staff reported room checks are conducted at intervals of ten minutes or less.
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 a written policy and procedures in place requiring direct care staff to always
know the exact number and location of all youth under their supervision. Seven randomly
selected days of logbook entries, one from each month since the last annual compliance review,
were examined. The logbooks documented head counts were conducted throughout the day, at
the beginning and end of each shift, and randomly during the day. Counts were called in to
master control and documented in the center’s master control logbook. Counts were conducted
following emergencies, drills, power outages, and any time a code was called. Observations
conducted during the annual compliance review week found staff conducted counts and the
counts were documented in the logbook, as required. Five interviewed staff reported counts are
conducted at the beginning and end of each shift, before and after school, and before and after
meals. If counts are not correct, all activities are stopped, and a recount is completed. Four staff
stated emergency counts are conducted when a youth is believed to be missing and when
visibility is hindered. Five staff reported counts are conducted after a major disturbance and one
staff reported after drills are conducted a count is completed.
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Office of Accountability and Program Support Page 52 of 60 (Revised July 2023)
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 a written policy and procedures outlining the use of logbooks to maintain a
chronological record of events, incidents, and activities. The center has separate logbooks for
master control and each living unit. A review of each logbook found they were bound, with pre-
printed, numbered pages. A review of logbooks since the last annual compliance review for
each living unit and master control verified all entries were legible and written in ink with no
erasures or whiteouts. All entries included the date and time of the event, name of the staff and
youth involved, a brief description of the event, initials of the person making the entry, and the
date and time of the entry. There were no obliterated or removed pages. All entries which
impacted the safety and security of youth were highlighted. Any errors were struck through with
a single line and initialed by the staff making the error. None of the errors required supervisory
intervention. A review of master control logbooks included 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, name of youth placed in confinement
including the time confinement began and the time confinement ended, name of youth placed
on precautionary/secure observation, including the time precautionary/secure observation
began and was discontinued. A review of the activity schedule and logbook found minimal
interference of educational instruction. A review of the logbook in comparison with various days
of observed surveillance video footage found youth arrived and departed school on time.
Reviewed documentation validated the superintendent, or a designee, reviewed all logbooks at
least once each week, and the supervisor and/or lead juvenile justice detention officer reviewed
the living unit logbooks daily. Supervisors reviewed the master control logbook when they
assumed center responsibility, and the staff in charge of the center toured the youth living areas
at least once on each shift.
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Office of Accountability and Program Support Page 53 of 60 (Revised July 2023)
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 a written policy and procedures requiring inventory, maintenance, and control of
all center keys. The policy documents the procedure for lost or missing keys and replacement of
damaged keys. The center keys are maintained on a color-coded tamper-resistant ring with a
tag identifying the ring number and the number of keys on the ring. The center keys are locked
and secured in master control and the supervisor’s office. The key box is only accessible by
master control, supervisors, the assistant superintendent, and the superintendent. The inventory
documented the ring number, number of keys assigned to the ring, the location assigned to the
keys, and the staff to whom the keys are assigned. A separate inventory is maintained for
emergency keys. Permanent keys are issued to the superintendent, assistant superintendent,
human resources, fiscal assistant, and the maintenance mechanic. Observations conducted
daily during the annual compliance review week found all visitors and staff were required to
secure their personal keys with master control upon arrival to the center. Staff sign-out the keys
at the beginning of the shift and sign-in the keys at the end of each shift. At each shift briefing
held by the juvenile justice detention officer supervisor, a form is used to document the name
and initials of the staff assigned to the key, the shift, the time the key was provided, and the time
the key was returned. A review of the shift report confirmed it matched the keys in use. A review
of twelve randomly selected shift reports since the last annual compliance review found keys
are issued and documented on the shift report with all required information. Observations
indicated keys were in the possession of the staff to whom the keys were issued, and youth did
not have access to center keys. A random review of three staff and their assigned keys
confirmed the keys in their possession matched the key log. A review of the Department’s
Central Communications Center (CCC) reports and internal incident reports found no instances
of staff leaving the center with keys or lost keys during the annual compliance review period.
The center tracks key issuance through the shift report and the Key Sign-In/Out Log maintained
in master control. The inventory is checked to ensure all keys are accounted for at each shift. A
review of the master key control inventory during the week of the annual compliance review
validated the inventory report matched the actual keys in use. The master control operator was
interviewed and reported in the event of lost keys, the superintendent and assistant
superintendent would be contacted, the center would be locked down and searched until the
keys were found, and the CCC would be contacted, if necessary. If a key is damaged, the
supervisor would be contacted to fill out a maintenance request and the key would be taken out
of service until fixed by the maintenance mechanic. The master control operator verified keys
are restricted only to staff authorized to have each key type and all key rings are color coded to
maintain control of the keys. Observations revealed some of the education key hubs where not
the correct color. An interview was conducted with the superintendent who confirmed the
center’s practice and stated the center is awaiting a previously placed order of additional brown
key hubs to be shipped. Five interviewed staff reported the center’s keys are restricted to
medical, youth property area, case management, and the kitchen.
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Office of Accountability and Program Support Page 54 of 60 (Revised July 2023)
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has a written policy and procedures to address transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of five vehicles
used to transport youth. Each van had documentation of an annual maintenance inspection
completed by a certified mechanic. The superintendent and maintenance mechanic are
responsible for the weekly and monthly vehicle inspections. Observations validated the five
vehicles had the appropriate number of seatbelts and were equipped with a window punch,
seatbelt cutter, fire extinguisher, and a first-aid kit. A logbook is maintained for each van which
was found to document all required information for each trip taken by center staff. An
observation was conducted of a youth transport preparing to depart which found the staff
inspected the vehicle for contraband, ensured the van had enough gasoline, ensured the
seatbelts were anchored securely, and tested the safety screen to ensure it was secured in
place. The van contained a vehicle folder which included all required documentation, including a
current transportation plan for the trip. The staff had a center-issued cellular telephone which
was operational and fully charged. The staff documented their inspection in the vehicle logbook,
as required. Prior to entering the vehicle, the van was found to be locked. The youth were
searched prior to entering the vehicle and youth and staff were found to have their seatbelts
securely fastened prior to departing. Each van was checked during the annual compliance
review week and were found to be secured when not in use. A total of five staff personal
vehicles were checked and each was locked, and all transport vehicles were secured. Five
youth were interviewed, and all reported never seeing anyone place contraband in a transport
vehicle. Each youth stated they feel staff drive safely when youth are being transported.
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 a written policy and procedures requiring all tools and equipment to be properly
maintained, secured, and inventoried. A perpetual inventory is maintained for all tools in the
maintenance shed and kitchen to document tools as they are used and returned. The
inventories were found to be signed by the superintendent. A review of the inventories found no
tools which were missing or not listed. All damaged tools are disposed of outside of the secure
area. The center’s maintenance mechanic completed a monthly inspection of the tool area
which was submitted to and signed by the superintendent. The kitchen staff maintained an
inventory of all equipment, including knives and other implements, which was completed at the
beginning and end of each shift. Each of the tool areas were observed to be neat, well-
maintained, and all tools were marked with an identification code. All tools were accounted for,
and reviewed inventory sheets confirmed there were no tools missing or documented as
missing from the center. Observations and a review of the inventory for ten randomly selected
tools confirmed the center’s inventories were correct and the tools were secured and marked for
easy identification. Each reviewed inventory was signed by the superintendent or their
designee. The maintenance mechanic was interviewed and verified all inventories are
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Office of Accountability and Program Support Page 55 of 60 (Revised July 2023)
completed as required. During an informal interview, the superintendent reported only the
maintenance mechanic and center administration have access to Class A tools. Five staff were
interviewed, and each staff reported they would notify a supervisor if any tool were missing or
damaged. Four interviewed staff reported youth are allowed to use mops and brooms and one
indicated youth are not allowed to use any 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 a written policy and procedures which prohibit youth from accessing or using
chemicals. The center maintains a written Safety Plan which addresses the proper use, storage,
and disposal of chemicals including flammable, toxic, caustic, and poisonous items.
Observations and a review of inventories for stored chemicals validated the center maintained
accurate inventories for each flammable, toxic, caustic, and poisonous item maintained at the
center. Safety Data Sheets (SDSs) were organized in a binder which was maintained in the
area where the chemicals were stored. The SDSs are available to staff; however, only
authorized personnel are permitted to access the chemicals. Five youth were interviewed, and
each stated they do not use flammable, poisonous, or toxic items at the center. Observations of
five randomly selected securely stored chemicals and a review of the SDS binder confirmed the
inventory forms were accurate and documented the actual count of each chemical, without any
discrepancies.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has a written policy and procedures specifying the maintenance mechanic or other
trained staff are to be responsible for disposal of all hazardous items and toxic materials in
accordance with Occupational Safety and Health Administration (OSHA) standards. The
superintendent reported there have been no chemical spills since the last annual compliance
review. The superintendent also reported the center stores kitchen grease in a grease trap and
utilizes a vendor to dispose of any grease from the kitchen, as needed. The center’s
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Office of Accountability and Program Support Page 56 of 60 (Revised July 2023)
administration staff reported the center does not dispose of any other chemicals, and all
chemicals are utilized until they are empty.
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 a written policy and procedures which outline the process of placing youth in
confinement for less than twenty-four hours. The center had 147 instances of confinement
under twenty-four hours since the last annual compliance review. Fifteen confinement reports
were reviewed in the Department’s Facility Management System (FMS). Prior to placement in
confinement, youth were notified of their right to file a grievance and the room was searched
and the search was documented in FMS. Throughout the confinements reviewed, each youth
was afforded all rights including meals, showers, mental health care, medical care, clothing,
bedding, and education, as applicable. Each of the fifteen confinements were approved by a
supervisor within the required time frame and the reason for the confinement was documented
upon the supervisor’s initial confinement review with additional reviews every three hours
thereafter. Each reviewed confinement log reflected visual observations were conducted in
accordance with policy. Each of the fifteen youth were continually counseled by staff to
determine if they could be safely reintegrated with other youth. Each of the fifteen confinements
were reviewed and approved by the supervisor within forty-eight hours of the youth being
released from confinement. Three youth were confined during school hours and there was
documentation the staff communicated the confinement to school staff and offered the youth
education materials. Each of the fifteen youth were supervised as required while in confinement
and the safety checks were documented on the required Visual Observation Report Log. None
of the reviewed youth were injured or pregnant while in confinement and none of the
confinements occurred during visitation. Observations confirmed confinement room windows
allowed visibility of the youth in confinement and surveillance video cameras were free of
obstructions. The superintendent was interviewed and verified the confinements are reviewed
for appropriateness daily. Five interviewed staff stated when a youth is placed in confinement,
staff must complete a confinement report and conduct ten-minute checks, four staff clarified
checks are to be completed every five minutes for the first hour of a youth confinement, and two
staff stated the confinement room must be searched. One staff indicated youth are to be
advised of their rights when placed in confinement, and one staff indicated a code blue should
be called. Each interviewed staff reported youth are provided education materials while placed
in temporary confinement.
5.12 Confinement Over Twenty-Four Hours and
Satisfactory Compliance
Confinement Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self. Confinements should not exceed
twenty-four hours; however, if a youth continues to exhibit behavior which poses a risk to him
or herself, staff, or others, a Confinement Review must be conducted.
The center maintains a written policy and procedures which detail processes for youth held in
confinement for more than twenty-four hours and for the review of confinements. The center had
nine instances of confinements lasting longer than twenty-four-hours during the annual
compliance review period. Five applicable confinement reports were reviewed in the
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Office of Accountability and Program Support Page 57 of 60 (Revised July 2023)
Department’s Facility Management System (FMS). In each instance, the supervisor conducted
reviews with the youth at least every three hours and the reviews were documented in FMS to
include the reason for each youth’s continued confinement. Each of the five reviewed
confinement reports documented staff continually counseled the youth and consideration was
given to the youth’s ability to safely rejoin the population without any threat to safety. The center
had no pregnant youth placed in confinement since the last annual compliance review. A
confinement review was conducted and chaired in person or by telephone by the regional
director or their designee, at least two hours prior to the time each youth had been in
confinement for twenty-four hours. Reviewed documentation confirmed the center emailed the
regional director a copy of each Confinement Report which documented all reviews and
interviews with the youth, and both the superintendent or their designee and a member of the
center’s mental health team met with the youth prior to the confinement review. The review chair
documented their decision to extend the use of confinement for no more than twenty-four hours,
and mental health staff saw the youth as soon as reasonably possible for regular reviews
thereafter. In each instance, the youth was removed from confinement once the youth’s
behavior no longer presented an imminent or substantial threat. Copies of each confinement
review, including the review chair’s decision, were distributed to the regional director and the
assistant secretary for detention services.
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 a written policy and procedures in place which include the center’s Disaster
Preparedness Plan and the Continuity of Operations Plan (COOP), which was reviewed. The
plan requires COOP drills to be conducted and documented, at a minimum, twice a year, with
one drill having to be completed prior to the hurricane season. The center provided
documentation of two completed COOP drills, one of which occurred prior to the start of
hurricane season. The drills were documented on an Emergency Drill Report and included all
required information. An interview was conducted with the superintendent who stated the center
utilizes the COOP, various safety, emergency, and medical drills as their planned and
comprehensive approach to effectively manage emergencies and disaster events, including
those which require the detention center to relocate its youth and staff while maintaining
operations, safety and security. Five interviewed staff reported participating in escape drills, fire
drills, weather drills, and drills with major disturbance scenarios. Three staff reported also
participating in a medical drill.
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 an Escape Prevention Plan which includes all required elements in accordance
with Department policy. The center’s policy requires drills to be conducted on a quarterly basis.
A review of escape drills for the previous seven months was completed and found drills were
conducted at least once each quarter since the last annual compliance review, each drill was
documented on the Department’s form, and each included all required information. Each drill
was also recorded in the master control logbook. A review of five pre-service and five in-service
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Office of Accountability and Program Support Page 58 of 60 (Revised July 2023)
staff training records confirmed the staff were trained in escape prevention annually. Five staff
were interviewed and each reported participating in escape drills.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a Fire Prevention Plan which was approved by the local fire official. Each of the
center’s fire extinguishers were inspected annually, as required. Documentation was reviewed
and found the center conducted fire drills monthly on each shift since the last annual compliance
review, with the exception of the Alpha and Bravo shifts in April 2024. Center administration was
previously aware of the two missing drills and corrective action was previously applied with the
supervisors responsible for completing the drills. Each drill was documented on the
Department’s form which included all required elements, and each was also documented in the
master control logbook. Five youth were interviewed, and four youth reported they were
instructed on what to do in case of a fire. One youth reported they were not, which was
addressed with the center. Five staff were interviewed and each reported participating in
monthly fire drills.
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 maintains a written policy and procedures detailing the process for searches,
delineating items and materials designated as contraband, a system to prevent the introduction
of contraband into the center, and procedures for when contraband is found. During the annual
compliance review week, a youth admission was observed. Prior to the admission, the youth
was frisk searched, searched with an electronic wand, and strip searched privately, as required.
The search was attended by two staff, one male and one female. The female staff was present
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for the search and was positioned to observe the male staff conducting the search while
wearing gloves. A review of documentation confirmed searches are noted in the logbook, and
electronically in the Department’s Facility Management System (FMS). A review of room search
documentation since the last annual compliance review indicated room searches are conducted
upon a youth’s release, prior to placing a new youth in the room, and all rooms are searched for
contraband on each awake shift. The center had four contraband incidents since the last annual
compliance review. Upon discovery and confiscation of the contraband, an incident report was
completed to detail the findings and the disposition of the contraband, and the incidents were
documented in the master control logbook. Law enforcement was contacted, as the contraband
was illegal as defined in Florida Statute. The contraband items were secured by the discovering
staff and hand-delivered to the supervisor. The shift supervisor documented the chain of
custody of the confiscated items and gave the information to the responding law enforcement
officer. The Department’s Central Communications Center (CCC) and the regional director or
designee were notified in each instance. The center conducts frisk and electronic wand
searches on all persons entering the center, including examination of all items entering the
secure area. Observations during the annual compliance review week confirmed searches of
staff, visitors, and contractors/vendors were completed prior to them entering the secure area.
All members of the annual compliance review team were electronically and physically searched
each day prior to entering the secure area of the center. Each member of the annual
compliance review team was required to read, acknowledge, and sign the center’s Contraband
Statement of Attestation. Each center staff is also required to document their understanding of
the center’s contraband policy through signature on the attestation, which is to be maintained in
each staff’s personnel record. A review of forty-one staff records confirmed the center’s practice.
The superintendent interview indicated youth searches take place as often as necessary to
control contraband and to ensure safety, and the center adheres to statewide policy and
procedures when searching youth. The superintendent stated the center has zero tolerance for
violations and if a staff were to be found with contraband, dismissal would be immanent.
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Office of Accountability and Program Support Page 60 of 60 (Revised July 2023)

source: DJJ