state: FL

facility_name: Miami Dade Regional 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
Miami-Dade Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3300 Northwest 27th Avenue
Miami, Florida 33142
Review Date(s): April 29- May 2, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Andrice Holley, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Interviews)
Dedilia Finlayson, Detention Services, Operations Consultant, (Standard 5)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard 2
and Standard 5)
Melissa Johnson, Office of Accountability and Program Support, Regional Supervisor, Central
Region (Standard 3)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Interviews)
Acasha Pressley, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Miami-Dade Regional Juvenile Detention Center MQI Program Code: 490
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Miami Dade County / Circuit 11 Number of Beds: 98
Review Date(s): April 29- May 2, 2025 Lead Reviewer Code: 199
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 59 (Revised July 2023)
A ll in d ic a to rs h a v e b e e n ra te d
O v e
S a tis
ra ll R a tin
fa c to ry a n
g S u m
d n o c o
m a
rre c
ry
tiv e a c tio n is n e e d e d a t th is tim e .
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 59 (Revised July 2023)
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
In d ic a to r R a tin g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g *
F iv e -Y e a r R e s c re e n in g /R e n e w a l
S ta ff C o d e o f C o n d u c t
In c id e n t R e p o rtin g C C C *
R ig h t In te ra c tio n s (R I)
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts *
In -S e rv ic e T ra in in g
G rie v a n c e s
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n *
D a ta T re n d A n a ly s is
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
SSSSSSSSSS
g ra
d o
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
m o p e ra te s
s o w ill re s u lt
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 59 (Revised July 2023)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
In d ic a to r R a tin g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n
O rie n ta tio n
C la s s ific a tio n
N o tific a tio n o f J P O C irc u it G a n g R e p
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty
R e le a s e
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n
D a ily A c tiv ity S c h e d u le
E d u c a tio n a l A c c e s s *
C a re e r E d u c a tio n
tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
g ra m o p e ra te s
d o s o w ill re s u lt
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 59 (Revised July 2023)
In d ic a to r R a tin g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
3 .0 1 D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
3 .0 2 L ic e n s e d M H /S A C lin ic a l S ta ff *
3 .0 3 N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
3 .0 4 M H /S A A d m is s io n S c re e n in g
3 .0 5 M H /S A A s s e s s m e n t/E v a lu a tio n
3 .0 6 M H /S A T re a tm e n t
3 .0 7 T re a tm e n t a n d D is c h a rg e P la n n in g
3 .0 8 P s y c h ia tric S e rv ic e s *
3 .0 9 S u ic id e P re v e n tio n P la n *
3 .1 0 S u ic id e P re v e n tio n S e rv ic e s *
3 .1 1 S e c u re O b s e rv a tio n *
3 .1 2 S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
3 .1 3 S u ic id e P re v e n tio n T ra in in g *
3 .1 4 M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
3 .1 5 E m e rg e n c y C a re P la n *
3 .1 6 C ris is A s s e s s m e n ts *
3 .1 7 B a k e r a n d M a rc h m a n A c ts *
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte
b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
n tio n if a p ro
rs . F a ilu re to
g ra
d o
SSSSSSSSSSSSSSSSS
m
s
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
a tis fa c to ry
o p e ra te s
o w ill re s u lt in
Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 59 (Revised July 2023)
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
In d ic a to r R a tin g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n
D H A /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g
S ic k C a ll P ro c e s s
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re
O ff-S ite C a re /R e fe rra ls
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s
M e d ic a tio n M a n a g e m e n t
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n
P re n a ta l C a re /E d u c a tio n
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
n ).
n tio n if a p ro
rs . F a ilu re to
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
g ra m o p
d o s o w
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
e ra te s
ill re s u lt
Standard 5: Safety and Security
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 59 (Revised July 2023)
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D
b e lo w D
re s u lt in
e p a rtm
e p a rtm
a p ro g
In d ic a to r R a tin g s
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th *
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t*
T e n -M in u te C h e c k s *
C e n s u s C o u n ts a n d T ra c k in g
L o g b o o k M a in te n a n c e a n d R e v ie w s
K e y C o n tro l
V e h ic le s a n d M a in te n a n c e
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s *
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills
E s c a p e D rills
F ire D rills
S e a rc h a n d C o n tra b a n d P ro c e d u re s
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte
e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to
ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
n tio n if a p ro g ra m o p e ra te
rs . F a ilu re to d o s o w ill
le
s
Program Overview
The Miami-Dade Regional Juvenile Detention Center is a state-owned detention center,
operated by the Department, located in Miami, Florida. The center serves youth in Miami-Dade
County in Circuit 11. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the ninety-eight-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 Miami-Dade County School District. The center’s
management team includes the superintendent, one assistant superintendent, one
administrative assistant, thirteen juvenile justice detention officer (JJDO) supervisors, and sixty-
four JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one
designated mental health clinician authority (DMHCA) and six licensed staff. Clinical services
provided by the center include mental health and substance abuse evaluations, mental health
treatment planning, individual, group and family therapy, mental health crisis intervention
services, on-site psychiatric services, and availability for substance abuse services for youth
with co-occurring disorders. Medical services are provided by one designated health authority
(DHA), one back-up DHA, one advanced practice registered nurse, one clinical manager, and
four registered nurses (RNs). The medical clinic maintains nursing coverage seven days each
week from Monday through Friday from 7:00 a.m. to 8:00 p.m. and Saturday and Sunday from
7:00 a.m. to 5:30 p.m. Food services are provided by Department staff and include menus, meal
planning, meal schedules, special diets, nutritional analysis, daily allowance, food preparation,
health certifications, food product standards, sanitation, and cleaning. Staff are responsible for
the custody and control of youth in their care, providing youth supervision twenty-four hours a
day, seven days a week. The center has five living modules which are divided by male and
female. There are one-hundred thirty-three security cameras at the center, of which one-
hundred thirty-two were operational. During the annual compliance review, observations of the
center’s grounds and landscaping, recreation areas, kitchen area, administrative offices. and
maintenance offices shoed all were in good condition. However, there was some graffiti
observed in the classroom and youth living modules which was discussed with the
superintendent, who addressed and had the issue corrected. Additionally, observations
included staff and youth interactions, medication administrations, sick call, youth movements,
key control, searches, and video surveillance footage. At the time of the annual compliance
review, the center had thirteen vacancies, which included one food support worker, two
assistant detention center superintendents, five juvenile justice detention officer IIs, four juvenile
justice detention officer Is, and one other personal services operations coordinator.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 59 (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 ensuring 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 6, 2025, meeting the annual requirement. The Annual Affidavit
of Compliance with Level 2 Screening Standards for school district teachers was submitted to
the BSU on January 11, 2025. A review of the initial background screenings for twenty-three
newly hired staff, fifteen volunteers, and seventeen contracted providers confirmed the center
received background screening results from the BSU/Clearinghouse prior to contact with youth
or confidential youth records. Reviewed documentation confirmed a criminal history report was
reviewed for staff. None of the staff were applicable for an exemption to be obtained prior to
working with youth. The center utilizes an ergometric pre-employment assessment tool for all
direct care applicants. Reviewed documentation confirmed the applicable fifty-five staff were
administered a pre-employment assessment, and a passing score was documented in each
applicant’s file. Reviewed documentation confirmed contracted providers added each volunteer
to the Clearinghouse Employee Roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center maintains a written policy and procedures ensuring background rescreening/renewal
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. Reviewed documentation confirmed six staff were 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 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 59 (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 addressing the staff code of conduct. Staff
are required to adhere to the code of conduct which prohibits any type of abuse, profanity,
threats, harassment, intimidation, horseplay, or personal relationships with youth. A review of
three staff personnel records documented the staff had signed a code of conduct form
prohibiting any form of abuse, profanity, threats, harassment, or intimidation. Reviewed
documentation confirmed management took immediate corrective action to address violations of
the staff code of conduct. Reviewed documentation confirmed management’s response was an
oral reprimand for one staff and a written reprimand for the other two staff. Three staff since the
last annual compliance review period were reviewed for commendations. Each commendation
resulted in a job promotion. Eight of the nine interviewed youth reported they have never been
stopped from reporting abuse to the abuse hotline since being at the center, and one reported
never having to report any abuse. Nine interviewed youth reported staff are respectful when
talking with youth and never heard staff use profanity when speaking with youth. Each youth
reported they have never heard staff threaten youth. Each youth reported they feel safe at the
center and have never exchanged emails, telephone numbers, or social media contact
information with staff. Nine interviewed staff were able to explain the process for allowing youth
to call the Florida Abuse Hotline and/or the Department’s Central Communications Center
(CCC). Each staff reported they have never observed a co-worker using profanity when
speaking with youth and have never observed a co-worker using threats, intimidation, or
humiliation when interacting with the youth. Five of the nine interviewed staff reported working
conditions at the center are good, two reported fair, and two reported very good. During an
interview with the superintendent, it was reported the staff code of conduct is to ensure staff
communicate and interact with youth in a manner which provides mentoring for appropriate
behaviors, and for staff to demonstrate behavior which shall be respectful and courteous to all
youth. Verbal/physical abuse shall be reported to the Florida Abuse Hotline and the CCC shall
be notified within two hours of gaining knowledge of an alleged incident. Staff will be placed on
no youth contact until an investigation is completed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 59 (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 ensuring when a reportable incident
occurs the center notifies the Department’s Central Communications Center (CCC) within two
hours of becoming aware of the incident. The center had two-hundred reportable incidents since
the last annual compliance review. A review of twenty incidents found all were reported to the
CCC within two hours of the incident. Each incident was documented in the center’s CCC
logbook. A review of the center’s internal incident/grievance reports confirmed there were no
additional internal incidents/grievances, which should have been reported to the CCC and were
not. During an interview with the superintendent, it was reported the incident reporting process
is to notify the CCC of any incidents which have the potential to disturb or disrupt the normal
flow of operations within two hours.
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 ensuring detention staff use of physical
intervention techniques is in accordance with Florida Administrative Code. Any a time staff uses
a physical intervention technique, such as countermoves, control techniques, takedowns, or
application of mechanical restraints, with the exception of regular transports, a Right
Interactions (RI) Report is completed. The center had a total of two hundred sixty-eight RI
incidents since the last annual compliance review. A review of nine RI Reports confirmed
reports were completed by the end of the staff’s workday. Each report included statements from
all staff involved and was reviewed by a supervisor or designee or an RI instructor. There were
no applicable RI’s which resulted in serious injury to the youth or staff. Each report received a
post-RI interview conducted with the youth by the administrator, or designee, as soon as
possible, and no longer than thirty minutes after the incident. None of the RI reports were
applicable for a medical review. No records were applicable for the use of mechanical restraints.
Reviewed documentation confirmed the superintendent/designee reviewed the report, after all
other reviews, and made comments, if appropriate, within seventy-two hours. There were no
additional RI incidents noted in internal incidents, grievances, or logbooks which were not
documented by an RI Report. The center’s RI rate during the third quarter was 14.02 , which is
above the statewide Detention RI rate of 13.49. Nine interviewed staff reported staff try to talk to
youth prior to using physical or mechanical restraints. During an interview with the
superintendent, it was confirmed the mechanical restraints are stored in a safe and secured
area on a shadow board, which is numbered, in addition to a tracking log/board. It was
confirmed the process for monitoring RI incidents and use of force is by reviewing incident
reports which involved physical interventions and reviewing video surveillance to ensure staff
are in compliance with the RI requirements.
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1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center maintains a written policy and procedures ensuring pre-service training is completed.
Staff are trained in accordance with Florida Administrative Code (FAC). Detention staff satisfies
pre-service/certification requirements specified by FAC within 180 days of hire. A review of nine
staff training records for pre-service training confirmed seven staff completed all pre-service and
certification requirements within 180-days of hire. Two staff were still within 180 days of hire.
Each staff completed a new staff orientation within thirty days of hire. The center had no
returning direct care and/or state support staff who returned less than one year from separation.
All pre-service trainings were documented in the Department’s Learning Management System
(SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center maintains a written policy and procedures ensuring staff 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 provides in-service training to
staff through a combination of the Department’s Learning Management System (SkillPro) and
instructor-led classes. A review of nine staff training records for in-service trainings, included six
direct care staff and three supervisory staff. All nine staff records confirmed each staff
completed the mandatory training topics to include active shooter preparedness,
cardiopulmonary resuscitation, first-aid, automated external defibrillator , human trafficking
intervention, information security awareness, mental health and substance abuse, Prison Rape
Elimination Act Right Interactions update, professionalism, interpersonal communication, and
ethics including standards of conduct, sexual harassment, suicide awareness and prevention,
and trauma responsive practices. Each staff completed Emergency Care Plan, infection control,
Exposure Control Plan to include blood-borne pathogens and infection control education,
escape prevention, and fire prevention plan/disaster procedure training. Three staff were
applicable for a minimum of eight hours of supervisory training. Each staff completed the
required eight hours of supervisory training. All trainings were entered into SkillPro. The center’s
licensed nurse provided in-service education on girls’ healthcare annually to all non-healthcare
staff involved in the supervision or treatment of girls and this in-service training included training
on monitoring, observation, and emergency care of the pregnant youth. The center maintains an
annual in-service training calendar which is updated as changes occur. The in-service training
was approved by the center superintendent, the assistant secretary of detention services, and
the director of the Department’s Office of Talent Leadership, and Culture. The interviewed
superintendent confirmed the center’s practice.
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1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center maintains a written policy and procedures ensuring youth’s right to grieve and
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. Grievance forms are available for youth access on each module of the center. During
an interview with the superintendent, it was confirmed the center’s grievance process has three
phases which include an informal phase where a youth complaint is attempted to be resolved by
a juvenile justice detention officer. If the youth is not satisfied, the grievance will go to the formal
phase where a youth submits a written grievance which must be addressed by a juvenile justice
detention officer supervisor within two hours from the original complaint. The grievance must be
entered into the Facility Management System and actions taken to resolve the complaint must
be documented. Once a grievance is resolved and entered in FMS, a hard copy of the
grievance is to be signed by the youth and each individual involved. The supervisor will notify
the youth of the actions taken, upload the form in FMS, and the hard copy should be stored in a
separate file or given to a designated administrator. Nine interviewed youth were able to explain
the grievance process. Four of nine youth rated the grievance process as good, three reported
they never filed a grievance, one rated the process as poor, and one rated the process as very
good. Nine interviewed staff reported they were able to explain the center’s grievance process.
During the annual compliance review period, the center reported only two grievances since the
last annual compliance review. Both grievances were resolved at the formal phase within the
required timeframes.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center maintains a written policy and procedures ensuring alerts are 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. Nine youth records were
reviewed for case management, medical, mental health, and substance abuse alerts. Each
reviewed youth record confirmed the alert type, name/title of staff removing/updating the alert,
documentation in logbook/shift report, and alert list/JJIS entry dates were entered. Reviewed
documentation confirmed JJIS alert reports were reviewed daily by supervisors and
administrators. Reviewed documentation indicated alerts were discussed during shift briefings.
During the annual compliance review, an observation of a shift briefing confirmed all alert
information was shared and discussed with staff. During an interview with the superintendent, it
was confirmed the center's medical alert process includes the completion of the Admission
Wizard, where the staff ensure all critical and special alerts are listed in JJIS. The process for
ensuring accuracy and consistency is to review information which is documented daily on an
alert list. Nine interviewed staff reported they are informed of alerts through logbooks, shift
debriefings, alert forms, JJIS, and an alert board.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a structured method for analyzing data trends. The center's practice regarding
data trends is to collect information in monthly management meetings, staff meetings,
parent/guardian visitor surveys, and through staff input. Reports capture the data and necessary
changes are made. The information collected is used in decision making practices then shared
with center staff through monthly management meetings and daily shift briefings. A review of
meeting agendas, surveys, and data collection software confirmed the center’s practices.
Additionally, the center participates in a Community Advisory Board meeting, in which
information is shared with stakeholders at least quarterly.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center maintains a written policy and procedures to ensure proper screening, evaluation,
and documentation is provided for each youth admitted into secure detention in accordance with
Florida Administrative Code. Nine active youth records were reviewed, and each contained a
completed Admission Wizard with all required admission sections in the Department’s Juvenile
Justice Information System. Additionally, all nine reviewed records included a completed arrest
affidavit, Detention Risk Assessment Instrument and a Suicide Risk Screening Instrument Each
record verified youth received a full-body frisk search completed by a detention officer of the
same gender, a phone call to their parent/guardian, and a snack/meal. Each reviewed youth
record contained documentation confirming reception of medical, mental health, and substance
abuse screenings upon admission.
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 an orientation to occur within
twenty-four hours of a youth being admitted into detention and documented accordingly. The
orientation includes the center’s rules and regulations, grievance procedures, visitation,
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telephone calls, availability of medical, mental health and substance abuse services, access to
the Florida Abuse Hotline or the Department’s Central Communication Center for youth
eighteen years of age or older, new law violations for destruction of property, youth rights,
expectations for behavior and correlated consequences for failure to meet vital expectations.
Nine active youth records were reviewed and contained documentation verifying orientation was
completed within the required timeframe of twenty-four hours with signed acknowledgement
booklets. The documentation supported expectations were explained to youth both verbally and
in writing by a juvenile justice detention officer The orientation booklet included additional
information regarding the Prison Rape Elimination Act (PREA). Additionally, the center has an
orientation videotape for PREA. Nine interviewed youth confirmed receiving orientation upon
arriving at the center.
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 confirming all youth admitted to the center
are classified by the officer completing admission. Nine youth records were reviewed confirming
the procedures for youth history, status, and inclusion of additional required information. The
center considers several factors such as gender, height, weight, age, level of aggression,
mental illness, intellectual disabilities, physical disabilities, history of violent behavior, gang
affiliation, criminal history, history of sexual offenses including sexual battery charges,
Vulnerability to Victimization and Sexually Aggressive Behavior screening results, medical
concerns, identified or suspected suicide risk, and escape or security risks prior to room
placement. The nine active youth records contained documentation confirming room
assignments were based on classification and youth were reclassified if changes in behavior or
status occurred. Any youth with a history of committing sexual offenses or identified as a victim
of such offenses, are to be placed separately from other youth. The superintendent remains
informed of identification and addressing local gangs through alerts and youth case
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management documentation. In addition, the center has a gang liaison. The superintendent’s
interview confirmed the center’s practice for classifying youth.
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 to guarantee pertinent gang information is
shared with the assigned juvenile probation officer (JPO) and the circuit’s gang representative to
disseminate suspected gang activity information. The center’s juvenile justice detention officer II
serves as the active gang liaison and communicates with the JPO gang liaison and law
enforcement officer by email when a youth is identified as a suspected gang affiliate. Nine case
management records were reviewed and two youth were suspected gang participants, so an
additional record was requested and reviewed. Email correspondence between gang liaisons
and law enforcement was reviewed and contained all necessary photographs of gang symbols,
and/or graffiti, when applicable. The Department’s Juvenile Justice Information System included
subsequent alerts. An informal interview with the center’s gang liaison verified the center’s
procedures and described their practice to forward all necessary updates and/or information to
the center’s staff, supervisors, and superintendent.
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 concerning the proper storage and
security of youth personal property including valuables collected at admission. Each item is
inventoried and recorded on a Property Receipt Form signed by youth as acknowledgment of
the center’s procedures. Nine records were reviewed, and each contained a letter of
acknowledgement regarding unclaimed property. Three records were applicable for valuable
property which was placed in a clear tamper-proof bag with the youth’s name, Department
identification number (DJJID), date, staff name, and signatures of the youth and staff. All
valuable property is stored in a drop safe which is under surveillance twenty-four hours a day.
The center’s drop safe logbook documents the time, youth’s name, name of the officer
safeguarding the property, and their initials. Shoes and clothes are stored in personal property
bags and then placed into the secured property room. The bags included the date, youth’s
name, DJJID, and a list of items in the bag. During the annual compliance review, an
observation of the center receiving youth personal property confirmed the center’s practice.
Access to personal property was limited to designated staff. The center had no Central
Communications Center reports regarding property incidents since the last annual compliance
review. Nine youth were interviewed and confirmed during admission, staff checked their
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personal property and they signed a Property Receipt Form. The superintendent interview
confirmed the center’s procedures regarding youth property.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center maintains a written policy and procedures addressing youth releases from detention.
The juvenile justice detention officer and juvenile justice detention officer supervisor must
complete the release and verify court authorizations prior to the release of youth. A thorough
case review must be completed to ensure there are no holds, court orders, or any other legal
reasons prohibiting the youth’s release. A parent/guardian is notified and confirms release. A
copy of the parent/guardian’s photo identification card is placed inside the youth record prior to
release. A review of three closed records verified the release checklist was utilized for each
youth. Each record contained the required documentation signed by the person accepting
custody of the youth. Release information contained future court dates and all applicable
release forms. The Department’s Juvenile Justice Information System admission and
termination dates correlated with youth case management records. During the annual
compliance review, an observation of a youth release confirmed the center’s practice.
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 ensure the youth’s release from
detention and retrieval of personal property, the releasing officer, the youth, and the youth’s
parent/guardian signs the Property Receipt Form to account for all the youth’s personal
property. The center guarantees procedures are in place to ensure prescribed medications and
instructions accompany detained youth upon release. Three closed youth records were
reviewed for compliance. Each record verified a signed Receipt of Property form, pending
appointments, court dates, medical, mental health and substance abuse needs were provided to
the parent/guardian. A Notice of Impending Disposal of Property is mailed to the youth’s last
known address after thirty days of a youth’s release. Personal property not claimed within a
timely manner is considered abandoned and is disposed of according to the center’s policy.
Three records were reviewed containing a Notice of Impending Disposal of Property Receipt
form and each followed the required process. During the annual compliance review, an
observation of a youth release confirmed the center’s practice
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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 confirming the center conducts Detention
Reviews on a weekly basis for appropriate management and sharing of information for youth
placed in secure detention. Youth shall be held in secure detention for the shortest time
possible. The center’s superintendent appoints suitable staff to organize reviews. A review of
weekly Detention Review logs confirmed meetings were held every Tuesday at 9:00 a.m. to
address the status of each youth. All required participants attended in person, virtual conference
or by telephone. An interview with the superintendent confirmed the center’s Detention Review
process for all youth in secure and home detention.
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 confirming youth participate in
constructive activities by maintaining a daily schedule, including weekdays, weekends, holidays
and incorporation of both structured and free time. Observations confirmed the center maintains
a daily schedule and it is posted in each living area. The schedule contained the time frames of
each daily activity provided to youth including wake-up, personal hygiene, mealtime, visitation at
a minimum of twice a week, recreation, physical activities including at least one hour of outdoor
exercise, indoor activities promoting education, problem solving and life skills, shift change,
bedtimes, groups and open program time including reading, art, movies, or games. Nine
interviewed youth and staff confirmed the daily activity schedule is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center maintains a written policy and procedures regarding educational access. The
center’s education module is directly supervised and administered by the Miami-Dade County
School District. It operates on a year-round basis, providing the youth with 250 days of
education distributed over twelve months with a minimum of twenty-five hours of instruction
each week. The annual academic calendar, aside from identifying the exact number of school
days, includes the provision of up to ten days of professional development/training for the
current teaching staff . Observation of the academic calendar noted the calendar identified 240
days of direct instruction and ten days of professional development.
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A review of the center’s movement videos on three separate dates confirmed youth arrived to
and exited the classes at the appropriate scheduled times. Each video confirmed classes were
being conducted with minimal disruptions, if any. Observations of the center’s logbooks for one
day each month beginning with the entries from May 2024 and concluding with entries dated
April 2025, showed three entry dates where staff did not notate the end of class. Observation of
all other dates confirmed classes were being conducted according to the academic daily
schedule. Six of the nine interviewed youth reported the program was preparing them very well
and three youth reported the program was preparing them somewhat well for their high school
equivalency diploma (GED), high school diploma, or the workforce. Nine interviewed staff
reported academic classes were being conducted with minimal interference and agreed there
was very little, if any, interferences with all on-going classes. During an interview with the
superintendent, it was confirmed there were no interferences for the ongoing classes.
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 maintains a written policy and procedures to provide career education. The center
provides youth the opportunity to attend appropriate career education classes. The course of
study is categorized as a Type 1 life skills curriculum and is based upon the age of the youth as
well as their intellectual and educational abilities. This classification which stresses “soft skills”,
includes activities which include, and are not limited to the learning and improvement of
effective communication skills as well as the focusing upon the development and enhancement
of interpersonal and decision-making skills. Nine interviewed youth reported being enrolled in
science and math. Seven of the nine interviewed youth reported being enrolled in history. Six
youth were enrolled in reading. Six interviewed youth reported being enrolled in English,
business, and language arts related classes, and two youth were enrolled in social studies
classes.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains a written policy and procedures ensuring a single licensed mental health
professional serves as the designated mental health clinician authority (DMHCA) to oversee
appropriate coordination and implementation of mental health and substance abuse services. to
provide mental health and substance abuse services to all applicable youth in the center. During
the first ten months of the annual compliance review period, the center had a licensed mental
health professional who served as the DMHCA. The DMHCA was a licensed mental health
counselor who held a clear and active license in the State of Florida, with an expiration date of
March 31, 2027. The current DMHCA is a licensed clinical social worker who has been serving
as the DMHCA since November of 2024. The current DMHCA holds a clear and active license
in the State of Florida, with an expiration date of March 31, 2027. The DMHCA is a fulltime staff
and scheduled to be on-site forty hours each week, Tuesday through Friday, between the hours
of 7:00 a.m. to 5:00 p.m. and is on-call twenty-four hours a day, seven days a week. A review of
the clinical staff sign-in/sign-out log confirmed the DMHCA was on-site weekly. When the
DMHCA was off-site, another licensed clinical staff was at the center. An interview with the
DMHCA indicated the designated back-up DMHCA was the VitalCore regional clinical staff. The
VitalCore regional clinical staff is a licensed mental health counselor with a clear and active
license in the State of Florida, with an expiration date of March 31, 2027. The back-up DMHCA
was not utilized during the annual compliance review period. The review of the VitalCore
behavioral health coordinator job description found the DMHCA oversees all clinical and
administrative operations. The DMHCA indicated during the interview, the responsibilities of the
DMHCA include maintaining consistent and ongoing communication with all clinical staff at the
center to ensure the delivery of high quality, coordinated, and effective mental health and
substance abuse services. Communication occurs on a daily basis, both formally and informally,
and includes direct check-ins, clinical consultations, and administrative coordination. The
DMHCA holds weekly treatment team meetings with clinical staff to review caseloads, treatment
planning, youth progress, supervision statuses, and any clinical concerns requiring collaborative
attention. In addition to scheduled meetings, the DMHCA provides real time clinical support and
direction throughout the day to address emergent issues, conduct risk assessments, guide
documentation practices, and offer supervision or feedback as needed. The DMHCA serves as
a point of contact between the clinical team and other departments, including education,
medical, administration, and security, ensuring consistent interdisciplinary communication. A
collaborative approach allows the staff to respond effectively to the complex needs of youth in
detention and promotes continuity of care. This high level of communication fosters a supportive
clinical environment and reinforces the shared goal of delivering comprehensive and trauma
informed services to every youth served. The DMHCA indicated in the role of DMHCA, both
direct and indirect clinical services are provided as needed to support the mental health and
substance abuse treatment needs of youth in the center. The DMHCA directly provides
individual counseling, crisis intervention, and risk assessments such as suicide risk, and/or self-
injurious behavior evaluations when clinically indicated or when additional support is required
beyond the scope of the assigned mental health staff. The DMHCA indicated they conduct
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follow-up assessments for youth on elevated supervision statuses, facilitate psychoeducational
sessions, and assist in treatment plan development and review when clinically appropriate. In
addition to providing clinical services, the DMHCA offers clinical supervision and consultation to
mental health staff, ensuring the quality and fidelity of services delivered. This includes
reviewing documentation, co-signing treatment plans when required, and guiding staff in case
conceptualization and therapeutic approach. The DMHCA indicated while the primary role
involves leadership, coordination, and oversight, they remain actively involved in service
delivery to ensure high-quality, consistent, and responsive care for youth within the center. The
DMHCA indicated the dual function as both administrator and clinician allows them to support
youth directly while enhancing the overall effectiveness of the behavioral health program.
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.
There are seven current clinical staff providing services to the youth. During the annual
compliance review period there were four additional staff who provided services to the youth. A
review of the licensed clinicians’ credentials indicated all eleven staff held a clear and active
license in the State of Florida, with an expiration date of March 31, 2027, with the exception of
one license with an expiration date of November 2, 2028. All clinical staff were qualified
professionals licensed under the appropriate Florida Statute’s Chapter. Copies of all licenses
were maintained on-site. The center does not have a Chapter 397 license. According to the
designated mental health clinician authority licensed clinical staff are on-site for at least 150
hours Monday through Friday and vary between sixteen and thirty-two hours on Saturday and
Sunday.
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.
Reviewed documentation supported all mental health services are provided by licensed mental
health professionals. The center does not have any non-licensed mental health clinical staff.
The center does not have a Chapter 397 license. Reviewed documentation supported all
substance abuse treatment and groups were facilitated by licensed mental health counselors.
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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 regarding mental health and substance
abuse admission screenings. The center has a comprehensive screening process including
procedures for a thorough review of a preliminary screening conducted by the Office of
Probation and Community Intervention. Mental health and substance abuse admission
screenings were review for nine youth admitted into the detention center. All nine youth were
processed through the Juvenile Assessment Center (JAC). The JAC staff 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). Documentation
supported the juvenile justice detention officer (JJDO) reviewed each youth’s MAYSI-2 results,
Face Sheet, and alerts during the admission process into the detention center. The JJDO
completed their assigned section of the SRSI for all nine youth. All nine SRSIs were reviewed
by a licensed mental health professional and included referral information in the screening
results sections. None of the reviewed MAYSI-2 screenings had all negative responses to make
the screening invalid. Two of the nine youth had an elevated suicide risk subscale on the
MAYSI-2. Four of the nine youth had results of the MAYSI-2 which indicated the need for a
comprehensive assessment. Eight of the nine reviewed youth had a positive response on the
SRSI. The eight applicable youth were placed on suicide precautions. All eight youth had a
mental health referral completed, which documented the youth’s need for an Assessment of
Suicide Risk (ASR). Each of the eight-youth applicable for suicide precautions placement had a
suicide risk alert opened in JJIS. Documentation supported the superintendent/designee was
notified for each of the eight youth who were referred for further screening. All nine-youth
reviewed were applicable for further assessment according to the SRSI and/or MAYSI-2.
Documentation supported four youth were referred for a comprehensive assessment by the
licensed mental health staff. The center was able to provide documentation to support JJDOs
were trained to complete the SRSI. There was no documentation to support clinical staff were
trained; however, all clinical staff were required to complete JJIS training with the Department’s
data integrity officer and completion of the SRSI was addressed during this training. An informal
interview with the designated mental health clinician authority (DMHCA) was conducted. The
DMHCA explained the process for a referral following a screening. The DMHCA indicated if a
youth is placed on precautionary observation (PO) during their length of stay, mental health staff
will conduct an assessment immediately or within twenty-four hours of placement. A referral is
expected to be submitted by the JJDO or staff member who initiated the PO status. In instances
where a referral is not submitted, mental health staff will generate the referral and document the
assessment findings in the referral’s comment section prior to closing it. This ensures timely
clinical response and proper documentation of the youth’s mental health status. Mental health
staff are notified of the referral through various channels, including formal referrals, phone calls,
or direct verbal communication from center staff. Notifications may occur in person or through
internal communication systems. The DMHCA is on call twenty-four hours a day, seven days a
week to respond to any and all mental health crises or emergencies, ensuring immediate
support and intervention as needed to maintain youth safety.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center maintains a written policy and procedures regarding the process to identify the
mental health and substance abuse needs of youth through comprehensive evaluations. When
the youth’s screening results require a referral for a comprehensive assessment, the clinical
staff will either review the comprehensive assessment completed by a community provider, or
the clinical staff will complete the Substance Abuse Mental Health (SAMH) assessment. Seven
of the nine youth reviewed were applicable for an assessment. Six of the seven youth were
identified upon admission and one youth was identified after admission. Each of the seven
youth had a referral completed. Three youth had a comprehensive assessment completed prior
to their admission to the detention center. Documentation confirmed clinical staff reviewed the
completed assessment. Four youth received a new SAMH assessment by 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. The
community assessment contained all required elements including the signature of the licensed
mental health professional who completed the assessment. All updated comprehensive
assessments and SAMH assessments were maintained in the Department’s Electronic Medical
Record (EMR). An interview with the designated mental health clinician authority (DMHCA)
confirmed as part of the intake and assessment process, the DMHCA will search the
Department’s Juvenile Justice Information System to determine whether a comprehensive
evaluation has been uploaded for the youth. If a comprehensive evaluation is not found in JJIS,
the assigned juvenile probation officer (JPO) is contacted to inquire whether one has been
completed. If the JPO confirms a comprehensive evaluation has been completed, mental health
staff will update the youth’s records and upload the document to the youth’s upload library in the
EMR. If no comprehensive evaluation exists, or if the JPO does not respond in a timely manner,
a SAMH assessment will be completed by the youth’s thirty-first day in secure detention and
entered into the EMR to ensure timely and comprehensive assessment documentation.
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 regarding 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. All nine
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reviewed youth were applicable for mental health and substance abuse treatment services.
Eight of the nine reviewed youth records included documentation of a mental health orientation
which was held within fourteen days of admission to the center. The orientation was not
documented for one youth. Five youth required an initial treatment plan which was completed
within seven days of the onset of treatment. The initial treatment plan was completed using the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each of the five initial
treatment plans addressed the reason for treatment referral, the initial Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, initial treatment methods, and
goals. Each of the five youth were applicable for receiving psychiatric services and plans
included the required medication information. All five initial treatment plans were created by a
licensed clinical professional. Each of the five plans were signed by the youth and the licensed
clinical professional. Documentation supported each of the five youth were assigned to a mini-
treatment team where the members of the treatment team were involved in the creation of each
youth’s initial treatment plan. Seven of the nine reviewed youth required the completion of an
individualized treatment plan. All seven applicable youth had an individualized treatment plan
developed within thirty-one days of the youth’s admission to the center. The individualized
treatment plan was completed on the Department’s form and included all required elements.
Three youth entered the center taking psychotropic medication. The individualized treatment
plan for each youth addressed the pharmacological interventions and matched the medication
each youth was prescribed at the time the treatment plan was developed. Each of the seven
individualized treatment plans were signed and dated by the youth and mini-treatment team
members. One youth was applicable for a thirty-day individualized treatment plan review. The
review was completed within the thirty-day requirement and modifications to the individualized
treatment plan were documented on the review form. The individualized treatment plan reviews
were signed and dated by the youth and all mini-treatment team members. None of the
reviewed youth were applicable for having been an alleged victim of a Prison Rape Elimination
Act incident. Three youth who were receiving mental health and/or substance abuse treatment
at the time of their discharge were reviewed. Each of the three youth had a completed mental
health/substance abuse treatment discharge summary. Each of the three discharge summaries
were completed on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form and signed by a licensed clinical professional. There was documentation to
support a copy of each discharge summary was emailed to the youth’s juvenile probation officer
(JPO). There was no documentation to support the youth and parent/guardian received a copy
of the discharge plan. The DMHCA indicated the discharge summary is emailed to the youth’s
JPO, and it is the responsibility of the JPO to provide a copy of the discharge summary to the
youth and parent/guardian. The DMHCA indicated they could not confirm if the youth and
parent/guardian received a copy of the discharge summary from the JPO. A mini-treatment
team meeting was observed during the annual compliance review week. The DMHCA, a
therapist, a representative from education, a nurse, and a juvenile detention officer were
participating as members of the mini-treatment team. Three youth were simultaneously brought
into the room to meet with the treatment team members. The DMHCA addressed one youth and
had the youth sign documentation and provided the mental health orientation to the youth. The
other two youth sat and listened while the DMHCA was talking. The DMHCA then discussed
general expectations which must be met while in detention. Individual goals were not discussed.
The mini-treatment team members did not attempt to reach the JPO’s and parent/guardians.
Once the first three youth left the room two more youth entered the room and the DMHCA
completed the same conversation with the two youth as they did with the three previous youth
who attended treatment team.
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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 center maintains a written policy and procedures ensuring mental health and substance
abuse treatment planning focuses on treatment provisions to reduce or alleviate youth’s
symptoms of mental disorder or substance abuse impairment and enable youth to function
adequately in the juvenile justice setting. All nine-youth reviewed were receiving some kind of
mental health and/or substance abuse service. All nine youth were assigned to a mini-treatment
team during their stay at the center. The mini-treatment team for each youth consisted of the
required parties. Eight of the nine youth were receiving individual therapy sessions according to
the frequency required by the youth’s individualized treatment plan. Individual and group
therapy were provided to the youth on a weekly basis. Seven youth were receiving group
therapy according to the frequency required by the youth’s individualized treatment plan. One
youth had not begun to attend groups at the time of the annual compliance review. One youth
had identified special needs and was receiving individualized mental health services. Five of the
nine youth required substance abuse treatment and received these services according to the
frequency required by the youth’s individualized treatment plan. All nine youth had a current
Authority for Evaluation and Treatment uploaded into the upload library of the electronic medical
record (EMR). Eight applicable youth signed the consent for substance abuse treatment using
the Department’s form. All treatment notes were documented on the Department’s
Counseling/Therapy Progress Notes form. Video review of three separate days of mental health
groups confirmed licensed therapists conducted group sessions with the youth as required. The
observed groups were conducted as scheduled, and the groups were limited to ten or fewer
youth for the mental health groups. A review of records confirmed group therapy was limited to
ten or less youth for mental health treatment groups. Nine interviewed youth were asked to rate
the mental health/substance abuse services they were receiving at the center. Three youth
rated the services as good. Five youth said the mental health/substance abuse services were
very good and one youth indicated they were not receiving any services. One youth shared an
additional comment and said the therapists are always there when needed. The designated
mental health clinician authority (DMHCA) indicated twenty-six youth were currently receiving
services during the week of the annual compliance review. Group and individual therapy are
offered once or as needed on a weekly basis. Treatment team meetings are held on a monthly
basis. The DMHCA described the process for ensuring services are provided. The DMHCA
indicated they ensure all youth who remain in the center for thirty days or more, or sooner if
behavioral indicators warrant earlier intervention, are provided access to mental health
treatment services. The DMHCA described the process used for individualized mental health
and/or substance abuse treatment planning. Once the youth are identified for mental health
and/or substance abuse treatment services, the youth are invited to participate in a treatment
team meeting, where they are encouraged to discuss their current needs and identify clinical
interventions they would like to focus on during their detention stay. During this collaborative
meeting, the youth will help establish treatment goals and objectives, which will be used to
develop an individualized treatment plan tailored to their emotional, behavioral, and
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psychological needs. This process promotes youth engagement, ensures treatment is
personalized, and supports continuity of care throughout their time in detention. The DMHCA
reported once a youth agrees to engage in services, the DMHCA tracks their progress using a
quality improvement tool, ensuring all services prescribed in the individualized treatment plan
are delivered appropriately and consistently. This process supports a youth-centered approach
to care, promotes accountability, and ensures compliance with clinical standards and treatment
objectives. The DMHCA described the process used to review and update the individual
treatment plans. The DMHCA indicated clinical staff will meet with the youth to review the
comprehensive evaluation together and process any questions or information the youth may
need clarified. Following the review, both the youth and the assigned mental health therapist will
sign and date the last page of the comprehensive evaluation to indicate the document was
reviewed and updated as necessary. The signed comprehensive evaluation will then be
uploaded into the youth’s upload library for documentation and recordkeeping purposes. The
DMHCA indicated the youth receive individual and group counseling services to address both
mental health and substance abuse diagnoses. Group sessions focus on life skills development,
preventative interventions, and psychoeducation, among other relevant topics. Groups are held
weekly on Wednesday and Thursdays from 2:45 p.m. to 5:00 p.m. The DMHCA stated clinical
staff meets with administration staff informally on a daily basis to discuss youth needs, center
operations, and any emergent concerns. Formal meetings occur twice weekly through
participation in both department head meetings and treatment team meetings, ensuring
consistent communication, collaboration, and coordination of care across departments.
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 addressing psychiatric services to youth in
need, to include psychiatric evaluation, consultation, medication management, and medical
supportive counseling. VitalCore has an independent contract for psychiatric services with a
medical doctor to serve as the center’s psychiatrist. The psychiatrist is an osteopathic physician
who maintains a clear and active license in the State of Florida, which expires March 31, 2026.
The designated mental health clinician authority (DMHCA) reported the center does not have a
back-up psychiatrist. The center does not utilize a psychiatric advanced practice registered
nurse. The psychiatrist is available for consultation, twenty-four hours a day, seven days a
week. The contract allows for tele-psychiatry which is used at the center. The DMHCA reported
the psychiatrist provides services two hours a week from 3:00 p.m. through 5:00 p.m. The
DMHCA reported they meet with the psychiatrist on a weekly basis and as needed to discuss
youth receiving psychiatric services. The review of the tele-psychiatry logbook confirmed the
psychiatrist provided services on a weekly basis for two hours throughout the annual
compliance review period. Three of the nine reviewed youth entered the center taking
psychotropic medication. All three youth were referred for a psychiatric interview and all three-
youth met with the psychiatrist within fourteen days of admission to the center. An additional two
youth were also referred for a psychiatric interview during their stay at the center. The interview
was completed within fourteen days of the referral. All five of the initial diagnostic psychiatric
interviews were documented on the Department’s Clinical Psychotropic Progress Note (CPPN)
and included all required information. Each reviewed evaluation included page three of the
CPPN outlining medication target symptoms, side effect descriptions, medication name,
dosage, and frequency. The psychiatrist signed all CPPNs the day the psychiatric interview was
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conducted. Four youth took psychotropic medication as a result of the psychiatric interview. The
CPPN included the name of the medication, dosage and quantity of the medication, normal
dosage range and the order dosage for each youth, frequency and route of administration, and
reasons for changes in medication and/or dosage. One youth required the monitoring of Tardive
Dyskinesia. The monitoring was not documented on the Medication Administration Record. All
four applicable youth records had a current Authority for Evaluation and Treatment (AET)
consenting for the continuation of the psychotropic medication. None of the applicable youth
were in foster care or turned eighteen years of age while in the center.
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 and a Suicide Prevention Plan which
details suicide prevention and procedures. The plan was reviewed and signed by the
superintendent and the designated mental health clinician authority (DMHCA) January 22, 2025.
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. The review process
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 ensuring suicide prevention services. The
policy and procedures address supervising, observing, monitoring, and housing youth identified
through screenings, documentation, and observation as being at risk for suicide, and protect
youth with elevated risk of suicide in the least restrictive means possible. Three of the nine
reviewed 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 three youth
were identified as at-risk based on the admission screenings. Each of the three youth had a new
suicide alert placed in the Department’s Juvenile Justice Information System (JJIS). 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 superintendent and designated mental health clinician
authority (DMHCA) were notified for each youth. The ASR was completed for each youth within
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twenty-four hours by a licensed therapist, using the Department’s form. Each youth was placed
on constant supervision based upon the Suicide Risk Screening Instrument (SRSI) findings.
After the completion of the ASR, two of the three youth were placed on standard supervision.
The third youth was continued on constant supervision. The review of all three youth’s Suicide
PO Logs confirmed each was completed in its entirety to include documented safe housing
areas and all required signatures. The PO logs for the one youth continued on PO was missing
the date and time of step down. These sections of the form were left blank. The one youth
applicable for a Follow-Up ASR had the assessment completed by a licensed therapist prior to
the youth being removed from PO. Documentation supported the clinical staff were involved
throughout the entire process and provided consistent feedback to the officers and the
superintendent. 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 times each JJIS alert was
opened and closed corresponded with the times of completed referrals and completed ASRs or
follow-up ASR. The processes in the center’s suicide plan were followed for each of the three
youth. None of the nine youth were released from the center prior to receiving an ASR or
released while on PO. The interviewed DMHCA stated all licensed mental health clinicians
complete ASRs using the Department’s ASR form and Suicide Risk Screening Instrument
(SRSI). The DMHCA indicated when a youth appears acutely suicidal mental health staff will
conduct an immediate assessment if a mental health staff member is on site at the time of
notification. If no mental health staff is present at the center, a clinician will report to the center
promptly to assess the youth in a timely manner, ensuring all crisis situations and elevated
supervision statuses are clinically addressed without delay. Nine staff were asked what steps
they take when a youth appears suicidal. All nine staff said they notify the mental health
authority, search the youth and their room for sharp objects, and document constant sight and
sound supervision. Two staff indicated they would place the youth in a locked room. Additional
comments made by the staff during interviews included one staff stating the supervisor will
contact the parents. One staff indicated they would notify the supervisor. One staff stated
everything is logged in a book and the supervisor will call the youth’s parent. One staff indicated
the supervisor or higher will contact the parent. One staff said all objects are checked in the
youth's room and everything is reported. One staff stated information pertaining to the youth’s
PO status is located in the logbook. One staff indicated information is given to all staff regarding
a youth. Nine youth were interviewed, and two youth stated they were placed on suicide watch
while at the center. These two youth said staff watched them all the time. The other seven youth
indicated they were never placed on suicide watch while at the center.
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). The
policy requires youth placed on suicide precautions to remain under SO if less restrictive
methods are not effective. The nine-youth reviewed during the annual compliance review week
were not applicable for placement in SO. The center provided three additional applicable youth
who were placed on SO. Reviewed documentation supported each youth placement was
authorized by a supervisor and the designated mental health clinician authority (DMHCA). The
secure room was not designated in writing; however, this is not a requirement in the policy and
procedures. Documentation supported each youth’s parent/guardian and juvenile probation
officer were notified of the placement. The Department’s Health Status Checklist was completed
for each youth. Staff completed the Suicide Precautions Observation Logs in their entirety and
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in real time. None of the youth were maintained on SO beyond twenty-four hours. One youth
was Baker Acted while in SO. The second youth was transferred to another detention center
while on SO. The third youth did not have a new Assessment of Suicide Risk (ASR) or Follow-
Up ASR completed within eight hours of being placed on SO. Progress notes supported the
therapist did meet with the youth within the first eight hours of being placed in SO and the youth
would remain in SO. 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.
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 outlining the process to safely screen,
refer, assess, monitor, and protect youth while elevated suicide risk in the least restrictive
means possible. Three of the nine reviewed 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. Each of the three youth had a PO Log maintained for the duration the
youth was on PO. One youth was maintained on PO as a result of the ASR. The review of the
PO Logs for all three youth found staff were documenting the youth’s behavior at thirty-minute
intervals or less. All PO logs documented safe housing requirements. Each youth’s log was
documented in real time and was maintained for the duration the youth was on suicide
precautions. None of the youth presented warning signs while on PO. All PO Logs included the
signature of the mental health staff and the center’s shift supervisors. A review of 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. A
review of nine pre-service and nine in-service staff training records verified each staff
participated in suicide prevention training. The center maintains four suicide response kits
located in each of the modules’ sub-control rooms. Each suicide kit contained the knife-for-life,
wire cutters, needle nose pliers, and first-aid supplies to include a one-way cardiopulmonary
resuscitation mask, face shield, and non-latex gloves. A review of mock suicide drills during the
annual compliance review period verified drills were held no less than quarterly on each shift. All
mock mental health drills were in response to a suicide attempt and/or incident of serious self-
injury. Program youth were not used in drill simulations. Documentation supported all staff who
come into contact with youth participated or were briefed on the suicide drill scenario. The
review of video footage confirmed suicide drills were simulated. All nine interviewed staff stated
the knife-for-life is kept in master control, sub-control, and medical. Eight of the interviewed staff
indicated there was a suicide kit in the shift supervisor’s office.
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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
the Crisis Intervention Services and Emergency Care Plan. The plan was reviewed and signed
by the superintendent and the designated mental health clinician authority on January 22, 2025.
The plan addressed the notification and alert system, means of referral to include self-referral,
communication, supervision, and documentation.
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 Crisis Intervention Service and Emergency Care Plan. The plan was
reviewed and signed by the superintendent and the designated mental health clinician authority
on January 22, 2025. The plan was last updated on March 15, 2022. The plan is accessible to
all staff and are located in each module, medical, mental health, supervisor’s office, and master
control. The plan addresses immediate staff response, notifications, communication,
supervision, authorization to transport for emergency mental health or substance abuse
services, and transport for emergency mental health evaluation and treatment under Chapters
394 and 397 of Florida Statute. The plan addressed 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 has a written Emergency Care Plan documenting the response procedures for youth
in crisis. None of the nine reviewed youth were applicable for Crisis Assessments. The center
reported having two you who required a Crisis Assessment during the annual compliance
review period. A review of the two youth Crisis Assessments supported each assessment
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Office of Accountability and Program Support Page 33 of 59 (Revised July 2023)
included all required information. Supervision, treatment recommendations, and
recommendations for follow-up were documented in the Crisis Assessments. Documentation
supported notification to both youth’s parents/guardians was made. Mental health alerts were
opened in the Department’s Juvenile Justice Information System due to the youth being placed
on precautions after the completion of the Crisis Assessment. Both youth received the Crisis
Assessment as a result of a Prison Rape Elimination Act incident. The Crisis Assessments were
completed within the required timeframe by a licensed mental health professional.
Documentation supported each youth was offered ongoing 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 addressing Baker and Marchman Acts.
None of the nine reviewed youth were applicable for Baker or Marchman Acts, three additional
youth were provided to the review team. Three Baker Act incidents were reviewed.
Documentation supported 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 Suicide Precautions
Observation Log until the time of the youth’s authorized release. Documentation supported each
youth was placed on suicide precautions upon re-admission to the center from the crisis
assessment facility. Each youth had a mental health referral completed for a Mental Status
Exam (MSE). Each youth had a MSE completed as part of the Assessment of Suicide Risk
(ASR). The MSE and ASRs were completed by a licensed mental health staff for each youth.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 59 (Revised July 2023)
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 MD holds an unrestricted license which expires
on January 31, 2027, and meets all requirements for independent and unsupervised practice in
the State of Florida. The MD has specialty training in pediatrics and family practice. 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. The DHA is
responsible for communication with the center and the medical staff regarding the youth’s
medical needs. The DHA is on-call twenty-four hours a day, seven days a week for consultation.
The DHA is on-site on Tuesdays from 12:30 p.m. to 4:30 p.m. at least weekly. A review of the
DHA’s sign-in logs for the last twelve months indicated the DHA was on-site at least once a
week as contractually 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 30, 2027. The APRN has Collaborative Practice Protocols in
place with the DHA. The APRN and DHA signed the collaborative agreement renewal in
January 2025. Nursing coverage is provided on-site from 7:00 a.m. to 8:00 p.m., Monday
through Friday, and from 7:00 a.m. to 5:30 p.m., Saturday and Sunday. The back-up MD, who
provides coverage when the DHA is on scheduled absences or vacation, holds an unrestricted
license in the State of Florida, which expires on January 31, 2026. The back-up DHA was not
utilized during the annual compliance review period. The center utilizes tele-health and has
facility operating procedures in place regarding how tele-medicine is utilized. A tele-health
agreement was established between VitalCore and the Department for DHA’s from other
centers to oversee the center’s APRN completing the CPAs and sick calls and being on-call for
evaluation consultations and episodic, first-aid, and emergency care. A log of tele-health
services was maintained at the center. An interview with the DHA was not available at the time
of the annual compliance review. The DHA’s last day was on Tuesday, during the week of the
annual compliance review, and the newly appointed DHA was not available to complete the
interview survey.
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 written facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. The designated health authority (DHA) conducts an annual review of
all respective treatment FOPs. Reviewed documentation reflected the DHA reviewed, signed,
and dated the FOPs on January 28, 2025. Reviewed documentation supported the
superintendent signed and dated the updated FOPs on January 23, 2025. The psychiatrist
reviewed all FOPs related to psychiatric services and psychotropic medication on January 23,
2025. The DHA authorized and approved all treatment protocols and standing procedures.
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Office of Accountability and Program Support Page 35 of 59 (Revised July 2023)
Reviewed documentation validated the registered nurse (RN) manager and the advanced
practice registered nurse signed the cover page in January 2025. All other medical staff
documented their review of the center’s VitalCore Health Strategies, LLC. (VitalCore) healthcare
FOPs and protocols on a cover page which was signed and dated between January 2025, and
February 2025. The center’s treatment protocols were signed and dated by the DHA on August
15, 2023. The center’s non-healthcare staff protocols were signed and dated by the DHA on
January 22, 2025. Training records supported all eight-nursing staff completed and maintained
current certifications in cardiopulmonary resuscitation and automated external defibrillator.
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 the
clinical orientation conducted by an 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 maintains a written policy and procedures requiring the completion of the Authority
for Evaluation and Treatment (AET) or Limited Consent for Evaluation and Treatment (LCET)
authorizing specific treatment for youth in the custody of the Department. A review of nine youth
Individual Healthcare Records (IHCRs) found each were applicable for requiring a signed AET.
There were no applicable youth who were over eighteen years of age. All nine reviewed IHCRs
contained a signed AET. There were no applicable IHCRs which required a LCET due to
involvement with the Department of Children and Families. Each applicable AET was obtained
prior to providing medical services to the youth. Each of the applicable signed AETs were
clearly marked as a “copy” on the form. The interviewed nurse indicated the AET is signed by a
parent/guardian when the youth is under eighteen years of age and is valid while the youth is
under the supervision/custody of the Department. An interview with the clinical manager
confirmed the center’s practice of obtaining a new or current AET or documenting consent when
a youth is eighteen years of age.
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 requires the notification of a
parent/guardian when there are significant changes in the youth’s condition and to obtain
consent when new medications and treatments are prescribed. A review of nine youth Individual
Healthcare Records (IHCRs) found eight youth were applicable for prescribed over-the-counter
medications not covered by the Authority for Evaluation and Treatment (AET). Each reviewed
IHCR supported the center notified the parent/guardian of significant changes in the youth’s
condition and obtained applicable consent when new medications and/or treatments were
prescribed. Three youth were applicable for taking psychotropic medication at admission and
the IHCR documented a staff witnessed all telephone call attempts and conversations for
psychotropic medications. Each of the reviewed applicable IHCRs contained chronological
progress notes documenting the parents/guardians were notified by telephone and followed-up
with a written Parental Notification/Consent form showing an attempt to obtain the signed
parent/guardian consent. Seven of the nine reviewed records indicated immunization records
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Office of Accountability and Program Support Page 36 of 59 (Revised July 2023)
were obtained through the Florida Department of Health website and are verified within seven
days and reviewed within thirty days of the youth’s admission. The remaining two youth had not
been at the center thirty days at the time of the annual compliance review. None of the youth
received vaccinations at the center. None of the youth were under the custody of the
Department of Children and Families; therefore, a court order was not required for any
treatment procedures. An informal interview with the clinical manager indicated youth over the
age of eighteen are responsible for authorizing their healthcare, and for youth under eighteen,
medical staff will send parental/guardian notifications to obtain consent when new medications
are ordered or stopped, if a youth sent off-site for care, has treatments prescribed, and/or to
inform the parent/guardian of significant changes in the youth's condition. These notifications
are first done verbally and followed with a letter, unless treatment or services are court ordered.
When a new psychotropic medication is prescribed, discontinued, or the drug dosage is
significantly changed, parent/guardian verbal consent is obtained. Additionally, the interview
with the clinical manager confirmed the center’s practice in case a youth’s illness or injury
requires emergency medical services or treatment. The clinical manager indicated immunization
records are obtained through Florida Shots and vaccinations are not provided at the center.
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 to ensure youth are screened upon
admission for any emergency medical conditions requiring immediate medical attention or
concerns which may need a referral for further assessment by healthcare staff. In the event a
youth is admitted, and an injury is discovered with the listed signs and/or symptoms, there will
be immediate communication with the designated health authority, and a request will be made
for an urgent assessment of the youth if licensed healthcare staff are available on-site.
Immediate transfer of the youth to the nearest emergency facility will occur if the licensed
healthcare staff are not on-site or after the evaluation if the condition so warrants. Nine youth
Individual Healthcare Records (IHCRs) were reviewed. All nine youth IHCRs found each
contained a Medical and Mental Health Admission Screening (MMHS) form completed on the
date of admission by a juvenile justice detention officer (JJDO), which was reviewed and signed
by the JJDO supervisor. Each MMHS indicated the screening was reviewed by a registered
nurse within twenty-four hours. Each screening form was completed in the Department’s
Juvenile Justice Information System. There were no records applicable for a change in physical
custody since the youth’s admission. Three additional records were reviewed for healthcare
admission re-screenings, and all three applicable IHCRs contained a completed re-screening.
Each re-screening was completed by a JJDO or JJDOS and reviewed by the medical staff
within twenty-four hours of the screening. There were no youth applicable for a qualitative urine
pregnancy screening test. An interview with the clinical manager confirmed the center’s practice
for admission screening and rescreening.
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Office of Accountability and Program Support Page 37 of 59 (Revised July 2023)
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains a written policy and procedures requiring all youth to be oriented to the
general healthcare delivery services at the center. A review of nine youth Individual Healthcare
Records supported each contained a completed Department Health Education form
documenting the youth’s orientation to the center’s healthcare services. Each youth received a
general healthcare orientation on the day of admission to the center. Reviewed documentation
supported each youth’s orientation included access to medical care, sick call, what constitutes
an emergency and when to notify staff, medication process and side effect monitoring, the right
to refuse care and how it is documented, and what to do in the case of a sexual assault or
attempted sexual assault. Additionally, youth are oriented on the non-disciplinary role of the
healthcare providers, availability of healthcare staff, dental hygiene, sexually transmitted
infections, personal hygiene, immunizations, infection control, nutrition, self-examinations, and a
review of healthcare contacts.
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 maintains a written policy and procedures which requires notification to the
designated health authority (DHA) of all youth admitted with chronic health conditions or youth
in need of emergency care. A review of nine Individual Healthcare Records (IHCRs) indicated
there were two youth identified with a chronic medical condition and one additional record was
reviewed. Evidence of referrals to the DHA were identified for the three applicable youth. None
of the youth were identified as in-need of emergency care upon admission. In each instance, the
DHA was notified within twelve hours of the youth’s admission and a notification was
documented in the IHCR. Each of the three youth were referred to the advanced practice
registered nurse or the DHA. Notification was documented on the nursing admission
chronological notes in each IHCR. One youth was applicable for being admitted while taking
psychotropic medication and the psychiatrist was notified of the youth’s admission. An interview
with the clinical manager indicated the DHA is notified by the nursing staff when there is a youth
with a chronic or medical condition or is taking prescribed medications. Notifications to the DHA
are documented in the admission chronological progress notes.
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. The center utilizes
and completes the HRH form for all youth admitted into physical custody. A review of nine youth
Individual Healthcare Records (IHCRs) found each contained an HRH form completed
electronically by a licensed nurse within seven days or less of the youth’s admission to the
center. All nine of the HRH forms were reviewed by the designated health authority or
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advanced practice registered nurse and were maintained in the youth’s IHCR. Each of the
applicable HRHs were completed before the Comprehensive Physical Assessment and
reflected the most current admission into detention. An interview with the clinical manager
indicated the nursing staff are responsible for completing the HRH and confirmed they are
completed within or before the seven days of 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) form to be completed or updated for all applicable youth admitted
determining the health and wellbeing of each youth. A review of nine youth Individual
Healthcare Records (IHCRs) indicated each youth had a current CPA on record at admission.
Each of the nine reviewed youth records verified the designated health authority (DHA)
completed the CPAs within seven days of admission to the center. Reviewed documentation
supported each current CPA documented a review of the Health-Related History by the DHA.
Each of the CPAs were completed in full to include the Medical Grade, Tanner Stage,
cardiovascular, body mass index, visual acuity field, and most recent Tuberculosis Skin Test. All
sections of the CPA for the applicable youth were marked with an “O” or “X”. Four of the nine
reviewed youth records indicated a refusal for portions of the examination, and each contained
a signed refusal form reflecting the refused portion of the CPA. Each youth was applicable for
an update to the Department’s Problem List and updates were made as required. The center’s
policy and procedures for Tuberculosis (TB) control and screening address the routine
screening of all youth for latent and active TB, as well as environmental controls in the case of a
youth with active TB. A review of nine youth IHCRs validated each of the youth had a TB
screening completed. There were no applicable IHCRs reviewed which contained a refusal for
TB examination. The results of the TB tests were documented on the CPAs and Infectious and
Communicable Diseases forms. None of the reviewed youth were applicable for a new
Tuberculosis screening or further evaluation. A review of the center’s practice reflected when
the CPAs are completed the Department’s Problem List is updated. Reviewed documentation
validated the center’s practice. An interview with the clinical manager indicated the youth’s CPA
and TB testing is completed within seven calendar days of admission and it is valid for at least
one year or depending on the youth’s Medical Grade. Gynecological exams are not routinely
completed for females.
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 to ensure all youth are evaluated and
treated for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV), if
necessary. All sexually active youth will be clinically screened and evaluated for STIs. After the
screening, the youth is referred to the designated health authority or advanced practice
registered nurse to determine if further testing is necessary. A review of nine youth Individual
Healthcare Records (IHCRs) indicated five youth were applicable and each were screened for
STIs. Each applicable youth required further evaluation and four were referred, due to one
youth’s refusal. Each of the applicable youth’s screening results were documented on the
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Office of Accountability and Program Support Page 39 of 59 (Revised July 2023)
Department’s STI form and Infectious and Communicable Disease (ICD) form located in the
IHCR. None of the reviewed youth were applicable for a gynecological exam. A review of nine
youth IHCRs found none of the youth were out of the Department’s physical custody for more
than thirty days. The center maintains a written policy and procedures providing each youth with
the opportunity to receive counseling, testing, and treatment for HIV. Nine youth records were
reviewed and showed four youth were applicable and requested to have a HIV test, as
documented on the Department’s Human Immunodeficiency Virus Antibody Test Youth Consent
form. Reviewed documentation of the four applicable IHCRs verified written consent was
obtained by the center and confirmed each of the applicable youth was offered counseling,
testing, and treatment for HIV. A review of the four applicable records validated each of the HIV
results were placed in a sealed envelope stamped “Confidential” and filed in the youth’s IHCR.
The pre-test and post-test counseling were documented in each youth’s IHCR. An interview with
the clinical manager indicated all youth who are sexually active will be screened for STI’s during
the youth’s admission to the center. Youth may consent to their own screening and treatment
and youth are able to request an HIV test at any time while in detention. The youth’s STI results
are noted on the ICD form and lab results are placed in the youth’s IHCR and/or uploaded to the
Electronic Health Record (EHR). Youth are rescreened if they have been out of the
Department’s physical custody for more than thirty days. HIV results are maintained in a
confidential manner and screening information for STIs are documented on the youth’s ICD
form. Each youth who receives HIV testing is offered pre- and post-testing education by the
nursing staff, and counseling is provided by a certified HIV counselor or licensed medical
professional. Pre/post-test counseling is documented in the youth’s IHCR. Nine youth were
interviewed, and seven indicated they can ask for an HIV test, and two youth said they could not
ask for one.
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 which require for all youth in the center to
be able to make sick call requests and have their complaints treated appropriately through the
sick call system. The center conducts sick call seven days a week to respond to a youth’s
medical illness or injury of a non-emergent nature by a healthcare professional. Postings
throughout the center indicate sick call takes place seven days a week on Monday through
Friday from 9:00 a.m. to 11:00 a.m. and 3:00 p.m. to 4:00 p.m., and on Saturday and Sunday
from 9:00 a.m. to 11:00 a.m. when youth are securely detained at the center. The center has
approved treatment protocols for registered nurses (RNs) and licensed practical nurses (LPNs).
The shift supervisors and authorized staff are trained by the RN clinical manager on the center’s
sick call procedures and are able to review the sick call requests in the absence of the
healthcare professionals. The center utilizes an electronic Sick Call Request form and youth
who require a sick call will inform staff of their complaint and staff will generate a sick call
request in the Department’s Juvenile Justice Information System. When the level of need for the
youth cannot be determined, the on-call practitioner/designated health authority (DHA) and/or
advanced practice registered nurse (APRN), shall be contacted for guidance and referral to the
emergency room or off-site emergent care. A review of nine youth Individual Healthcare
Records (IHCRs) indicated four youth had submitted sick call requests. Documentation in each
of the four IHCRs indicated the sick call was conducted by the RN and was documented on the
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Office of Accountability and Program Support Page 40 of 59 (Revised July 2023)
Sick Call Referral Log. There were no instances in which a youth presented with a similar sick
call complaint three or more times within a two-week period. There were three applicable youth
who were treated where an immediate referral was needed to be made to the DHA and the DHA
was notified immediately of the youth’s medical condition. Each Sick Call Request form was
filed in the IHCR in chronological order. None of the youth were in restricted housing. Sick call
forms documented the nature of the complaint, assessment, and plan to in the subjective,
objective, assessment, and plan note format. All applicable sick call events were documented
on the Sick Call Index and corresponded with the Sick Call Request forms. A review of the
center’s policy confirmed the shift supervisor shall discuss youth’s medical issues in
confinement with medical staff. Nursing staff are required to make daily visits when youth are in
confinement. All youth in confinement will receive all prescribed medication, as required. The
nursing staff will evaluate youth every two hours if a youth in confinement has an active medical
condition. A sick call observation for one youth was conducted during the annual compliance
review week. The youth was escorted by a direct care staff to the medical office. The RN
obtained consent for the sick call to be observed and the RN discussed the nature of the sick
call with the youth. The youth was seen in the medical clinic for privacy. The medical office
contains a private examination area where youth are examined, and the direct care staff is able
to maintain supervision. An interview with the clinical manager confirmed the sick call process
and indicated when youth notify staff of a medical complaint, staff then input a sick call through
the electronic sick call system. Furthermore, nursing staff conduct sick calls twice a day, and
within twenty-four hours, or sooner. The nurse said youth are seen by either an RN or LPN and
if a LPN completes sick call, the RN will conduct a review within twenty-four hours. The youth
are assessed, and vital signs, treatment, education, and follow-up plans are completed. The
clinical manager confirmed sick calls are conducted daily from 9:00 a.m. to 11:00 a.m., and
Monday to Friday from 3:00 p.m. to 4:00 p.m. in the medical office. The clinical manager
indicated if there are youth with repeated similar sick call complaints, a referral is submitted to
the DHA and/or APRN. The nurse confirmed youth in confinement are assessed and evaluated
for medical complaints or distress every twenty-four hours and this is documented, and if there
is a need or a non-emergent issue, the supervisor will complete a Sick Call Request form. Nine
staff were interviewed, and each stated the doctor and/or nurse conducts and reviews sick calls.
Nine youth were interviewed, and four youth indicated they can see a nurse immediately after
requesting a sick call, and five indicated they can see a nurse within twenty-four hours. All nine
youth said nurses conduct sick calls. Additionally, five youth indicated staff can conduct sick
call.
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 ensuring a comprehensive process for
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 contains information to include the
date, name of youth, the youth’s Department identification number, nature of illness or injury,
treatment rendered, staff initials, nurse initials, verification of who provided episodic care, and if
the youth was recommended for off-site care. When licensed staff are not on-site to assess the
youth, the designated health authority’s (DHA) approved non-healthcare protocols shall be
utilized to provide on-site care. Care shall be reported on the Report of On-Site Care by Non-
Healthcare Staff form. When the level of need for the youth cannot be determined, the on-call
practitioner/DHA shall be contacted for guidance and referral to the emergency room for off-site
emergent care. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and two were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 59 (Revised July 2023)
applicable for episodic or first-aid care events, and one additional record was requested and
reviewed. Each of the three applicable incidents showed the on-site care was provided by the
licensed healthcare staff and was documented in problem-oriented charting, which included
subjective, objective, assessment, and plan (SOAP) elements. In all three instances, the nature
of the complaint, findings, treatment rendered, and education/instruction was provided. A review
of the applicable youth IHCRs indicated the center had no applicable episodic care events
conducted by non-healthcare staff. None required a referral for off-site care. Each applicable
record contained parental/guardian notification, and documentation of required follow-up/future
care. Each applicable youth was placed on the alert list because of the medical encounter. The
episodic care events were documented in the Episodic Care Log for each of the applicable
youth. Each reviewed applicable record had a documented progress note identifying first-aid or
emergency care, the date and time of care, nature of the complaint, findings regarding care, and
treatment rendered. The center has twenty-two first-aid kits strategically located in areas
frequented by youth. Ten of the twenty-two kits were designated for the center’s transport
vehicles. Observations of three first-aid kits from master control, the youth’s module’s sub-
control, and one vehicle, verified each kit was stocked with approved supplies with no expired
contents. Reviewed documentation confirmed the kits were monitored monthly by the nursing
staff and were replenished as needed. The center has three automated external defibrillators
(AEDs) located in the medical clinic, classroom I, and classroom II. Each AED is equipped with
automated instructions. The medical staff monitor the AEDs monthly to ensure the devices are
operable. A review of the AED check logs since the last annual compliance review validated this
practice. The AED’s batteries are monitored by the contracted provider annually, and were last
replaced in July 2022, and each battery had an expiration date of August 2026. The AED pads
were last changed on March 6, 2023, and each had an expiration date of July 28, 2025. During
the annual compliance review week, observations were conducted for each AED, and all
devices were operational. The center conducts emergency medical drills at least once quarterly
on each shift, and emergency drills including cardiopulmonary resuscitation (CPR)/AED are
conducted at least once a year on each shift. A review of quarterly emergency drills from March
2024 to April 2025, verified the center conducted drills, as required. A total of forty-five medical
drills were conducted in the past year. The drills included the use of CPR/AED, which was
practiced annually. Each of the drills simulated an episodic care event which called for
immediate first-aid, administration of CPR techniques, and the initiation of the emergency
procedures to follow when a life-threatening emergency occurs. A list of emergency numbers,
including the Poison Information Control Center, were posted and accessible for non-licensed
and licensed staff and inaccessible to youth. The center provided documentation which
confirmed supervisory and authorized direct care staff were trained on the administration of the
epinephrine auto-injector by a registered nurse. Reviewed documentation supported the DHA,
the advanced practice registered nurse, and all nursing staff maintained current certifications in
CPR and AED. Nine staff training records verified staff received CPR/AED/first-aid training, and
the required training on the center’s Emergency Care Plan. The center has a written policy
which details the use, access, and inventory of Naloxone (NARCAN®). The nursing clinical
manager confirmed all nursing staff, and authorized supervisory staff are trained in the
NARCAN® procedures and NARCAN® is stored in the medication cart. During the annual
compliance review week, observations made confirmed the center maintained their stock of
NARCAN® within the locked medication cart, which is kept in the medical office. Documentation
confirmed the nursing staff conducted weekly and perpetual counts of NARCAN® during the
annual compliance review period. An interview with the clinical manager confirmed the center’s
first-aid kit locations. The clinical manager confirmed episodic care is conducted by licensed
staff and documentation shall be in such a manner which conforms to professional standards in
SOAP note format. In the event episodic care is provided by non-licensed Department staff,
these notes shall be documented on a Report of On-Site Care by Non-Healthcare Staff form.
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Episodic care provided by non-healthcare staff must have a follow-up evaluation by medical
staff when they return to the center. The clinical manager indicated, for youth who are sent for
off-site care are tracked for off-site emergency care on the Off-Site Care Log. The nursing staff
verified and confirmed all of the information regarding the center's three AEDs. The nursing staff
confirmed the center conducts monthly medical drills on each shift. Nine staff were interviewed,
and each stated they can call 9-1-1 if they feel it is necessary. Nine youth were interviewed, and
three stated the medical services at the center are very good, five stated good, and one
indicated they were not receiving medical services.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center maintains a written policy and procedures requiring timely referrals, documentation,
and coordination of medical services to an off-site healthcare provider, both emergent and non-
emergent, for youth, as required by the Department. A review of nine Individual Healthcare
Records (IHCRs) found five youth were applicable for off-site care. Each applicable youth was
taken off-site for medical care. Each of the five applicable IHCRs contained documentation
which verified the Summary of Off-Site Care Consultation Report form was utilized. Each
instance of off-site emergency care was documented on the Episodic Care Log. The designated
health authority (DHA) was notified of each healthcare event. A Summary of Off-Site Care
Consultation Report form was completed, and discharge documentation was filed in each of the
applicable IHCRs. Each reviewed applicable IHCR contained discharge documentation and
instructions. The DHA documented a review of the off-site care findings, instructions, and
information. Two of the youth required follow-up appointments and both had the referrals
entered in the center’s referral tracking log. An interview with the clinical manager indicated all
youth sent off-site for first-aid or emergency care are tracked on the off-site care log and with
the center’s medical tracker. The Summary of Off-Site Care form is utilized if a youth is sent off-
site and follow-up testing, referrals, or additional appointments are requested by the provider.
The clinical manager reported the licensed nursing staff reviews the discharge and hospital
orders with the DHA. Additionally, the nursing staff ensure the DHA reviews and initials all off-
site care findings by placing them in a folder for the DHA to review, when the DHA is on-site.
The nurse confirmed, the nursing staff track, follow-up with referrals, testing, and appointments
by documenting them in the youth’s Electronic Medical Record.
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 maintains a written policy and procedures to ensure youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. The frequency
of the periodic evaluation is determined by the youth’s condition, clinical needs, and clinically
appropriate medical standards. Youth are screened during the intake process for medical
conditions warranting periodic evaluations and follow-up care. A review of nine youth Individual
Healthcare Records (IHCRs) indicated two youth were identified with a chronic condition. One
additional youth record was requested for a youth with chronic conditions. None of the reviewed
youth were diagnosed with a communicable disease. The three youth were applicable for taking
a prescribed medication on an on-going basis. Each of the applicable youth received on-site
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care for a physical health condition which was documented in the IHCR chronological progress
notes with clearly written treatment orders. Two youth had a Medical Grade between two and
four. None of the youth were pregnant, and there were no youth applicable for taking
Tuberculosis medication, which required monthly evaluations. An interview with the clinical
manager verified the center had only one youth who was pregnant since the last annual
compliance review. The one applicable youth had an off-site evaluation, and the IHCR
contained a documented Summary of Off-Site Care form. There were no indications of any
lapses in care or missed evaluations. A review of the Chronic Physical Health Conditions Roster
indicated there were no youth applicable for periodic evaluations as the youth were not due for
periodic evaluations. Reviewed records reflected each youth’s Department Problem List was
updated, as required. An interview with the clinical manager confirmed the center’s practice of
chronic condition evaluations and periodic evaluations.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center maintains a written policy and procedures ensuring all medications and
pharmaceutical products are 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. Medications shall have a current, valid order, and are to
be given according to a current prescription or practitioner’s order. Nursing staff are to verify
medication with the parent/guardian when they deliver the medication to the center. The
Medication Receipt, Transfer, and Disposition form is used to document medication received in
the original packaging from a licensed pharmacy with a current legible patient-specific label
affixed. Youth who are taking medication while in the care of the center will have medication
administered by the healthcare professionals. The center utilizes the Department’s Medication
Administration Record (MAR) for each youth receiving either prescription medications on a
routine basis or over-the-counter (OTC) medications. Nine youth Individual Healthcare Records
(IHCRs) were reviewed and identified. Four youth were taking prescribed medication upon
admission and were applicable for medication management. Each applicable IHCR contained
documentation indicating the medication was verified by a licensed pharmacist or the
designated health authority (DHA). The DHA was contacted to obtain an order to resume the
medications, and this notification was documented in the chronological progress note for each
of the youth. All medications had a current, valid order, were administered pursuant to a current
prescription, and the DHA placed an order on the Practitioner Order form for all youth with
medications. All the youth required over-the-counter medications not listed on the Authority for
Evaluation and Treatment. Three of the youth were in restricted housing requiring medication
and the nursing staff to completed daily visits as required. The Electronic Medical Record
(EMR)/MAR was utilized to document all medication and treatment including start and stop
dates. None of the medications were administered by non-healthcare staff. There were no
lapses or errors noted for any medication administration. The nursing staff documented weekly
side effect monitoring on each MAR. The reviewed policy and procedures indicated when a
youth refuses the medication administration, the refusal will be clearly documented on the MAR
and the Department’s Refusal of Treatment form will be completed. Five applicable records
indicated the youth refused medication. Documentation confirmed the refusal was documented
on the MAR, and on the Department’s Refusal of Treatment form. The MARs contained all
required elements, to include youth name, Department of Juvenile Justice identification number,
date of birth, allergies, precautions, Medical Grade, medical alerts, start and stop dates,
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monitored side effects, and a current picture of the youth. Reviewed documentation reflected
the nursing staff and the youth initialed each administered medication entry on the MAR. None
of the youth were taking any parenteral medication. The center utilizes a licensed psychiatrist
who provides tele-psychiatry for medication management. Three youth were prescribed
psychotropic medication prior to admission and the DHA and psychiatrist were notified of each
youth’s admission. Each applicable youth record contained an Initial Diagnostic Psychiatric
Interview completed within fourteen days of admission. Three youth were applicable for
medication monitoring reviews every thirty days, which was conducted as required. The center
did not have any standing orders, emergency treatment orders, or pro re nata (PRN) orders for
psychotropic medications. An observation for a medication administration was conducted during
the annual compliance review week. The youth provided verbal consent prior to observation.
The youth was escorted to the medical office by the juvenile justice detention officer.
Observations supported the youth approached the nurse administering medication individually
and the nurse adhered to the Six Rights of Medication Delivery/Administration by having the
youth identify themself, identify the medication prescribed, and applicable side effects. None of
the medication was pre-poured from the original packaging or placed in another container. The
nursing staff administered the youth’s medication. Both youth and nursing staff signed the MAR,
and the medication administration was documented as required. An informal interview with the
nursing staff confirmed all medications must have a current, valid order, and are given as
ordered on a current prescription or the Practitioner Order form. Observations of medication
storage indicated all medications were separated by type, stored in a locked area designated for
storage, and inaccessible to youth. The center maintains a contract with a licensed pharmacy
who comes on-site to dispose of all biohazardous material. An informal interview with the clinical
manager indicated the center has a policy and procedures for medication disposal. This
requires a registered nurse (RN) to be responsible for the disposal of medications in conjunction
with the pharmacy consultant. The center has trained supervisory and authorized staff to assist
youth with self-administration of medication, in the absence of the healthcare professionals. The
center maintains a list of staff who are required to have access to the clinic and medications. A
review of supervisory training records confirmed each of the authorized staff were trained in
medication administration. An interview with the clinical manager indicated if a youth arrives with
medication, nursing staff have protocols to verify the medication upon admission. All
medications must have a current, valid order, and are given as ordered on current prescription
or the Practitioner Order form. The RN clinical manager indicated, all non-licensed supervisors
are trained to assist in medication administration and the approved staff list is located in the
medical office. Medication administration is scheduled every day beginning at 8:00 a.m.,12:00
p.m., 5:00 p.m., and 7:00 p.m. and is held in the medical office. Nine youth were interviewed,
and five youth said the nurse administers medication and two said the doctor administers their
medication. Four youth indicated they do not take any medication. Nine staff were interviewed,
and one supervisory staff stated they administer medication to youth and eight staff indicated
they did not administer medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains a written policy and procedures requiring for any medical equipment
classified as sharps and stock medications to be secured and inventoried by using a routine
perpetual inventory with a descending count as each sharp is utilized and disposed of, or when
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the medication is utilized. Documentation of each individual dosage of medication administered
to youth is maintained on the Medication Administration Record to demonstrate the distribution
of medications. Observations of the medical clinic indicated it is secured and only accessible to
the healthcare professionals and approved supervisory staff. The juvenile justice detention
officer supervisors are non-healthcare, authorized staff who are trained by the registered nurse
(RN) to assist youth with self-administration of over-the-counter (OTC) medication and, in an
emergency, the epinephrine auto injector. The center has a secure refrigerator inside the locked
medical office. All medication requiring refrigeration is stored in a secured refrigerator used for
medication only. Nursing staff track daily temperatures of the refrigerator. A locked medication
cart is maintained in the medical clinic and stores oral prescription and OTC medications
prescribed for youth. The medication cart was clean and organized with stock items separate
from youth-specific medications. Narcotics and controlled medications had individual perpetual
descending inventories and were secured in a separate locked area inside of the medication
cart, behind two locks. Injectable, topical, and liquid medications were stored separately and
securely maintained. The center’s practice is for two nursing staff to conduct shift-to-shift
inventory counts of all controlled medications. Three different controlled medications, three
different sharps, and three different OTC medications were physically observed and counted.
These counts were compared with the counts listed on the individual inventory logs for each of
these items. All of the physical inventories matched what was listed on the inventory logs for
each of the items. The center maintains an inventory of all sharps and medical equipment
classified as sharps. A review was conducted of the medical binders for sharps and OTC
medications and confirmed a perpetual inventory was maintained for OTC medications. Items
designated as sharps are stored in a designated locked cabinet in the medical clinic and are
inaccessible to youth. An informal interview with the clinical manager validated the center’s
practice and procedures as to when inventory discrepancies occur. The center maintains a
contract with a licensed pharmacist. In an informal interview with the nursing staff, indicated the
center’s disposal practice for controlled medications and non-controlled medications is for the
licensed consultant pharmacist and the on-site nurse to dispose of the expired medication(s)
utilizing a chemical medication disposal agent. The nursing staff also confirmed the center
maintains a copy of the consultant pharmacy license on-site. All disposals are documented on
the Disposition and Destruction of Medications form. An interview with the clinical manager
confirmed the center's process for securing all medications and the process for the center’s
disposal of all discontinued medication.
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 requiring the implementation of infection control
procedures including prevention, containment, treatment, and reporting requirements related to
infectious diseases, according to the Occupational Safety and Health Administration (OSHA)
federal regulations and the Center for Disease Control (CDC) and Prevention guidelines. The
center maintains a separate Exposure Control Plan/Infection Control Plan, approved by the
designated health authority on January 21, 2025. Reviewed documentation supported the
Exposure Control Plan/Infection Control Plan was written in accordance with OSHA standards.
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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, bloodborne pathogens, other outbreaks and epidemics, outbreaks of
pediculosis, methicillin resistant staphylococcus aureus and other antibiotic-resistant micro-
organisms, food-borne illnesses, bioterrorism agents, chemical exposure in the workplace, and
protocols for needlestick post-exposure intervention and treatment. The community health
department completes all infectious disease and sexually transmitted infection testing, who
would then report to the CDC and Prevention . The local county health department, CDC, and
the Department’s Central Communications Center are notified of all incidents related to
infectious/communicable diseases. The center had no incidents of occupational exposure or
quarantining of at least ten percent of the population reported since the last annual compliance
review. The center ensures Hepatitis B immunizations are made available for staff and staff
have access to protective equipment. A review of nine youth Individual Healthcare Records
(IHCRs) supported each youth received infection control training within seven days of
admission. The infection control training included handwashing techniques, universal/standard
precautions, prevention/transmission of communicable diseases, vaccinations, and the CDC
guidelines for infection control. A review of nine pre-service and nine in-service staff training
records supported each staff received training on the center’s Exposure Control Plan/Infection
Control Plan. An interview with the clinical manager confirmed the center maintains an
Exposure Control Plan, which is available to the staff in the medical office. Additionally, the
clinical manager conducts the exposure control training for staff and youth. Nursing staff are
responsible for providing infection control training to both youth and staff. The clinical manager
indicated the center utilizes the local county health department services to provide additional
medical services for the youth.
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. Nursing staff ensure all
pregnant youth receive prenatal education to include alcohol and drug use, smoking, nutrition,
sexually transmitted infections, contraception, prenatal care, birthing process, postpartum care,
basic baby care, child/infant development, and parenting skills. While at the center, nursing staff
monitor each pregnant youth for weight and nutritional status. Nine youth Individual Healthcare
Records (IHCRs) were reviewed, and none were applicable for prenatal care/education. The
center was able to provide one IHCR for a pregnant youth who was at the center during the
annual compliance review period. A review of the applicable IHCR revealed the applicable youth
received prenatal care immediately upon determination of pregnancy which was continued until
discharge. The designated health authority provided routine, focused medical evaluations of
each pregnant youth every thirty days, while each youth was at the center. The youth was
placed on the Department’s Juvenile Justice Information System alert system. The reviewed
IHCR revealed the youth received education related to pregnancy including alcohol and drug
use, smoking, nutrition, sexually transmitted diseases, contraception, prenatal care, birthing
process, postpartum care, basic baby care, child development, and parenting skills. All required
topics were documented on the Education Health Record. The youth received nutritious food in
quantities appropriate for a pregnant youth. Nursing staff provided routine monitoring of
nutritional and weight status for each youth while at the center. A review of nine staff training
records verified each staff received girls’ health training specific to working with pregnant
youth/girls. Staff training was provided by the registered nurse at the time of hire and annually,
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thereafter. The center’s nursing protocols include treatment plans for pregnant youth. Nine
youth were interviewed, and two said they received prenatal, obstetrical, or gynecological
services when needed at the center and seven were not applicable. An interview with the
clinical manager confirmed female youth are given a pregnancy test upon admission if the youth
consent. In the event a youth is pregnant upon admission, the youth is educated on pregnancy
issues by the clinical manager, issued a special diet, started on pregnancy vitamins, and
scheduled for prenatal appointments and oversight by an obstetrician.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center maintains a written policy and procedures which outlines supervision of youth. Daily
observations were conducted each day of the annual compliance review. Staff were observed
actively supervising youth throughout the week. Observations included youth on the living
modules, preparing for court, lunch, breaks, frisk searches, participating in school, line
movements, staff youth interactions, and admissions. Staff were aware of the location of youth
assigned to their supervision. Several staff were asked the count, and they responded with the
number of youth under their supervision. Logbook reviews confirmed youth counts are
conducted by master control at the beginning, randomly, and at the end of each shift. The
center has a method of ensuring the counts are properly tracked and accurate. The center uses
the Department’s Juvenile Justice Information System census sheet and SharePoint as a
method of tracking. Nine staff were interviewed, and all stated the center has enough staff to
provide safety and security of the youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center maintains a written policy and procedures which provides a system of rewards,
privileges, and consequences to encourage youth to fulfill the program’s expectations. During
the annual compliance review week, youth and staff observations were conducted and
interactions between staff and youth appeared positive. Postings of the behavior management
system (BMS) were in all living areas and areas youth are housed. The system outlines
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appropriate and inappropriate behaviors, rules, norms, and expectations. The master control
and module logbooks for the past twelve months were reviewed, and there was documentation
to support youth received rewards and privileges for positive and appropriate behaviors. There
was documentation confirming youth received consequences for inappropriate behaviors as
well. The centers incentive calendar was posted on the living modules and throughout the
facility. All the youth living modules had level boards, where youth can see their progress
throughout the day. Nine youth were interviewed, and six stated the BMS is very good, and
three stated it was good. Nine interviewed youth all stated they are never allowed to punish
other youth. Nine youth were interviewed, and six stated the staff are fair when using rewards,
two stated staff are consistent with rewards, and one stated all staff are the same. All nine youth
were able to explain the difference between each level and how to move from level to level.
Nine staff were interviewed and were asked to explain the BMS. They all stated the system is
effective and all nine were able to explain how the system works. Nine staff were interviewed,
and nine stated rewards are provided to youth as part of the BMS. All nine reported rewards
include canteen, seven stated youth are given parties, eight stated extra phone privileges. All
nine staff stated they speak with youth to discuss the consequences being imposed and youth
are given an opportunity to explain their behavior. All nine staff stated staff speak with youth
regarding alternative acceptable behaviors. Nine staff were interviewed, and all nine stated staff
receive daily feedback on the implementation of the behavior management system. Additionally,
five stated they receive feedback on a as needed basis. The interviewed superintendent
reported the BMS is utilized to encourage positive behavior during a youth’s stay. The youth are
provided certain perks when they reach level three and maintain their level. The BMS sets
parameters for youth to govern their behavior without being coerced.
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 addressing ten-minute checks. Staff use
an electronic system by tapping it on the checkpoint sensor located outside each door.
However, as of September 2024, the system is no longer functioning, and the center is currently
using paperwork to document the ten-minute checks. The center has 133 cameras, and all were
operational, except for one. The center reported they have a work order to fix it. Videos are
stored for thirty days. Camera reviews were conducted for nine separate days across a variety
of shifts for the completion of ten-minute checks, and for all of the days all the checks were
completed under the ten-minute designated timeframe. Reviewed documentation reveal weekly
reviews of management oversight was conducted. Visual Observation Reports (VORs) and
camera review confirmed checks were conducted in the required frequency ensuring the checks
were met with fidelity. Nine staff were interviewed and each stated room checks are conducted
every ten minutes when a non-suicidal youth is placed in their room for seeping or non-
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punishment reasons. An interview with the superintendent reported once a youth is secured in a
room, a VOR is to be placed on the door with the youth's name, Department identification
number, room number, and the start time. Every eight and a half minutes a new check should
be documented on the VOR.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains a written policy and procedures ensuring staff always know the exact
number and location of all youth under their supervision. Observations of counts conducted
during the week of the annual compliance review showed counts were conducted at the
beginning of each shift, during emergencies, and randomly throughout the shift. A review of the
past twelve months of the master control logbooks confirmed census counts of youth were
conducted and documented at the beginning of each shift, randomly throughout the shift, and at
the end of each shift. A full day for each month for the past twelve months were reviewed and
confirmed counts were being conducted and documented as required. Counts were
documented following emergencies, disturbances, power outages, and drills. Census counts
were documented upon any change of population. Living module counts were recorded in their
assigned module logbooks by detention staff. The center conducts status checks of the areas,
in which the counts are recorded. Twelve months of logbooks were reviewed and confirmed the
center’s practice. Nine staff were interviewed, and all nine stated counts are conducted at the
beginning of the shift, end of the shift, before and after school, and before and after meals. Nine
staff were interviewed and asked when emergency counts were conducted. All nine stated when
a youth is believed to be missing, when visibility is hindered, and after a major disturbance.
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5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center maintains a written policy and procedures regarding logbooks. The center maintains
separate logbooks in master control and for each living module. There are logbooks for visitors,
contracted employees and education staff. During this annual compliance review, a review of
logbooks for the last twelve months revealed each logbook was bound with numbered pages, all
entries included the date and time of the event or incident with the name of the staff and youth
involved, and the initials of the staff making the entry. Entries regarding issues impacting safety
and security are highlighted. Observations included emergency situations, incidents, drills,
population counts at the beginning and end of each shift, group movements, searches, strip
searches, disturbances, admissions and releases, and the presence of law enforcement.
Logbooks appeared to be in good condition. The center’s superintendent or designee reviews
all logbooks on a weekly basis. The juvenile justice detention officer supervisor reviews the
logbooks maintained in master control when accepting the responsibility of the center and each
living area. The juvenile justice detention officer reviews the logbook maintained in living areas
when accepting responsibility of the area. Three full days of each month were reviewed during
the annual compliance review period with no issues noted.
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 maintains a written policy and procedures on key control. This policy addresses key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or
lost keys and reporting and replacement of damaged keys. All staff are trained in key control
prior to key assignment. All keys are stored on a tamper-resistant key ring which inhibits the
removal of keys. The center maintained a master key inventory which accounts for all key rings
by ring number, the number of keys on each ring, the capability of each key and to whom the
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keys are assigned to. Emergency keys which provide egress through exterior doors are stored
in master control and the living modules. The keys on the modules are in a secure key box with
limited access. Staff are required to count the keys upon accepting the module. A review of the
Key Control Logs, key control storge units, and observation of distribution and collection of keys
all confirmed staff were following policy and were using procedures to track center keys. The
center has several logbooks for providers and visitors, and they utilize a key control form to
assist in tracking center keys. Staff sign-out the keys at the beginning of the shift and sign-in at
the end of the shift. Education and provider staff keys are signed in and out using the logbook.
During the annual compliance review, the process for distribution of keys was observed and
there were no issues. Several staff were asked to show their keys, which were located on their
persons, staff were able to explain the process of missing or lost keys, and they explain the
capabilities of the keys. A review of the master key control inventory revealed the inventory
report matched the actual key rings in use. There were no reported incidents during the annual
compliance review period where the center had missing or lost keys. Personal keys are stored
in staff lockers, and visitor keys are stored inside master control on a hook. Once the visitor
departs the keys are returned. Supervisors, administration, and maintenance staff have access
to emergency keys. Nine staff were interviewed and all nine stated keys are given to master
control upon entry. Seven staff stated personal keys are securely stored, and visitors personal
keys are given to master control upon entry. Four stated a chit or token is provided to visitors,
and five stated the center keys are assigned to staff. Seven stated there is an inventory of keys,
youth do not have access to keys, they would notify master control of missing keys, the center
shall search for missing keys, and youth are searched for missing keys. Six staff stated keys are
replaced if damaged. The interviewed superintendent reported permanent keys are not
assigned.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains a written policy and procedures addressing transportation and the
maintenance and operation of Department vehicles. The center has twelve vehicles; however,
they only used ten to transport youth. Reviewed documentation confirmed annual vehicle
inspections were completed, and the maintenance staff/designee conducts monthly visual
checks of all transport vehicles which includes water coolant, lights, oil, emergency equipment,
brakes, horn, interior/exterior, and cleanliness. Documentation confirmed the maintenance
staff/designee conducts monthly visual checks of all transport vehicles which includes tires,
including spare, a battery test, windshield and wipers, windows, mirrors, and damage to include
all scratches and/or dents, and inspections are documented on the mandatory inspection form
and a copy of the form is maintained by the maintenance staff. Observations confirmed each of
the center’s vehicles had the appropriate number of seatbelts, a seatbelt cutter, a window
punch, a current fire extinguisher, and a first-aid kit with items approved by the designated
health authority. Reviewed documentation confirmed the van logbook documented
acknowledgement the vehicle was checked, destination, number of youth and staff names,
name of the officer riding in the back of the van, the time transport began, and the time transport
ended. Video observation confirmed prior to transport staff inspected the vehicle for
contraband, making sure the cage area of the vehicle is physically checked for objects and/or
contraband, ensured the vehicle had sufficient gasoline to reach the assigned destination,
maintained copies of current transportation procedures in each vehicle, verified seatbelts were
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securely anchored, tested the security screen/cage to ensure it was secure, confirmed the
vehicle folder contained the vehicle logs, vehicle and mechanical restraint keys, gas credit card,
and vehicle registration, ensured a cellular telephone was assigned to the vehicle and was
charged and turned on prior to departure, ensured the inspection was documented in the
vehicle logbook, ensured the vehicle was secured at all times, ensured all youth were searched
prior to being placed in a vehicle, and ensured youth and staff wore seatbelts. Observations
confirmed after transport, the transport staff ensured vehicles were searched for contraband,
ensured vehicles were locked to prevent the introduction of contraband, ensured youth were
searched upon return to the center, and ensured youth and staff wore seatbelts. Five vehicles at
the center were checked and all were locked when not in use. Nine youth were interviewed,
and each reported they feel staff are driving safely when transporting youth and have never
seen anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains a written policy and procedures ensuring all tools and equipment related
to maintenance are properly maintained, stored, and inventoried. During the annual compliance
review period, tools were secured behind two secure doors in the area restricted to
maintenance personnel and center administrators. The reviewed inventory was accurate at the
time of the annual compliance review and there were no missing tools noted. Ten randomly
selected tools were compared against the inventory and the inventory was accurate. The center
has a shadow board to easily identify any missing tools. The center maintains a perpetual
inventory of tools. All tools are checked out prior to use and checked in after use. The center
uses a tracking sheet to ensure tools are returned and accounted for. Maintenance staff
indicated inventory is conducted monthly and forwarded to the center’s superintendent or
designee for review. Kitchen tools included knives and other sharps which were stored in a
locked box in the kitchen area. A perpetual inventory of kitchen tools is maintained, and counts
are documented at the beginning of the day and at the end of the shift. All kitchen knives and
sharps were accounted for on the inventory sheets reviewed. There was no inventory missing or
documented as being missing at the center. Food service and maintenance staff were both
interviewed, and both were able to explain the process for missing or damaged tools. Nine staff
were interviewed and all stated youth are not allowed to use tools; however, they can use mops
and brooms. Nine youth were interviewed, and all stated they do not use any tools. The
interviewed superintendent reported the maintenance mechanic shall have an area designated
away from the secure floor for tools and supply storage. A shadow board will be utilized, to
ensure all tools are inventoried. Only superintendents and captains have access to tool areas.
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5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center maintains a written policy and procedures ensuring the proper use, storage,
disposal, and inventory of chemicals including poisonous, flammable and toxic materials. During
the compliance review week, the inventory was reviewed for five selected chemicals and
compared to the inventory sheet. All were accounted for. All chemicals are stored away from the
youth. The maintenance mechanic and the center’s administration only have access to the
storage. Safety Data Sheets were on hand at the time of review, and no sheets were missing.
Nine staff were interviewed, and all stated youth are not allowed to clean with substances
which are toxic, flammable, or poisonous. Nine youth were interviewed, and six stated they do
not clean with any type of cleaning agent such as bleach, laundry soap, window, or toilet
cleaners. Three youth stated, staff spray and they wipe it down.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains a written policy and procedure to ensure proper use, storage, disposal,
and inventory of chemicals including poisonous, flammable and toxic materials. During the
annual compliance review, observations of the storage area where chemicals, flammable and
toxic materials were kept indicated items were secured with limited access. An interview with
the maintenance staff determined flammable, toxic, caustic, and poisonous items were disposed
of appropriately. The center uses a contracted vendor for the bio-hazardous waste, in which
services are provided monthly. Monthly Inventories of flammable, toxic, caustic, and poisonous
items are conducted by the food service director, maintenance mechanic, and janitorial staff.
During the annual compliance review week, several months of inventory were reviewed and
each was signed by the center’s administrators. All poisonous, flammable and toxic materials
had the Safety Data Sheets on hand during the annual compliance review. The inventories
were compared to the items on-site and were found to be accurate and complete.
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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 maintains a written policy and procedures outlining the process of placing youth in
confinement under-twenty-four hours. Confinement under twenty-four hours shall be used as an
immediate, short term response strategy during volatile situations in which one or more youth’s
behavior immediately and substantially threatens the physical safety of others and compromises
security. During the annual compliance review period, the center had a total of five hundred
twenty-nine documented confinements under twenty-four hours. During the annual compliance
review, a total of fifteen confinement records under twenty-four hours were reviewed. Each
confinement record contained documentation which ensured each youth had the required
meals, access to medical care as required daily, access to mental health care as needed, daily
shower, clean clothing, access to hygiene items, mattress/bedding, and the right to grieve a
confinement placement. Three of the confinement reviews did not document the youth were
afforded education materials. Documentation reviewed for all fifteen confinements verified the
youth rooms were searched prior to placement. The center’s policy ensures any youth placed in
behavior confinement shall be supervised. The youth shall be supervised according to how they
are classified on the Detention Supervision Matrix thereafter. Supervision shall be documented
on the confinement Visual Observation Report log at the minimum of every five minutes for the
first hour in confinement and uploaded in the Facility Management System. All fifteen-
confinements reviewed were supervised according to policy. All fifteen verified staff conducted
five-minute checks every five minutes for the first hour. All fifteen reports verified the supervisor
conducted an initial confinement review with the youth no later than two hours from the incident,
and documentation for continued confinement was noted on the confinement reviews. All
fifteen-confinements had documentation the supervisor reviewed confinement every three
hours or less, while documenting youth behavior at the time of review. The superintendent or
designee reviews were documented on the confinement report within forty-eight hours excluding
weekends and holidays. All fifteen confinements were approved, and reports were completed
within the required timeframes. During this annual compliance review period there were no
pregnant youth placed in confinement. Nine staff were interviewed, and stated youth placed in
temporary confinement are provided educational materials. Each staff stated a confinement
report is completed, ten-minute checks are conducted, and the confinement room is searched.
Eight staff reported the parents/guardians are contacted, staff attempts to counsel youth, prior
to confinement, youth are checked every five minutes, confinement is logged in the logbook, the
supervisor is contacted, documentation is written on the on the confinement log, information is
logged in the logbook, and the lights are never turned off. The center’s superintendent stated,
the superintendent or designee shall review all confinements within forty-eight hours, excluding
weekends and holidays. They shall determine whether each confinement was appropriate or
inappropriate.
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5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center had no confinements over twenty-four hours for the annual compliance review
period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has a Continuity of Operations Plan which requires drills to be conducted and
documented, at a minimum, twice a year, with one drill being completed prior to the hurricane
season. The center has a planned and comprehensive approach to effectively manage
emergencies and disaster events, including those which require the center to relocate its youth
and staff while maintaining operations, safety, and security. A review of the center’s
documentation verified the center conducted the required drills during the annual compliance
review period. The center documented three drills for the past twelve months. One drill was prior
to the hurricane season and one was an actual event.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains a written policy and procedures ensuring the center is prepared to
address youth escapes, escape notifications, and prevention. All staff are required to be trained
in escape prevention annually. A review of the center’s Escape Prevention Plan confirmed it
included the Department’s established policies and procedures regarding escapes. During the
annual compliance review period, a review of the center’s escape drills for the past twelve
months showed all drills were documented, and drill forms were attached along with the staff
rosters. The Emergency Drill Reporting From included scenarios, a synopsis of the incident,
start and end date and time of drill, detailed information of issues, concerns, and training. Nine
staff interviews showed all nine staff have participated in an escape drill since the last annual
compliance review.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
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The center maintains a written policy and procedures for addressing fire prevention and safety.
The center has evacuation egress plans posted throughout the center. A review of the fire drills
and logbook documentation since the last annual compliance review found the center
conducted fire drills each month and on each shift. Reviewed documentation confirmed fire
extinguishers are inspected annually. Informally interviewed staff reported drills are reviewed
during staff meetings and shift briefings. Nine youth were interviewed and eight reported they
had been instructed on what to do in the case of a fire. Nine staff were interviewed and each
confirmed fire drills were conducted monthly.
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 to address searches and contraband.
Video observations of room inspections confirmed staff wore gloves during frisk and room
inspections. During the annual compliance review week, no strip searches were conducted. The
center conducts electronic/wand searches on all persons entering the center. All bags, cases,
jacket pockets and other items were searched. All personal keys, personal cell phones, and
other contraband items are prohibited from entering the secure area. Observations confirmed
rooms were searched prior to placing a youth in the room, and all rooms were searched for
contraband on each awake shift. A review of random shift reports for one day for each month
during each awake shift for the annual compliance review period confirmed youth room
searches were documented and completed as required. The center did not report any instances
which may have compromised the safety or security of the center throughout the annual
compliance review period. Observations during the annual compliance review week confirmed
searches of staff, visitors, and contractors/vendors were completed electronically and a frisk
search was completed prior to entering the secure area. Reviewed documentation confirmed
the center’s visitor log did contain a contraband attestation statement. Nine reviewed staff
records confirmed all staff had a contraband attestation form included in their record. Twenty-
three reviewed newly hired staff records contained a contraband attestation form. Reviewed
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documentation confirmed the center documented confiscation of contraband in the master
control logbook, completed incident reports identified findings and disposition of contraband, law
enforcement was contacted if any found item was considered illegal, or if there was evidence of
any type of unlawful activity, confiscated items were secured by the discovering officer and
hand-delivered to the supervisor, the shift supervisor documented the chain of custody of
confiscated items, the Department’s Central Communication Center (CCC) was notified of
discovery and confiscation of illegal contraband, and the regional director or designee was
notified of discovery and confiscation of contraband. An interview with the superintendent
reported contraband is to be confiscated immediately, an incident report shall be completed, a
CCC report will be initiated, and law enforcement will be called if the items are deemed illegal.
To ensure contraband is prevented from entering the secure area. Youth shall be electronically
searched, frisk searched, and strip searched within a juvenile detention center.
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source: DJJ