state: FL

facility_name: Collier Juvenile Detention Center

summary: QI Detention - FY24-25 - 1 finding

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Collier Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated )
3351 Tamiami Trail East
Naples, Florida 34112
Review Date(s): November 5-8, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Rosa Flores, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Serena Brown, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Interviews,
Video Observations)
Evan Hald, Office of Education, Regional Education Coordinator, South Region (Standard 2-
Education)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Welton Sanders, Palm Beach Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Yvrose Sylvain, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Collier Regional Juvenile Detention Center MQI Program Code: 1046
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Collier County / Circuit 20 Number of Beds: 40
Review Date(s): November 5-8, 2024 Lead Reviewer Code: 182
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
2.10 Educational Access*
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 58 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 58 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 58 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58 (Revised July 2023)
Program Overview
The Collier Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Naples, Florida. The center serves youth in Lee, Hendry, Glades,
and Charlotte counties in Circuit 20. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
forty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Collier County School District.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant II, seven juvenile justice detention officer supervisors (JJDOSs),
thirteen juvenile justice detention officer (JJDO) IIs, seventeen JJDOIs, a training coordinator, a
food service director, and two food service workers. Mental health and healthcare services are
provided through the contracted provider, VitalCore Health Strategies, LLC. Mental health
services are provided by a licensed clinical social worker (LCSW) who serves as the designated
mental health clinician authority (DMHCA). In addition to the DMHCA, the center has one
regional licensed supervisor and three licensed full-time therapists on-site. A licensed
psychiatrist provides psychiatric services for applicable youth in the center. Clinical services
provided by the center include mental health and substance abuse evaluations, mental health
treatment planning, individual, group, and family therapy, mental health crisis intervention
services, on-site psychiatric services, and availability for substance abuse services for youth
with co-occurring disorders. Medical services are provided by one medical doctor (MD) who
serves as the designated health authority (DHA), one advanced practice registered nurse
(APRN), four registered nurses (RNs), and one licensed practical nurse (LPN). The medical
clinic maintains nursing coverage Monday through Sunday from 8:00 a.m. to 5:00 p.m. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has two living modules which are divided by male and female. There are sixty-eight
security cameras at the center, and all were operational the week of the annual compliance
review. A tour of the center was conducted during the annual compliance review week and
observations found it to be clean, the exterior was free from debris, the grass was manicured,
and the center was free from insect infestation. The observed lobby area was clean and had no
broken furniture. The youth living areas and bathrooms were observed to be clean and the
bathrooms were functional. There was no graffiti observed at the center. The classrooms,
kitchen, and dining area were found to be clean and well organized. At the time of the annual
compliance review, the center had ten vacancies, which included four JJDOIs, two JJDOIIs, one
food service worker, one administrative assistant I, one other personnel services (OPS) clergy,
and one maintenance mechanic.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures ensuring initial background screenings are
conducted on all newly hired staff, contracted providers, mentors, interns, and volunteers. The
Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the
Department’s Background Screening Unit (BSU)/Clearinghouse on January 29, 2024, meeting
the annual requirement. The Annual Affidavit of Compliance with Level 2 Screening Standards
for school district teachers was submitted to the BSU/Clearinghouse on January 31, 2024. A
review of the initial background screenings for eight newly hired staff revealed the center
received background screening results from the Department’s BSU/Clearinghouse prior to each
staff’s date of hire. There were no new volunteers or any contracted staff applicable for
background screenings since the last annual compliance review. All required documentation
was reviewed prior to hire for each staff. None of the reviewed staff were applicable for a break
in service. One of the eight staff was applicable for a background screening exemption. The
center utilizes ergometric (ERGO), which is a pre-employment assessment tool, for all direct
care applicants. Seven applicants were applicable for being direct care, and each record
included a copy of the pre-employment assessment passing score or exemption, which was
maintained in accordance with policy. One staff was not a direct care staff and did not require a
pre-assessment. Reviewed documentation validated the center added all applicable staff to the
Clearinghouse employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures which require staff, contracted staff, and volunteers
to be rescreened every five years from the initial date of employment. A review of the staff roster
found the center had three staff eligible for a five-year rescreening. The center had no
contracted staff or volunteers eligible for rescreening. Reviewed documentation confirmed each
applicable staff’s rescreening was completed and submitted to the Department’s Background
Screening Unit (BSU)/Clearinghouse within the required time frames.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures regarding 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 revealed the staff signed a code of conduct. The code of conduct addressed
officer professionalism, poor performance, negligence, insubordination, conduct unbecoming of
a public staff, and misconduct. Each of the reviewed personnel records contained disciplinary
actions for violations of the code of conduct. A review of the three code of conduct violations
indicated two staff received a written reprimand and one received a suspension. In each
instance, management took immediate corrective action to address misconduct when staff
violated policies and procedures. None of the reviewed staff had received any commendations.
Five youth were interviewed, and each youth reported they never had to report abuse. Five
youth reported staff are respectful when talking with them and other youth. Four youth reported
they have never heard staff use profanity when speaking to them or other youth, and one youth
indicated having heard a staff use profanity once; however, indicated the staff used profanity in
a general conversation and not towards any youth. Each youth reported they have never been
threatened or heard staff threaten other youth. Five interviewed youth indicated they feel safe in
the center, and have never exchanged emails, telephone numbers, or social media contact
information with staff. Five interviewed staff were able to explain the process for allowing staff
and youth to call the Florida Abuse Hotline or the Department's Central Communications Center
(CCC) to report suspected abuse. Four of the five interviewed staff indicated they have never
observed a co-worker using profanity when speaking to youth. One staff indicated they heard a
staff use profanity on one occasion due to the staff getting injured and using profanity in
response to the pain. All five staff indicated they have never observed a co-worker using
threats, intimidation, or humiliation when interacting with the youth. Two staff reported working
conditions were very good at the center, and three reported conditions were good. An interview
with the superintendent confirmed staff must act in a professional manner with youth and peers,
staff’s behavior shall be respectful towards others, and staff are expected to be role models for
the youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures to ensure when a reportable incident occurs the
center notifies the Department’s Central Communications Center (CCC) within two hours of
becoming aware of the incident. The center had thirty-eight reportable incidents since the last
annual compliance review. A review of five incidents confirmed all were reported to the CCC
within two hours of the incident or when staff became aware of the incident. Four of the five
incidents were documented in the center’s CCC logbook, and one was not documented in the
center’s CCC logbook. This information was shared with the administration staff during the week
of the annual compliance review. A review of the center’s internal incident/grievance reports
revealed there were no additional incidents which should have been reported to the CCC. An
interview with the superintendent indicated all reportable incidents must be called in to the
Florida Abuse Hotline and/or the CCC within two hours of the incident, as required.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures pertaining to the use of Right Interactions model
(RI), in accordance with Florida Administrative Code. The center had a total of forty-nine RI
incidents since the last annual compliance review. A review of nine RI incident reports
confirmed each of the nine reviewed RI Reports were completed by the end of the staff’s
workday. Each of the reviewed reports contained statements from all the staff involved. None of
the incidents resulted in serious injury to the youth or staff, required the use of mechanical
restraints, or needed to be reported to the Florida Abuse Hotline. All nine RI Reports were
reviewed and processed by a supervisor or an RI instructor. Each of the RI Reports confirmed a
post-RI interview was conducted with each youth by the center’s administration within thirty
minutes after the incident. None of the youth were applicable for a post-RI medical review. The
superintendent reviewed each report after all other reviews and made any necessary comments
within seventy-two hours. A review of internal incident/grievance reports and logbooks since the
last annual compliance review confirmed there were no additional RI incidents which did not
have a report. Five interviewed staff reported staff try to talk to youth prior to using RI or
mechanical restraints. An interview with the superintendent indicated physical and mechanical
restraints are tracked. Additionally, they indicated the process for monitoring RI incidents and
use of force is through the Department’s Juvenile Justice Information System (JJIS).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures addressing the training and certification
requirements for all new staff. Phase One training consists of instructor-led and web-based
courses. Phase Two consists of 120 hours of academy instructor-led training. A review of five
staff training records for pre-service training indicated each staff completed all required trainings
within 180-days of hire. Reviewed documentation showed each applicable staff completed all
trainings required by the Department prior to having contact with youth. Three of the five staff
training records showed all pre-service trainings were completed and documented in the
Department’s Learning Management System (SkillPro), and two staff training records confirmed
completion; however, had not been entered into SkillPro. An informal interview with the training
coordinator indicated the staff’s training had not been added to SkillPro due to Department-wide
system outages. Reviewed documentation confirmed the staff’s completion of training and the
center authorization to enter the trainings into SkillPro during the annual compliance review
week.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures which require staff to complete twenty-four hours of
in-service training each calendar year after completion of pre-service certification training. The
policy requires supervisors to complete eight hours of supervisory training in addition to the
twenty-four hours of in-service training. The center provides in-service training to staff through a
combination of the Department’s Learning Management System (SkillPro) web-based and
instructor-led classes. Five staff training records were reviewed for in-service trainings, which
included three direct care staff and two supervisory staff. Each of the reviewed staff records
confirmed each staff completed the required twenty-four hours of the mandatory training topics
which are to be completed annually. Two staff were applicable for a minimum of eight hours of
supervisory training and each staff completed the required minimum hours. All trainings were
documented in SkillPro. Reviewed documentation confirmed the center has a licensed
registered nurse (RN) who provides in-service training annually for the education on girls’
healthcare, to all non-healthcare staff involved in the supervision or treatment of girls. The
center has an annual in-service training calendar which is updated as changes occur. The in-
service training plan was approved by the highest ranking official at the center, the
Department’s assistant secretary for Detention Services on November 17, 2023, and by the
director of the Department’s Office of Talent, Leadership, and Culture (TLC) on December 15,
2023. An interview with the superintendent confirmed the center’s practice for training and
development.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures in place related to youth grievances to ensure each
youth has the right to grieve and ensure all youth are treated fairly, respectfully, without
discrimination, and their rights are protected. The grievance process is posted in each living
module and explained to each youth during the admission and orientation process. The center
keeps blank grievance forms on the youth living modules which are available for youth upon
request. The center’s staff will then input the completed grievance into the Department’s Facility
Management System (FMS) in the Department’s Juvenile Justice Information System (JJIS).
The process includes an informal phase, formal phase, and the appeal phase. During the week
of the annual compliance review, the center had one documented grievance. One youth
grievance was reviewed and found the grievance was resolved at the formal phase and was
reviewed within the required time frame. An interview with the superintendent confirmed the
center’s grievance process. Additionally, the superintendent indicated all completed grievance
forms are maintained in JJIS and a hard copy is maintained in the administration office. Five
interviewed youth were able to explain the grievance process. Each of the five youth reported
never having filed a grievance. Five staff were interviewed, and all staff were knowledgeable
and could explain the center’s grievance process.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58 (Revised July 2023)
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures outlining the process of entering and sharing alerts.
The center’s practice is to appropriately enter, downgrade, or discontinue alerts in the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been identified prior to the youth’s admission. A review of five youth records
confirmed alerts were documented in accordance with the center’s policy. The reviewed youth
were applicable for nineteen separate alerts. Each reviewed youth record documented alert
types and the name/title of staff removing/updating alerts. Each alert was documented in the
logbook. Documented alerts were accurately entered and matched in JJIS. Reviewed
documentation indicated alerts were discussed during shift briefings and reviewed daily by
supervisors and administrators. All applicable alerts were downgraded and removed by the
medical staff and/or the mental health staff, as applicable. A printed copy of the alert report is
provided to the supervisory and detention staff on each shift daily, and the alerts are reviewed
with staff during each shift briefing. An observation of a shift briefing during the annual
compliance review week confirmed the youth alert information is discussed with the staff during
the meeting. An interview with the superintendent confirmed the center’s practice for medical
alerts. Five staff were interviewed and reported they are informed of security, safety, medical,
and mental health alerts which are specific to youth, through shift debriefings, the alert forms,
JJIS, and logbooks. Five staff were interviewed, and each staff reported management informs
staff about issues within the center through staff debriefings, meetings, as well as other forms of
communication, and through emails. Five interviewed staff indicated the process for
communicating information within the center is very good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a practice in place regarding data trend analysis. The center uses data to
minimize confinements, use of Right Interactions (RI), and incidents. An informal interview with
the superintendent indicated the center’s practice regarding data trend analysis is to review
incident reports, confinements, RI Reports, the Department’s Central Communications Center
(CCC) reports, staff retention reports, and vacancies. The center conducts monthly meetings to
ensure all staff are made aware of imperative information regarding the center; additionally, the
information is accessible to staff for review. Reviewed documentation, such as sign-in sheets
and Detention Review meeting notes confirmed the center’s practice of sharing information with
staff and administration. The center conducts weekly Detention Review meetings where
information is provided to the juvenile probation officers (JPOs), medical staff, mental health
staff, and lead teachers. Additionally, the center shares information with providers and
stakeholders during quarterly advisory board meetings.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 58 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures to ensure all youth are admitted to the center in
accordance with Florida Administrative Code. Five youth case management records were
reviewed. Each reviewed record included an arrest affidavit/custody order, a Detention Risk
Assessment Instrument (DRAI), and a Suicide Risk Screening Instrument (SRSI). All five youth
records included documentation to confirm each youth was full-body and electronically searched
by a juvenile justice detention officer (JJDO) of the same gender as the youth. Each youth
record reflected the youth were offered telephone calls and none of the youth refused to make
the call. All five records documented a meal was provided to each youth upon intake.
Documentation supported all five youth received medical, mental health, and substance abuse
screenings upon admission. An observation of one youth intake was conducted during the
annual compliance review week. The youth was full-body and electronically searched by a
JJDO of the same gender. The youth was offered a telephone call; however, the youth refused
to make a call. The youth was given snacks in the morning and was provided a hot meal at
lunchtime. During the admission process, the youth received an orientation to the center
verbally and in writing, which included all required elements. The staff reviewed and followed all
the procedures.
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
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9. Youth rights.
10. PREA-related information
The center has facility operating procedures to advise youth of center rules and regulations,
expectations for behavior and related consequences for failing to meet those expectations, and
youth rights within twenty-four hours of a youth being admitted into the center. A review of five
youth case management records found four of the five records contained an orientation
acknowledgment form signed by each youth confirming orientation took place within twenty-four
hours of the youth’s admission into the center. The fifth youth refused to sign all the orientation
documents and the juvenile justice detention officer (JJDO) documented the youth refusal in
writing on each form. Each reviewed record revealed all youth were advised both verbally and in
writing of the orientation process. Each packet included information regarding rules and
regulations, grievance procedures, visitation, telephone calls, access to medical treatment,
mental health and substance abuse services, access to the Florida Abuse Hotline, the
Department's Central Communications Center (CCC), behavior expectations and related
consequences, possible new law violations for destruction of property, youth rights, and Prison
Rape Elimination Act (PREA) related information. A youth admission which included an
orientation was observed during the annual compliance review week and included all elements
as outlined in the center’s policy. The staff explained the rules and regulations, expectations for
behavior, youth rights, and policies to the youth. In addition, the youth watched the PREA video.
Five youth were interviewed and each reported receiving information about the center’s rules
and regulations, daily schedule, education services, visitation, abuse reporting, and behavior
management system (BMS) when admitted.
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.
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The center has facility operating procedures regarding classification and orientation to ensure
each youth is protected from harm, violence, and/or victimization. Five youth case management
records were reviewed, and each documented information concerning each youth’s history and
status, as well as all other required information. Considerations on the classification form
included mental illness, intellectual disabilities, physical disabilities, history of violent behavior,
gang affiliation, criminal behavior, history of sexual offenses, Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) screening results, medical issues, identified or suspected
suicide risk issues, escape, security, and history of human trafficking. The Department’s
Juvenile Justice Information System (JJIS) Admission Wizard was completed and located in all
five youth records. This information is reviewed for room assignment based on potential safety
and security concerns, which included information on the youth’s gender, height, weight, age,
and level of aggressiveness. All five youth records indicated each youth was assigned to a room
based on classification procedures, and if the youth had a history of committing sexual offenses
or was a victim of a sexual offense they were placed in a single room. None of the youth
reviewed had a reclassification at the time of the annual compliance review. The center’s
practice is to enter all suspected gang affiliation alerts into JJIS and notify the youth’s juvenile
probation officer (JPO) by email. The center has a screening process for youth newly admitted
into the center to determine if the youth is a gang member or gang affiliated. None of the five
case management records reviewed were applicable for suspected gang affiliation. The center’s
superintendent reported being notified of any related gang information by email and through the
JJIS alert system. An interview with the superintendent confirmed all factors included VSAB,
youth charges, and youth alerts are taken into consideration when assigning youth to a room.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has a screening process for youth newly admitted into the center to determine if the
youth is a gang member or gang affiliated. The center's gang representative is responsible for
notifying the circuit’s juvenile probation officer (JPO), designated as the circuit gang
representative, regarding any indication of gang activity by email. The assistant superintendent
serves as the gang representative who reviews identified youth for suspected gang involvement.
The center’s gang representative enters all suspected gang affiliation alerts into the
Department’s Juvenile Justice Information System (JJIS), when applicable. All staff are made
aware of the alerts during daily shift briefings. A review of five youth case management records
found none were applicable for suspected gang affiliation. The center reported not having any
gang identified or affiliated youth since the last annual compliance review. An informal interview
was conducted with the center’s gang representative. The center’s gang representative stated
the documented gang members’ information is emailed to the youth’s JPO, and the center’s
superintendent. An alert is entered into JJIS if a youth is admitted/identified with gang affiliation
and then the youth’s JPO reports this information to local law enforcement.
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2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures to ensure a youth's personal property is maintained
securely and returned to the youth in a timely manner upon their release. The youth’s property
is itemized and documented on the Property Receipt form in the Department’s Juvenile Justice
Information System (JJIS). Five youth case management records were reviewed. Four of the
five reviewed youth case management records contained a Property Receipt form. Each receipt
form documented each youth’s and staff name, a Letter of Acknowledgement of Unclaimed
Property form, and a list of each surrendered item for the youth's personal property. One youth
was on a courtesy hold/pending placement from another detention center and did not have
personal property. Three youth with property signed, and the fourth youth refused to sign a
Property Receipt form and the juvenile justice detention officer (JJDO) documented the youth
refusal in writing on the form and notified a supervisor. Documentation showed the supervisor
reviewed and documented the youth’s refusal on the Property Receipt form. The center
maintains a secure drop safe logbook. Documentation supported all valuable property is placed
in a clear tamper-proof bag, logged into the drop safe logbook with date, time, name of the
youth, Department identification number (DJJID), name of the JJDO securing the property, and
the officer's initials. The center's practice is to place the clear bag into a drop safe, which is
under video surveillance twenty-four hours a day. Personal property such as clothes and shoes
are placed in property bags and placed into the secured property room. The information
documented on the bag included the date, the youth’s name, the DJJID, and a listing of items in
the bag. Observations of the center’s secured property room during the annual compliance
review week found non-valuable property such as clothing and shoes placed in a property bag,
zipped, and secured in the property room. Observations of three youths’ personal property
revealed each youth’s personal property had the youth DJJID and a completed inventory form.
Reviewed documentation of three youth’s valuable property verified the valuable property was
documented in the drop safe logbook for each youth. Observations indicated the valuable
property was stored in a clear tamper-proof bag for all three youth. There were no releases
available for observation during the week of the annual compliance review. An observation of a
youth’s admission into the center validated the center’s process for securing and storing youth
property. The center’s supervisors are the designated staff who have access to the youth’s
personal property. The Department's Central Communications Center (CCC) reports since the
last annual compliance review did not document any reported incidents regarding youth
property. Four of the five interviewed youth verified staff checked their personal property upon
their admission at the center and had the youth sign a form stating the personal property was
correct. One youth reported they couldn't really remember because they have memory
problems. The interview with the center’s superintendent indicated upon a youth’s admission to
the center, the youth property is documented in JJIS and a property form is signed by the officer
and the youth. The property is then placed in the secure property room, and only administration
and supervisors have access to the room.
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2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures to ensure all releases from the center occur
promptly and accurately. Five youth case management records were reviewed, and none were
applicable for release procedures. Three additional closed records were requested and
reviewed. All three closed records documented the on-duty supervisor reviewed all release
paperwork prior to each youth's release. All three closed youth case management records
included documentation the juvenile justice detention officer supervisor (JJDOS) reviewed the
release paperwork received from the court, and each youth’s identification was verified prior to
release. All three youth were released to a parent/guardian. A copy of the parent’s/guardian's
driver’s license and/or identification card was placed in the record, and the parent/guardian was
notified, in writing, of each youth's next court date. None of the youth had an endangered
person alert. The date of admission and the date of release were documented in each youth’s
record and correlated with the Department's Juvenile Justice Information System (JJIS). All
applicable parties signed all applicable release paperwork. There were no youth released during
the annual compliance review week; therefore, an observation of a youth being released was
not conducted.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures to ensure youth's personal property is maintained
securely and returned to the youth in a timely manner upon their release. The center’s policy
outlines procedures regarding release of youth with prescription medications. Three closed
youth case management records were reviewed. All three closed records documented each
youth and parent/guardian signed the Property Receipt form, acknowledging receipt of each
youth's personal property. Each reviewed record documented each youth was released to an
appropriate person and a copy of their identification was obtained. None of the reviewed youth
were on medications at the time of release from the center and three additional closed records
were reviewed for release with prescription medications. Each of the three closed additional
records supported the receipt of medications was signed by the person receiving the youth
using the Department’s Health Discharge Summary Transfer Note form. All three closed records
documented each youth, and the person to whom the youth were released, were reminded of
any health or welfare issues, including medical, mental health, and/or substance abuse needs,
and any pending appointments. An informal interview with the center’s superintendent reported
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the center did not have any property held for more than thirty days since the last annual
compliance review. There were no youth released during the annual compliance review week;
therefore, an observation was not conducted.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention Review meetings are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate Detention Reviews.
The center has facility operating procedures ensuring Detention Reviews are conducted weekly
for youth securely detained and to ensure proper management of youth and the sharing of
information. During the annual compliance review week, an observation of a Detention Review
meeting was conducted. All parties were present from all required departments. The juvenile
justice detention officer II (JJDOII) chaired the meeting. The center’s JJDOII reviewed and
discussed all securely detained youth, alerts, and waiting lists, which included youth waiting for
placement in a commitment program and items needed to be completed before the Department
can place the youth on applicable waiting lists. During the Detention Review meeting, the
JJDOII discussed all medical and mental health updates. Weekly Detention Review meetings
are attended by the JJDOII, juvenile probation officer supervisors (JPOSs), mental health staff,
medical staff, and education staff. Reviewed documentation from March 21, 2024, to November
7, 2024, supported Detention Review meetings were held weekly at the center. An interview
with the center’s superintendent reported education staff, medical and mental health staff,
JPOSs, juvenile probation officers (JPOs), and detention staff participate in the Detention
Review meetings, which are conducted through video conferencing in the center’s conference
room. During the meeting, all aspects of the youth are discussed and include youth releases,
legal status, detention status, medical and mental health status, and the youth's behavior in the
classroom, and in the center is reviewed.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures to address the daily activity schedule. Youth are
provided the opportunity to participate in constructive activities benefiting the youth and the
center. The daily activity schedule outlines the activities and is posted in each living module and
the dining hall. The schedule included times for wake-up and personal hygiene, mealtimes,
visitation, recreation and physical activities, indoor activities, shift change, bedtimes, groups,
and open program time. Observations of youth engaged in various activities throughout the
annual compliance review week were conducted which included youth searches, educational
programming, lunch times, indoor recreation times, and open programming times. Five
interviewed youth reported the center has a daily activity schedule and the daily schedule is
followed. Five interviewed staff reported the center has a daily schedule which is followed.
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2.10 Educational Access (Critical) Limited Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to ensure educational access for youth. Collier
County School District provides educational services and approves the educational calendar,
which incorporates days for teacher planning and/or training. The daily school schedule reflects
five hours of instruction each day, which meets the required minimum of 300 minutes of
instruction each day. Three random days of video footage were reviewed for educational access
which confirmed education classes were not facilitated as scheduled. Each of the three random
days of video footage reviewed for the boy’s module reflected education instruction ended
between twenty-one and forty minutes early. A review of logbooks for one random day from
each month from December 18, 2023, to November 5, 2024, for start and stop times was
completed. Documentation confirmed the school schedule was followed for nine of the twelve
random days reviewed. For three randomly chosen days, school ended between twenty-five
minutes and one hour and forty minutes early. Documentation for the three days did not reflect
why the school schedule was not followed. The center’s staff reported medication administration
was scheduled and was occurring during first period for youth who take medications; however,
the center reported the scheduled medication administration was approved by the Department’s
Office of Health Services. Five youth interviews were completed, each of the interviewed youth
reported they attend school Monday through Friday while in the center. Each interviewed youth
reported the program was preparing them very well or well for high school, high school
equivalency diploma (GED), vocational school, employment, and/or college. Five staff were
interviewed and four reported there is minimal interference with educational instruction. One
staff reported there is interference with educational instruction due to the time medications are
administered daily. An interview with the center’s superintendent reported there is minimal
interference in educational instruction.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide career education. The center provides
career education programming which meets the requirements of a Type 1 program and
incorporates communication, interpersonal and decision-making skills, as well as life skills and
activities through the personal career and social development class. Five interviewed youth
reported taking core classes such as life skills, career choices, math, science, history, reading,
and social studies.
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Office of Accountability and Program Support Page 22 of 58 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA), who is
responsible for the coordination and implementation of mental health and substance abuse
services. The Department maintains a contract with VitalCore Health Strategies, LLC. to provide
mental health and substance abuse services to all applicable youth in the center. The contract
requires a full time licensed professional to serve as the DMHCA for forty hours each week. The
DMHCA is a licensed mental health counselor (LMHC) with a clear and active license in the
State of Florida, with an expiration date of March 31, 2025. The DMHCA is a full-time staff and
scheduled to be on-site forty hours each week, Monday through Friday from 8:00 a.m. to 4:00
p.m. A review of the mental health sign-in logbook since the last annual compliance review
confirmed the DMHCA was on-site, as required by the contract and their position description.
The DMHCA is available seven days a week, twenty-four hours a day, by way of telephone for
consultation. The center has a back-up DMHCA in the event of scheduled leave and/or
absences, who is a full-time clinical staff. The back-up DMHCA is a licensed clinical social
worker (LCSW), licensed in the State of Florida, with a license expiration date of March 31,
2025. An interview with the DMHCA verified the DMHCA is responsible and accountable for
ensuring appropriate coordination and implementation of mental health and substance abuse
services at the center. The DMHCA promotes consistent and effective services and allows the
superintendent and staff a specific source of expertise and referral. The DMHCA indicated the
frequency of communication with the center's staff is weekly.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The center requires
mental health and substance abuse services to be provided by individuals with appropriate
qualifications. The clinical supervisor ensures the licensed clinical staff are performing services
based on their education, training, and experience. The center has three licensed mental health
staff contractual positions, in addition to the designated mental health clinician authority
(DMHCA). Copies of all licenses were provided and were on-site for review in the mental health
office, as required. A review of the licensed clinician credentials indicated one clinician had an
active license in the State of Florida as a licensed mental health counselor (LMHC) with an
expiration date of March 31, 2025, the second was a licensed clinical social worker (LCSW) with
an active license in the State of Florida expiring on March 31, 2025, and the third was a mental
health clinician registered as a marriage and family therapist with an active license expiring on
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January 31, 2027. The informally interviewed DMHCA stated all mental health staff are licensed;
therefore, a Chapter 397 license was not needed.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. The center does not
have a Chapter 397 license with the Department of Children and Families. All mental health
services are provided by licensed mental health professionals and the center does not have any
non-licensed mental health clinical staff. Reviewed documentation indicated only the licensed
mental health counselors were facilitating all substance abuse treatment and groups. In an
informal interview, the designated mental health clinician authority (DMHCA) stated all mental
health staff are licensed; therefore, a Chapter 397 license was not needed. There were no
reported vacancies for clinical staff during the annual compliance review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure the mental health and substance abuse
needs of youth are identified through a comprehensive screening process. The center’s policy
requires referrals to be made when youth are identified with mental health and/or substance
abuse needs or are identified as a possible suicide risk in accordance with Florida
Administrative Code. A review of five youth mental health and substance abuse records
indicated each youth was processed in the Juvenile Assessment Center (JAC). The juvenile
probation officer (JPO) conducts the intake process by completing 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). The juvenile justice detention officer (JJDO)
reviewed each youth’s MAYSI-2 results documented on the Department’s form, Face Sheet,
and alerts upon admission. The JJDO completed their assigned section of the SRSI for all five
youth. All five SRSIs were reviewed by a nurse and/or mental health professionals. Each of the
five SRSIs had completed entries, which included an accurate referral selection in the
“Screening Results” section. All five reviewed records had a positive “YES” response on the
SRSI and indicated each youth was placed on suicide precautions and a mental health referral
was completed, which documented the youth’s need for an Assessment of Suicide Risk (ASR).
All five reviewed youth records were applicable for suicide precaution placement based on an
open or closed suicide risk alert in JJIS. All five of the MAYSI-2s were completed by trained
staff. Four of the five reviewed records’ SRSIs and MAYSI-2s indicated further assessment was
needed. One of the five records was applicable for having all negative responses marked no by
the screener, invalidating the screening. Three of the five reviewed MAYSI-2s required a
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referral, a referral was made, and the superintendent or designee was notified of the referrals
made for assessments. Two youth were not applicable.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures outlining the process to identify the mental health
and substance abuse needs of youth through a comprehensive screening. The center’s policy
requires the youth with identified needs to be referred for a further, in-depth mental health
and/or substance abuse evaluation. Five reviewed youth records indicated three youth were
identified after admission and referred for an evaluation. One youth was applicable for a
Substance Abuse and Mental Health Assessment (SAMH) update completed by center staff and
had a community assessment completed as well. One youth was applicable for a new SAMH to
be completed by center staff, and the final youth was applicable for a community assessment
while they were in the center. Both the SAMH update and new SAMH were completed by each
youth’s thirty-first day. The juvenile probation officer (JPO) was contacted to obtain an updated
status of the community assessment for the one applicable youth. The two applicable SAMHs
included treatment recommendations made for all diagnosed mental health or substance related
disorders. Each of the evaluations obtained from a community provider contained treatment
recommendations which corresponded to all diagnosed mental health or substance related
disorders and all the required elements including signature of the licensed mental health
professional (LMHP). An interview with the designated mental health clinician authority
(DMHCA) indicated youth will receive a new or updated comprehensive mental health and or
substance abuse assessment evaluation within thirty days of admission. Additionally, youth will
receive a comprehensive mental health evaluation/comprehensive substance abuse evaluation
if the youth is exhibiting behavior indicating the need for an assessment while in detention.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures for mental health and substance abuse treatment
and discharge planning. The provider’s contract requires the superintendent and designated
mental health clinician authority (DMHCA), or mental health/substance abuse clinical staff to
ensure the development and review of an initial and/or individualized treatment plan for each
youth receiving mental health/substance abuse treatment in the center. Five youth mental
health and substance abuse records were reviewed, and three records were applicable for
mental health and substance abuse treatment services. All three applicable youth had a mental
health orientation held within fourteen days of admission and required a treatment plan. All three
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initial treatment plans were documented on the Department’s Initial Mental Health/Substance
Abuse Treatment plan form which had all required information and were created within seven
days of the onset of treatment. Three records had an individualized treatment plan (ITP) created
within thirty-days of the youth’s admission by mental health staff. Each ITP indicated the reason
for referral for treatment, the initial Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis/symptoms, treatment goals, methods of treatment, including group or
individual counseling, treatment-focused symptoms, strengths/needs, the medication the youth
was admitted on, and psychiatric services including the frequency. The mental health/substance
abuse professional’s signature and youth’s signature were present on all three ITPs. All three
youth were assigned a mini-treatment team, and all required staff were involved with the
development of the initial treatment plan. A review of the documented ITPs indicated two of the
three youth had prescribed psychotropic medications listed at the time the plan was developed.
All three plans had progress notes documenting the youth was receiving treatment services as a
stipulated in the treatment plan. One youth had two reviews, another youth had three reviews,
and the last applicable youth had one documented review which occurred at thirty-day intervals,
as required. Modifications were documented on the review form. Documentation confirmed the
clinical staff, youth, licensed mental health professional, parent/guardian, and treatment plan
members reviewed and signed all three ITPs. Each of the three applicable ITPs included
treatment and services provided by a licensed psychiatrist. None of the youth were applicable
for having been an alleged victim of a Prison Rape Elimination Act (PREA) incident, requiring
additional services. A review of three closed records indicated all three youth, their
parent/guardian, and their juvenile probation officer received a signed discharge plan
documented on the Department’s Mental Health/Substance Treatment Discharge Summary
form. All three closed records had documentation showing the completion of services and
signature of the licensed mental health professional. No additional documentation was
uploaded. A mini-treatment team was observed during the annual compliance review week. The
mini-treatment team consisted of mental health, medical, youth, direct care staff, the youth, and
the therapist. Discussed topics consisted of youth’s changes in medication, the level on the
behavior management system, and their relationship with family members. According to the
DMHCA, youth determined to have a serious mental disorder or substance abuse impairment
receive mental health and/or substance abuse treatment at the center. Additionally, youth have
an initial or individualized mental health or substance abuse treatment plan based off findings in
the comprehensive mental health and or substance abuse assessment/evaluation or psychiatric
evaluation/diagnostic interview. A youth's individual treatment plan is reviewed once every thirty
days. Changes or updates are made as youths' objectives and goals are met or as they change.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The provider’s contract has facility operating procedures in place for mental health and
substance abuse treatment planning to focus on treatment provisions to reduce or alleviate
youth’s symptoms of mental disorder or substance abuse impairment and enable youth to
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function adequately in the juvenile justice setting. Five youth mental health and substance
abuse records were reviewed, and three were applicable for receiving initial mental health and
substance abuse treatment services. All three reviewed youth records included documentation
the youth required treatment, and each was assigned to a mini-treatment team which consisted
of clinical mental health staff, one staff from a different service area, the youth, and the youth’s
parent/guardian. Each reviewed record contained documentation of the youth receiving mental
health treatment in the form of individual therapy, group, family, and/or supportive counseling
sessions at the frequency required by the plan. Two of the three records indicated the youth
received substance abuse treatment in the form of group, individual, and/or supportive
counseling sessions. Reviewed records supported each youth had an Authority for Evaluation
and Treatment (AET) and proper consent forms for substance abuse treatment and information
release. Each youth’s record contained progress notes documented on the Department’s
Counseling/Therapy Progress Notes form. A review of the center’s video footage for mental
health groups confirmed licensed therapists conducted group sessions with the youth. A review
of mental health/substance abuse group sign-in sheets confirmed the groups were conducted
according to the schedule. Documentation verified mental health staff had adequate access to
youth and had a confidential space to provide treatment services. In addition, sign-in sheets
confirmed mental health groups were limited to ten or fewer youth and substance abuse
treatment groups were limited to no more than fifteen youth. An interview with the designated
mental health clinician authority (DMHCA) confirmed if a youth needs substance abuse
treatment, the youth must receive individual or group counseling. Youth receiving substance
abuse treatment must sign a substance abuse consent and release form. A goal and objective
specific to substance abuse is included in the youth’s individualized mental health treatment
plan as needed. The DMHCA explained individualized treatment plans (ITPs) are developed for
youth receiving mental health and/or substance abuse treatment in the center within thirty days
of the youth's admission date. The ITP includes objectives, symptoms, goals, duration, and
renewal dates. The ITP can include medication management, if applicable. Five youth were
interviewed regarding their rating of the center’s mental health and substance abuse services.
Two youth rated services as good, and three youth rated services as very good.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures summarizing the provision of psychiatric services to
youth in need, to include psychiatric evaluation, consultation, medication management, and
medical supportive counseling. The policy requires the center to provide psychiatric services to
the youth determined to need services, as indicated by symptoms of a mental disorder or a
substance related disorder, or to youth who are treated with psychotropic medication after their
admission to the center. The center maintains a contract with VitalCore Health Strategies, LLC.,
for the provision of a licensed psychiatrist to provide psychiatric services for applicable youth in
the center. A review of the psychiatrist’s license showed they maintain a clear and active license
with an expiration date of March 31, 2026. The center did not utilize a back-up psychiatrist since
the last annual compliance review; however, would provide a back-up psychiatrist working at
another center. Documentation confirmed the backup psychiatrist was not utilized during the
annual compliance review period. The center did not utilize tele-psychiatry since the last annual
compliance review. The interviewed designated mental health clinician authority (DMHCA)
indicated they meet with the psychiatrist weekly and the psychiatrist is on call twenty-four hours
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a day for any emergency needs. A review of five mental health and substance abuse records
indicated three youth were applicable for entering the center on psychotropic medication or
referred for a psychiatric interview. All three youth’s initial diagnostic psychiatric interviews
contained a reason for the referral, medical, mental health and substance abuse history, Mental
Status Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-
5) diagnosis, and treatment recommendations. Two of the three youth were prescribed
medication at the center. The need for psychotropic medication and frequency was documented
for the two youth receiving prescribed medication. A review of the Clinical Psychotropic
Progress Note (CPPN) indicated an in-depth psychiatric evaluation was conducted on all
referred youth within thirty days of referral/admission, and the CPPN was clearly marked as a
psychiatric evaluation. All three referrals indicated the factors and reason of the referral. Each
referral listed the youth’s medical and mental health history. All three reviewed records
confirmed the youth had a history of psychiatric illness, psychotropic medication management,
mental health treatment, and/or substance abuse treatment. All three reviewed CPPNs
indicated the practitioner conducting the psychiatric evaluation signed the CPPN. Two youth
record contained the third page of the CPPN when new psychotropic medication was prescribed
or there were any changes to the existing prescription. The third youth was not applicable for
any changes. One youth was applicable for having a documented psychiatric evaluation
completed six months prior to admission, and an updated evaluation was completed for the
youth. Each reviewed evaluation included page three of the CPPN and documented the side
effect descriptions, medication target symptoms, medication name, dosage, and frequency,
youth’s adherence to the medication, height, weight, blood pressure, most recent serum drug
levels, the dated signatures from the psychiatrist, and frequency of monitoring for Tardive
Dyskinesia. Two records had documented telephone contact with a parent/guardian on the
CPPN. All three applicable youth records had a current Authority for Evaluation and Treatment
(AET) consenting for the continuation of the psychotropic medication. Whenever a medication
was prescribed, discontinued, or the dosage was changed, parent/guardian consent was
obtained and documented as required. The designated mental health clinician authority
(DMHCA) interview confirmed psychotropic medication management is provided by a
psychiatrist as needed.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures requiring a Suicide Prevention Plan. The plan
details the center’s procedures to safely screen, refer, assess, monitor, and protect youth with
elevated risk of suicide in the least restrictive means possible. The policy requires the suicide
prevention procedures to be reviewed and signed by the designated mental health clinician
authority (DMHCA) and the superintendent. The policy and plan were approved by the
superintendent and the DMHCA on August 8, 2023. The plan elements include identification
and assessment of youth at-risk of suicide utilizing the Department’s Assessment of Suicide
Risk (ASR) and Follow-Up ASR forms, staff training of at least six hours annually, suicide
precautions, levels of supervision, the referral process, communication, notification,
documentation, immediate staff response, and a review process. The center’s plan includes an
established review process for every serious suicide attempt or serious self-inflicted injury and a
mortality review for a completed suicide, which includes circumstances surrounding the event,
center procedures relevant to the incident, all relevant staff training, pertinent medical and
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mental health services involving the victim, possible precipitating factors, and any
recommendations for policy changes 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 has facility operating procedures requiring 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. A review of five youth
mental health and substance abuse records showed three 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. Documentation revealed an ASR was completed using the Department’s
form. Each youth had a constant level of supervision prior to the completion of the ASR. The
Suicide Precaution Observation Logs were completed in their entirety and indicated the mental
health provider was involved. None of the youth were released prior to receiving an ASR or
released while on suicide precautions. Two of the three records indicated the staff documented
a consultation with the designated mental health clinician authority (DMHCA) or licensed mental
health professional (LMHP) on the mental health/substance abuse referral summary, and the
third was completed by the DMHCA. All three reviewed records documented the immediate
notification of suicide risk to the superintendent or designee. A review of the logs indicated the
date and time of the referral and the date and time each youth was placed on suicide
precautions coincided. Each of the ASRs were completed within twenty-four hours and had
documentation of a conference held by the superintendent and LMHP to reduce the level of
supervision. Discontinuation of supervision was documented in accordance with the center’s
Suicide Prevention Plan. Logbooks indicated instructions related to each youth’s ASR findings
and suicide precaution decisions. Only one youth required a Follow-Up ASR to be completed
prior to the removal of the youth from precautionary observation. A review of the center’s
logbooks revealed the starting and ending time of each youth’s precaution period was
documented. Two youth were transitioned to close supervision. Each ASR was documented as
completed by a LMHP and included recommendations for supervision and follow-up. A review of
the Department's Juvenile Justice Information System (JJIS) confirmed the appropriate youth
alerts were entered and closed in the system. An interview with the DMHCA confirmed the
process for revising a youth’s level of supervision. According to the DMHCA, documentation of
the actual date/time the clinician conferred with the superintendent/designee must be recorded
on the ASR. Furthermore, if a youth is placed on precautionary observation due to a potential
suicide or suicide attempt, a mental health clinician notifies the youth's parent/guardian and
juvenile probation officer by telephone or email. Five youth were interviewed, and two youth
stated they were placed on suicide watch while at the center, and three indicated they had not.
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Each of the two youth indicated staff had observed them while they were on suicide watch. Five
staff were interviewed and all staff stated if a youth expresses suicidal thoughts, staff will notify
the mental health authority, place the youth on constant sight and sound supervision, and keep
documentation of supervision.
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 facility operating procedures regarding secure observation. The policy
requires youth placed on suicide precautions to remain under secure observation if less
restrictive methods are not effective. Five youth records were reviewed, and one youth was
applicable for placement in secure observation; therefore, two additional records were reviewed.
Each of the secure observation rooms were designated in writing. A review of the Department's
Juvenile Justice Information System (JJIS) indicated two of the three youth had a completed
Health Status Checklist form completed prior to placement in secure observation. The third
could not be completed due to combative behavior, and the youth was subsequently transferred
from secure observation to a Baker Act facility. A review of the Suicide Precaution Observation
Logs confirmed they were completed in their entirety. Reviewed documentation confirmed a
new Assessment of Suicide Risk (ASR) was completed within eight hours for each applicable
youth placement into secure observation, and each youth’s parent/guardian was notified of the
youth’s potential suicide risk. Two records were applicable and indicated the juvenile probation
officer (JPO) was notified of each youth’s potential suicide risk as indicated by the ASR. None of
the youth were placed in secure observation beyond twenty-four hours. All three youth’s
observation logs documented proper supervision of each youth as required, and mental health
staff provided supportive counseling services while each youth was on secure observation
status. Reviewed documentation for three youth indicated two of the three youth in secure
observation had their level reduced only after a conference with the superintendent/licensed
mental health professional. Additionally, both youth were discontinued from secure observation
and placed on close supervision. The third youth was transferred to a Baker Act facility. A
review of the center’s logbook and youth records confirmed the center’s practice.
3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures for the process to safely screen, refer, assess,
monitor, and protect youth with elevated suicide risk in the least restrictive means possible. A
review of five youth mental health and substance abuse records verified two youth were
applicable and a review of two additional records was completed for youth having been placed
on suicide precautions. Each youth had a maintained Suicide Precaution Observation Log. Each
youth’s log was documented in real time and was maintained for the duration each youth was
on suicide precautions. The review of the Suicide Precaution Observation Logs for all four youth
found the staff were documenting the youth’s behavior at thirty-minute intervals or less. When
warning signs were observed for two youth, staff notified the superintendent and mental health
staff, and documented the warning signs on the Suicide Precaution Observation Logs. Each log
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was reviewed and included the signature of the mental health staff and the center’s shift
supervisors. Each log documented safe housing requirements. Observations of video footage
for three dates and documentation of youth placed on precautionary observation (PO) confirmed
each youth was placed on constant supervision. Observations showed each youth sleeping on a
portable bed in the module activity area. A review of video footage confirmed staff were always
present while youth were on precautionary observation (PO).
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures to address suicide prevention training. The policy
requires all staff who work with youth to be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions. Five in-
service and five pre-service staff training records were reviewed. Each reviewed staff record
documented staff completed suicide awareness and prevention training. A total of seven suicide
response kits are located throughout the center. Two kits are maintained in the administration
office, one in medical, one in master control, and one in each of the three youth living modules.
All suicide prevention kits include the knife-for-life, wire cutters, and needle nose pliers. The
suicide response kits are co-located with the first-aid kits. Reviewed documentation of mock
suicide drills conducted for the past twelve months showed the center completed drills on all
three shifts at least quarterly, as required. Reviewed documentation confirmed for the past
twelve months, suicide drills included the use of the suicide response kits and cardiopulmonary
resuscitation (CPR) and were documented in the logbook with a sign-in sheet to confirm staff
participation. The mock mental health drills in response to a suicide attempt and/or incident of
serious self-injury were simulated and did not include any center youth. Staff who were not
present during a quarterly drill had the opportunity to review each drill scenario, procedures, and
critique to understand the process and receive the necessary training to respond to an incident
of a suicide attempt or incident of serious self-inflicted injury. Five interviewed staff all stated
they have access to the suicide response kit, including the knife-for-life located in master
control, medical, and the administration offices.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures regarding crisis intervention services and a
combined Emergency Services Plan. The policy requires the center’s staff to respond to youth
in crisis in the least restrictive means possible and to protect the safety of the youth and others
while maintaining control and safety of the center. Assessments should be completed by a
mental health clinician to determine the severity of the youth’s distressing symptoms, level of
risk to self or others, and recommendations for treatment and follow-up care. Documentation
and a review of the combined Emergency Services Plan confirmed the plan consisted of the
notification and alert system, means of referral, including self-referral, communication,
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supervision, documentation, review, and requirements for Prison Rape Elimination Act (PREA)
response. The plan was accessible to all staff.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures to address the Emergency Services Plan which
stipulates the response procedures for youth in crisis. The center’s plan includes procedures for
immediate staff response, notifications, communication, supervision, authorization to transport
for emergency mental health or substance abuse services, transport for emergency mental
health evaluation and treatment for Baker Act, and the transport for Emergency Substance
Abuse Assessment and Treatment for Marchman Act. The Emergency Services Plan was
updated and signed on August 8, 2023. A copy of the approved plan is maintained in the mental
health office and is accessible to all staff in the center’s facility operating procedures binder.
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 facility operating procedures regarding Crisis Assessments. The policy requires
a Crisis Assessment for any youth demonstrating acute psychological distress. Five youth
records were reviewed, and none were applicable for a Crisis Assessment. Additional records
were requested, and the center reported having only one youth applicable for a Crisis
Assessment since the last annual compliance review. The assessment was completed the
same day the youth was determined to be in crisis and was documented on the Department’s
Crisis Assessment form. The Crisis Assessment included a reason for assessment and a
Mental Status Examination and interview. The Crisis Assessment contained documentation for
the determination of danger to self/others, initial clinical impressions, supervision and treatment
recommendations, follow-up evaluation recommendations, and notification to the
parent/guardian regarding follow-up treatment. The licensed mental health professional
completed the Crisis Assessment within two hours for emergency, based on the needs of the
youth. Reviewed records confirmed there were no youth relating to allegations of a Prison Rape
Elimination Act (PREA) event.
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3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures for Baker and Marchman Acts. The policy requires
youth who are believed to be an imminent danger to themselves or others because of mental
illness or substance abuse impairment require emergency mental health or substance abuse
services. Five youth records were reviewed, and only one youth was applicable for requiring
Baker Act or Marchman Act procedures. Two additional youth records were reviewed. A review
of Suicide Precaution Observation Logs for all three applicable youth showed each was placed
on one-to-one supervision and a suicide rusk alert was opened while pending transport for the
youth. Each youth had a completed mental health referral for a Mental Status Examination
(MSE) and was placed on suicide precautions upon re-admission from Baker Act or Marchman
Act. All three of the youth supervision levels were maintained based upon the Assessment of
Suicide Risk (ASR), and discontinuation of the mental health alerts was completed in the
Department's Juvenile Justice Information System (JJIS) when applicable after the mental
health staff conferred with the l8censed supervisor and superintendent or designee. According
to the designated mental health clinician authority (DMHCA), during the annual compliance
review period a total of four youth were required to be transferred to the local crisis stabilization
unit for Baker Act services. No youth were applicable for Marchman Act services.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains facility operating procedures (FOPs) requiring a contractual agreement
with a licensed physician to serve as the designated health authority (DHA). The center
maintains a contract with VitalCore Health Strategies, LLC, which subcontracts with an
osteopathic physician (DO) to serve as the center’s DHA. The DHA holds an unrestricted, clear,
and active license which meets all requirements for independent and unsupervised practice in
the State of Florida expiring March 31, 2026. The DHA’s specialty is in family practice with
experience in adolescent health. A review of the Florida Department of Health records
documentation revealed the DHA did not have any disciplinary cases or public complaints on
record at the time of the annual compliance review. The center utilizes a part-time advanced
practice registered nurse (APRN) whose license expires April 30, 2025. The APRN and the
DHA both signed the Collaborative Practice Protocol agreement on January 3, 2024. The APRN
has a clear and active license in the State of Florida with no disciplinary case or public
complaints on record at the time of the annual compliance review. The DHA is contracted to be
on-site at least once a week, with a week defined as the seven-day period beginning on Sunday
and ending on Saturday; however, at no time are more than nine days to pass between on-site
visits. The DHA is on-call twenty-four hours a day, seven days a week. The DHA is on-site
every Tuesday from 9:00 a.m. to 11:00 a.m. Reviewed documentation confirmed the DHA was
on-site as required. In the event the DHA should go on vacation or on a scheduled absence, the
center has a back-up DHA designated by VitalCore Health Strategies, LLC. to provide clinical
services. The program did not use a back-up DHA since the last annual compliance review. A
review of the medical policy and procedures indicated there was no inclusion or approval from
the Department’s Office of Health Services for telemedicine/telehealth services. The DHA at the
center was interviewed. The DHA interview results indicated the DHA performs comprehensive
physical assessments (CPAs), conducts periodic evaluations, sick call, and policy and
procedure development. The CPAs are completed on youth after intake and a review of their
health history is completed. The nurses at the center are on-call for urgent questions and issues
to evaluate youth when they are sick or have urgent medical issues, and to review protocols and
make recommendations. The DHA is on-site at least once each week and communication is
provided to staff through telephone calls and emails. The DHA is available through on-call
services twenty-four hours a day, seven days a week, and provides on-site clinical services at
least once a week. The center has an APRN who is scheduled to be on-site once a week.
Additionally, the DHA and/or APRN ensure all off-site care findings, instructions, and information
are reviewed by the DHA or designee and documented in the Electronic Medical Records
(EMRs). The center has a formalized procedure for many different health related complaints and
issues which are printed and kept in a folder for staff and are reviewed yearly. Periodic
evaluations for youth with chronic conditions are completed and tracked depending on the
condition and usually every thirty days at a minimum. All youth with a chronic condition receive
periodic evaluations as required. The DHA arranges for coverage when on vacation or during
scheduled absences by contacting the supervisor who will find a DHA from another center for
coverage. The DHA did not have any concerns with healthcare at this center.
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4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center maintains facility operating procedures (FOPs) for all health-related protocols
utilized. The center’s designated health authority (DHA) and superintendent sign and date all
respective FOPs and conduct an annual review of all healthcare protocols. The reviewed
documentation indicated the DHA reviewed, signed, and dated the FOPs on January 3, 2024,
the psychiatrist signed on January 2, 2024, and the superintendent signed on January 3, 2024.
The nursing staff reviewed, signed, and dated the cover page acknowledging review of all FOPs
and healthcare protocols on February 13, 14, and 17, 2024. The FOPs were last annually
reviewed on August 6, 2024. VitalCore Health Strategies, LLC. has an established
comprehensive clinical orientation for all newly employed healthcare staff, which includes the
Department’s healthcare policy and procedures, which is provided by a registered nurse (RN).
Reviewed documentation confirmed all newly hired healthcare staff received a comprehensive
clinical orientation to the Department’s healthcare policies and procedures by a RN. The
approval of treatment protocols or standing procedures was written and authorized by the DHA.
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 facility operating procedures requiring the parent/guardian to be afforded
the right to give or withhold consent regarding the healthcare provided to the youth and ensures
the completion of the Authority for Evaluation and Treatment (AET) for all youth admitted into
the center. A review of five Individual Healthcare Records (IHCRs) was completed. One youth
was applicable for being under the care and custody of the Department of Children and Families
(DCF). The youth record showed there was a limited consent form upon entering the
Department’s custody. The Department then obtained a court order authorizing services.
Thereafter, the youth’s parent/guardian signed an AET while the youth was in the center. The
remaining four youth records had an AET signed by the parent/guardian, in addition to being
signed by a Department representative. Each AET was obtained prior to providing medical
services for each youth. Reviewed documentation revealed the original AET form was filed in
each youth’s IHCR. All five youth were under the age of eighteen. An interview with the nursing
staff indicated the original AET is filed in the IHCR. It is the responsibility of the Department
representative obtaining the signatures to verify the form is completed with all required
documentation. In the event a parent/guardian refuses to sign the AET, or there shall be a court
order, and the court order shall be filed in the youth’s IHCR/Electronic Medical Record (EMR).
Additionally, the AET is valid for as long as the youth is under any type of supervision, custody
or other form of legal control by the Department, for one year after it was signed by the
parent/legal guardian, whichever comes later, or until the youth’s eighteenth birthday. The
center has a policy for documenting consent for youth who are eighteen years of age or older,
as those youth can sign their own AET and consent for medical care. If a youth reaches
eighteen years of age while in the center and is not incapacitated or otherwise emancipated, the
youth is responsible for authorizing their healthcare and authorizing the release of their
healthcare information and records.
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4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains facility operating procedures outlining requirements to ensure the
parent/guardian is notified of significant changes in the youth’s condition and obtain consent
when new medications and treatments are prescribed. A review of five youth Individual
Healthcare Records (IHCRs) indicated four of the five youth records included notifications of
documented parental notifications for over-the-counter (OTC) medications beyond those
covered by the Authority for Evaluation and Treatment (AET). Each of the four records
documented consent was provided by the parent/guardian. All four youth had written
notifications sent utilizing the Department’s Parental Notification of Health-Related Care form.
None of the five youth were applicable for new medications ordered or for the attempted contact
with the parent/guardian in the progress notes for new medications. Two of the five youth were
taking psychotropic medications at admission. Reviewed documentation indicated staff
witnessed all telephone call attempts and conversation for psychotropic medications. The
parent/guardian consent for psychotropic medications was documented on page three of the
Clinical Psychotropic Progress Note (CPPN) in each applicable record. Each record confirmed
parental verbal consent was received for psychotropic medication whenever a new psychotropic
medication was prescribed, discontinued, or the dosage was significantly changed. Each of the
five reviewed IHCRs documented the center verified vaccinations within thirty days of each
youth's admission. None of the five reviewed youth were applicable for requiring new
vaccinations or having a religious exemption. An interview with nursing staff indicated
parental/guardian notifications shall be utilized when the designated health authority (DHA) or
advanced practice registered nurse (APRN) orders medication, treatment, or changes
medication. For new non-psychotropic medication, verbal attempts/contacts/consents shall be
documented in the chronological progress notes in the IHCR. Additionally, all psychotropic
medications, verbal attempts, contacts, and consents shall be documented on the third page of
the Clinical Psychotropic Progress Note or on an informed consent chronological progress note.
The nursing staff interview indicated the process for ensuring timely parental/guardian
notifications are made when required, is for the nurse on duty to ensure a call is made to the
parent/guardian to inform them of the medication changes or treatment services, and nursing
staff will follow-up with a written notice.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures to ensure each youth receives a screening for
health concerns upon admission, or, at a minimum, each time the physical custody of the youth
changes and they are returned or re-admitted to the center. The center’s facility operating
procedures require each youth, at the time of admission, to receive a Facility Entry Physical
Health Screening form (FEPHS) and the Department’s Medical and Mental Health Admission
Screening form. Five youth Individual Healthcare Records (IHCRs) were reviewed. Each of the
five reviewed records indicated the Department’s Medical and Mental Health Admission
Screening form was completed on the date of admission by a juvenile justice detention officer
(JJDO), and each indicated the screening was reviewed by a licensed medical staff within
twenty-four hours. Each youth’s screening form was completed in the Department’s Juvenile
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Office of Accountability and Program Support Page 36 of 58 (Revised July 2023)
Justice Information System (JJIS), as required. Reviewed documentation validated the
designated health authority (DHA) was notified of each youth’s admission. None of the youth
had a change in physical custody; therefore, they did not require a re-screening. Two of the
reviewed records showed the youth were female and were applicable to receive a qualitative
urine pregnancy screening test. This was documented in the chronological progress notes and
included documentation of verbal and/or written consent. The nursing interview results indicated
newly admitted youth are usually seen within twenty-four hours or less from their admission
time. The nursing staff are notified when youth are admitted to the center by the officer on duty.
An intake packet is left in master control in the nursing folder. Admission screenings are
completed by a registered nurse (RN), licensed practical nurse (LPN), direct care staff, or the
medical doctor (MD)/advanced practice registered nurse (APRN). If the admission screening is
completed by direct care staff, a licensed medical staff will complete a review with the youth
within twenty-four hours. If there is a change in physical custody since the youth's admission,
the center’s process for re-screening the youth upon return to the center, is for a healthcare
admission re-screening to be completed each time the physical custody of the youth changes
with subsequent return or readmission to the center.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures for youth orientation to healthcare services. A
review of five youth Individual Healthcare Records (IHCRs) revealed each youth received a
general care orientation on the day of admission to the center. Each record contained a
completed Department Health Education Record form documenting orientation to the center’s
healthcare services within twenty-four hours of admission to the center. Each youth orientation
included topics addressing access to medical care, sick call, what constitutes an emergency
and when to notify staff, medication process to include side effect monitoring, the right to refuse
care and how it is documented, what to do in case of a sexual assault or attempted sexual
assault, the non-disciplinary role of the health care providers, a review of the list of healthcare
contacts to ensure accuracy, and standard universal precautions. The center has general health
education for all youth. The general health orientation informs the youth of the general process
of healthcare delivery services at the center.
4.07 Designated Health Authority/Designee Admission
Notification [Contract Provider] Satisfactory Compliance
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures to ensure the designated health authority (DHA) is
notified when youth are admitted to the center. It is the center’s practice to notify the DHA of all
new admissions regardless of their medical condition and the notification is documented in the
admission chronological progress note. A review of five Individual Healthcare Records (IHCRs),
reflected three youth were applicable for a known or suspected chronic condition upon
admission. None of the reviewed IHCRs were identified as in need of emergency care upon
admission into the center. Each of the three applicable records documented the DHA was
notified of each youth’s admission. Two youth records were applicable for the youth having
been admitted while taking psychotropic medication. Reviewed documentation confirmed the
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psychiatrist was notified within twelve hours of each youth’s admission. An interview with the
nursing staff indicated if a youth is admitted with a serious or chronic condition, the center has a
process to immediately notify the DHA. The nursing staff are responsible for making
notifications, and all notifications to the DHA shall be documented in the youth’s chronological
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 has facility operating procedures ensuring the nursing staff complete the
Department’s Health-Related History (HRH) form prior to the Comprehensive Physical
Assessment (CPA). A review of five youth Individual Healthcare Records (IHCRs) indicated
each had an HRH form completed/updated within seven calendar days of admission. Reviewed
documentation indicated the center’s practice is to complete the HRH form on the day of
admission for each youth. Each of the five reviewed records indicated the HRH forms were
completed prior to each youth’s CPA. Each HRH form was completed by a licensed nurse and
reviewed by the designated health authority (DHA), as indicated by the checkbox on the CPA.
An interview with the nurse was completed. The nursing interview results indicated the HRH
form shall be updated/completed within seven days of admission. The HRH shall be completed
and signed as completed by a licensed nurse or practitioner.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures (FOPs) ensuring each youth admitted shall receive
and/or shall have on record a current Comprehensive Physical Assessment (CPA) and Health-
Related History (HRH) form completed no later than seven calendar days of admission into the
center. Five youth Individual Healthcare Records (IHCRs) were reviewed, and each youth’s
physical assessment was completed on the Department’s CPA form. Each reviewed record had
a current CPA which was reviewed by the designated health authority (DHA) or by the
advanced practice registered nurse (APRN). Each youth’s Medical Grade was documented on
their CPA. There was no indication of any missing or incomplete elements on any of the
reviewed CPAs. Each reviewed CPA had all sections complete in full utilizing “O” and/or “X”
markings. Five of the reviewed youth records indicated the physician documented “not medically
necessary” on the CPA, and no youth were applicable for refusing any portion of the exam. The
Department’s Problem List was updated as required for each of the five youth. Each of the five
youth had at least one verified Tuberculosis Skin Test (TST) documented in the IHCR within the
last year. Each youth’s result was documented on their CPA and on the Infectious and
Communicable Disease (ICD) form. An interview with the nurse was completed and indicated
the DHA completes a new CPA within seven calendar days of admission. The tuberculosis (TB)
screenings were completed within seventy-two hours of admission if one was not documented
in the youth's Individual Healthcare Record (IHCR) within the past year. Additionally,
gynecological exams are not routinely completed at the center. A review of the FOPs confirmed
the procedures to be followed when any part of the exam is refused or not conducted and for TB
screening and re-screening.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures in place to ensure all youth entering the center are
clinically screened, evaluated, and treated, if necessary, for sexually transmitted infections
(STIs) and human immunodeficiency virus (HIV). The center’s policy and procedures reflected
HIV test results are only disclosed to the youth with the youth’s legally authorized
representative, healthcare providers during the course of consultation, diagnosis, or treatment of
the individual, the Department of Health for purposes of reporting and controlling the spread of
disease, health facility staff committees conducting center monitoring, evaluation, and service
reviews, medical personnel who have been subjected to a significant exposure, and healthcare
facility personnel or agents for the healthcare provider who have a need to know in the course
of patient care activities or administrative operations. A review of five youth Individual
Healthcare Records (IHCRs) reflected only four youth were identified as sexually active and
each was clinically screened and evaluated for STIs utilizing the Department’s Sexually
Transmitted Infections Screening form. Three youth records indicated no further evaluation was
required. Two youth records included referrals and were ordered testing. The referrals were
documented on the STI screening tool for the two applicable youth. Each of the applicable
youth’s IHCRs included documentation of testing, screening results, clinical evaluations, and
diagnosis, which were documented on the Department’s Infectious and Communicable Disease
(ICD) form. Each of the applicable youth records documented testing had been performed.
There were no applicable youth who were out of the Department’s custody for over thirty days
and/or required a rescreening, and none of the youth required a gynecological exam. One of the
five reviewed records were applicable for the offering of counseling and testing for HIV. Four of
the five youth declined consent for HIV testing. and the youth who consented was provided pre
and post-test counseling, which was documented in the youth’s Health Education Record. The
designated health authority (DHA) or advanced practice registered nurse (APRN) documented
their review of the test results which were maintained in a sealed envelope. A review of the
applicable record confirmed the results were signed by the DHA and maintained in the youths
IHCR. HIV results were not included on the center’s internal alerts for the applicable youth and
results were maintained in a confidential manner. The HIV pre-test, post-test, and counseling
services are provided by the nursing staff on-site. Five youth were interviewed, each youth
indicated they can ask for a HIV test. An interview with the nursing staff indicated youth entering
the center are screened and evaluated for STIs including HIV. The DHA or APRN review the
youth’s screening tool and can refer youth for additional testing. STI screenings, consents,
evaluations, referrals, and pre/post-test counseling are documented in the youth’s IHCR and/or
Electronic Medical Record (EMR). Youth are afforded the right to request or decline HIV testing.
Testing results shall be noted on the youth’s ICD form and located in the youths IHCR.
Furthermore, HIV test results are filed in a confidential manner, according to policy. A certified
HIV counselor/licensed nurse conducts the testing and HIV counseling, under the
direction/order of a practitioner. Rescreening is conducted if the youth was out of the
Department’s physical custody and was sexually active.
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4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures (FOPs) ensuring all youth can make sick call
requests and have their complaints treated appropriately through the sick call system. Sick call
care, including dental care, are available to all youth. Five Individual Healthcare Records
(IHCRs) were reviewed, and only two were applicable; therefore, an additional record was
requested for sick calls. None of the three applicable youth presented with a similar sick call
complaint three of more times within a two-week period. Each of the three youth completed a
Sick Call Request form, and each Sick Call Request form was completed by a registered nurse
(RN). Each youth’s Sick Call Request form was filed in their (IHCR). Each sick call was
conducted by a licensed practical nurse (LPN) and subsequently reviewed with the designated
health authority. None of the reviewed youth were in restricted housing. Each of the three
reviewed Sick Call Request forms were documented in accordance with Florida Administrative
Code. The reviewed sick calls were found to be recorded appropriately on the Sick Call Index.
In addition, each sick call was documented on the center’s Sick Call Referral Log. The dates
listed on each of the Sick Call Index Logs corresponded to the completed Sick Call Request
forms located in each of the youth’s IHCRs. The center offers youth the opportunity to make a
sick call request seven days a week. Only licensed healthcare staff may conduct sick calls, and
all sick calls are conducted in the medical clinic to ensure youth privacy. Sick Call Request
forms are available to youth and located in the day room areas of the living modules. Sick call
hours are posted in the medical office and in each of the living modules. A review of the daily
schedule, posted sick call schedule, and nurse interview found sick call is held daily from 9:00
a.m. to 10:00 a.m. and 4:00 p.m. to 5:00 p.m. When there is not a licensed nurse on-site, the
center has procedures for where the shift supervisor reviews all sick call request as soon as
possible. A review of the FOPs confirmed the procedures for when youth are in room restriction
or confinement and request a sick call. Five youth were interviewed, and two youth stated they
are seen immediately after placing a sick call, and three youth stated they are seen within one
day. An interview with five staff was conducted, and each of the five staff confirmed the youth at
the program can make a sick call request, medication management is conducted by the nursing
staff, and sick calls are conducted twice a day. The nursing staff review and conduct sick calls.
An interview with the nurse indicated sick calls are placed and nursing staff have twenty-four
hours to see the youth. Only RNs and LPNs shall conduct sick calls, based on the approved
treatment protocols. All sick calls are reviewed daily either in person, or by telephone with the
designated health authority (DHA), or the advanced practice registered nurse (APRN). An
informal interview with the nurse indicated the DHA conducts sick calls when they are on-site in
the medical office. The nursing staff validated the center’s practice when youth are presented
with three or more repeated sick call complaints by referring them to the DHA. A sick call was
observed during the annual compliance review week. Youth consent was obtained by the
regional monitor prior to observing the sick call. The assistant superintendent escorted the youth
to the sick call, the medical provider identified themselves and stated why the youth was there.
The youth was seen in a private area with no other youth present to hear or see the
examination, the youth was examined by licensed staff using the proper exam table and
equipment. The assistant superintendent was present during the exam; however, the medical
staff was able to maintain privacy due to the staff being outside of the exam room.
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Office of Accountability and Program Support Page 40 of 58 (Revised July 2023)
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures (FOPs) ensuring there is a written plan to provide
twenty-four-hour emergency medical, mental health, and dental care to youth, as needed, in
response to unexpected illnesses, accidents, or conditions requiring immediate attention or an
immediate professional assessment to determine the severity. Five youth Individual Healthcare
Records (IHCRs) were reviewed and all five were applicable for episodic care. On-site care was
provided by licensed healthcare staff for each event. Each event was documented in the
required subjective, objective, assessment, and plan (SOAP) format. All events were
documented on the Episodic Care Log, which corresponded with the on-site events observed in
the IHCRs. One youth was referred for off-site care, and two youth were applicable for episodic
or first-aid care needing a follow-up. Parental/guardian notification was made and documented
on behalf of the applicable youth. The follow-ups were documented and completed as required.
The center has written FOPs which address episodic and emergency care practices. The center
has nine first-aid kits, to include one in each of the three living modules, one in each of the three
vans, one in the kitchen, one in administration, and one in the medical office. Additionally, the
first-aid kits for the vans are stored in master control. The center has a process for ensuring
contents are maintained and stored in accordance with guidelines, to prevent expiration or
deterioration, and are replenished as needed. Checks are conducted by medical staff on a
weekly basis, an inventory of contents is maintained, expiration dates are documented, and
contents are replenished as needed. Medical staff ensure inventories and logs match each
month. An observation of three first-aid kits revealed each kit was fully stocked with the
designated health authority (DHA) approved contents. During the annual compliance review
week, the nurse conducted a self-test of the automated external defibrillators (AEDs) and there
were no discrepancies. The center has two AEDs located in the medical office and in master
control. The AED procedures are located in the medical logbook. Reviewed documentation
confirmed nursing staff monitored the AEDs, as required. The expiration date for the AEDs’
batteries is on December 17, 2024. The AEDs’ pads were changed in 2020. The expiration date
for the AED pads are July 28, 2025, and December 28, 2025. A list of emergency numbers was
posted and accessible for the non-licensed and licensed staff, which were inaccessible to the
youth in the center. Documentation indicated authorized direct care staff were appropriately
trained in the administration of the epinephrine auto-injector. A review of five staff training
records showed requirements were met in reference to episodic, first-aid, and emergency care.
A review of the center’s emergency medical drills reflected drills included the demonstration of
first-aid and the AED. Drills were conducted each shift monthly for the last twelve months. The
emergency medical drills consisted of both announced and unannounced drills and were
conducted at least monthly on each shift. A review of the center’s logbooks showed direct care
staff participated in at least one drill which included the use of cardiopulmonary resuscitation
(CPR) annually. Video observations of drills confirmed each drill simulated an episodic care
event which called for immediate first-aid and/or the administration of CPR techniques, and the
initiation of the emergency procedures to follow when there was a life-threatening emergency.
The center currently has a policy in place for the use of NARCAN®. The center’s policy on the
use, access, and inventory of NARCAN® indicated it is used for the usage of medication
overdose. The instructions for the use of NARCAN® are located on the box. The center stores
NARCAN® in the locked medication cart. The nursing staff and supervisors have access to
NARCAN ®. Each staff with access to NARCAN® has been trained on when and how to use
NARCAN ® by the nurse. The center’s inventory process for NARCAN® is for the inventory to
be conducted weekly by the medical staff. Five staff were interviewed, and each stated they are
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personally allowed to call 9-1-1 if a youth has a medical emergency. Five youth were
interviewed, four youth rated the center’s medical care as very good, and one rated the center’s
medical care as good. An interview with the nurse confirmed the center’s practice for first-aid
kits and AEDs. The nurse indicated on-site episodic care is documented in the progress notes
and on the episodic log, and if non-healthcare staff provides emergency care the non-healthcare
form is reviewed by the nurse. All off-site care or emergency care is tracked on the off-site log.
Nursing staff confirmed, all emergency drills are simulated and conducted on each shift on a
quarterly basis, with a demonstration of CPR/AED at least once annually.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures for the provision of off-site emergency and non-
emergency referrals for medical care and treatment. Evaluations conducted off-site shall be
recorded on the Department's Summary of Off-Site Care Consultation Report form. The
designated health authority (DHA) reviews, signs, and dates the off-site care instructions. Five
youth Individual Healthcare Records (IHCRs) were reviewed; however, only one was applicable.
Two additional records were requested for off-site first-aid or emergency care. The Summary of
Off-Site Care Consultation Report form was utilized and filed within each of the youth’s IHCRs.
Off-site emergency care was documented on the Episodic Care Log and the parental/guardian
and DHA notification efforts were documented as required. Applicable discharge documents
were found to be filed within all three of the youths’ IHCRs. The DHA or designee reviewed and
signed each of the youth’s off-site care findings, instructions, and/or information. None of the
reviewed youth required follow-up testing, referral, and/or an appointment. An interview with the
nurse was completed. An off-site log is utilized to track all youth who are sent off-site for first-aid
or emergency care. For all youth who require routine off-site medical or off-site emergency care,
the Department’s Summary of Off-Site Care form shall be utilized and filed in the IHCR. The
center has a process to ensure the DHA is reviewing and initialing all off-site care findings,
instructions, and information. The nursing staff tracks follow-up testing, referrals, and
appointments on the medical list which is used daily.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures ensuring youth who have been identified with a
chronic illness receive regularly scheduled evaluations and necessary follow-up treatment. A
review of five youth Individual Healthcare Records (IHCRs) indicated three of the five youth
were identified with a chronic condition as documented on the Facility Entry Physical Health
Screening (FEPHS) form. Additionally, the three youth were identified on the Department’s
Medical/Mental Health Screening form with a current chronic condition. None of the youth were
identified as having a communicable disease. One youth was applicable for taking prescribed
medication on an ongoing basis. There were no youth who were undergoing treatment for a
physical health condition or who were pregnant. Each youth had an appropriate Medical Grade
assigned. Each of the three youth were placed on the center's chronic conditions list. A review
of progress notes found only one of the three youth received periodic evaluations at least every
ninety-days; however, services were terminated prior to the evaluation due to the youth being
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Office of Accountability and Program Support Page 42 of 58 (Revised July 2023)
placed in a commitment program, and the other two youth records were not applicable as they
have not been in the center for long enough. None of the youth were applicable for taking anti-
tuberculosis medications. None of the three identified youth were applicable for an evaluation
completed prior to a prescription renewal, change, or expiration. None of the three reviewed
youth were applicable for an off-site evaluation. There were no indications of lapses in care or
missed periodic evaluations for any of the reviewed records. The Department’s Problem List for
each youth was updated in accordance with Florida Administrative Code. The designated health
authority (DHA) was interviewed and reported formalized procedures are in place with the
healthcare staff to review the important youth medical issues. A review with healthcare staff
occurs daily during the morning management meeting and weekly for DHA updates.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures which outline the process of how medications are
to be received, stored, inventoried, and administered in a safe and effective manner. A review of
five youth Individual Healthcare Records (IHCRs) indicated two of the five youth were admitted
on prescribed medications and one youth was prescribed medication after admission.
Documentation revealed the two youths’ medications were verified prior to being admitted into
the center utilizing the Department’s Prescription Medication Verification Checklist form. The
prescription verification was included in the chronological progress note. For both applicable
youth, the designated health authority (DHA) and the psychiatrist were contacted to obtain the
order to resume the specified medications prescribed prior to admission. All medications for
each youth had a current, valid order and were administered pursuant to a current prescription.
Three youth were applicable for current medications which were continued, discontinued,
changed, or new, and the DHA placed an order on the Practitioner Order form. None of the
youth were applicable for restricted housing and none of the five youth were applicable for over-
the-counter medications not listed on the Authority for Evaluation and Treatment (AET) form.
The center utilizes a pre-printed Medication Administration Record (MAR) to document all
medication and treatment. Three youth records were reviewed, and the MARs met all
requirements outlined within Florida Administrative Code. There were no instances where
trained non-healthcare staff assisted in the delivery of medications. Documentation indicated
staff initialed each administered medication entry. There were no undocumented explanations
for a lapse or errors in medication administration for any of the reviewed youth. Each reviewed
record confirmed the nursing staff documented side effect monitoring at a minimum of weekly
on each MAR. None of the three reviewed youth were applicable for signing the Refusal of
Treatment form indicating refusal. The MAR contained all required elements, to include youth
name, Department identification number, date of birth, youth allergies, precautions, Medical
Grade, medical alerts, and a current picture of the youth. Each youth initialed each provided
medication entry. There were no youth in need of parenteral medication during the annual
compliance review period. The DHA and psychiatrist were notified at admission on behalf of one
youth, due to the youth entering the center with psychotropic medication upon admission. The
psychiatrist conducted an Initial Diagnostic Psychiatric Interview with the youth within fourteen
days of admission. Each youth received a medication monitoring/review every thirty days, as
required. None of the youth had a standing order, emergency treatment order, or pro re nata
(PRN) order for psychotropic medication. An observation of medication pass was conducted
during the annual compliance review week with the verbal consent of the youth. Medication
delivery was the sole responsibility of the nurse during the time of medication administration.
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The youth was escorted to medication administration by the superintendent. The nursing staff
asked the youth their name and allergies. The nurse identified themselves, reviewed the MAR,
and provided a brief overview as to why the youth was there. The youth approached the nurse
individually, provided their name, date of birth, what medications they were prescribed, and if
they had any allergies. The registered nurse (RN) verified the Six Rights of Medication
Administration for the youth and the youth’s allergy and alert status were confirmed. No
medications were observed to be pre-poured and the nurse was the sole staff handling the
medications. After administering the youth's medication, the RN swiped the youth’s mouth and
searched under the youth’s tongue, and both signed the MAR. Five youth were interviewed at
the center and revealed the nurse keeps the medication in a cart. The youth are asked their
name and date of birth by the nurse. Their name is found in the medical chart and the verified
medication is given to the youth. An interview with the nurse indicated the process for nursing
staff to verify a youth’s medication regimen when a youth is admitted with medications is by
completing the prescription verification form, verifying with the pharmacist and prescribing
doctor. The nursing staff review medications upon admission and document the review in the
IHCR. According to the nurse, the center uses the standard Department MAR. The interviewed
nurse stated there is a training curriculum to train non-healthcare staff on the administration of
medication, the nurse trains non-healthcare staff at least annually on medication administration,
and the list is in the medical clinic. According to the nurse, medications/prescriptions are
procured through a local pharmacy. The center utilizes a psychiatrist which is on-site bi-weekly
for medication management and treatment team. Three of five interviewed youth indicated they
are currently not taking any medications, and three youth indicated the nursing staff gives the
youth their medication. Four of five staff indicated they do not give youth any medication, and
one supervisory staff indicated they are able to provide youth with their medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures regarding the requirements for the storage and
inventory of medications and sharps, ensuring all medication is inaccessible to youth at the
center. Observations of the medication cart showed it was clean and organized, with stock items
separate from youth specific medication, and all medications were stored in the locked cart
which is kept in the locked medical clinic. All types of medications were stored separately from
others. Narcotics and other controlled medications are securely stored and double locked within
the medication cart. Observations found all medications were securely stored in the medical
clinic inaccessible to youth. The center had no medication requiring refrigeration during the
annual compliance review week; however, the center has a refrigerator which is used only for
medication, if needed. Perpetual inventories with running balances are maintained on all
controlled substances with a shift-to-shift inventory conducted by the nurses. A review of three
controlled medications was conducted at the time of the annual compliance review, and the
review confirmed the inventories were accurate. A review of three over-the-counter (OTC)
medications was conducted, and each validated the respective inventories were accurate and
kept perpetually and weekly. Syringes and sharps are counted through a perpetual inventory
and are verified weekly. Observations of a count were conducted with the registered nurse
(RN). A review of three sharps verified all three matched the count on the perpetual inventory. It
is the center’s practice for inventory discrepancies to be reviewed with the clinical nurse
manager to determine when and how the error occurred and to subsequently document the
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Office of Accountability and Program Support Page 44 of 58 (Revised July 2023)
correction on the related inventory. The medication management training for a non-health care
staff is provided by the (RN) at the center. An interview with the nurse was completed in
reference to the medication/sharps inventory storage process. The nursing interview results
confirmed the center’s process for disposal of medication and medical equipment. The center’s
process for when there are inventory discrepancies is to conduct another count, search, and
report the discrepancy. Medications are disposed with the consulting pharmacist. The center
maintains a copy of a pharmacy consultant license on-site. Medication is disposed of when the
pharmacy consultant is on-site. The pharmacy consultant comes on-site monthly and counts
medications, documents medical errors, and disposals.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures in place and there is an approved plan for exposure
control and infection control ensuring staff, youth, volunteers, and visitors are not exposed to
infectious and communicable diseases. The infection control procedures in place include
prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to the Occupational Safety and Health Administration (OSHA) federal regulations and
the Centers for Disease Control and Prevention (CDC) guidelines. The designated health
authority (DHA), superintendent, and nursing staff reviewed and signed the Infection Control
and Exposure Control Plan on November 1, 2024. A review of five youth Individual Healthcare
Records (IHCRs) was conducted. Reviewed documentation indicated each youth received
infection control training within seven days of admission. The infection control training included
hand-washing techniques, universal/standard precautions, prevention/transmission of
communicable diseases, vaccinations, and the CDC guidelines for infection control. A review of
the center’s Exposure Control Plan/Infection Control Plan showed the plan was written in
accordance with OSHA guidelines to include risk assessment and methods of compliance. The
plan addresses common infectious diseases of childhood, self-limiting, episodic contagious
illnesses, viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), infectious diseases caused by bloodborne pathogens, other
outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant micro-
organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures. The center
maintains procedures for staff to adhere to universal precautions and the center provides staff
with the opportunity for Hepatitis B immunizations and access to protective equipment. There
were no instances in which the local county health department, CDC, and/or the Department’s
Central Communications Center (CCC) should have been notified of an infectious disease,
since the last annual compliance review. The Exposure Control Plan was written in accordance
with OSHA standards and is available to all staff. All records are maintained as confidential for a
ten-year period as required. The center’s process for needle stick post-exposure evaluation
consists of counseling, evaluation of reported illness, and providing information to the individual
who was exposed. An interview with the nurse indicated the Exposure Control Plan is available
to staff and located in the medical office. Infection control training is provided to youth during the
medical admission intake. The medical staff are responsible for providing training to staff on the
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Office of Accountability and Program Support Page 45 of 58 (Revised July 2023)
center’s Exposure Control Plan. A review of five pre-service and in-service staff training records
confirmed each staff completed Exposure Control Plan/Infection Control Plan training.
4.18 Prenatal Care/Education [Contract Provider] Non-Applicable
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center did not have any pregnant youth during the annual compliance review period;
therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 46 of 58 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures which outline supervision of youth requirements.
Observations were conducted each day of the annual compliance review week regarding staff
supervising youth. Youth and staff observations were made on the living modules, in the
classrooms, in the cafeteria, in the booking area, and during line movements throughout the
center. There was proper supervision during each of these observations and staff were aware
the number of youth they were supervising. Observations showed youth were supervised as
required, and at a minimum had two detention officers on the living modules. The facility uses a
bound logbook in each living module and one in master control. All youth movements were
communicated to master control prior to movement. Master control authorizes each movement,
and each entry is logged in the master control logbook. Daily counts are tracked in the master
control logbooks, living module logbooks, and the Department’s Juvenile Justice Information
System (JJIS). The census is updated, as needed, when youth are admitted and/or released
from the center. A review of the daily shift documentation verified each youth in the center was
listed on the census. Observations during the annual compliance review showed staff were
aware of the location of youth in their care, were positively interacting with youth, and staff were
observed supervising youth during school hours, lunch time, line movement, and shift change.
Five staff were interviewed regarding whether they thought there were enough staff to provide
for the safety and security of the staff and youth at the center, and each staff responded yes.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
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Office of Accountability and Program Support Page 47 of 58 (Revised July 2023)
The center has facility operating procedures addressing the behavior management system
(BMS) to ensure the safety and security of youth and staff, which offers rewards, privileges, and
consequences for youth behaviors. The center has a system of rewards, privileges, and
consequences to motivate youth to meet the center’s expectations. Reward calendars were
posted throughout the center to make youth aware of rewards and privileges which can be
earned. Observations conducted during the annual compliance review week revealed the center
had the BMS posted in both living modules and staff were observed implementing the BMS
properly. The postings describe appropriate and inappropriate behaviors, as well as rewards
and consequences for such behavior. Each youth is informed of the BMS during the admission
process through an orientation. The BMS is a three-tiered level system. Each youth enters at
level “2.1” when admitted, and the level may increase or decrease, depending on the youth’s
behavior in the center. The center has incentives for every youth earning level three status such
as later bedtime, extra telephone calls, extra visitation outside of the allotted visitation time,
participation in special events, and canteen food items. The incentives can change based on the
center’s needs. The center has an incentive calendar detailing daily incentives for the month. A
review of the level sheets and logbooks confirmed the center’s practice. Five youth were
interviewed, and all five youth stated the BMS is very good. All five youth were able to articulate
the difference between each level and how youth are rewarded in the center. All five youth
confirmed all staff use the rewards the same way. Each youth stated youth are never allowed to
punish other youth. Four of five youth stated they have never been sent to their room for
punishment, and one stated yes. Four of five interviewed youth indicated when receiving
consequences, they felt it was fair, and one youth stated they have never received
consequences. Each of the five interviewed youth indicated when consequences are given, they
have their level or points taken away; additionally, one youth indicated youth are placed in their
rooms if they are getting into trouble or for the “stop, orient, and self-check (SOS)” de-escalation
technique. Two of the five youth indicated when placed in their room it was with a closed door,
and three youth indicated it was not applicable. Five interviewed staff stated the center’s BMS is
a point system, level system, the BMS is posted throughout the center, listed in the youth
handbook, and discussed during orientation. Each of the five interviewed staff were
knowledgeable in the types of rewards the center utilizes as part of the BMS. Five staff were
interviewed, and all five reported they felt the BMS is effective. Each of the five staff stated they
speak to the youth to discuss the consequences being imposed and alternative acceptable
behavior. Each interviewed staff stated the youth are provided an opportunity to explain their
behavior and discuss alternative acceptable behaviors. Five interviewed staff explained they
receive feedback from their supervisor regarding the implementation of the BMS on a daily or
weekly basis, during one-to-one meetings, or during briefings. Each of the five staff reported
points/levels can be taken away as a consequence and one staff reported other items can be
taken away consequently. The center’s BMS prohibits the use of group punishment and
corporal punishment. Each interviewed staff advised consequences never include loss of meals,
snacks, school, or other rights afforded to the youth. All interviewed staff further indicated they
have never witnessed a coworker utilize group punishment or corporal punishment. All five staff
indicated they never witnessed a coworker encourage a youth to beat up another youth. An
interview with the superintendent indicated the center utilizes the BMS beginning at the youth’s
admission, and levels increase depending on the youth’s behavior. The youth’s level will
increase each day, and the youth will be rewarded. The youth earn incentives on designated
days such as extra telephone calls, and once a youth reaches level three, the youth will be able
to participate in other activities which are designated for level three youth.
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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 facility operating procedures addressing ten-minute checks. Staff utilize an
electronic wand system by tapping it on the check point sensors on the outside of each youth’s
room. The juvenile justice detention officer (JJDO) must observe the youth behind the closed
door before the check point sensor is activated. The data from the wand is downloaded daily to
ensure no data is lost. The center has a total of sixty-eight cameras, and all were operational
during the week of the annual compliance review. The center stores all video recordings for
thirty days. A review of the documentation and surveillance coverage was conducted for three
randomly selected dates and times, from across three shifts, on two separate youth living
modules. The review confirmed the ten-minute checks were being conducted at intervals of ten-
minutes or less, except for one check, which was late by six minutes. A review of ten-minute
check log samples reflected checks were consistently conducted at intervals of no more than
ten-minutes. There was a weekly review of management oversight, which reflected checks were
conducted in the required frequency to ensure the checks were met with fidelity. Five staff were
interviewed, and all five reported room checks are conducted every ten-minutes or less when a
non-suicidal youth is placed in their room. Each interviewed staff was knowledgeable of the
requirements and policy when youth counts are to be conducted. An interview with the
superintendent reported anytime a youth is placed in their room, ten-minute checks must be
conducted with the center’s wand system. Additionally, staff are responsible for providing
supervision while youth are inside the rooms.
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).
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The center has facility operating procedures in place to ensure staff always know the exact
number and location of all youth under their supervision. A review of one full day from each
month since the last annual compliance review confirmed counts were being conducted and
documented as required. Counts were documented following emergencies, disturbances, and
drills. Census counts were documented upon any change of population and updated on the
Department’s Juvenile Justice Information System (JJIS) census. Additional counts were
conducted and documented, at a minimum, one extra time randomly on each shift. Living
module counts were documented in the assigned module logbooks. An observation of counts
was completed during the week of the annual compliance review, and staff were observed
conducting counts before and after each movement. Five staff were interviewed, and four
indicated youth counts are conducted at the beginning of shift and before/after meals. Five staff
stated counts are conducted before/after school, and three staff stated counts are done at the
end of shift. Three of five interviewed staff confirmed emergency counts are conducted when a
youth is believed to be missing, four of the five said when visibility is hindered, after any major
disturbance, and when drills or codes are called.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures regarding logbooks. The center maintains separate
logbooks in master control, for transportation, and for each living module, as well as one for
visitors, and one for contracted staff. A review of logbooks for the past twelve months, revealed
each logbook was bound with numbered pages, all entries included the date and time of the
event or incident, the name of the staff and youth involved, and the initials of the staff making
the entry. All reviewed entries revealed safety and security of the center, including medical,
special needs, and mental health alerts, which were highlighted. Reviewed logbooks reflected
all errors were struck through with a single line and voided and initialed by the person correcting
the error. The juvenile justice detention officer (JJDO) supervisor records comments regarding
the corrected errors. Reviewed master control logbooks included emergency situations, youth
counts following emergency situations, incidents, fire and escape drills, population counts at the
beginning and end of each shift, counts throughout each shift as they changed, group
movements, admissions and releases, presence of law enforcement, searches, name of youth
placed in confinement including the time confinement began and the time confinement ended,
name of youth placed on precautionary/secure observation, including the time precautionary
and secure observation began, and the time precautionary and secure observation was
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discontinued. A review of the center’s activity schedule and logbook documented minimal
educational instructional interference and education was conducted, as scheduled with classes
ending early on three instances. The master control and module logbooks for twelve months
were reviewed. The officer assigned to the modules conducted reviews of the logbook upon
accepting the shift, documenting the pages reviewed. The supervisors review the logbooks each
shift, including the master control logbook when accepting the shift, to document they are aware
of current relevant situations in the center. A review of the center’s logbooks confirmed the
superintendent, or designee reviewed the logbooks on a weekly basis, provided any
recommendations, and documented their visit in each area on each shift. An interview with the
superintendent indicated logbooks are reviewed weekly by the superintendent or designee.
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 facility operating procedures detailing the requirements of the center’s key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or
lost keys, and reporting and replacement of damaged keys. All keys are stored on a tamper
resistant key ring which inhibits the removal of keys and is color coded specific to the position to
which the keys are assigned. 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 keys are assigned and issued to. Emergency keys which provide egress through
exterior doors are stored in master control. The key storage areas are in the master control and
sub control rooms, and all keys were observed to be securely stored. A review of the Key
Control Logs confirmed logs included the control and use of keys including key assignment and
usage including restrictions on usage, inventory, daily tracking, reconciliation of keys, secure
storage of keys not in use, procedures addressing missing or lost keys, and reporting and
replacement of damaged keys. A review of the Key Control Logs and observations of the
distribution and collection of keys, confirmed the issuance of keys and key rings were
documented on the Key Control Logs on each shift with the date and time of issue, name of
staff receiving the key ring, and the time each key was returned. The issuance of keys and key
ring numbers were documented on each shift report. During the annual compliance review
week, staff were observed carrying the keys on their person and youth did not have access to
center keys. The center keys carried by five staff were examined and were confirmed to have
the correct number of keys on the ring, as well as the correct assigned key ring number
documented for the shift. Informal interviews conducted with three staff confirmed all staff knew
the number of keys on their key ring and the function of each key. A review of the master key
control inventory confirmed the inventory report matched the actual key rings in use. There were
no reported incidents of lost keys since the last annual compliance review. An informal interview
with the assistant superintendent confirmed there were no incidents of a staff taking their keys
home with them since the last annual compliance review. Additionally, personal keys are stored
in staff lockers, visitor lockers, or in master control within the non-secure area of the center.
There were no incidents regarding key control reported to the Department’s Central
Communications Center throughout the annual compliance review period. Five interviewed staff
reported medical records keys, case management keys, and mental health keys are restricted,
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and one staff stated the youth property area and kitchen area are restricted. Four of the five
staff stated staff can access the kitchen and the youth property area; however, staff indicated
they have no access to the kitchen’s secure area/tools or to the valuables safe. All staff reported
they knew the key control process and were able to explain the process for reporting missing or
damaged keys as outlined in the policy. An interview with the superintendent indicated there are
no permanent keys assigned to staff.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures in place for transportation and operation of
Department vehicles. The center has three vehicles used to transport youth. Each transportation
vehicle had documentation of an annual maintenance inspection completed by a certified
mechanic. Reviewed documentation verified the center’s maintenance staff conducted monthly
visual checks for all transportation vehicles. During the monthly maintenance checks, staff
visually checked the vehicle water coolant, lights, oil, emergency equipment, brakes, horn,
interior/exterior, and cleanliness. In addition, the tires, battery, windshield and wipers, windows,
mirrors, and vehicle damage were visually inspected. The inspections were documented on the
Monthly Inspection forms which were maintained by the maintenance staff. Documentation
supported the maintenance mechanic’s completion of weekly and monthly vehicle checks. A
review of the vehicle maintenance invoices revealed all vehicles received an annual inspection
since the last annual compliance review. Reviewed documentation confirmed each vehicle was
inspected prior to transport. Each inspected vehicle had the appropriate number of seatbelts
and a current fire extinguisher. Transportation staff take the emergency transport kit prior to
transporting youth which included the window punch, first-aid kit, and seatbelt cutter. An
observation of a youth transport was conducted. Prior to transporting youth, staff inspected the
vehicles for contraband, conducted a fuel check, maintained copies of transportation procedures
in the vehicle, verified the seatbelts were operational, ensured the security screen was secure,
confirmed the vehicle folder included the logs, vehicle and mechanical restraint keys, gas credit
card, and vehicle registration. Staff had a center issued cellular telephone and ensured it was
charged and turned on prior to departure, documented the inspection in the logbook, ensured
the vehicle was always secured, ensured the youth were searched prior to being placed in the
vehicle, and ensured youth and staff were wearing their seatbelts. Staff ensured youth were
searched upon return to the center. Observations confirmed the transport staff ensured the
vehicle was searched for contraband and locked to prevent the introduction of contraband. The
center’s vehicles are to be securely locked when not in use. A check of the three vehicles found
all to be securely locked when not in use. The vehicle logbooks documented the
acknowledgement the vehicle was checked, destination, staff names, number of youth, and the
time transport began and ended. Five youth were interviewed regarding safety while being
transported in center vehicles and all youth indicated they feel staff drive safely. None of the
youth ever observed anyone placing contraband in a transport vehicle.
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5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures to ensure all tools and equipment related to
maintenance and the kitchen area are properly maintained, stored, and inventoried. All tools
used must be signed in and out when removed from respective areas. All tools were secured
behind two secure doors accessible to the maintenance staff, supervisors, and administrators.
The center maintains an inventory of tools. A review of the inventory logs confirmed they
included documentation of the issuance and return of tools. Kitchen tools included knives and
other sharps which were stored in a locked box in the kitchen area. An inventory of kitchen tools
was maintained, and counts were documented. Observations of the tool room and the kitchen
verified all tools were secured when not in use. A review of ten tools and the tool inventory lists
verified there were no tools found to be missing. There were no tools which were not listed on
the inventory sheets. Ten tools were randomly selected, and each tool was secured, marked for
easy identification, inventoried accurately, and the inventory was signed by the
superintendent/designee. An informal interview with the maintenance staff confirmed service
vendors were always accompanied by designated center staff when in the center. Additionally,
after the completion of a work project, the area is to be cleaned and inspected for contraband
prior to allowing youth access. An informal interview with maintenance and kitchen staff
confirmed the center’s practice for missing and damaged tools. The center maintains facility
operating procedures detailing the requirements and restrictions for youth access to tools and
cleaning items. At the center, youth are only allowed to have access to mops, scrub brushes,
and brooms. During the annual compliance review week, there was an observation of a youth
utilizing a broom to sweep their room. An interview with the superintendent indicated only the
maintenance mechanic and detention staff have access to Class A tools. Five youth were
interviewed, and all youth responded when they clean, they are allowed to use mops, scrub
brushes, and brooms, and are not allowed to use any other tools. Five staff were interviewed,
and each staff indicated youth are allowed to use mops, scrub brushes, and brooms with staff
supervision. Five interviewed staff had knowledge of the center's practice for damaged and/or
missing tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
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permitted to clean, handle, or dispose of any other person’s biohazardous material, bodily
fluids, or human waste.
The center has facility operating procedures which state flammable, toxic, caustic, and
poisonous fluids and other dangerous substances may only be drawn or acquired by authorized
staff and prohibit youth from using or handling these items. A review of the flammable, toxic,
caustic, and poisonous materials storage area confirmed the area is inaccessible to youth and
only permitted staff can access these items. Inventories of flammable, toxic, caustic, and
poisonous items are maintained by the maintenance mechanic. Safety Data Sheet (SDS)
logbooks are in the same location as the center’s stored chemicals. The center maintains an
inventory of all chemicals which includes the quantity of each chemical. Monthly Inventories of
flammable, toxic, caustic, and poisonous items are maintained by the maintenance staff and
reviewed and signed by the superintendent or designee. The inventories were compared to the
items on-site and were found to be accurate and complete. A review of five SDSs and
corresponding items was completed, and all five chemicals were properly accounted for and
stored in a secure place. All five interviewed youth stated they did not have access to
flammable, toxic, caustic, and poisonous items. Two of the five interviewed youth indicated they
did not clean with any type of cleaning agent, and three youth stated they have cleaned with a
cleaning agent; however, the youth explained the staff spray the cleaning agent. Five staff were
interviewed, and four staff stated youth were not allowed to clean with substances which are
toxic, flammable, or poisonous and one staff stated yes; however, only when staff sprays the
cleaning product for the youth.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains facility operating procedures to ensure flammable, toxic, caustic, and
poisonous items are disposed of according to the manufacturers Safety Data Sheet (SDS). A
review of the flammable, toxic, caustic, and poisonous materials storage area confirmed the
area is inaccessible to youth. All kitchen liquid waste is disposed in the kitchen drain. The
kitchen has a container for grease designated for disposal. Reviewed documentation verified
the grease trap is cleaned on a quarterly basis. An interview with the facility maintenance
mechanic confirmed there were no instances of chemical spills or disposal of any flammable,
toxic, caustic, or poisonous items since the last annual compliance review. Additionally, the
center has a policy and procedures requiring staff to notify master control of the location, and
the shift supervisor or master control staff to contact the maintenance mechanic for directions in
the event of a chemical spill.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures which outline the process of placing youth in
confinement under twenty-four hours. The procedure requires staff to use behavioral
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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 themself. Eleven youth confinement records were reviewed. Each of
the eleven reviewed youth confinement records contained documentation which ensured each
youth had the right, when applicable, to have three meals a day plus evening snack, access to
mental health care as needed and requested, daily showers, clean clothing, mattress/bedding,
education materials during school hours, and the right to grieve a confinement placement. The
center documents confinements under twenty-four hours in the Facility Management System
(FMS) within the Department’s Juvenile Justice Information System (JJIS). Documentation
verified the supervisor approved the confinements, staff placed only one youth in the
confinement room, the room was searched, and documentation of the search was entered in
FMS prior to placing a youth in confinement for all eleven reviewed records. Reviewed
documentation confirmed each of the reports contained the initial confinement and were
reviewed by the juvenile justice detention officer supervisor (JJDOS) within two hours to
determine the appropriateness and the use of confinement. A review of eleven Visual
Observation Reports (VORs) verified staff were observing youth in confinement at least every
five minutes for the first hour of confinement and the supervisor conducted an initial confinement
review within one hour of the incident. A report was completed before the end of the
supervisor’s shift. After the first hour, youth were observed according to the Detention
Supervision Matrix. None of the reviewed records documented a physical injury was observed
prior to placing youth in confinement. A review of the eleven youth confinement reports showed
youth were afforded education materials. Each of the reviewed confinement records
documented the reason for the confinement, which was explained to the youth. Each of the
eleven reviewed confinements documented a review conducted by the supervisor at least every
three hours, including the reason for continued confinement based on severity of rule infraction,
past disciplinary history, or behavior confinement in FMS. All eleven reports were reviewed by
the superintendent or designee within forty-eight hours excluding weekends and holidays.
Reviewed confinements confirmed supervisors/staff continually counseled the youth to consider
removing them from confinement as soon as the youth was able to safely rejoin the population
and there was no threat to safety. Reviewed documentation verified the confinements did not
interfere with visitation. The center did not have any pregnant youth in confinement under
twenty-four hours during the annual compliance review period. An observation of the
confinement rooms verified the cameras and plexi-glass windows were free of obstructions. An
interview with the superintendent indicated confinements are entered, tracked, and monitored in
JJIS. Additionally, the superintendent stated all confinements, lockdowns and/or restraints are
reviewed daily. Five interviewed staff had knowledge of the center's step-by-step process for
placing youth in confinement. Each of the five interviewed staff indicated when youth are placed
in confinement, educational materials are offered.
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.
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The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains a written policy and procedures to ensure a plan is in place to manage
various emergencies and disaster events. The center’s Continuity of Operations Pan (COOP)
was approved by the regional director. Reviewed documentation showed there were three
COOP drills conducted, during the annual compliance review period. One drill was conducted
on January 14, 2024, the second drill was conducted July 31, 2024, and the third drill was
conducted on October 8, 2024. Documentation confirmed a drill was completed prior to
hurricane season as required. Each reviewed drill had documentation containing the type of
drill, time and date, participants, a brief scenario, findings, recommendations, critique forms, and
emails used to document the drills. Additionally, drills are reviewed during monthly management
meetings and during shift briefings. An interview with the superintendent confirmed the center’s
comprehensive safety/emergency process is to conduct safety and security audits on a
quarterly basis, using the standardized safety/security quarterly inspection form. These
inspections are to be uploaded in the inspections section of each center’s shared network drive.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures regarding developing, implementing, and
maintaining an Escape Prevention Plan. The center’s policy requires the center to conduct
escape drills at least quarterly. Documentation for drills conducted since the last annual
compliance review was examined. The center completed quarterly escape drills on January 20,
April 15, July 15, and October 21, 2024. The documentation of the drills included scenarios, as
well as the dates and times of the drills. The drill documentation form included the signatures of
the supervisor and the staff coordinating the drill. Recommendations and critiques of the drills
were included in each report. A review of logbooks revealed each mock escape drill was
documented in the logbooks, as required. A review of five staff training records validated each
staff completed escape prevention training during the previous year. Five staff were interviewed,
and all staff reported they participated in fire, weather, major disturbances, chemical spills,
flooding, medical, and escape drills 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.
The center has facility operating procedures for the implementation of disaster preparedness
and fire prevention plans. Fire drill documentation was reviewed and found the center
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Office of Accountability and Program Support Page 56 of 58 (Revised July 2023)
conducted fire drills monthly, on each shift, during the annual compliance review period. Each
drill was documented in the master control logbooks. A review of staff sign-in sheets confirmed
staff participation in each drill. Observations confirmed the annual inspection of fire
extinguishers was completed as reported. Five staff were interviewed and all five indicated fire
drills take place at least once a month. Five youth were interviewed, and all stated they had
been instructed on what to do in the case of a fire.
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’s superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures which address illegal contraband and prohibited
items and to reduce the introduction of contraband into the center. A review of the center’s
policy and observations verified prior to admission, a full body search and electronic search are
completed. In addition, searches are conducted when deemed appropriate by the shift
supervisor, when there is a reasonable suspicion the youth is harboring contraband, and during
center-wide initiatives to reduce the introduction of contraband. An observation of a new
admission into the center verified staff wore gloves during the search. There were two same
gender staff present when the search was conducted. There was no documentation of a strip
search being conducted at any other time than admission. The observation verified the search
was conducted individually in a private area and not in a group setting. A review of the center’s
policy and observations verified staff and visitors were electronically searched when entering
the secured area of the center. All bags, cases, jacket pockets, and shoes were searched. All
personal keys, personal cellular telephones, and other contraband items were prohibited in the
secured area of the center. Youth room searches are documented on the shift reports and are
uploaded electronically. A review of random shift reports for one day for each month during
each awake shift for the annual compliance review period verified youth room searches were
documented and completed as required. A review of the Department’s Central Communications
Center (CCC) reports since the last annual compliance review found there were three instances
of contraband found at the center. The contraband and the calls to the CCC were documented
in the master control logbook. Documentation verified incident reports were completed
identifying findings and disposition of the contraband found. Confiscated items were secured,
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Office of Accountability and Program Support Page 57 of 58 (Revised July 2023)
immediately reported to the supervisor, and hand delivered to the supervisor. Reviewed
documentation showed the shift supervisor documented the chain of custody for the contraband
items and the regional director was notified. Local law enforcement was contacted for the items
considered illegal as defined by Florida Statute. An interview with the superintendent stated staff
shall be diligent in their efforts to prevent the introduction of contraband into the center and all
searches are conducted as necessary to control contraband and to ensure safety. In the event
contraband is located on a youth or staff, all contraband will be confiscated and law
enforcement, and the CCC will be notified. The center’s visitor log does not contain a
contraband attestation statement; however, the center does have separate visitor contraband
attestation forms. A review of the attestation forms and visitors’ log revealed no discrepancies.
Twelve staff records were reviewed, and all contained a contraband attestation form. Six newly
hired records were reviewed, and all contained a contraband attestation form.
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Office of Accountability and Program Support Page 58 of 58 (Revised July 2023)

source: DJJ

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance