summary: QI Detention - FY25-26 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Department of Juvenile Justice
Marion Regional Juvenile Detention Center
(State-Operated)
3040 NW 10th Street
Ocala, Florida 34475
Review Date(s): July 22-25, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Lori Bright, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Department of Education, (Standard 2, Education Standard)
Jessica Gibson, Office of Accountability and Program Support, Co-Lead Reviewer (Standard 1)
Forrest Hallam, Office of Accountability and Program Support, (Standard 2)
Kristine Harshaw, Office of Accountability and Program Support, (Standard 5)
Michele Maynard, Office of Accountability and Program Support, (Standard 4)
Rebecca Smith, Office of Accountability and Program Support, (Standard 3)
Meghan Thrasher, Office of Accountability and Program Support, (Interviews)
Program Name: Marion Regional Juvenile Detention Center MQI Program Code: 94
Provider Name: State Operated Contract Number: N/A
Location: Marion County / Circuit 5 Number of Beds: 60
Review Date(s): July 22-25, 2025 Lead Reviewer Code: 230
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 54
L im ite d R a tin g s F a ile d R a tin g s
1.05 R ight Interactions (R I)
2.10 E ducational A ccess *
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 54
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a
S ta ff C o d e o f C o n d u c t S a
In c id e n t R e p o rtin g C C C * S a
R ig h t In te ra c tio n s (R I)
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a
In -S e rv ic e T ra in in g S a
G rie v a n c e s S a
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a
D a ta T re n d A n a ly s is S a
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
tis fa c to ry
tis fa c to ry
tis fa c to ry
tis fa c to ry
F a ile d
tis fa c to ry
tis fa c to ry
tis fa c to ry
tis fa c to ry
tis fa c to ry
ra m
a ilu re to d o
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 54
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n S a tis fa c to
O rie n ta tio n S a tis fa c to
C la s s ific a tio n S a tis fa c to
N o tific a tio n o f J P O C irc u it G a n g R e p S a tis fa c to
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty S a tis fa c to
R e le a s e S a tis fa c to
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa c to
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n S a tis fa c to
D a ily A c tiv ity S c h e d u le S a tis fa c to
E d u c a tio n a l A c c e s s * F a ile d
C a re e r E d u c a tio n S a tis fa c to
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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ry
d o
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 54
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
* T h e D e p
b e lo w D e p
in a p ro g ra
aam rtm
rtm
a
eele n t h
n t s
rt fo
a s id e n
ta n d a rd
rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia
m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
N o n -A p p
te a tte n tio n if a p ro g ra m o p
d ic a to rs . F a ilu re to d o s o w
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
lic a b le
e ra te s
ill re s u lt
Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 54
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * S a tis fa c
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa c
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm S a tis fa c
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n S a tis fa c
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa c
H e a lth -R e la te d H is to ry S a tis fa c
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g S a tis fa c
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g S a tis fa c
S ic k C a ll P ro c e s s S a tis fa c
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re S a tis fa c
O ff-S ite C a re /R e fe rra ls S a tis fa c
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s S a tis fa c
M e d ic a tio n M a n a g e m e n t S a tis fa c
P s y c h ia tric S e rv ic e s * S a tis fa c
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s S a tis fa c
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n S a tis fa c
P re n a ta l C a re /E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to d o
Standard 5: Safety and Security
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 54
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D e p a
o p e ra te s b e
d o s o w ill re
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th * S a tis fa c to ry
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t* S a tis fa c to ry
T e n -M in u te C h e c k s * S a tis fa c to ry
C e n s u s C o u n ts a n d T ra c k in g S a tis fa c to ry
L o g b o o k M a in te n a n c e a n d R e v ie w s S a tis fa c to ry
K e y C o n tro l S a tis fa c to ry
V e h ic le s a n d M a in te n a n c e S a tis fa c to ry
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s * S a tis fa c to ry
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs S a tis fa c to ry
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs N o n -A p p lic a b le
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills S a tis fa c to ry
E s c a p e D rills S a tis fa c to ry
F ire D rills S a tis fa c to ry
S e a rc h a n d C o n tra b a n d P ro c e d u re s S a tis fa c to ry
rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to
s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
Program Overview
The Marion Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Ocala, Florida. The center serves youth in Citrus, Hernando, Lake,
Marion, and Sumter counties in Circuit 5. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
sixty-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 Marion County School Board.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, seven juvenile justice detention officer supervisors (JJDOS), and
thirty-six juvenile justice detention officers (JJDOs). Mental health and healthcare services are
provided through the contracted provider, VitalCore Health Strategies, LLC. Mental health
services are provided by a designated mental health clinical authority (DMHCA), three licensed,
and two non-licensed staff. Clinical services provided by the center include mental health and
substance abuse evaluations, mental health treatment planning, individual, group and family
therapy, mental health crisis intervention services, on-site psychiatric services, and availability
for substance abuse services for youth with co-occurring disorders. Medical services are
provided through the provider, VitalCore Health Strategies, LLC. Medical services are provided
by a designated health authority (DHA), one advanced practice registered nurse (APRN), one
clinical manager, two registered nurses (RNs), and two licensed practical nurses. The medical
clinic maintains nursing coverage Sunday through Monday from 7:30 a.m. to 7:30 p.m. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has four living modules which are divided by male and female. There are eighty-
eight security cameras at the center, of which eighty-four were operational. The center was
clean and orderly indoors and the grounds were mowed and free of weeds. The center was free
of graffiti and inappropriate messages. The center had no discernable odors, and the youth and
staff were neatly dressed. At the time of the annual compliance review, the center had six
vacancies, which included a food support worker and five JJDOs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 54
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 (FOPs) for background screenings on all
Department staff, contracted providers, volunteers, mentors, and interns with access to youth
and their confidential records. The center has a FOP for volunteers, interns and mentors who
work less than ten hours a month requiring sight and sound supervision. An Annual Affidavit of
Compliance with Level 2 Screening Standards was completed on January 9, 2025, for the
Department staff. An Annual Affidavit of Compliance with Level 2 Screening Standards was
completed on January 7, 2025, for education staff. Nine initial background screenings were
reviewed for each new hire employed since the last annual compliance review. All nine staff had
a background screening completed prior to contact with youth or youth’s confidential information
and each criminal history was reviewed. Four staff were deemed ineligible and an exemption
was obtained for each staff. A pre-employment assessment tool was administered to all nine
staff who were hired as direct care employees and eight of the nine had passing scores. One
staff did not have an assessment passing score which was not in staff’s record; however, a copy
of the detention services cumulative rating score for direct care positions was completed and in
the file. Staff had a a score of 68.50, close to the passing score of 70.00 and approved by the
Northeast Regional Detention Office.
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 (FOPs) for five-year background rescreening of
Department staff, volunteers, contracted providers, mentors, interns and grant recipient staff
who continue to work for the Department for an extended time. Four staff met the criteria, and
each had five-year rescreening completed less than twelve months and before ten days prior to
the staff’s anniversary date.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 54
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 (FOPs) for staff code of conduct. The center’s code
of conduct prohibits any form of abuse, profanity, threats, harassment, intimidation, or personal
relationships with youth. Any physical abuse or threats toward a youth will be reported to the
Florida Abuse Hotline, the Department’s Central Communications Center (CCC), and/or law
enforcement. Three staff were reviewed for disciplinary actions due to violations of the staff
code of conduct. Two of the staff received disciplinary actions to include a written reprimand and
an oral reprimand. The other staff is pending disciplinary action and has not had any youth
contact according to the superintendent. The superintendent was informally interviewed and
reported staff commendations and recognition were not done during the annual compliance
review period. The center recently released a memo which allows for the center to begin
providing commendations.
Nine staff were interviewed. All nine staff indicated they were able to make an abuse call and if
any youth wanted to make an abuse call, they were permitted to. Staff also indicated they would
make sure their supervisor was notified of the occurrence and youth should be allowed as much
privacy, as is possible, while making the call. Six of the interviewed staff stated they had
witnessed other staff using curse words and profanity around the youth; however, it was not
directed at the youth themselves. Three staff had never heard other staff utilizing profanity. All
nine staff reported they had never observed a co-worker using threats, intimidation, or
humiliation when interacting with the youth. Overall, working conditions in the center over the
past year was rated very good by one staff, good by five staff, and fair by three staff.
Nine youth were interviewed. None of the youth interviewed have witnessed or experienced any
type of physical or sexual abuse. Eight of nine youth indicated staff are respectful when talking
to them as well as other youth in the center; one youth stated some staff target others, being
denied supplies when asking for them such as feminine products, and one staff was mentioned
as having made sexually charged comments around the youth. This reported by another youth
who would not give the name of the youth or staff involved and refused to call the abuse hotline
when asked. Seven of nine youth stated they have heard staff use curse words when speaking
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 54
with them or other youth at the center, with two youth stating they hear it often. All youth stated
they have never heard staff threaten them or other youth at the center. Eight youth stated they
felt safe while one indicated it is not a staff issue; however, the other girls detained made her
feel unsafe. None of the interviewed youth have ever exchanged emails, telephone numbers, or
social media contact information with staff. Administration was made aware of all issues
reported, which would be addressed and discussed with all staff about professionalism.
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 (FOPs) for reporting incidents. The center had 115
reported incidents during the annual compliance review period. Ten reports were reviewed and
nine were reported to the Department’s Central Communications Center (CCC) within the
required timeframe, with one not reported by the medical staff to the CCC within two hours. All
ten incidents were documented in the logbook. There were no additional incidents/grievances,
which should have been reported to the CCC. The superintendent’s interview confirmed
reportable CCC incidents must be reported within two hours of learning about the incident and
staff are able to contact the abuse hotline at any time.
1.05 Right Interactions (RI) Failed 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 (FOPs) for Right Interactions (RI), which is the
Department’s approved Protective Action Response (PAR) curriculum. The center uses physical
intervention techniques in accordance with Florida Administrative Code. If staff use a physical
intervention technique, such as countermoves, control techniques, takedowns, or mechanical
restraints, a RI incident report is completed and, if the restraint results in a serious injury to
youth or staff, the Department’s Central Communications Center (CCC) must be contacted
within two hours. The center had 100 RI incidents during the annual compliance review period.
Nine incidents were reviewed, and seven reports were not completed by the end of the staff’s
workday. Nine reports did have statements from the staff, two within the timeframe and six after
the fact. One incident did not have a statement from the staff. None of the nine incidents
resulted in serious harm to any youth or staff. The reviewed incidents confirmed there were no
youth alleging abuse. Each RI report was reviewed by a supervisor or a RI-certified supervisor.
A post-RI was conducted by the superintendent/designee within thirty minutes of the completed
intervention. Two of the youth’s incidents required further medical review; one youth was
assessed by medical staff, and the other youth was not assessed by medical staff. The youth
who was seen had a medical review documented in their Individual Healthcare Record. Neither
of the two youths needed to be sent off-site for further evaluation. Four of the nine reports did
not have a superintendent/designee review completed within seventy-two hours. The remaining
five reports were reviewed by the Superintendent after the seventy-two hour timeframe. The
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centers RI rate during the previous quarter was 3.17, which is below the statewide detention
rate of 13.49.
Nine staff were interviewed and all indicated they try to talk to youth prior to utilizing any
physical or mechanical restraints. The superintendent’s interview relayed mechanical restraints
are located behind a locked door and there is a log staff must sign-in/out when using
mechanical restraints for transports. The superintendent also stated supervisors conduct
inventory on mechanical restraints daily. The superintendent went on to state supervisors
review RI reports and the superintendent/designee review RI reports and video coverage.
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 procedure (FOPs) regarding training in accordance with the
Florida Administrative Code. New detention staff shall satisfy pre-service/certification
requirements within 180 days of hiring. Three staff records were reviewed for training completed
during the first 180 days of being hired. Two of the staff were hired within the last month and did
not have any training completed; therefore, they have had no contact with the youth in the
center. One staff was hired within the last two months and had fifty-four completed hours
including all training needed to be in the presence of a youth except for Right Interaction. Nine
staff training records were reviewed for pre-service/certification requirements. All nine staff
completed certification requirements within 180-days of hire. Each received a new staff
orientation within thirty days of hire, and completed academy training which consisted of 120
hours.
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.
Nine records were reviewed for annual in-service training. All nine had more than the required
twenty-four hours needed annually for 2024. The records indicated all required training topics
were completed in the Department’s Learning Management System (SkillPro). Three of nine
records were reviewed for annual supervisor training. Supervisors must complete eight hours of
coaching, leadership and personal accountability training and all three supervisor’s records
confirmed twenty-seven, twenty-five, and thirty-nine hours were completed during the 2024
calendar year. The center maintains an annual in-service training calendar which is updated as
changes occur. The in-service training calendar was signed and approved by the
superintendent, the assistant secretary of Detention, and the director of Talent, Leadership and
Culture. A review of the superintendent’s interview confirmed Tier Three management training
includes Certified Program Manager training, Motivational Interviewing training, Detention
Services annual training, as well as the mandatory annual training.
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Office of Accountability and Program Support Page 13 of 54
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 (FOPs) for grievance procedures to ensure youth
are treated fairly, respectfully, and without discrimination. There are grievance forms for youth to
fill out and place in a box which is located on each dorm. There were no grievances filed since
the last annual compliance review. During an interview with the superintendent, they were able
to articulate the process for grievances to include the three phases: informal, formal and final. In
the informal stage the staff attempts to solve the issue with the youth, and in the formal stage,
the supervisor attempts to solve the issue during the shift if possible, but no later than twenty-
four hours. In the final stage, if the issue hasn’t been resolved, the superintendent/designee
makes a final decision within seventy-two hours. The superintendent keeps a copy of the
grievance for the entire review period. All nine interviewed staff were able to explain how a
youth can file a grievance if needed. Overall, four staff believed these processes were very
good and five believed the processes to be good in terms of effectiveness. Nine youth were
interviewed. Seven of nine youth have never had to file a grievance and six youth were able to
articulate the grievance process or at least know how to start the process. Two youth were
unsure how the grievance process worked, and one youth indicated there are supposed to be
forms on the living unit; however, there are none and sometimes when youth ask for a form to
fill out, they must wait to get the form. The two youth who had experience filing a grievance
rated the process between fair to poor. These issues were brought to the attention of
administration who stated due to youth using the grievance forms to make paper airplanes, spit
balls, and write letters to other youth, the youth now must request a grievance form from staff
who do provide them.
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
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notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures (FOP) to ensure critical or special alerts for youth
are documented, reviewed, and responded to appropriately. Alerts are entered into the
Department’s Juvenile Justice Information System (JJIS), as well as the internal alert system.
Internal alerts and JJIS alert reports are distributed and reviewed daily by the juvenile justice
detention officer supervisors (JJDOS) and administration. Alerts are entered, downgraded, or
discontinued in JJIS by the appropriate staff on the date identified and/or when the alert is no
longer applicable. All alerts regarding youth medication or medical information are confirmed
and verified between the medical staff and the youth’s parent/guardian. The center’s practice is
to relay alert information to all staff during shift briefing and review alerts during detention review
and follow-up accordingly. Nine youth’s critical/special alerts were observed in JJIS, and all
were opened, closed, and/or updated as required. There were no additional alerts found which
should have been entered into the alert system. An interview with the superintendent confirmed
staff enter alerts upon admission and supervisors and medical staff review alerts to ensure they
are correctly tracked. Supervisors review alerts daily with staff. Nine staff were interviewed and
each was able to articulate how they are notified of alerts and indicated it is done through shift
briefings, alert forms, JJIS, e-mail, radio, and the youth’s juvenile probation officer (JPO). Staff
stated information regarding issues at the center are disseminated by shift briefings, meetings,
e-mails, and relaying the information verbally.
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 facility operating procedures (FOPs) for the review and analysis of data in
decision making practices. Administration shares data trends with staff to make policy, practice,
and changes designed for center improvement. The center sets their principles of data-informed
decision making and alignment of data with system improvement goals and practices. The
center has all-staff meetings on a regular basis and shares information during the north region
detention services meetings. The providers and stakeholders are able to review the north
region detention trends during quarterly community meetings. The center implemented a data-
informed rating system for team members, work/evaluations, system improvement goals, and
practices.
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Office of Accountability and Program Support Page 15 of 54
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.
Nine youth records were reviewed for admission documentation. All nine records contained the
Admission Wizard, Detention Risk Assessment Instrument (DRAI), and Suicide Risk Screening
Instrument (SRSI). In all nine records, the Admission Wizard documented the arrest
affidavit/custody order, the completion of a full-body and/or electronic search of the youth, along
with a medical, mental health and substance abuse screening. Five of nine youth received a
telephone call during admission, two received their phones at a later time due to the time of
admission, and two did not receive telephone calls. Each youth was provided a meal. An
observation of a youth admission was conducted, and the youth received a phone call, a meal,
and all procedures were followed.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operation procedures (FOPs) which outlines the center orientation is to
be provided verbally and in writing, and include rules and regulations, grievance procedures,
visitation, telephone calls, access to medical, mental health and substance abuse services,
access to the Florida Abuse Hotline or the Department’s Central Communications Center
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(CCC), behavior expectations and related consequences, possible new law violations for
destruction of property, youth rights, and Prison Rape Elimination Act (PREA) related
information. The center conducts orientation as part of the intake process. Nine youth records
were reviewed and contained a signed orientation form with all required components. An
orientation was observed as part of the intake process and the staff went over the orientation
components and explained them all to the youth. Nine youth were interviewed about the
orientation process. Six youth stated they were informed about the rules and regulations, daily
schedule, education services, visitation, abuse reporting, and the behavior management system
(BMS). Three youth stated they were not; however, one youth stated it was because this was
not his first time at the center, and he had been informed the previous time. These issues were
reported to administration to be addressed.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operation procedures (FOPs) to ensure consideration for classification
includes physical characteristics, age and level of aggressiveness, special needs, history of
violent behavior, gang-affiliation, criminal behavior, history of sexual offenses or any pending
sexual offenses, vulnerability to victimization and/or sexually aggressive behavior, suicide risk,
and suspected human trafficking. Nine records were reviewed and each contained all required
classification components which were reviewed prior to making a supervision level and room
placement decision. The superintendent shares and receives gang information through
communication with probation staff at the weekly detention review meeting. The superintendent
was interviewed and stated the center collects information on the components of the
classification policy prior to making decisions on room placement and supervision level prior to
the youth going to the living module.
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Office of Accountability and Program Support Page 17 of 54
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.”
Nine youth records were reviewed for notification to the juvenile probation officer (JPO) circuit
gang representative for youth suspected of gang activity or involvement. None of the reviewed
records were applicable for gang involvement. No additional records for youth identified with
gang involvement were applicable during the annual compliance review period. Notification to
the circuit’s gang liaison was not applicable. Upon discussing with the superintendent, the
center notifies the JPO assigned as the detention coordinator if a youth suspected of or
documented as a gang member is admitted into the center. Alerts in the Department’s Juvenile
Justice Information System (JJIS) are entered for suspected gang affiliation and all alerts are
reviewed as part of the Detention review process, as well as during shift briefing with Detention
staff by the superintendent, who is the center’s gang representative.
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.
Nine record were reviewed, and contained a Department Juvenile Justice Information System
(JJIS) Property Receipt form signed by each youth and staff as well as a letter of
acknowledgement regarding unclaimed property signed by all nine youth. All nine interviewed
youth stated they had their property documented and they signed and verified the property
receipt form. One of the nine reviewed youth records had valuable property. A copy of the
valuable property inventory documented on the Department’s Valuable Property Receipt form
was in the youth’s record, and the property was in the safe located outside of the
superintendent’s office. Valuable property is sealed in a clear, tamper proof bag. The safe is
kept locked and only supervisors and administration have access to the safe. The valuable
property is documented in a bound logbook and includes the date, time, youth’s name,
Department of Juvenile Justice identification number (DJJID), printed name of the officer, and
initials. Personal property is place in a numbered bag and secured in the property room after
documentation of the inventory and search is complete. Valuable property and the personal
property room are both secure and have limited staff access. A review of the Department’s
Central Communications Center (CCC) reports for the annual compliance review period did not
show any incidents regarding youth property valued over fifty dollars being reported. Both the
valuable and personal property locations were under video surveillance. The superintendent
interview confirmed valuable property is placed in a secure tamper proof bag, signed and
verified by the youth and staff, and placed in the secure filing cabinet outside of the
superintendent’s office.
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Office of Accountability and Program Support Page 18 of 54
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.
Three closed records were reviewed for release procedures. Each record had a Detention
Release Wizard completed in its entirety. Two youth were released from the center, and one
was released from a courthouse in an adjacent county. The on-duty supervisor reviewed the
paperwork in two of the three records prior to release. The third release was conducted at court,
and the Detention officer documented the identification of the person accepting the youth and
the relevant information for the center on a center form. The Detention Release Wizard was
completed upon return to the center for this youth. None of the three records had an
endangered person alert. The release documentation date was verified with the release date
correlated to the Department’s Juvenile Justice Information System (JJIS). A release was not
observed during the annual compliance review due to no scheduled releases during the review
week.
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.
Three closed records were reviewed and each had parent/guardian and youth signatures for the
youth’s personal property. The identification of the person receiving the youth correlated to the
family member listed on the release wizard for two of the three youth. One youth was released
to a program staff for commitment. The identification of the commitment program staff was
copied and maintained with the youth’s release paperwork. One of the three youth had
medications, and a medication receipt was completed and signed by the parent accepting the
youth. None of the youth had additional appointments or needs to be addressed with the
parent/guardian upon release. The center has disposed of property which remained in the
center over thirty days. A copy of the valuable property documentation is kept with a list of the
property and youth information, and the property is given to the sheriff’s office in accordance
with the center’s policy and procedures. All monetary funds from valuable property are counted,
inventoried, and sent to headquarters. A release was not observed during the annual
compliance review due to no scheduled releases occurring at the time of the review.
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Office of Accountability and Program Support Page 19 of 54
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
A review of Detention review records confirmed Detention reviews were conducted weekly, with
one exception were the Detention review was not present in the center’s management system.
A signed roster of attendees was present with a list of youth containing relevant court
information and requests for documentation to be given to or provided from clinic and mental
health staff. Attendees regularly included the center representative, the juvenile probation officer
(JPO) assigned as the Detention coordinator, the designated mental health clinical authority
(DMHCA), the nursing manager, and probation supervisors and probation administration.
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.
During the week of the annual compliance review observations of activities and programming at
various times of the day were conducted and found programming was in accordance with the
activity schedule, posted in all living areas. Wake up and personal hygiene, mealtimes, indoor
activities which promote education, problem-solving and life skills, bedtimes, groups, and open
program time were observed to be provided regularly. Documentation in the logbooks supported
the daily activity schedule is being followed. Recreation and physical activities were conducted
as part of the school curriculum. Nine staff were interviewed and each indicated the center has
a daily activity schedule they do adhere to as much as possible, given staffing issues including
vacancies and call outs. Nine youth were interviewed and each stated the center has a daily
activity schedule, with seven youth reporting it is followed. One youth reported youth are locked
in their rooms starting at 3:00 p.m. every day until dinner, and then after dinner they are
returned to their rooms. The remaining youth indicated they do not go to all their required
classes, and on weekends they are locked in their rooms for most of the day. These issues
were reported to administration who reported due to high youth population, youth takes showers
starting right after school ends, and youth are placed in their rooms during shower times;
however, all youth attend their required classes. Due to security, safety, and staffing,
adjustments to the schedule must be madesome days.
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Office of Accountability and Program Support Page 20 of 54
2.10 Educational Access (Critical) Failed 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 a facility operating procedure (FOP) to provide educational access. The center
provides education services through the Marion County School Board. It operates on a 250-day
calendar, distributed over twelve months, which includes ten days reserved for teacher training
and planning. The center’s daily bell schedule meets the required twenty-five hours of
instruction weekly. All youth have an opportunity to earn course credit upon completion. A
review of the daily school schedule revealed the center provides five one-hour classes daily,
fulfilling more than the weekly requirement of twenty-five hours of instructional time. A review of
the center’s activity schedule and the educational bell schedule showed no discrepancies. The
superintendent and staff reported the center interferes minimally with educational instruction. A
review of the logbooks since the last annual compliance review for each month revealed
students were late to transition for the start of classes, left early for lunch, and/or transitioned
early from educational classes every month with the exception of one month. There was no
documentation of classes ending on the reviewed days for three months. Reviewed
documentation revealed students are only receiving a half day of school. Half of the population
goes in the morning, with the other half going in the afternoon due to overpopulation and staff
shortages’ therefore, receiving only half of the required twenty-five hours of education
instruction a week.
Video observations were conducted for three days and showed school taking place as
scheduled on two days One reviewed day revealed school ended six minutes early for lunch
and ended fifty-one minutes early. Logbook noted it was an early release day.
Nine youth were interviewed. Seven reported the center was preparing them very well or well for
a high school diploma or a high school equivalency diploma provided through the General
Educational Development platform (GED), vocational school, employment, and/or college. Two
youths reported not well and felt they were receiving lower-level classwork and watching too
many videos. Eight youth reported they attend school Monday through Friday, with one youth
reporting they sometimes go every day, but some weeks they only attend three or four days a
week.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
An interview with the lead teacher confirmed the center provides Type 1 career education
development integrated into the curriculum, which includes Career Learning Strategies such as
interviewing skills and techniques, career interest, and completing employment applications.
The lead teacher also indicated every youth in the center is enrolled in a credited course of
careers and personal development. Nine youth were interviewed and reported taking core
classes, including math, science, history, social studies, and life skills.
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Office of Accountability and Program Support Page 21 of 54
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 a single licensed mental health professional who has been designated as the
acting designated mental health clinician authority (DMHCA). The DMHCA is on-site forty hours
each week and ensures the appropriate coordination and implementation of mental health and
substance abuse services takes place. The Department maintains a contract with VitalCore
Health Strategies, LLC to provide mental health and substance abuse services to all applicable
youth in the center. The DMHCA is a licensed mental health counselor with a clear and active
license in the State of Florida expiring March 31, 2027. The center has a back-up DMHCA with
a clear and active license in the State of Florida expiring March 31, 2027, who provides
coverage in the DMHCA’s absence. Copies of the DMHCA’s agreement and position description
were reviewed and confirmed the weekly hours of coverage are provided, as required.
An interview with the DMHCA confirmed the position is responsible for ensuring all treatment
requirements are met for every youth in the center. The DMHCA coordinates the care for
various youth, full-time mental health staff, monitors caseloads, and reviews charts to ensure
all treatment requirements are satisfied. The DMHCA also is responsible for scheduling to
ensure hours and coverage requirements are met/satisfied. The DMHCA manages a caseload
and is also responsible for completing all treatment requirements for each of the youth. The
DMHCA also participates in suicide assessments, crisis assessments, and other intervention
needs.
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 clinical supervisor ensures the licensed clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
The licensed mental health professionals are licensed under the appropriate Florida Statute
chapter and copies of the licenses are available on-site. The center has eight licensed mental
health counselors, one licensed social worker, and one licensed marriage and family therapist.
All licenses of the mental health professionals and licensed qualified professionals were
reviewed on the Department of Health (DOH) website, and all were clear and active in the State
of Florida, expiring March 31, 2027.
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Office of Accountability and Program Support Page 22 of 54
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. There are two non-
licensed mental health staff providing services at the center. The clinical supervisor ensures the
non-licensed clinical staff working under their supervision are performing services they are
qualified to provide based on education, training, and experience. A review of documentation
reflected the non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the center during the annual compliance
review period. Direct supervision was recorded on the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form. The center does not have a Chapter 397 license, as such, all substance abuse services
are being provided by licensed mental health professionals only. The contract with the
Department confirms the center is not required to have any non-licensed clinical staff. The non-
licensed staff hold a master’s-level degree from an accredited university or college in the field of
counseling, social work, psychology, or other related human services field and completed
twenty hours of training and supervised experience in assessing suicide risk, mental health
crisis intervention, and emergency mental health services prior to conducting assessments of
suicide risk as evidenced by a review of training records on the Department’s Learning
Management System (SkillPro).
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.
Nine youth mental health records were reviewed. Each youth had a Suicide Risk Screening
Instrument (SRSI) and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2)
completed in the Department’s Juvenile Justice Information System (JJIS). The screening
documents were reviewed by Detention staff and completed at intake for all nine youth. The
nurse andmental health staff completed the required sections in each SRSI and the completed
entries included an accurate referral selection in the “Screening Results” sections, as required.
Four of nine applicable SRSIs included a “yes” response and each of the four youth were placed
on suicide precautions and a mental health referral was completed, which documented the
youth’s need for an Assessment of Suicide Risk (ASR). Three of four applicable SRSIs included
a “yes” response when the youth had any open or closed suicide risk alerts in JJIS, as prompted
within the JJIS SRSI navigation screen in red font. Two of the MAYSI-2s were determined to be
“invalid” due to all negative responses, the screenings were marked as “invalid,” and each youth
was referred for a comprehensive assessment on the MAYSI-2 referral section, as required.
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The results of the SRSI and MAYSI-2 indicated a need for further assessment in eight of the
nine records. Each applicable youth who required further assessment had a referral made and
the superintendent/designee was notified. Two of the youth’s MAYSI-2s indicated elevated
suicide risk subscales. The results of two of the MAYSI-2s indicated the need for
comprehensive assessment, and the screener referred both youth for a comprehensive
assessment within the detention center.
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.
Nine youth records were reviewed for mental health and substance abuse evaluations, five were
applicable. All five youth were identified after admission and referred to the center’s provider.
Four of the five youth had a new evaluation completed by the center’s mental health provider
on-site by the youth’s thirty-first day. One youth had an updated evaluation completed by the
thirty-first day. Treatment recommendations were made which corresponded to all diagnosed
mental health or substance abuse disorders in all five records. None of the youth were
applicable for receiving a new comprehensive assessment from a community provider. The
designated mental health clinician authority (DMHCA) was interviewed and stated if a detained
youth who was referred for a Comprehensive Assessment by the Juvenile Assessment Center
(JAC) or juvenile probation officer (JPO) and has not received an assessment by the
community-based service provider within thirty days, the center's mental health provider shall
administer a Comprehensive Mental Health Evaluation to the youth by the thirty-first day in the
center.
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.
Nine records were reviewed for treatment and discharge planning. All nine youth received
a mental health orientation within fourteen days of admission. Seven of the nine youth required
an initial treatment plan and each were in place within seven days of the onset of treatment.
Each of the plans were developed on the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form and contained the reason for referral for treatment, initial Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis/symptoms, initial
treatment methods to include counseling and frequency, initial treatment goals, psychiatric
services including psychotropic medication and frequency of monitoring and medication the
youth was admitted with, if applicable. All seven plans included the signatures of the licensed
mental health professional and youth. All seven youth were assigned a mini treatment team as
evidenced by signatures of those team members on each plan.
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Seven youth were reviewed and four were applicable for receiving an individualized treatment
plan which was developed for youth receiving mental health and/or substance abuse treatment
in the center by the thirty-first day of the youth’s admission. Three youth have not been at the
center long enough to receive a treatment plan. All four individualized treatment plans included
the youth’s DSM-5 diagnosis, symptoms which are treatment focused, treatment goals which
include mental health services if the youth have a mental illness, substance abuse services if
the youth have a substance-related diagnosis, and strengths and needs. Three youth were
applicable for coming in on psychotropic medications or being prescribed psychotropic
meditations. The psychotropic medications listed in the initial treatment plan matched the
psychotropic medications the youth was prescribed at the time the treatment plan was
developed. A review of the progress notes in the seven youth’s records demonstrated each
youth was receiving treatment services as stipulated in the plan. A review of documentation
reflected the individualized treatment plans were signed and dated by each youth, mental
health/substance abuse professionals, treatment team members, and parent/guardian, or the
center attempted to get the signature of the parent/guardian, in all seven applicable records.
One of the four youth was applicable for a required thirty-day treatment plan review at the time
of the annual compliance review as their individualized plans were completed within the thirty-
day time frame. The remaining three youth have not been at the center long enough to require a
plan review and upon consultation with the center and review of the youth census, no additional
applicable youth were applicable for review.
Given none of the youth’s records were applicable for Mental Health/Substance Abuse
Treatment Discharge Summaries, the center provided three additional records for review. All
three discharge plans were documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form and documentation supported copies were provided to the
youth, parent/guardian, and juvenile probation officer (JPO) at the youth’s discharge or
transition. All documentation included the completion on the day of service, signature of the
licensed mental health professional, and was uploaded into the Statewide Electronic Health
Record within fourteen days. The center conducts treatment team reviews during the weekly
detention review meeting conducted every Thursday at 3:00 p.m. An observation of the meeting
was completed and detention staff, mental health, medical, education, and probation
representatives were in attendance to discuss applicable youth.
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.
Nine youth records were reviewed for mental health and substance abuse treatment. Four of the
nine youth required treatment and were assigned a mini-treatment team. Each youth’s assigned
treatment team consisted of a mental health staff, one other staff from a different service area,
the youth, and the youth’s parent/guardian, if possible. Each applicable youth required mental
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health treatment and were receiving individual, group, and family counseling according to the
frequency of the youth’s treatment plan and at a minimum of once a week. Three of the four
applicable youth required substance abuse treatment and a review of their treatment plans and
progress notes indicated receipt of individual, group, and family counseling at the frequency
required by the plan. Each youth had proper consent for treatment documented on the
Department’s Authority for Evaluation and Treatment (AET) and Youth Consent for Substance
Abuse Treatment form. None were applicable for release of records. Each youth record
contained treatment notes documented on the Department’s Counseling/Therapy Progress Note
forms. A video review was conducted to review groups, as well as sign-in logs and progress
notes, to ensure fidelity and compliance indicating group therapy was limited to less than ten
youth for mental health treatment groups and limited to less than fifteen for youth receiving
substance abuse treatment groups. Nine youth were interviewed. Seven youth stated they were
receiving services of some kind; three youth rated the mental health and substance abuse
services they were receiving as very good, three rated them as good, and one rated them as
fair. One youth stated they do not feel like they get enough time to talk to the therapist. These
issues were reported to administration to be addressed.
3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written suicide prevention plan detailing suicide prevention procedures which
is reviewed and signed by the designated mental health clinician authority (DMHCA) and
superintendent annually. The plan includes the identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referrals, communication,
notification, documentation, immediate staff response, and the review process. The center has
an established review process for every serious suicide attempt or serious self-inflicted injury
(requiring hospitalization or medical attention) and a mortality review for a completed suicide,
which includes the circumstances surrounding the event, procedures relevant to the incident,
training received by the staff involved, pertinent medical and mental health services involving
the victim, possible precipitating factors, and recommendations for changes in policy, training,
physical plant, medical or mental health services, and/or operational procedures, if any.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Nine youth records were reviewed for suicide prevention services. Seven of the nine youth were
determined to be a suicide risk during their admission screening. An alert in the Department’s
Juvenile Justice Information System (JJIS) was initiated for the seven applicable youth when
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placed on precautionary observation (PO), and a suicide risk assessment documented an
assessment of the youth on the day of service. Each of the seven youth were on a one-to-one
level of supervision prior to the completion of the Department’s Assessment of Suicide Risk
(ASR). All seven youth had a qualified mental health professional involved when placed on
constant supervision and the suicide precaution observation logs were completed in their
entirety, to include documented “safe housing” areas and required signatures. None of the
seven youth were released prior to receiving an ASR or while on suicide precautions. Staff
documented a consultation with the designated mental health clinician authority (DMHCA) or
licensed mental health professional on the mental health/substance abuse referral summary,
and the superintendent or designee was notified immediately of suicide risk for all seven
records. The ASR or Follow-Up ASR was completed prior to the removal of youth from PO, and
there was documentation of a conference held by the superintendent and licensed mental
health professional to reduce the level of supervision in the seven records. The discontinuation
of close supervision was documented in accordance with the center’s suicide prevention plan.
All seven suicide risk assessments were completed by a licensed mental health professional
and results of the assessments included recommendations for supervision follow-up. A review
of JJIS determined alerts were appropriately entered and closed following youth removal from
PO. A review of logbooks determined the beginning and ending times for PO were documented
for youth in five of the seven youth, the remaining two youth were missing ending times for PO.
Nine staff were interviewed. All nine staff were able to articulate in the event a youth has
suicidal thoughts, staff will submit a mental health referral. Five staff also stated they would
notify their supervisor. Two staff indicated the need to document their observations, one staff
indicated the youth should be placed on constant sight and sound, and two staff indicated they
would speak with the youth and use their active listening. The discrepancies regarding the
procedures for youth on constant sight and sound in the staff interviews was reported to
detention administration. Nine youth were interviewed. None of the nine youth stated they had
been placed on suicide watch while at the center. The DMHCA was interviewed and stated the
provider’s mental health staff conduct suicide risk screenings using the suicide risk screening
instrument (SRSI). Mental health professionals and mental health referrals are notified by email,
phone, and in person. There is an on-call licensed clinician twenty-four hours a day. The
DMHCA explained a youth’s supervision level revision is completed after an ASR is completed
and the youth is observed. The supervision level is communicated by email and documentation
is noted in the center’s logbook. The DMHCA stated there have been less than twenty incidents
during the annual compliance review period for youth attempting suicide by cutting, hanging, or
other means. Eleven of the youth are still currently placed at the center. The DMHCA meets
with the psychiatrist a minimum of one day a week to review the youth’s services.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
Nine youth records were reviewed for secure observation. Two of the nine reviewed youth
records were applicable for secure observation. No additional applicable youth had been placed
on secure observation during the annual compliance review period. For the two applicable
youth, placement in secure observation was authorized by the superintendent and designated
mental health clinician authority (DMHCA), designated in writing. The Department’s Health
Status Checklist was completed prior to placement in secure detention and the Department’s
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Suicide Precaution Observation Logs were completed in their entirety for both youth. Within
eight hours of placement, an Assessment of Suicide Risk (ASR) and/or Follow-up ASR was
completed for both youth. The youth’s parent/guardian and juvenile probation officer (JPO) were
notified of the youth’s potential suicide risk as indicated by the ASR. Neither youth remained on
observation beyond a twenty-four-hour period. Mental health staff provided supportive
counseling services during secure observation and the observation log documented supervision
for both youth. The level of supervision for each youth was reduced after a conference with the
superintendent and licensed mental health professional for all both records. The discontinuation
of secure observation and step-down to close supervision was documented in the center’s
logbook and in each of the two youth mental health records by mental health clinical staff.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Nine youth records were reviewed for Suicide Precaution Observation Logs and seven youth
were applicable. The Department’s Suicide Precaution Observation Logs were maintained for
the duration the youth was on suicide precaution in each applicable record. The appropriate
level of supervision and observations of the youth’s behavior were documented in real time and
not exceeding thirty-minute intervals in all records reviewed. None of the youth records were
applicable for warning signs. When warning signs are observed, the center has a policy
outlining the expectation of notification of the superintendent or designee and mental health
clinical staff to be documented on the Suicide Precaution Observation Log. The logs were
reviewed and signed by each shift supervisor and signed by mental health clinical staff in each
record. All logs documented safe housing requirements. A review of video footage and
corresponding documentation of youth on precautionary observation or secure observation
confirmed the proper supervision was maintained for youth placed on PO.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Nine pre-service and nine in-service staff training records were reviewed. Training includes
suicide drills no less than quarterly, on each shift. The center has six accessible suicide
response kits which include a knife-for-life, wire cutters, and needle nose pliers which are
located in the kitchen, master control, medical, and in each of the modulars. Suicide response
kits are co-located with first-aid kits. Video review of the last two suicide drills were observed. A
review of the documentation and an interview with the designated mental health clinician
authority (DMHCA), who conducted the drill, resulted in all the required elements being present
during the simulation. Though facility operating procedures (FOPs) require quarterly suicide
drills, the Department’s Office of Health Services requires monthly drills on each shift. A review
of the center’s drill book indicated all required drills had been completed during the annual
compliance review period. The drills completed did involve all staff encountering youth and did
not utilize center youth in the simulations. A review of training records did indicate all nine pre-
service and all nine in-service staff received semi-annual training in emergency response
procedures relating to a suicide attempt or incident of serious self-inflicted injury. Staff who were
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not present during a quarterly drill can review each drill scenario and procedures to understand
the process and receive the necessary training to respond to an incident of a suicide attempt or
incident of serious self-inflicted injury in the center. Nine staff were interviewed about the
location of the center’s suicide response kits. Staff indicated they are located throughout the
center to include master control, medical, all sub controls and posts, classrooms, vans, and the
kitchen.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined written Crisis Intervention and Emergency Services Care Plan for
mental health services which includes a notification and alerts system, means of completing
referrals including self-referrals, communication, supervision, documentation, and reviews.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
A review of the center’s emergency care plan confirmed it included immediate staff response,
notification, communication, supervision, authorization to transport for emergency mental health
or substance abuse services, transport for emergency mental health evaluation and treatment
under Chapter 394 Florida Statutes, Florida’s Baker Act, transport for emergency substance
abuse assessment and treatment under Chapter 397 Florida Statutes, Marchman Act,
documentation, training, and review. The plan was approved June 1, 2025. A copy of the plan is
in the office of the designated mental health clinician authority , medical office, master control,
conference room, and the offices of the captain and major.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
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Nine youth records were reviewed and none were applicable for Crisis Assessments. The
center provided three applicable records for review. The Crisis Assessment included the reason
for the assessment, Mental Status Examination and interview, determination of danger to
self/others, initial clinical impressions, supervision recommendations, treatment
recommendations, recommendations for follow-up or further evaluation, and notification to the
parent/guardian of follow-up treatment for the applicable youth. A mental health alert was
entered into the Department’s Juvenile Justice Information System (JJIS) when each youth was
placed on precautions after completion of Crisis Assessment. Each youth was identified by
direct care staff or clinical staff as having acute emotional or behavioral problems, or acute
physiological distress. The Crisis Assessments were conducted by a licensed mental health
professional immediately, or within two hours for emergencies, or within twenty-four hours
based on the needs of the youth. None of the three youth were an alleged victim of a Prison
Rape Elimination Act (PREA) event.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
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 did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD) who specializes in Pediatrics. The DHA license is unrestricted and meets
all requirements to practice in the state of Florida, which expires on January 31, 2027. The
center utilizes an advanced practice registered nurse (APRN) who has a collaborative practice
protocol in place which is signed by the DHA and APRN. A review of the sign-in logs for the
annual compliance review period indicated the DHA was on-site once a week, with no time
lapses more than nine days between visits, as contractually required. If the DHA has scheduled
absences, the center has a backup DHA which can be utilized from a licensed pool. No tele-
medicine was used during the annual compliance review period. The DHA was interviewed and
stated their role was performing Comprehensive Physical Assessment’s, conducting periodic
evaluations, sick call, and policy and procedure development. The DHA stated they
communicate with the center staff regarding youth medical needs by phone or when they are
on-site. If off-site, they are on call twenty-four hours a day, seven days a week, and staff call
them with any needs or concerns. Any off-site care findings, instructions, or information is
reviewed by the DHA by paper records on a weekly basis.
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 utilizes facility operating procedures (FOPs) for all health-related procedures and
protocols. During the annual compliance review period, it was found the designated health
authority (DHA), superintendent, and psychiatrist all signed all respective treatment FOP’s on
June 1, 2025. Nursing staff reviewed, signed, and dated a cover page for all medical FOP’s,
treatment protocols, and other procedures between the dates of June 20, 2025, and June 26,
2025. No new policies or changes had been made during the annual compliance review period.
The center’s psychiatrist reviewed and developed the FOPs and other protocols related to
psychiatric services and psychotropic medication management as evidenced by signature and
date. FOPs and nursing protocols were reviewed annually as required and signed June 1, 2025.
A review of the center’s FOPs demonstrated the inclusion of all health-related procedures and
treatment protocols utilized at the center. New employed healthcare personnel received a
comprehensive clinical orientation to the Department’s health care policies and procedures,
which was conducted by a registered nurse (RN). The approval of treatment protocols or
standing procedures were written and authorized by the center’s DHA as evidenced by a
signature and date.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for Authority of Evaluation
and Treatment (AET) requirements. Five of nine IHCRs included an AET obtained prior to
providing medical services and two IHCRs included a Limited Consent for Evaluation and
Treatment signed by the superintendent pending a court order. The remaining two records
belonged to youth under the supervision of the Department of Children and Families (DCF) and
had standing court orders authorizing all treatment procedures. Each of the five applicable
youth’s AETs were either originals or stamped as a “COPY” and filed in the youth’s IHCR. All
five IHCRs were signed by the youth’s parent/guardian. Each applicable AET was signed by a
Department representative, were valid, and were obtained prior to the provision of medical
services. The nurse was interviewed and stated the youth’s juvenile probation officer (JPO) is
responsible for ensuring the AET is signed and dated by the parent/guardian and then
forwarded to the location where the youth is in custody. If the parent/guardian is unavailable
during the detention screening, the assigned JPO shall schedule an intake conference as soon
as possible to complete the AET. If the youth is eighteen years of age or older, the youth will
provide consent at the point of contact of healthcare services and the consent will be
documented in the youth's IHCR.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for parental
notification/consent requirements. Three out of nine youth were found to have parental
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). All three youth IHCRs included documentation of consent
provided by the parent/guardian. All three youth IHCRs included written notification sent utilizing
the Department’s Parental Notification of Health-Related Care form. Three of the nine youth
were taking psychotropic medications upon admission to the center. Written notification was
sent for two of the youth and telephonic contacts were recorded in the progress notes to the
youth’s parents/guardians. The remaining youth was in the care of the Department of Children
and Families (DCF) and a current court order was on file authorizing all treatment and
procedures. Three of the nine youth on OTC medications, which included one also on
psychotropic medications, had medications which were prescribed, discontinued, or had a
significant change in the dosage. Parental notifications were noted in the progress notes of all
three applicable youth and the Acknowledgement of Receipt of the Clinical Psychiatric Progress
Note (CPPN) was sent to all three parents/guardians as required. Two of the youth IHCRs
reviewed were involved/committed to DCF and two of the youth IHCRs reviewed contained
Limited Consent for Evaluation and Treatment signed by the Superintendent pending a court
order. All nine youth vaccines were verified within thirty days of the youth’s admission with no
vaccines needed. None of the nine youth required a “Religious Exemption from Immunization”.
The nurse was interviewed and reported the juvenile probation officer (JPO) is responsible for
ensuring the AET is fully executed by the parent/guardian of the youth and forwarded to the
holding center. Where parental rights have been terminated, DCF has limited authority to consent
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to treatment and youth eighteen years of age or older can provide consent. The nurse detailed
the procedures for parent/guardian notifications for emergency treatment, medication changes,
immunizations, and other services. The vaccination information for each youth is obtained through
the Florida Shot Record and reviewed within twenty-four hours of admission. Religious
Exemptions will be documented on the designated form and filed in the Department’s Electronic
Medical Record (EMR).
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for healthcare admission
screening requirements. All nine youth received a medical and mental health admission
screening completed on the Department’s Facility Entry Physical Health Screening form on the
date of admission by the juvenile justice detention officer (JJDO), with the screening reviewed
with the youth by a licensed nurse within twenty-four hours. Notification was made to the
designated health authority (DHA) for all nine youth and documented in the youth’s IHCR. Only
two of the reviewed youth changed physical custody since admission to the center, and as such,
the center provided an additional record to review. Each of the three applicable youth received a
complete Healthcare Admission re-screening completed by a JJDO and reviewed by a licensed
nurse within twenty-four hours. Two of the nine youth received a qualitative urine pregnancy
screening test and the chronological progress note in each of the applicable youth’s IHCR
included documentation of verbal and/or written consent. The nurse was interviewed regarding
healthcare admission screenings and re-screenings and stated the youth are seen by medical
staff within twenty-four hours of admission to the center. At a minimum, vital signs are taken,
and the youth is questioned concerning medical needs, chronic conditions, medications, and
medical complaints. The admission packet is reviewed, and each page must be signed and
dated by the nurse.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for youth orientation to
healthcare services and health education. The center’s facility operating procedures (FOPs)
included the following: access to medical care, sick call access, 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 the case of a sexual assault or
attempted sexual assault, the non-disciplinary role of the health care provider, and general
infection control/hygiene. All nine youth received a general healthcare orientation within twenty-
four hours of admission and was documented on the Department’s Health Education Form. One
of the nine youth were applicable for a chronic condition and a review of this youth’s Health
Education Form included education regarding diagnosed chronic condition and prescribed
medication.
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4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for notification requirements
to the designated health authority (DHA). One of the nine youth was admitted with a known or
suspected chronic condition, in which a referral was made to the DHA within twelve hours. No
youth were identified as in-need of emergency care upon admission. The notification to the DHA
for all nine youth was documented in the youth’s ICHR in the Chronological Progress notes in
accordance with the center’s protocol. Three of the nine youth were currently taking
psychotropic medications upon admission. The psychiatrist was also notified within twelve hours
of admission of each applicable youth and the notification was documented in the chronological
progress notes section in each youth’s IHCR. The nursing staff interview stated the DHA is
notified within twenty-four hours of admission of all youth, as well as the psychiatrist, if the youth
are admitted on any psychotropic medications. All notifications are documented on the intake
progress note of the IHCR by the licensed medical staff. If the notification is made by non-
healthcare staff after hours, the report of the Department’s Healthcare by Non-Healthcare Staff
form is completed and placed in the youth’s IHCR.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for Health-Related History
(HRH). All nine applicable youth’s HRH form was updated or completed within seven calendar
days of admission. The HRH form was completed prior to the Comprehensive Physical
Assessment (CPA) or focused evaluation by evidence of a signature and date by a licensed
nurse in all nine youth IHCRs. The designated health authority (DHA) or advanced practice
registered nurse (APRN) reviewed each HRH for all nine youth by documenting review on the
HRH with a date and signature. A review of the HRH forms for all nine youth confirmed
signatures and dates correspond with each youth’s most current admission. Nursing interviews
were conducted, and the nurse stated the HRH is completed or reviewed by the nursing staff
with the youth no later than seven days from admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for the Comprehensive
Physical Assessment (CPA) and Tuberculosis (TB) screening requirements. Each of the nine
youth’s CPAs were completed on the Department’s form. Two out of the nine youth had a
current CPA on file at the time of admission. The other seven youth did not have a CPA on file
at the time of admission and all seven were completed within seven calendar days of the
youth’s admission. Six youth CPAs were conducted by the advanced practice registered nurse
(APRN) and three conducted by the medical doctor (MD). The correct medical grade was listed
on all nine CPAs with no missing or incomplete elements noted. Two youth were applicable for
the utilization of current CPAs with no changes in the youth’s medical condition. Both youth’s
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current CPAs were reviewed by the DHA or APRN and a focused evaluation was completed
and dated during the current admission. In all nine IHCRs reviewed, all sections of the CPA
were marked with either an “O” or an “X” with any “X” documenting in further detail in the
comment section to elaborate on the abnormality. All nine youth were not clinically in need of a
genital exam as noted by examining practitioner. All nine youth’s problem list was updated to
reflect any current issues and dates resolved if any issues were resolved. All nine CPAs had
current Tuberculosis Skin Test (TST) documented in the IHCR, which was administered within
the last year. The results of the TST for each youth was found documented on the Infectious
and Communicable Disease forms which matched the results documented on the CPA. None of
the nine youth required further evaluation, treatment, or transportation for hospitalization as a
result of the TST. A review of the center’s facility operating procedures (FOPs) included the
documentation process for youth refusals of any part of an exam as well as Tuberculosis
screening and rescreening processes which were found to contain all the required elements.
The nurse reported the designated health authority (DHA) is responsible for conducting a new
CPA at a minimum of every two years for grades two through five but at Marion Regional
Juvenile Detention Center (MRJDC), all are completed yearly or with any significant health
changes. All youth are required to undergo Tuberculosis Skin Test (TST) and have a
documented TST in their Electronic Medical Record (EMR).
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.
Nine youth Individual Healthcare Records (IHCR) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. Three out of
nine youth stated they were sexually active and were screened for STI’s. Further evaluation was
required for all three youth and the referral was documented on the STI form. All three youth
requested to be tested, and testing was ordered and conducted within seven days of admission,
with the results documented on the Infectious Communicable Diseases (ICD) form and filed in
the lab section of the IHCR. None of the nine youth received a gynecological exam or were ever
out of the Department’s physical custody. All nine youth were offered counseling and testing for
HIV. Three of the nine youth were tested for HIV within thirty days of request and a documented
consent from each youth was obtained. The three applicable youth were given pre-test/post-test
counseling which was documented in each youth’s IHCR. The results were filed in all three
youth’s IHCR in a sealed envelope marked “CONFIDENTIAL” and precluded from inclusion in
any of the center’s internal alert systems. Refusals were documented for the remaining five
youth. All interviewed youth stated they were able to request an HIV test if they have the desire
to test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
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Nine youth Individual Healthcare Records (IHCRs) were reviewed for Sick Call Process
requirements. Given none of the nine records were applicable, as such, the center provided
three more records for review. Each of thethree youth’s sick calls were documented on the
Department’s Sick Call Referral Log. None of the three youth presented with a similar sick call
complaint three or more times within a two-week period; therefore, no referral was needed to
the designated health authority (DHA). None of the youth complaints involved severe pain or
required an immediate referral to a licensed healthcare professional or notification to the DHA.
All three youth submitted a sick call on the Department’s Sick Call Request form. Only nursing
staff completed the Sick Call Request form. None of the youth’s sick calls were conducted by a
licensed practical nurse (LPN). Each of the three three youth’s sick calls were filed in the youth’s
IHCR in reverse chronological order. None of the youth reviewed were in restricted housing
during sick call hours. All three youth’s sick call forms were documented in accordance with the
Health Services Rule. All three youth’s sick calls were documented on the Department’s Sick
Call Index inside the IHCR with the dates listed on the sick call forms matching the dates of the
sick call index. A review of the center’s daily schedule demonstrated sick call is conducted
seven days a week from 10:00 a.m.-11:00 a.m. and from 3:00 p.m.-4:00 p.m. These hours are
posted in the medical clinic area and common areas. There are approved treatment protocols
the registered nursing staff utilize. Only licensed nurses complete sick calls. When there is not a
licensed nurse on-site, the center has procedures whereby the shift supervisor reviews all the
sick call requests as soon as possible but within four hours after the request is submitted and
notifies the DHA. The center has in place a policy for room restrictions/confinement in which
youth in restricted housing shall be afforded access to healthcare at equal or greater intervals of
youth which are in regular housing. No observation of a sick call was completed during the
annual compliance review as the center did not have any requests for sick call submitted during
the annual compliance review. The nurse was interviewed and confirmed the sick call schedule
and where the hours are posted in the center. Nine youth were interviewed. One youth stated
they were seen within one day once they made a sick call. Two stated they requested one and
never received a sick call, and six youth indicated they have never needed to make a sick call.
The three applicable youth stated the nurse conducts the sick call. These issues were reported
to administration who stated all youth are seen by medical when a sick call is requested. Nine
staff were interviewed. All staff stated the nurse reviews sick call submissions as well as
conducts the sick calls.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for episodic, first aid, and
emergency care requirements. Given only one of the nine records was applicable, as such, the
center provided two more records for review. All three youth received episodic care or first-aid
by a licensed healthcare staff and was documented in subjective, objective, assessment, and
plan (SOAP) format. None of the youth received episodic or first-aid care by a non-healthcare
staff. Each youth’s documentation included the nature of the complaint, the findings of the
person rendering care, treatment rendered, and education/instruction to youth. None of the
youth required follow-up or a referral for off-site care. Parental notifications were documented in
each of the three youth’s IHCRs, and an entry was made in the center’s Episodic Care Log.
The center has a total of eighteen first-aid kits located throughout the center, and accessible to
staff in the event of an emergency. A first-aid kit is available for each of the five transport
vehicles. Additionally, one is in Master Control and one in each of the three Sub Controls, front
intake room, laundry, maintenance, training trailer, staff breakroom, and kitchen. The first-aid
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kits include an approved list of items present documented on each kit. Three kits were opened
and examined. All three had contents within their date of expiration. First-aid kits are inventoried
monthly by the medical staff. Documentation of the inventory was conducted and notated on the
monthly first-aid kit and automated external defibrillator (AED) logs. The center has a total of
two AED units located in sub control and conference room. Both are inspected monthly by
medical staff and a log is kept documenting any findings, discrepancies fixed, and dates the
pads and batteries are changed. The batteries and pads of the device were observed within
their date of expiration (conference room: battery expiration September 16, 2025 and pads
expiration February 28, 2027, and sub control: battery expiration September 6, 2026 and pads
expiration February 28, 2027). A licensed medical staff was observed performing an inspection
of both AED units during the annual compliance review. The devices were operating as
required.
Unannounced emergency drills have been conducted every month, on each shift, in which a
simulated episodic care event took place. All the drill scenarios simulated an episodic event
which called for immediate first-aid, use of the AED and/or Cardiopulmonary Resuscitation
(CPR), and the initiation of the emergency procedures for a life-threatening event. The center
maintains documentation of all emergency drills conducted. A list of emergency numbers was
found accessible to licensed and unlicensed staff which included the number to Poison
Information Center. The numbers were not accessible to any youth. All authorized direct care
staff were appropriately trained by a registered nurse on the administration of an epinephrin
auto-injector. Nine staff records were reviewed which showed training requirements were met
regarding episodic care, first-aid, and emergency care. The policy on the use, access and
inventory of NARCAN states the center must stock and inventory NARCAN for emergency
treatment of a known or suspected opioid overdose. The center stores NARCAN in their
medication cart and is accessible to the registered nurse (RN) and non-healthcare supervisory
staff. Each staff with access to NARCAN has been trained on when and how to use it and it is
inventoried by a licensed nurse weekly. Training sign in logs were reviewed to ensure
compliance.
The nurse was interviewed and described in detail the process for on-site episodic care for the
center’s youth and monthly tracking and testing requirements for first-aid kits and the AEDs.
Nine staff were interviewed and indicated they can call 9-1-1 if they ever feel it is necessary.
Nine youth were interviewed. Three youth do not have need to receive medical services. Three
youth rated the medical care at the center as being very good, one rated it good, one rated it
poor, and one rated it very poor. This information was reported to administration to be
addressed.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for completion requirements
concerning off-site care/referrals. Given none of the nine records was applicable, as such, the
center provided three more records for review. All three youth required off-site care in which the
summary of off-site care consultation report form was utilized and filed in the IHCR and was
also documented on the Department’s Episodic Care Log. Parental notifications were made for
each youth and documented in the IHCR. Discharge documents were filed in each youth’s
IHCR, and the designated health authority (DHA) reviewed the discharge instructions, findings,
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and care rendered as evidenced by signature and date. All three youth received nonemergent
off-site care. All three youth receiving off-site care required follow up testing, referrals, or
appointments and the referrals were entered in the center’s referral tracking log. The nurse was
interviewed regarding off-site care and referrals. The nurse stated any off-site care appointment
or treatment is tracked in the episodic log. The DHA is contacted upon the youth’s return to the
center regarding outcomes and instructions. The DHA will review and sign all off-site medical
documentation during next on-site weekly visit. Nursing staff track any follow-up appointments.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions/periodic
evaluation requirements. One youth was identified on the Medical/Mental Health Screening form
for having a chronic condition, and as such, the center provided two additional records to
review. None of the youth reviewed had a communicable disease. Three of the applicable youth
were taking prescribed medication on an on-going basis. Three of the applicable youth reviewed
were undergoing treatment for a physical health condition. All three applicable youth were
classified with a Medical Grade of between two and four. None of the applicable youth records
reviewed were identified as pregnant. Each youth was placed on the chronic conditions list. Two
of the three applicable youth had periodic evaluations, at least every ninety days and prior to
renewing a prescribed medication, which were documented and found in the progress notes
section with proof the review was conducted. The third youth had not been at the center for
ninety days. None of the youth were identified as taking anti-tuberculosis medication. Two of the
three applicable youth required an evaluation by off-site care and the designated health
authority (DHA) completed a follow-up with the youth as evidenced by signature and date on
discharge documentation. There were no indications of lapses in care or missed periodic
evaluations in any of the three youths IHCRs. The Department’s Problem List was updated in
accordance with the Administrative Rule for the three applicable youth. The nurse was
interviewed and confirmed the center utilizes the Chronic Physical Health Conditions Roster to
track periodic evaluations for all youth with chronic conditions. The DHA was interviewed and
stated all youth with chronic conditions are seen for evaluations for chronic conditions every
ninety days or sooner if needed. The DHA also reported each youth with a chronic condition is
discussed at their weekly clinic meeting to ensure appropriate tracking and appointment
scheduling.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. Three of the nine youth were taking medication at admission and the medication
was verified prior to being admitted into the center. Prescription verification for all three youth
were completed utilizing the Department’s Prescription Mediation Verification Checklist form.
The three prescription verifications were noted in the progress notes, IHCR, and Electronic
Health Record (EMR). The designated health authority (DHA) and psychiatrist were notified and
an order to resume the medications was ordered for all three applicable youth during the
admission process. One youth was prescribed medication after admission. The four applicable
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youth on medications had a current, valid order and medications were administered pursuant to
the current prescription. One youth was applicable for a current medication being continued,
discontinued, changed or new one ordered, and the DHA placed the order utilizing the
Practitioner Order form. None of the applicable youth reviewed were in restricted housing during
medication administration hours. Three of the nine youth were given over-the-counter (OTC)
medications which were not listed on the Authority for Evaluation and Treatment (AET) form
which were administered according to approved protocols or Practitioner Orders. Each of the
four youth utilized a standard Department Medication Administration Record (MAR) in the EMR.
Each youth had MARs which clearly indicated medication start and stop dates. None of the four
youth received medication by a trained non-healthcare staff after hours when a licensed staff
was not on-site. No lapses or errors in medication administration was noted. Side effect
monitoring and documentation was noted on eachof the youth’s MARs. One youth was
applicable for refusing medications and each refusal was clearly documented and a Department
Refusal of Treatment Form was completed for each refusal and filed in the youth’s IHCR. Each
youth had MARs which contained all required elements to include the youth’s name,
Department of Juvenile Justice identification number (DJJID), date of birth, youth allergies,
precautions, Medical Grade, medical alerts, and current picture of the youth attached. Nursing
staff documented weekly side effect monitoring on each of the four applicable youth’s MARs.
Both staff and youth initials were found on each medication administration in each of the youth’s
MARs and all refusals were clearly documented. None of the youth required parenteral
medication. One of the four youth received medication monitoring by the psychiatrist every thirty
days, as required. The other three youth had not been at the center for thirty days at the time of
the annual compliance review. The center’s medical department reported there are no standing
orders, pro re nata (PRN), or emergency treatment orders for psychotropic medications. A
medication pass was observed, and medication administration was completed by the licensed
medical staff. The youth was escorted to medical by the juvenile justice detention officer (JJDO).
The youth approached the nurse station individually and identified themselves. The medical
provider identified themselves and prepared the medications for the youth as prescribed. The
allergy and alert status were verified on the MAR. The youth initialed for their medication after
receiving it and the nurse indicated they have given the medication by initialing. A mouth check
was completed to ensure the youth had swallowed the medication. The nurse stated non-
healthcare staff can administer medications if trained. The last training was completed by a
registered nurse (RN) on December 19, 2024, and the training log and names of trained
supervisory staff remain in a binder in the medical clinic area.
The nurse was interviewed and indicated the disposal process for any medications included the
proper logging and disposal through a return to the pharmacy or the utilization of the RX
destroyer in conjunction with the pharmacy consultant. This system is monitored and verified by
the DHA and clinic manager. Nine staff were interviewed. Seven staff stated they can provide
medication to youth while two indicated they are not. The seven staff further stated they only
give medication to youth due to having received training from medical and it is only if there is no
nurse on-site. Nine youth were interviewed. Five of the interviewed youth are not currently on
medications. The four who do take medications stated the nurse provides them their medication.
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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’s psychiatric services are provided by a physician licensed pursuant to Chapter 458
or 459, F.S., who is board certified in Psychiatry. The psychiatrist’s license is unrestricted and
meets all requirements to practice in the state of Florida, which expires on January 31, 2026.
The center does not utilize an advanced practice registered nurse (APRN) and no collaborative
practice protocol is in place. A back up psychiatrist was not utilized during the annual
compliance period but a psychiatrist from the detention pool would be utilized if the need did
arise. Tele-psychiatry is included in the contract and currently utilized for access to psychiatric
services.
Nine youth Individual Healthcare Records (IHCRs) were reviewed psychiatric services. Four of
the nine youth were applicable for entering the center on psychotropic medication or referred for
a psychiatric interview and all four received an initial diagnostic interview within fourteen days of
the youth’s admission. The initial diagnostic psychiatric interview included reason for referral,
youth’s history, mental health status, Diagnostic Statistical Manual of Mental Disorder-Fifth
Edition diagnosis, treatment recommendations specific to mental health and substance abuse
diagnosis, and prescribed medication. The initial diagnostic psychiatric interviews documented
the name of the medication, the explanation of the need for the medication, and were conducted
within thirty days of admission for all four applicable youth. Each of the four applicable youth’s
psychiatric interviews included the reasons and factors for the referral, youth history, history of
psychiatric illness to include medication management, substance abuse and mental health
treatment, mental health status exam, identification of individual, family or environmental factor
may potentially account for, influence or ameliorate the youth’s difficulties, diagnostic
formulation, treatment recommendations for stabilization of the youth, prescribed medication
and frequency of medication, explanation of the need for the psychotropic medication, most
recent applicable therapeutic serum drug level, and signature of the practitioner. All four youth
were applicable for having page three of the Clinical Psychiatric Progress Note (CPPN)
completed due to newly prescribed or changes in prescribed medications and has been clearly
identified as the “Psychiatric Evaluation” in each youth’s IHCR. None of the youth were
applicable for a previous psychiatric evaluation. All four youth were applicable for prescribed
psychotropic medications and the evaluations included identifying data, diagnosis, target
symptoms of each medication, evaluation, and description of effect of prescribed medication on
target symptoms. Prescribed psychotropic medications in each of the four applicable youth’s
psychiatric evaluations included name, dosage, quantity, frequency and route of administration,
reasons for changes, side effects, youth’s adherence to the medication regime, height, weight,
blood pressure, and most recent serum drug levels. Two of the four youth IHCRs included
parental notification, with the remaining two youth being in the care of the Department of Youth
and Families. All four psychiatric evaluations were signed and dated by the psychiatrist and
included monthly monitoring directives for Tardive Dyskinesia. Only one youth’s IHCR included
the monthly monitoring documentation as the other three youth had not been at the center for
thirty days at the time of the annual compliance review. Two of the youth had an Authority for
Evaluation and Treatment completed at admission. One of the two youth were applicable for a
new psychotropic medication being prescribed or discontinued or changed and page three of
youth’s CPPN showed documented verbal parental consent. The two-remaining youth’s IHCRs
contained court orders authorizing treatment. None of the youth were over eighteen years of
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age. Tele-psychiatry was utilized to conduct the psychiatric evaluations of all four youth and the
proper consents were documented in each of the four youth’s IHCRs.
4.17 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 medical office was found to be neat, clean, organized, and inaccessible to youth in the area
where sharps and medications were maintained. Medical equipment classified as sharps was
found secured and inventoried utilizing a routine perpetual inventory descending count as each
sharp was utilized or disposed of in the medical clinic. A sample of three sharps were reviewed
and counts of the items matched the ending inventory numbers. All medications were identified
and secured in the locked area designated for storage of medications inside the medical office.
The medication cart was found to be clean and organized with stock items separate from youth-
specific medications. All medications were stored in a separate, secured (locked) area,
inaccessible to youth. Narcotics and other controlled medications were stored behind two locks.
No oral medications were stored with topical medications. Medications requiring refrigeration
were found inside a secured refrigerator labeled “Medication Only”. For youth on controlled
medications, a perpetual shift-to-shift inventory count was conducted and documented on the
youth’s individualized Controlled Medication Inventory Record. Non-healthcare staff were
trained in the delivery and oversight of medication self-administration when nursing staff are not
on-site. This training was delivered by a registered nurse. The last training was conducted on
December 19, 2024. Three controlled medication samples were observed with no discrepancies
and counts matched ending counts. Three over-the-counter (OTC) medication samples were
reviewed with no discrepancies and counts matched ending counts. Perpetual weekly
inventories of all sharps and OTC medications were observed. Observations of inventories
conducted confirm the center’s medical staff conduct inventories of medications and sharps as
required. The procedure for reporting inventory discrepancies states any medication inventory
discrepancy shall require notification to the superintendent and the Department’s Central
Communications Center (CCC). Medical staff are responsible for all disposal of medications,
along with the pharmacy consultant. Each disposal will be inventoried prior to destruction, with
the pharmacy consultant present. Destruction of medication is completed utilizing the RX drug
buster. The nurse was interviewed and stated all outdated medications are removed and
securely stored in a quarantine area. Disposal utilizing the RX drug buster is completed at least
monthly in the presence of the pharmacy consultant. All disposals are documented in the
Destroyed Medication Log.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
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Nine youth Individual Healthcare Records (IHCRs) were reviewed for infection control, exposure
control, and education requirements. All nine reviewed youth received infection control training
upon admission to include hand-washing techniques, universal/standard precautions,
prevention/transmission of communicable disease, vaccinations, and the Center for Disease
Control and Prevention (CDC) guidelines for infection control. The Exposure Control Plan was
written in accordance with Occupational Safety and Health Administration (OSHA) and included
a risk assessment listing job classifications in which staff have the potential for occupational
exposure, including tasks and procedures which would cause staff in specific job classifications
to have an occupational exposure. A method of compliance outlining infection control practices
and engineering and work practice controls was also found in the plan. Engineering and work
practice controls included availability of hand washing facilities, procedure for disposal of
needles and other sharps, procedures for maintaining the work site in a clean and orderly
manner, use of specified signs and labels to communicate hazards to staff, procedures for
handling contaminated laundry, procedures for post-exposure evaluation and follow-up, and
system of medical record keeping for staff with occupational exposure. Infection control
procedures in place included prevention, containment, treatment, and reporting requirements
related to infectious diseases, according to OSHA and the CDC guidelines. Infection control
procedures outlined include all required elements such as for common infectious diseases of
childhood, the common cold, viral or bacterial infections, Tuberculosis, Hepatitis A, B, and -C,
human immunodeficiency virus (HIV), other outbreaks or epidemics caused by any other
infectious agent, pediculosis and or scabies, food-borne illnesses, chemical exposure, bio-
terrorist agents, and Methicillin-Resistant Staphylococcus Aureus (MRSA). The center’s facility
operating procedures (FOPs) containing the inflection control plan includes processes for
needle stick post-exposure evaluation. Hepatitis B immunizations are made available for staff.
All staff have access to protective equipment. The registered nurse (RN) stated there have been
no instances in which infectious diseases and sexually transmitted infections needed to be
reported to the local health department as required or to the Department’s Central
Communications Center (CCC). There were not three or more cases of reportable infectious
diseases which needed to be reported to the local health department and/or CDC. There were
also no hospitalizations or quarantine of at least ten percent of the total population for youth or
staff. The superintendent was interviewed and stated a separate file is maintained containing all
documents for youth and staff who have experienced facility/occupational exposure. These files
are maintained for a ten-year period as required. Nine staff training records were reviewed. All
nine staff received pre-service or in-service training on the center’s specific Exposure Control
Plan by the clinic manager as noted in the nursing interview results and found in the staff’s
training records.
4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
None of the selected youth were identified as pregnant at the center during the time of the
annual compliance review. Three additional youth records were provided to review prenatal care
and education. All three youth received prenatal care immediately upon determination the youth
was pregnant at admission. Each youth received routine, focused medical evaluations every
thirty days or sooner, if ordered. Prenatal care was provided at recommended intervals for all
three youth. Each were placed on an internal alert system for vital nutrition and health
awareness for staff along with an alert in the Department’s Juvenile Justice Information System
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(JJIS). An alert was entered into the center’s internal alert system for sleeping arrangements for
two mattresses and pillows for support for two applicable youth and a doctor’s order was written
for the third youth. All three youth have been at the center less than a month, so none were
applicable for focused medical evaluations by the designated health authority (DHA) every thirty
days. One of the three youth had complaints or issues during their stay but daily monitoring for
danger signs of pregnancy complications was not warranted. All three youth had a documented
plan for post-birth psychological and physical care. Education for all three youth was found in
the youth’s Individual Healthcare Record (IHCR) under the education tab to include alcohol and
drug use, smoking, nutrition, sexually transmitted infections, contraception, prenatal care,
birthing process, postpartum care, basic baby care, child/infant development, and parenting
skills which was conducted by a licensed staff. The youth received nutritious food and
appropriate servings as ordered by the DHA and evidence of routine monitoring of nutritional
and weight status of the pregnant youth was found in each of the youth’s IHCRs. A review of in-
service training was found to include observation and monitoring of emergency care
needs/symptoms for possible miscarriage and has nursing protocols and treatment in place for
pregnant youth. Staff training records were reviewed to ensure compliance.
The nurse was interviewed regarding prenatal care and education of pregnant youth. Each
female is offered screening for pregnancy at admission. Prenatal services begin immediately
upon determination and the DHA will monitor the pregnant youth at the minimum of once every
thirty days. Nutritional and sleep accommodations are ordered, and weight and nutrition are
monitored by healthcare staff. Off-site obstetrician appointments will be managed by the
center’s healthcare staff and all documentation reviewed by the DHA. A licensed healthcare
staff will be responsible for providing in-service training to all non-healthcare staff regarding
pregnant youth and cover all required topic areas. Nine youth were interviewed; three were
female. None of youth were applicable for prenatal, obstetrical, or gynecological services as it
relates to pregnancy; however, one youth stated she has asked to be seen for female issues
and not been granted a sick call. This was reported to administration to be addressed.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
Observations of youth supervision were completed during the annual compliance review week,
with no exceptions noted. Each of the juvenile justice detention officers (JJDOs) were aware of
the number and location of all youth assigned to their supervision, as reflected by their correct
answers when asked by the review team. Observations also confirmed staff supervise youth
during movements from one location to another in accordance with Florida Administrative Code,
and staff are properly positioned with youth in line of sight. Master control authorizes all
movement of youth prior to the actual movement, and no movement occurs until cleared by
master control. This practice is documented in the center logbook and verified by observations
during the annual compliance review week. All youth were accounted for and always
accompanied by staff, and the interactions between youth and staff demonstrated active
supervision. Observations made during the review week included daily activities such as
school/education, meals, breaks, searches, census counts, and youth-staff interactions. Positive
interactions were consistently observed between youth and staff during the review week. Nine
staff were interviewed. Five staff believe the center is adequately staffed to provide for the
safety of the youth and other staff in the building. Four stated the center is not adequately
staffed and further indicated reasoning is due to people quitting and open vacancies, people
calling out, and anytime a youth is seen for medical issues and having staff out with them. This
information was reported to administration who also stated the center is staffed for sixty beds;
however, the center has an increased population and due to vacancies, call outs, and staff on
leave, the center struggles with adequate daily staffing.
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
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Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) in place to address the behavior
management system (BMS), a system of rewards, privileges, and consequences to encourage
youth to fulfill the center’s expectations. The center maintains a BMS implemented to meet the
needs of the youth and the center. The system is approved by the regional director and includes
rewards for positive behavior and consequences for inappropriate behavior. Postings of the
BMS are displayed in all living areas which clearly specify appropriate and inappropriate
behaviors, rules, norms, and expectations. Daily activities were observed to determine
implementation of the BMS by staff. A review of supporting documentation confirmed positive
rewards are given to youth to match the BMS incentive calendar and are given in accordance
with the BMS. Reviewed documentation showed there were no instances of inappropriate use of
restrictions or group punishment. The assistant superintendent reported the center uses a three-
level system which tracks youth behavior. All youth are placed on level one upon admission.
Youth can move up to level two after seven days on level one with appropriate behavior. Youth
can move up to level three after seven days on level two with appropriate behavior. Each level
receives more privileges. After seven days on level three, the youth can become a Peer
Ambassador. Youth are subject to level drops base on negative behaviors.
Nine staff were interviewed. All nine staff were able to articulate the BMS level system and how
youth can progress or regress. Rewards provided to youth for good behavior and leveling up
include extra snacks, canteen, staying up later past bedtime, extra visitation, food brought in
from outside, ice cream, and assisting staff with cleaning and laundry. All nine staff believed the
BMS to be effective so long as they are working with youth who care about it. All staff reported
they speak to youth prior to giving any consequences to them, allow youth to explain their
behavior, and talk to them about alternative acceptable behaviors. All nine staff stated feedback
is given regarding the BMS to include emphasizing it needs to be fair and consistent, giving
kudos if it is implemented correctly, and giving correction if it is not. Six staff indicated feedback
is provided daily during briefing meetings. One staff indicated it is done weekly and two staff
indicated it is provided as needed. All nine staff reported no basic needs can be taken away
from the youth as a form of consequence; however, youth levels can be dropped, and youth can
lose privileges such as visitation or a phone call. None of the interviewed staff have ever
witnessed a co-worker taking away meals, snacks, clothing, education, or medical care from a
youth because they were acting out. None of the staff reported ever having witnessed staff
encouraging a youth to beat up another youth.
Nine youth were interviewed and were able to articulate the difference between levels and how
they were able to move from level to level. Three youth rated the system as being very good,
three rated it as being good, two rated it as being fair, and one rated it as being very poor. Eight
of the interviewed youth reported they are rewarded by various incentives to include ice cream,
canteen, and extra food. One youth was not aware of any rewards. Six youth stated staff are
consistent in using the reward system; however, two reported staff are inconsistent, and the
remaining youth was unaware of any rewards as previously reported. All the interviewed youth
reported youth are never permitted to punish other youth at the center. Five youth stated they
have not been sent to their room for punishment. Four youth indicated they had been sent to
their room, with two stating it was due to their own negative behavior and they were placed in
confinement. The remaining two, as well as additional youth reporting on what they have
witnessed, indicating it was due to low staffing or having to go because of one other youth
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acting up so everyone must go to their room. The four youth having been placed in their room
and the two additional reporting what they had witnessed all indicated the door is shut and
locked when a youth is placed in their room. One youth stated when they received
consequences, they were fair; however, four youth indicated they were not. The remaining
youth had never received consequences. All youth reported they do not have things taken away
as a consequence. None of the youth have witnessed staff utilizing handcuffs or leg irons on
out-of-control youth to prevent them from hurting themselves or others. These issues were
reported to administration to be addressed.
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 (FOPs) requiring visual ten-minute checks to
be conducted on youth during sleep time or other times such as during an illness or room
restriction. The center has a total of eighty-eight cameras, and four were not operational during
the week of the annual compliance review. The cameras are supposed to retain video
recordings for thirty days, however there was an issue with the recording system and the
retained days are not consistent. Cameras are recording between seven and twenty-eight days.
The appropriate technicians were alerted to the issue. An electronic wand system is used in the
Detenion center to document and record the visual ten-minute checks conducted. The Detenion
center could not access the completed wand check reports to review for the annual compliance
review period while the review team was on-site for the annual compliance review. The
appropriate center staff were notified and the Detenion center was able to send some wand
checks after the annual compliance review. A review of one thirty minute section for eight
months found five months completing the checks as required, two months having only one
check one minute late, and one month having two checks one minute late. A review of video
coverage was conducted for all three modules for ten-minute checks. One of the nine recording
samples revealed a juvenile justice detention officer (JJDO) failed to conduct ten-minute checks
for over an hour during the shift. The assistant superintendent was present during the review of
camera footage, and the superintendent was notified. The remaining checks were completed,
as required by policy. The assistant superintendent reported center administration provides
management oversight by conducting weekly reviews of ten-minute checks to ensure fidelity.
Nine staff were interviewed. When a youth is placed in their room for sleeping or non-
punishment reasons, staff conduct checks every ten-minutes according to all the staff
interviewed.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The Detenion center maintains facility operating procedures (FOPs) to address census, counts,
and tracking, which require staff to always know the exact number and location of all youth
under their supervision. Counts conducted by the master control operator were observed daily
during the annual compliance review. Each count was started by stopping movement, master
control conducting the count, and ended when the count of youth was confirmed. A sample of
logbooks for twelve months, one full day a month, was reviewed for the annual compliance
review period. All twelve reviewed months included documentation counts were conducted: at
the beginning of each shift, following any emergency, emergency drills, prior to and following
routine group movement, anytime a population change occurs, randomly, and at least once on
each shift.. Nine staff were interviewed and all indicated census counts are done at the
beginning of their shift, eight stated at the end of their shift, three stated before and after school,
and one indicated before and after meals. All staff indicated counts are also done randomly
throughout the day. In the event a count cannot be reconciled, staff indicated all movement
stops and counts are done manually until the count can be reconciled. Staff indicated
emergency counts are also conducted after a power outage, when a youth is believed to be
missing, and after any major disturbance or drill.
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
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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 Detenion center has facility operating procedures (FOPs) outlining the requirement of a
chronological record of events, incidents, and activities in logbooks maintained at master control
and in each living area. The Detenion center maintains separate logbooks in master control,
each living area, for visitors, and for each vehicle. A review of logbooks for one full day for each
month during the annual compliance review period revealed the logbooks were bound with
numbered pages with the dates documented on the top of each page. All entries included the
times of the events in a.m. or p.m. with the name of the staff and youth involved. All entries
detailing mental health or medical health issues and safety and security concerns of the
Detenion center were highlighted, and all errors were struck through with a single line and
initialed by the staff. The master control logbook included all required entries including
emergency situations, incidents, drills, counts, movement, admissions and releases,
confinements, and precautionary observations. Supervisors reviewed the master control
logbook when accepting responsibility for the Detenion center as well as reviewed living area
logbooks daily. The juvenile justice detention officers (JJDOs) documented their review of
logbook entries from the previous shift when accepting responsibility for the living area. The
superintendent indicated upon receiving responsibility for the shift, the supervisor must
document and review the master control logbook. The supervisor must also review all living
area logbooks daily. The superintendent or designee reviews the logbook weekly. All reviews
are to be highlighted.
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 Detenion center has facility operating procedures (FOPs) describing the Detenion center’s
process for key control, key assignment and usage, key restriction, inventory, tracking, storage,
missing or lost keys, and reporting and replacement of damaged keys. The Detenion center has
a master inventory of all keys which includes all required information to include a tamper-
resistant key ring and color coding specific to the position to which the keys are assigned. An
inventory of staff keys confirmed the key rings on the inventory matched the actual key rings in
use. Observations of the key storage locations were made. The Detenion center’s keys are
maintained in three locations, none of which are easily accessible when locked. Juvenile justice
detention officer (JJDO) keys are kept in a cabinet in the staff briefing room and are distributed
by the supervisor during briefing. JJDOs may store their personal keys in the briefing room key
box or in their personal lockers located inside the staff restrooms. The keys for all other
positions are maintained in master control by role and are managed by the master control
operator. Master control gives staff keys in exchange for their personal keys. All the remaining
keys, including emergency and back-up keys, are kept in the assistant superintendent’s office in
a locked key cabinet. Key distribution logs are maintained by the master control operator and
the shift supervisor and include all the necessary elements. Observations of staff confirmed they
always carry issued keys on their person, they do not allow youth to handle keys, and they do
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not remove them from the Detenion center grounds. There were no instances of keys being
removed or lost during the annual compliance review period. Five key rings were observed and
compared to the key inventory and all five sets of keys matched the key inventory and the key
log. Three informal interviews were conducted with staff and each staff knew the number of
keys and function for each key on their key ring. An informal interview with the master control
staff revealed only medical and mental health staff have access to keys with access to
confidential youth records. The superintendent stated there are permanent issued keys for a
limited number of staff, and those staff are responsible for keeping them secured. Eight of nine
interviewed staff indicated medical record keys are restricted, two indicated youth property area
keys were restricted, seven stated keys to mental health records were restricted, two stated
keys to case management records were restricted, and four staff stated keys to the kitchen were
restricted. Three staff also indicated supervisors have restricted keys and one stated teacher
keys are restricted. All nine staff were able to articulate the key control process. Six staff were
able to articulate what to do in the event a key is lost or stolen past notifying master control.
Seven staff were able to identify what to do if a key is damaged.
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 Detenion center maintains facility operating procedures (FOPs) for transportation,
operation, and maintenance of each vehicle used to transport youth. The centerhas a total of
five vehicles used to transport youth. Reviewed documentation validated each of the five
vehicles had an annual vehicle inspection and the Detention center’s transportation staff
conducted weekly and monthly visual checks of all transport vehicles which included all required
elements. All five vehicles have the appropriate number of seatbelts, a seatbelt cutter, a window
punch, updated fire extinguishers, and a first-aid kit with approved items by the designated
health authority (DHA). The vehicle logbooks indicated each vehicle was searched for
contraband prior to use and again upon return, number of youth transported, and the destination
with date and time for each transport. An observation of a transport was conducted during the
week of the annual compliance review and the transporting staff were observed following all
required transportation procedures prior to transport. Five detention center vehicle checks were
conducted, and each was found to be securely locked when not in use. Nine youth were
interviewed. All nine-youth stated they feel staff are driving safely during transportation. None of
the youth stated they had seen anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOPs) requiring all tools and equipment related to
maintenance and kitchen area be properly maintained, stored, and inventoried. Youth are
forbidden to use or access any tools, except for cleaning items such as mops, brooms, buckets,
and other common household items under direct supervision. Inspections of the maintenance
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room, kitchen tool and knife storage, and broom closets found each area to be secured and
inaccessible to youth. Maintenance tools are placed on a shadow board or stored in a large
toolbox and engraved with a Department identification code in the maintenance building, which
is located off-site. A sample of ten items listed on the maintenance inventory were observed and
each was logged and accounted for. Documentation indicated kitchen staff conduct an itemized
inventory of all equipment, including a storage box for all knives, upon reporting for duty daily.
All kitchen items were accounted for, and logs were up to date at the time of the annual
compliance review. An informal interview with maintenance staff confirmed service vendors are
accompanied by designated center staff all times when in a secure area. Informal interviews
with the maintenance and kitchen staff revealed if there are any missing, lost, or damaged tools,
it would be reported to the supervisor and maintenance. The superintendent was interviewed
and reported the maintenance mechanic has access to the center’s tools. Nine staff were
interviewed on what to do if a tool goes missing. All staff indicated searches needed to be
completed, supervisors notified, and tool turned in for replacement if it is damaged. All staff
indicated the only tools youth are permitted to use are cleaning tools such as mops, brooms,
and scrub brushes. Nine youth were interviewed. Four reported they were not permitted to use
tools; however, the remaining five reported being allowed to use items such as scrub brushes,
squeegees, mops, brooms, and dustpans.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has a safety plan included in their Continuity of Operations Planning (COOP) Plan
addressing proper use, storage, and disposal of chemicals including flammable, toxic, caustic,
and poisonous items. All flammable, toxic, caustic, and poisonous items are inventoried and
secured when not in use. All Safety Data Sheets (SDS) were in a logbook, posted near the
items, and available to staff. Only authorized personnel are permitted access to flammable,
toxic, caustic, and poisonous items. No chemicals were observed to be accessible to youth.
Five items and the corresponding SDS were reviewed. The actual counts of all items matched
the ending count observed on the inventory form. Six of the nine interviewed staff stated youth
do clean with chemicals; however, the staff handle the chemicals and spray them, and the youth
then uses cleaning tools to wipe it up. Three staff stated youth do not use chemicals. Five of th
nine interviewed youth stated they can clean with cleaning agents; however, staff either spray
them, or the youth sprays them and give the container immediately to staff, then the youth use
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cleaning utensils to wipe it away. None of the youth reported having access to flammable, toxic,
caustic, and poisonous items.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) requiring the inventory, storage, and
disposal of any flammable, toxic, caustic, and poisonous items. There were no instances of
chemical spills during the annual compliance review period. The maintenance mechanic
confirmed the center has disposed of flammable, toxic, caustic, and poisonous items during the
review period. The center provided receipts for disposal from the Marion County Solid Waste
Department as documentation. The maintenance mechanic additionally confirmed there is a
container in the kitchen designated for grease disposal, which was observed by the review team
during the facility tour.
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 had a total of 290 confinements since the last annual review. A sample of fifteen
confinement reports were reviewed. A review of confinement reports found thirteen of fifteen
youth were provided a meal. Two records did not document meals during the confinement time.
One confinement record occurring during the appropriate time frame confirmed the youth was
given a shower, none of the other confinements were applicable. Five of six records reflected
the applicable youth were given access to mental healthcare as requested and one was not. A
review of eleven applicable youth found no youth were provided education materials. The
assistant superintendent explained at this time, typically, youth are not allowed any writing
utensils in confinement due to their behavior. All fifteen youth were notified of their right to
grieve the confinement. Documentation reflected the supervisor approved fourteen of the
confinements and one was not approved. All fifteen youth were placed into the confinement
room alone and all fifteen youth had their rooms searched prior to confinement. Each youth
confinements were documented on a completed Visual Observation Report (VOR). All fifteen
VOR logs had documentation of five-minute checks for the first hour in confinement, with two
exceptions. In both exceptions, the five-minute checks were performed until the last few checks,
in which the checks were completed in ten-minute increments. In all fifteen records, the youth
was notified of the reason for confinement. In fourteen of the fifteen confinement records, the
supervisor conducted an initial confinement review with the youth within one hour of the
incident. One review was not completed. Fourteen of the fifteen confinement reports were
completed by end of shift, and one was not completed. Twelve of fifteen records reflected an
additional review with a youth was completed every three hours by the supervisor. One record
showed one supervisor review was three minutes late, one record showed one review was
twenty-five minutes late, and in one record reviews were not completed. In all fifteen
confinements, the supervisors and staff continually counseled the youth and considered
removing the youth from confinement as soon the youth was able to safely rejoin the population
with no threat to safety. In ten of the fifteen confinement reports, the superintendent or designee
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reviewed the confinement report within the required forty-eight-hour time frame. One report was
six days late, two were three days late, and two were one day late. No pregnant youth were
reportedly placed in confinement during the annual compliance review period. All windows and
cameras were free of obstructions and scratches so the youth could be visually observed.
All nine interviewed staff indicated when a youth is placed in confinement the room is searched,
a report is completed, and checks are completed every five minutes for the first hour and every
ten minutes thereafter. Eight staff stated youth are still provided or given the opportunity to be
provided their educational materials. One staff stated they are not. This was reported to
administration who stated whether a youth is given their educational materials depends on the
nature of their confinement as some youth confined cannot have a pencil. The superintendent
reported confinements are entered into the Department’s Juvenile Justice Information System
(JJIS) and staff are required to document on the confinement VOR every five minutes the first
hour, then every ten minutes thereafter. Supervisors are to conduct an initial confinement review
no more than two hours from the incident. Supervisors should personally counsel youth
throughout the confinement and document this on the VOR.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center documented having completed two Continuity of Operations Planning (COOP) drills
during the annual compliance review period, with no exceptions noted. Two weather drills were
completed prior to hurricane season. Documentation of the center’s COOP drills included brief
scenarios, type of drill, date and time, any notable critiques and/or corrective action required,
and copies of corresponding logbook entries.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures (FOPs) to address escape drills and escape
prevention. The procedures require the center to conduct escape drills at least quarterly. Drill
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records reflected escape drills were conducted quarterly on both shifts. Documentation of each
drill included scenarios as well as the dates and times of the drill. The drill documentation form
included the signatures of the supervisory staff and the staff participating in the drill.
Recommendations and critiques of the drills were included in each report, as well as a copy of
the corresponding logbook entries. A review of logbooks revealed each escape drill was
documented, as required. Nine in-service training records and nine pre-service training records
were reviewed, and each staff completed training in security and escape prevention annually.All
nine interviewed staff participated in some type of drill since the last annual compliance review.
Four completed weather drills, three completed major disturbances, chemical spills, flooding,
and terrorism drills, five completed bomb threat drills, eight completed escape drills, and all nine
completed fire drills. All nine staff indicated they participated in medical and mental health drills.
This was reported to administration who stated they conduct escape drills quarterly. The
superintendent was interviewed and stated there is a COOP plan in place which requires fire
drills to be conducted monthly and escape drills quarterly.
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 implemented a Fire Prevention Plan. The center provided documentation of fire
drills conducted during the annual compliance review period. The center has completed monthly
fire drills, as required, apart from day shift in October 2024 and night shift in May 2025. A review
of drill documentation reflects all documents were completed and/or signed by the
superintendent, as required. A review of the master control logbooks revealed all fire drills were
documented as required. Additionally, copies of the logbook page corresponding to drills are
included in drill documentation. All thirty-five fire extinguishers were inspected annually. Nine
interviewed staff indicated fire drills are completed at least monthly at the center. Five of the
nine interviewed youth reported having been instructed on what to do in case of a fire and four
stated they had not. This was reported to administration who stated they conduct fire drills
monthly.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
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manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures in place for searches to ensure contraband is
prevented from entering the secure area of the center. The policy includes procedures for
electronic, frisk, strip, room, and staff/visitor searches. Documentation confirmed youth
electronic and strip searches were conducted prior to each admission. Youth frisk searches are
conducted when deemed appropriate by the shift supervisor when there is reasonable suspicion
the youth was harboring contraband, and during facility-wide initiatives to reduce the
introduction of contraband. All searches were documented in the logbook and electronically.
During the annual compliance review, observation of a youth and room search was conducted.
Staff wore gloves during the searches of seven male youth departing for court. Two staff were
observed wearing gloves while conducting room searches, and the search was purposeful and
neat, following Detention center policy. Reviewed documentation confirmed an incident report
for any strip search conducted at any time other than admission, two staff of the same gender of
the youth were present when conducting the search, and all strip searches were conducted
individually and not in a group setting. Electronic searches were conducted on all persons
entering the facility; staff searched all bags, cases, jacket pockets, and other items, and all
personal keys, personal cell phones, and other contraband items were prohibited from entering
the secure area. Room searches occurred upon a youth’s release, prior to placing a new youth
in the room, and for contraband on each awake shift.
A reviewed sample of room searches for one day of each month of the annual compliance
review period for each awake shift found the room searched was documented and completed as
required, with no exceptions noted. Nine staff records were reviewed, and all included the
contraband attestation. The center documented four incidents of contraband being discovered,
which included the confiscation of the contraband and noted in the master control logbook.
Incident reports were completed to identify findings and disposition of contraband. Law
enforcement was contacted when any found item was considered illegal as defined in Florida
Statutes or when there was evidence of any type of unlawful activity. Confiscated items were
secured by the discovering officer and hand-delivered to the supervisor. The shift supervisor
documented the chain of custody of confiscated items, and the process was documented in the
incident report. The Department’s Central Communications Center (CCC) and the regional
director (RD) or designee were notified of the discovery and confiscation of contraband. The
superintendent was interviewed and stated prior to admission and when youth are returning
from a transport, frisk searches are conducted. Strip searches are conducted during the intake
process and all searches must be done by the same sex as the youth. When contraband is
found, the contraband must be immediately secured and documented in the master control
logbook. Next, an incident report is completed, and law enforcement is contacted if the
contraband is considered illegal. A report to the CCC must be made as well as informing the
RD.
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report_type: QI Detention

rule: Indicator 1.05

excerpt: Right Interactions (RI)

rating: Failed Compliance

rule: Indicator 2.10

excerpt: Educational Access (Critical)