summary: QI Detention - FY24-25 - 8 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Manatee Regional Juvenile Detention Center
(State-Operated )
1803 5th Street West
Bradenton, Florida 34205
Review Date(s): March 11-14, 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:
Jeremy Curvan, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Teresa Andersen, Office of Accountability and Program Support, Deputy Regional Supervisor
(Interviews, Video Review)
Lenon Anderson, Orange Regional Juvenile Detention Center, Juvenile Detention Officer
Supervisor (Standard 5)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Evan Hald, Office of Education, Southwest Region Education Coordinator (Standard 2)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Manatee Regional Juvenile Detention Center MQI Program Code: 298
Provider Name: State Operated Contract Number: State
Location: Manatee County / Circuit 12 Number of Beds: 60
Review Date(s): March 11-14, 2025 Lead Reviewer Code: 213
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
1.07 In-Service Training 1.05 Right Interactions (RI)
2.10 Educational Access* 5.03 Ten-Minute Checks*
3.12 Suicide Precaution Observation Logs * 5.11 Confinement Under Twenty-Four Hours
5.15 Fire Drills
5.16 Search and Contraband Procedures
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 57 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Failed
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Limited
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 57 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 57 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Limited
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 57 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 57 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Failed
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Failed
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Failed
5.16 Search and Contraband Procedures Failed
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will
result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 57 (Revised July 2023)
Program Overview
The Manatee Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Bradenton, Florida. The center serves youth in Manatee,
Sarasota, and DeSoto counties in Circuit 12. 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 Manatee County School Board.
The center’s management team includes the superintendent, two assistant superintendents, two
administrative assistants, four juvenile justice detention officer supervisors (JJDOSs), and thirty-
five 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 one licensed mental health counselor, who serves as the center’s
designated mental health clinician authority (DMHCA), one additional licensed mental health
counselor, one psychiatrist, five pro re nata licensed staff, and one non-licensed staff. Clinical
services provided by the provider include mental health and substance abuse evaluations,
mental health treatment planning, individual, group and family therapy, mental health crisis
intervention services, on-site psychiatric services, and availability for substance abuse services
for youth with co-occurring disorders. Medical services are provided by one medical doctor (MD)
who serves as the center’s designated health authority (DHA), one advanced practice registered
nurse (APRN), two full-time registered nurses (RNs), one part-time RN, and one fulltime
licensed practical nurse (LPN). The medical clinic maintains nursing coverage seven days a
week, from 7:00 a.m. to 7:30 p.m. Monday through Friday and from 7:00 a.m. to 5:30 p.m. on
Saturdays and Sundays. 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. Three living modules were in use at the time of the annual
compliance review, two for boys and one for girls. There are sixty-four security cameras at the
center, of which fifty-eight were operational. Observations of the facility found the exterior was
landscaped and free of debris. The common day room area, classrooms, and cafeteria were
clean and in good repair. Youth and staff restrooms were clean; however, appeared dirty due to
the age of the restrooms. Graffiti was observed in youth rooms, confinement rooms, cafeteria,
and youth modules. It was immediately brought to the attention of the floor staff. Peeling paint
and paint splatters on the floor were observed throughout the facility. The center is in the
process of painting the facility. The floor in the mental health area as well as the hallways, was
peeling. At the time of the annual compliance review, the center had fifteen vacancies, which
included two JJDOs, twelve JDDO II’s, and one JJDOS.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures ensuring a background screening is conducted for
all Department staff, contracted staff, volunteers, mentors, and interns with access to youth and
confidential youth records. The center provided an Annual Affidavit of Compliance with Level 2
Screening Standards for the center, which was signed by the superintendent on January 22,
2025, and an Annual Affidavit of Compliance with Level 2 Screening Standards for the school
board, which was signed by a school board representative on January 28, 2025. The center had
five new contracted staff, seven new volunteers, and fifteen newly hired staff since the last
annual compliance review. All newly hired staff and volunteers had an initial background
screening completed prior to contact with youth or confidential youth records and a criminal
history report was reviewed for each, except for with the exception of two volunteers. The center
had two volunteers whose start date was February 14, 2025, and have yet to volunteer at the
center. Furthermore, both volunteers are expected to work less than ten hours a month, which
does not require a background screening. Each staff and applicable volunteer received an
eligible background screening; therefore, no exemptions were needed. A pre-employment
assessment tool was administered for all fifteen newly hired staff, and a passing score was
documented for each. The remaining five contracted staff and seven volunteers were not
applicable for a pre-employment assessment tool, as they were not direct care staff. The
contracted provider, VitalCore, did add four of the five contracted staff to the Clearinghouse
employee roster. The remaining contracted staff is employed by the Manatee County School
District, thus not applicable.
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 ensuring all staff, contracted staff, and volunteers
are rescreened every five years. The center had one staff and three volunteers who required a
five-year rescreening since the last annual compliance review. The one Department staff had a
five-year rescreening completed every five years, calculated from their agency hire date. Two of
the three volunteers had a five-year rescreening which was completed every five years,
calculated from the agency hire date. One volunteer was eligible for a five-year rescreening;
however, a rescreening was not completed because the volunteer has not been currently active
in the center in over a year. Furthermore, the volunteer was removed from the volunteer roster
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during the week of the annual compliance review. None of the rescreening’s were completed
more than twelve months prior to the staff or volunteer’s five-year anniversary date.
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)ensuring all staff adhere to a code of
conduct. Seven staff code of conduct violations during the annual compliance review period
were reviewed. All seven reviewed staff personnel records included a code of conduct form
which was signed upon hire. Reviewed documentation indicated management responded to
each code of conduct violation. One staff received an oral reprimand, five staff received a
written reprimand, and one staff received a written reprimand and a memo for retraining. The
center provided staff commendations for three staff who received commendations during the
past year. One staff received the Manatee Star Award for assisting a youth with education. One
staff received the Manatee Star Award for assisting with the Manatee Regional Juvenile
Detention Center Job Fair at a local college on February 27, 2025. One staff received the
Florida Youth Foundation Everyday Hero award for exceeding expectations in assisting youth,
families, and their fellow Department of Juvenile Justice (DJJ) colleagues. Seven youth were
interviewed, and all seven indicated they have never had to report abuse at the center. All
seven youth stated staff are respectful when speaking with them and other youth. One youth
indicated they have never heard staff use profanity when speaking with them or other youth,
one youth stated they have heard staff use profanity often, and five youth stated they have
heard staff use profanity occasionally in general conversation. All seven youth stated they have
never heard staff threaten them or other youth. Each youth stated they feel safe at the center.
All seven youth stated they have never exchanged contact information or social media contact
information with staff. Seven staff were interviewed, and all were able to explain the process for
allowing youth and staff to call the Florida Abuse Hotline or the Department’s Central
Communications Center (CCC), if age eighteen or older, to report suspected abuse. Three staff
indicated they have never observed a coworker using profanity when speaking to youth, four
staff indicated they have observed it occasionally. All seven staff stated they have never
observed a coworker using threats, intimidation, or humiliation when interacting with youth.
When asked how the staff would rate the working conditions at the center over the past year,
five staff answered good, one staff answered very good, and one staff answered fair. During an
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interview, the superintendent confirmed staff must adhere to a code of conduct which prohibits
any form of abuse, profanity, threats, harassment, intimidation, or personal relationships with
youth. Officers shall not verbally abuse, demean or humiliate any youth, and shall not use
profanity in the performance of their job. Violation of the center’s FOP on Staff Code of Conduct
shall subject an employee to disciplinary action up to and including dismissal or criminal
prosecution. Detention officers sign the standards of conduct at time of hire. The Officer Code of
Conduct poster is also posted in the briefing room and conference room for all staff. The center
has no current examples of disciplinary action for these violations.
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 indicating they will notify the Department’s Central
Communications Center (CCC) within two hours of a reportable incident occurring, or within two
hours of becoming aware of the incident. The center had one hundred and twenty-nine CCC
incidents reported during the annual compliance review period. Twelve incidents were reviewed,
and all twelve were reported within two hours of the incident occurring, or the center becoming
aware of the incident. All twelve incidents were documented in the center’s logbook, as
required. No additional incidents which should have been reported to the CCC were discovered
during the annual compliance review week. During an interview, the superintendent stated all
staff at the center are aware they are mandated reporters and must report any incident to the
CCC within two hours. Youth also can report any form of Prison Rape Elimination Act (PREA)
allegations. If the allegation is against a facility staff member, the individual should be removed
from youth contact pending the investigation. All PREA guidelines, and/or protocol are followed.
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 indicating they must use physical intervention
techniques in accordance with Florida Administrative Code. Anytime a physical intervention
technique is used, a Right Interactions(RI)/Protective Action Response(PAR) incident report
must be completed. The center had fifty reported RI incidents during the annual compliance
review period. The center had a deficiency related to RI incidents closed on September 26,
2024; therefore, only eight RI incidents were reviewed. Six of the eight reviewed RI Reports
were not completed by the end of the staff’s workday. Two of the eight were completed by the
end of the staff’s workday. Five of the eight RI Reports were missing staff narratives. Three
included all staff narratives. None of the reviewed incidents resulted in serious injuries to the
youth or staff or required a call to the Florida Abuse Hotline or the Department’s Central
Communications Center (CCC). Two of the eight RI Reports were determined to be incomplete
by the superintendent, and six were completed as necessary. One of the eight RI Reports was
missing a lead staff signatures, while seven included the lead staff signature. One of the eight
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RI Reports was missing a supervisor signature, and seven included a written supervisor
signature. Seven of the eight RI Reports documented a post-RI interview signature; one did not
have a post RI interview signature. Four of the seven RI Reports which had a documented post
RI interview signature was more than thirty minutes after the incident. One post RI interview was
twelve days late, another was sixteen hours late, another was ten and a half hours late, and the
remaining was twelve hours late. Seven of the eight RI Reports indicated no need for a RI
medical review and mechanical restraints were not used in any of the incidents. It was not
determined if a medical review was conducted on one incomplete RI report because there was
no signature. Seven of eight RI Reports were reviewed by the superintendent/designee within
seventy-two hours; one was undetermined if it was reviewed on time, because it was missing
the administrator/designee signature. No additional RI incidents which were not documented by
a RI Report were discovered during the annual compliance review week. The center’s PAR rate
during the previous quarter was 5.47, which is below the statewide Detention PAR rate of 9.79.
Seven staff were interviewed, and each stated staff try to talk with youth prior to using physical
restraints. During an interview, the superintendent stated regional management receives an
alert when a confinement or RI Report is generated, which allows them to track the use of
physical restraints. The superintendent indicated mechanical restraints are only used for
transports outside of the facility. The superintendent indicated supervisors are required to
review and sign all RI Reports during their shifts and administrators must review them within
forty-eight hours.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures indicating all staff are trained in accordance with
Florida Administrative Code. Pre-service/certification requirements shall be satisfied within 180
days of hire. Seven staff records were reviewed for pre-service training. Each staff completed a
new staff orientation within thirty days of hire. All seven staff completed their pre-service and
certification requirements within 180 days of hire. Academy Training consisting of 120 hours
was completed for all seven staff, and each staff’s trainings were documented in the
Department’s Learning Management System (SkillPro), as required. None of the seven staff
records reviewed were rehires for the Department; therefore, were not required to complete
annual update training requirements
1.07 In-Service Training Limited Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures in place to ensure all center staff receive twenty-
four hours of in-service training, including mandatory topics specified in Florida Administrative
Code, each calendar year. Seven staff training records were reviewed for in-service training. All
reviewed staff completed at least twenty-four hours of required training in calendar year 2024.
Four staff completed training in all mandatory topics throughout the year. One staff was not
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Office of Accountability and Program Support Page 13 of 57 (Revised July 2023)
applicable for in-service training for the year 2024 as the staff completed pre-service the
beginning of 2024. Two of the seven staff completed all required trainings except for Active
Shooter Preparedness, Information Security Awareness, Professionalism, Interpersonal
Communication, and Ethics including Standards of Conduct, Trauma Responsive Practices, and
the Escape Prevention Annually. The center had three supervisory staff applicable for
supervisory training at the time of the annual compliance review. Three reviewed supervisor’s
training records confirmed none of the staff completed any of the eight additional hours of
training in coaching, leadership, or personal accountability. Each staff’s completed trainings was
documented in the Department’s Learning Management System (SkillPro), as required, with the
exceptions of the three supervisors and one staff, who did not complete all required trainings.
The center submitted three retraining memos on January 6, 2025, for three of four staff who did
not complete their mandatory trainings and/or supervisory trainings. The center had a list of in-
service trainings which included course names, descriptions, objectives, and training hours for
any instructor-led trainings which was approved by the Department’s regional director
November 29, 2023. The center maintains an annual in-service training calendar which is
updated as changes occur, and was approved by the highest ranking official at the center,
assistant secretary of detention, and the director of talent, leadership, and culture. During an
interview, the superintendent described the management trainings they have received and
confirmed staff are required to complete twenty-four hours of annual in-service training, with an
additional eight hours required for supervisory staff.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures in place addressing the center’s grievance
procedures. Grievance forms are available to youth on each living module, and at the time of
the annual compliance review week, grievance forms were located on all three active living
modules. The center recently had a deficiency related to grievances which was closed on
September 13, 2024; therefore, there were no applicable grievances to review during the annual
compliance review week. During an interview, the superintendent indicated if a youth requests a
grievance, the officer will provide the youth with a grievance form to complete.Staff, supervisors,
and administrators are required to review the grievance with the youth in the different phases
and the youth has a right to appeal. The phases are signed by all individuals involved and then
the grievance is uploaded into the Department’s Facility Management System(FMS). Seven
youth were interviewed and asked about the grievance process. Six of the seven youth stated
they can ask for a grievance form and either return it to staff or a supervisor, and they will place
it in the grievance box. One youth stated they have never filed a grievance. Seven youth were
asked to rate the grievance process at the center, and all seven youth confirmed they have
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never filed a grievance. Seven staff were interviewed each were able to explain the grievance
process.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures (FOPs) ensuring all critical and special alerts are
entered in the Department’s Juvenile Justice Information System (JJIS), reviewed, and
responded to appropriately. Seven youth records were reviewed for alerts, with a total of fifty-
four alerts. A review of the center’s logbooks found out of the fifty-four alerts thirty four
applicable alerts were documented as required. The remaining twenty alerts are not required to
be entered into the center’s logbook. The center keeps a copy of the current alerts in the
logbooks for each module, which is required by the center’s FOP’s. Each alert was placed on
the alert list on the same day it was entered in JJIS, or when the youth entered the facility, if the
alert was previously placed in JJIS, as the center utilizes the JJIS alert list as their internal alert
system. All alerts in JJIS and the center’s internal alert system matched. An observation of a
shift briefing the week of the annual compliance review, found alerts were reviewed with staff.
Alert lists are given to the lead staff on each module, who then document applicable alerts in the
logbook. Medical and mental health staff are responsible for updating alerts in their areas.
During an interview, the superintendent explained the center’s medical alert process, and stated
alerts are entered by juvenile justice detention officers and medical staff based on assessment,
observation, and/or information provided by the youth or parent/guardian. The alerts are
reviewed during each shift briefing and dining hall staff receive a copy of alerts for dietary needs
and allergies. Seven staff were interviewed on how they are informed of alerts. Two staff
answered logbooks, five staff answered shift debriefings, seven staff answered alert forms, four
staff answered JJIS, and three staff stated the supervisor reviews alerts with incoming staff, the
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alerts are in master control, and they are notified by email by medical and mental health staff.
Seven staff were asked how management informs staff about issues within the center and all
stated debriefings, one staff stated as a captain he goes to briefings and discusses it with the
staff. One staff explained a discussion takes place if needed between staff. One staff confirmed
issues are addressed through staff retraining’s and emails. One staff stated the supervisor
keeps the staff up to date as the day goes on. Finally, one staff explained the issues are passed
on. Seven staff were asked how effective they believe the process is for communicating
information, one stated fair, three stated good and three stated very good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a process in place for including the review and analysis of data in decision
making practices. The detention center has a quarterly report card based on data pulled from
the Department’s Tableau system and Juvenile Justice Information System (JJIS). The regional
director will pull reports from JJIS monthly, including the Department’s Central Communications
Center (CCC) reports and Right Interactions model (RI) reports. The center will review factors
including staff involved in incidents, the time-of-day incidents occurred, and youth involved. An
email is then sent to the superintendent which includes the findings and identified issues.
Superintendent meetings are held quarterly, and conference calls are held monthly to discuss
updates. Information is shared with staff and administration through emails, monthly staff
meetings, and regular meetings with the department heads. Regional management staff attend
calls with residential and probation to share information. Management meets monthly with
probation and with the Juvenile Assessment Centers through a video meeting held quarterly
where this information is shared. These meetings include members from community providers.
The center provided an agenda from a leadership meeting which included data trend analysis.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) which require the admission process to
address a review of required paperwork from law enforcement, an electronic, frisk, and strip
search of youth by an officer of the same gender, the allowance for youth being admitted to
make a telephone call to their parent/guardian, the provision of food for a youth in the event the
admission process is completed two or more hours before serving the next scheduled meal, and
for all youth to be screened to identify medical, mental health, and substance abuse needs.
Seven youth case management records were reviewed, and all contained a printed copy of the
Admission Wizard from the Department’s Juvenile Justice Information System (JJIS). Each of
the Admission Wizards contained an arrest affidavit or custody order, a completed Detention
Risk Assessment Instrument (DRAI), a completed Suicide Risk Screening Instrument (SRSI),
and documentation of a completed full body and electronic search by an officer of the same
gender. Documentation confirmed six youth made a telephone call to their parent/guardian.
Reviewed documentation did not indicate if the remaining youth completed or refused a
telephone call. All seven youth records contained verification each youth was provided a meal
during admission, and a medical, mental health, and substance abuse screening. An
observation of a youth admission process was not able to be completed during the annual
compliance review week due to no youth admission occurring while the review team was on-
site.
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);
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7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures (FOP) to ensure each youth admitted into the
center is informed of the center rules and regulations, grievance procedures, visitation,
telephone calls, expectations for behavior, related consequences for failing to meet behavior
expectations, and youth rights within twenty-four hours of admission. Seven youth case
management records were reviewed, and each included an orientation packet which was
completed within twenty-four hours of admission. All seven records had documentation to
validate the orientation was explained verbally and in writing by the juvenile justice detention
officer (JJDO). An observation of a youth orientation process was not able to be completed
during the annual compliance review week due to no youth admission occurring while the
review team was on-site. Seven youth were interviewed and asked were they told about the
rules and regulations, daily schedule, education services, visitation, abuse reporting, and
behavior management system and all stated yes.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) requiring the classification of all youth
being admitted while providing the highest level of safety and security. Seven youth case
management records were reviewed, and all contained a printed copy of the Admission Wizard
from the Department’s Juvenile Justice Information System (JJIS). Each Admission Wizard
contained verification showing the classification for youth included a screening for mental
illness, intellectual and physical disabilities, history of violent behavior, gang affiliation, criminal
behavior, history of any sexual offenses to include sexual battery which may have been reduced
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to a minor offense, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB),
medical issues, Suicide Risk Screening Instrument (SRSI), escape threat, security threat, and
history of human trafficking to ensure each youth is housed in a room which will provide the
highest level of safety and security. The classification process also included the following
additional factors in determining proper room assignment: youth’s age, sex, height, weight, and
level of aggressiveness. Each youth is reclassified if changes in behavior or status are
observed, youth with a history of committing sexual offenses or are a victim of a sexual offense
are placed in a room alone. The superintendent receives an email from staff anytime a youth is
suspected or confirmed as to their involvement with a gang. An interview with the
superintendent confirmed facility staff are instructed to use professional sound judgement when
classifying youth.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOP) in place to ensure all information regarding
suspected youth gang affiliation is shared with the circuit gang representative. The
superintendent has been designated to serve as the gang representative for the center. It is the
center’s superintendent who then corresponds with the chief probation officer (CPO) regarding
all suspected gang activity. The center is required to enter the suspected gang affiliation alert
into the Department’s Juvenile Justice Information System (JJIS) if there is a youth suspected to
have gang affiliation. Staff are notified of all updates and alerts during shift briefings and on the
daily alert sheet. An informal interview with the superintendent confirmed the center’s practice.
Seven youth case management records were reviewed in which none of the records were
applicable for gang affiliation. There were no additional youth applicable for suspected or
known gang involvement during the annual compliance review period. The informal interview
with the center’s gang liaison revealed there has been no suspected gang activity at the center
during the annual compliance review period to warrant communication with the circuit 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.
The center has facility operating procedures (FOP) in place ensuring the proper safe handling
and security of personal property, including valuables, which are collected and secured at the
time of a youth’s admission. Staff must inventory all personal property in the youth’s possession
and record each surrendered item on the Property Receipt Form. The center must safeguard
youth personal property until it is returned to the youth and/or parent/guardian. Personal items,
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such as clothing and shoes, are placed in a mesh bag and secured in the center’s inventory
locker room. Valuable items are listed and placed in a clear tamper-proof property bag,
identified with the youth’s name and Department of Juvenile Justice identification number
(DJJID), then secured in the property cabinet located in the administrative office which is under
video surveillance. Valuable items are secured in the drop safe located in the admission office.
The center maintains a drop safe logbook to document the time, youth’s name, name of the
juvenile justice detention officer (JJDO) securing the property, and the JJDOs initials. Seven
youth case management records were reviewed, and each record contained a Personal
Property Receipt Form. All seven youth signed their property receipts. All seven youth Personal
Property Receipt Forms were signed by center staff, and all contained a letter of
acknowledgement regarding unclaimed property, which were signed by each youth. Each of the
personal Property Receipt Forms were placed in each youth’s active record. Four of the seven
youth had money and personal items of value, and these items were secured in a clear, tamper-
proof bag, which contained the date, youth name, DJJID, and a listing of items stored in the
bag. The tamper-proof bag was placed in a drop-safe, which is under video surveillance. A
review of the drop-safe confirmed these tamper-proof bags were secured as required. The drop-
safe logbook included the date, time, youth name, DJJID, printed name and initials of the officer
who secured the property. The applicable youth with valuable items had the items stored in a
clear tamper-proof bag and securely stored in the drop safe. Three of the seven youth had no
personal property. An observation of three youth valuable property items and three youth
personal property items received prior to the annual compliance week were observed. All six
youth property items were placed in a bag which contained a completed inventory form. Three
applicable youth valuable property items were documented in the safe logbook and stored in a
clear tamper-proof bag. Four applicable youth had valuable property, and a valuable Property
Receipt Form was completed and placed in each youth’s active record. An observation of the
center receiving youth personal property was not able to be completed during the annual
compliance review week due to no youth admission occurring while the review team was on-
site. A review of the Department’s Central Communications Center (CCC) reports since the last
annual compliance review found no incidents regarding youth property. All seven interviewed
youth stated staff check their property inventory and each youth signed stating the inventory
was correct. The superintendent interview confirmed the center’s property storage practice.
Youth property is inventoried, then each is assigned hanging bags during admission. Each
youth personal property is stored in a mesh bag inside the storage closet. A disposal letter is
explained during the admission process, and all youth have thirty calendar days after being
released to reclaim their personal property.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures (FOPs) requiring center staff to ensure appropriate
authorization before releasing youth from detention. Three closed youth case management
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records were reviewed and all contained documentation which verified the on-duty supervisor
reviewed all paperwork related to release prior to releasing the youth. The on-duty juvenile
justice detention officer supervisor (JJDOS) verified each youth’s release by reviewing the court
order and signing the secure detention release form. The supervisor initialed the release
paperwork verifying the identification of the youth prior to release. Two of the closed youth
records had a copy of photo identification of the person taking custody. The one remaining
youth was not applicable as the youth was released to a program. Each of the closed youth
records had the appropriate documentation which included notifications of any future court
dates, and all parties signed all required release forms. None of the released youth had an alert
reflecting an endangered person. The three closed records date of admission and release
correlated with the Department’s Juvenile Justice Information System (JJIS). An observation of
a youth being released was not able to be completed during the annual compliance review week
due to no youth releases occurring while the review team was on-site.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures (FOP) in place to ensure all youth personal
property is released to the youth or the youth’s parent/guardian. The parent/guardian, youth,
and staff must sign a receipt acknowledging all property was returned upon the youth’s release.
A review of three closed youth case management records revealed each youth record contained
the required information with all required signatures of receipt of youth’s personal property. Two
closed records contained documentation which verified the youth was released to an
appropriate person, with a copy of their identification included. The one remaining youth was not
applicable due to being released to a program. None of the reviewed three records had youth
released with medication. All three records contained documentation signed by the youth and
parent/guardian showing they were reminded of any health or welfare issues, to include
medical, mental health, substance abuse need, and any pending appointments. The center did
not have any inventory of unclaimed property held for more than thirty days during the annual
compliance review period. An observation of the release process was not able to be completed
during the annual compliance review week due to no youth releases occurring while the review
team was on-site.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOP) ensuring detention reviews are
conducted weekly for youth securely detained, placed on home detention, or placed on
electronic monitoring to ensure proper management of youth and the sharing of information.
Detention reviews are conducted on a weekly basis to address the status of each youth. An
observation of a detention review was conducted during the annual compliance review week.
The review consisted of a census review, a review and discussion on exceptional cases,
courtesy holds, transfers, a commitment residential placement review, education update,
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medical update, mental health update, a review of center alerts, and a detention review of all
youth currently at the center. Observation of the weekly detention review confirmed virtual
attendance included the following participants, mental health, medical, education, probation
officers, superintendent and intake center staff. All staff attended by video conference and the
video conference attendance logs were maintained for each meeting. An interview with the
superintendent confirmed detention reviews are conducted every Wednesday and Thursday by
video call. Youth statistical notes and information are discussed and uploaded into the
Department’s Juvenile Justice Information System.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures (FOP) addressing the daily activity schedule. A
center tour was conducted during the annual compliance review. During the tour youth were
observed in the dayroom area reading and on the recreation field playing basketball. The daily
activity schedule was observed posted in the dayrooms of all living areas. The center’s daily
activity schedule includes wake-up and personal hygiene time, mealtimes, visitation twice each
week, indoor and outdoor recreation, shift changes, bedtimes, groups, and open program time.
The center did not meet the minimum requirement of conducting visitation twice each week. The
center conducts visitation one day a week on Wednesday’s. An informal interview with the
superintendent confirmed visitation days have been reduced to one day each week due to
staffing issues. Seven youth were interviewed, and all stated the center has a daily activity
schedule. Seven staff were interviewed, and all stated the daily activity schedule is followed.
The center was unable to provide documentation of granted approval to reduce visitation to one
day a week.
2.10 Educational Access (Critical) Limited Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center provides
education services through the Manatee County School District. A review of the daily school
schedule revealed the center provides six fifty-five-minute class periods daily, fulfilling the
weekly requirement of twenty-five hours of instructional time. The school schedule was
reviewed and does coincide with the provided facility daily activity schedule with one exception;
the activity schedule shows lunch starting at 11:30 a.m., while the school bell schedule shows
11:35 a.m. A review of three randomly chosen dates of the logbook demonstrated the daily
class schedule was not adhered to, and classes were not facilitated as they were scheduled,
with students arriving late to first period, as well as not being transported to class from the mod
due to staffing shortages. A review of video was not available due to the video surveillance
system currently not working properly. Seven youth were interviewed; with each reporting they
attend school Monday through Friday. Seven youth felt the school was preparing them very well
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regarding preparation towards General Education Development (GED) platform, high school,
vocational, employment, and/or college. Seven staff were interviewed, and all indicated there
was minimal interference in educational services. The interview with the superintendent also
confirmed there is minimal interference with educational services.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has established facility operating procedures to deliver career education to students,
offering a Type 1 program which includes communication, interpersonal, and decision-making
skills. The facility currently employs career education software to provide diverse career learning
opportunities. Seven youth were interviewed, and each reported they were taking core classes
such as math, science, history, reading, social studies, career choices, and Life Skills.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has identified one licensed individual to serve as their designated mental health
clinician authority (DMHCA) as required. The DMHCA is responsible and accountable for
ensuring appropriate coordination and implementation of mental health and substance abuse
services in the center. The DMHCA’s position is under the contracted provider, VitalCore Health
Strategies, LLC. The center’s DMHCA is a licensed clinical social worker with a clear and active
license, which expires March 31, 2027, and is required to be on-site forty hours each week.
Additionally, the DMHCA is on-call when not on-site for emergency mental health and
substance abuse related needs. The center has had only one DMHCA during the annual
compliance review period. The center’s back-up DMHCA is a licensed mental health counselor
with a clear and active license, which expires March 31, 2027. A review of the DMHCA’s sign-in
logs for the annual compliance review period and the DMHCA’s contract requirements/job
description was conducted. This review confirmed the DMHCA, or back-up DMHCA, is providing
the required weekly forty-hour coverage as specified by the contract. The DMHCA was
interviewed and described their role at the center as providing oversight for the mental health
and substance abuse services provided to youth and families. In this position the DMHCA
conducts mental health and suicide risk assessments, develops treatment and discharge plans,
provides supportive counseling, brief support and crisis support/interventions, and ensures each
juvenile probation officer (JPO) receives treatment information and updates. The DMHCA
confirmed the clinical services provided to the youth at the center, as needed, to include
Assessment for Suicide Risk (ASR) and Follow-Up ASRs; initial and individualized treatment
plans; discharge summaries with community-based service referrals; individual, supportive,
group, and crisis counseling; and treatment team meetings. The DMHCA and the clinical staff at
the center communicate daily and have meetings weekly as needed. The DMHCA
communicates with the center’s superintendent or designee on a daily and weekly basis, as
needed.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center’s superintendent is responsible for ensuring mental health and substance abuse
services are provided by qualified staff. The center has a contracted provider who hires all
mental health and substance abuse clinical staff for the center. The contracted provider has four
full-time clinical mental health staff and one clinical staff utilized on an as needed basis, in
addition to the designated mental health clinician authority (DMHCA). During the annual
compliance review period, the center did have two additional licensed clinical staff who provided
service and are now separated from the contracted provider. Six of the seven licensed mental
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health clinicians were utilized during the annual compliance review period, and each clinician
has a clear and valid license, expiring on March 31, 2027; the remaining staff utilized as
needed has a clear and valid license, expiring on March 31, 2025. The DMHCA was able to
provide each clinician’s license as the copies are available in a binder within the DMHCA’s
office.
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 center’s superintendent is responsible for ensuring mental health and substance abuse
services are provided by qualified staff. The center has a contracted provider who hires all
mental health and substance abuse clinical staff for the center. The contracted provider assures
all non-licensed mental health clinical staff are working under the supervision of a qualified
licensed clinical staff, and the non-licensed staff have the required education, training, and
experience described in the job description. The center has one non-licensed staff graduate-
level intern. A review of the job description and staff record confirmed the non-licensed mental
health clinical staff met all the required qualifications. The designated mental health clinician
authority (DMHCA) provided documentation of all the weekly supervision for the non-licensed
mental health clinical staff for the annual compliance review period. Each weekly supervision log
was completed on the required Department form. The center, nor the contracted provider, have
a Chapter 397 license. The DMHCA confirmed only licensed mental health clinical staff provided
substance abuse treatment during the annual compliance review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures (FOPs) to ensure all youth have a mental health
and substance abuse comprehensive screening process at admission to identify any needs the
youth may have. A review of seven youth mental health records was conducted to verify this
process. All seven youth records contained a completed Suicide Risk Screening Instrument
(SRSI) and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) which were
completed by the Department’s probation staff prior to each youth being admitted to the center.
During the center’s intake process these documents are reviewed by detention staff, and
detention staff complete the required sections on the SRSI in the Department’s Juvenile Justice
Information System (JJIS). The center’s medical staff and/or mental health staff are also
responsible for completing a required section on the SRSI. All seven reviewed youth mental
health records contained documentation of both the SRSI and MAYSI-2 having been completed
in JJIS, and each required section of the SRSI was completed by the appropriate staff. Three of
seven reviewed youth records had at least one positive response on the SRSI; the remaining
four youth record did not have any positive responses noted. All three applicable youth records
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contained documentation confirming each youth was placed on suicide precautions and
detention staff initiated a mental health referral which indicated the youth’s need for an
Assessment of Suicide Risk (ASR) at intake. All three applicable SRSIs also included a positive
response for having any open or closed suicide risk alerts in JJIS. Two of the seven youth
records contained an invalid MAYSI-2 due to the youth providing all negative responses; the
remaining five records did not have an invalid MASYI-2. Two of the remaining five youth records
had an elevated score in at least one domain on the MAYSI-2, the remaining three did not have
any elevated score. Four of seven reviewed youth required a referral based on the SRSI or
MAYSI-2. All four applicable youth records had documentation on the mental health referral,
initiated at intake by detention staff, of the MASYI-2 results requiring further assessment. The
superintendent or designee notification was documented in all four of the reviewed youth
records as evidenced by the electronic signature in JJIS. All screenings located in the seven
reviewed youth records were completed by a trained staff, which was confirmed in the
Department’s Learning Management System (SkillPro).
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures (FOPs) which ensures each applicable youth
receives a mental health or substance abuse assessment. A review of seven youth mental
health records was conducted and five were identified and referred to the center’s provider for
further assessment; the remaining two youth records were not identified for or referred for
further assessment. All five of the applicable youth records contained documentation of a
referral for assessment created on the date of admission. Four of five applicable youth records
contained an updated comprehensive evaluation completed by the center’s contract provider
prior to each youth’s thirty-first day at the center; the remaining youth record contained a new
comprehensive evaluation completed by the center’s contract provider prior to each youth’s
thirty-first day at the center. Each updated assessment completed at the center contained
treatment recommendations which corresponded to all mental health or substance abuse
related diagnoses; and each reviewed evaluation was located in the Department’s Office of
Health Services Electronic Medical Record. The designated mental health clinician authority
(DMHCA) confirmed youth are referred by the intake screener to the juvenile probation officer
(JPO) if there are any responses on the Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2) or the Comprehensive Assessment Tool (CAT) above the state approved cut
off score or other information regarding the youth's behavior or history indicates the need for
further mental health assessment. In addition, the mental health staff review documentation on
all youth entering the center. Part of the review process includes a thorough review of
preliminary screening which assists the mental health team in identifying youth in need of a
comprehensive assessment. If a need for a comprehensive assessment was identified by
detention staff screening, and not by juvenile assessment center screening, a referral for a
comprehensive assessment is sent to the assigned JPO through e-mail and is marked
confidential. The e-mail gives the date of admission and identifying data for the youth in need.
Reception of a comprehensive assessment does not preclude needed services from being
provided. Reminder e-mails are sent to the JPO after ten days from the initial referral if a
comprehensive assessment has not been received at detention. This e-mail is courtesy copied
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to the assistant superintendent and continued e-mail correspondence occurs until the
comprehensive assessment is received.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center’s superintendent and designated mental health clinician authority (DMHCA) are
responsible for ensuring a treatment plan is developed for every youth receiving mental health
or substance abuse services. Each youth who receives mental health and/or substance abuse
services in the center is required to have a completed discharge summary upon release. The
discharge summary should include the focus on treatment received in the center and
recommendations for community-based services. All seven reviewed youth mental health
records confirmed the mental health orientation was held within fourteen days of admission. Six
of the seven youth required and had a treatment plan due to the youth receiving services in the
center; the remaining youth did not require a plan. All six youth records contained an initial
treatment plan completed within seven days of the onset of treatment which was documented
on the required Department form. Each plan had the reason for the treatment referral, initial
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnoses/symptoms, initial treatment method and goals, and the signature of the licensed
clinician, youth, and assigned mini-treatment team members. Two of the six reviewed initial
treatment plans included psychiatric services and medications; the remaining plan was not
applicable for psychiatric services. Five of the six reviewed youth mental health records with
initial treatment plans were applicable for individualized treatment plans to be developed as the
youth had been receiving services appropriating thirty-one days; the remaining record had not
been receiving service for the required length of time. The five applicable youth records
contained an individual treatment plan developed prior to the youth’s thirty-first day of services.
Both applicable individual treatment plans with psychiatric services were documented on the
required Department form and contained all the required elements to include the DSM-5
diagnoses and treatment-focused symptoms, treatment goals, youth’s strengths and needs,
psychiatric services and medications, and pharmacological interventions, as needed. Each
applicable youth record also contained progress notes validating the treatment services the
youth had received as outlined in the treatment plan, and each individualized treatment plan
contained the dated signatures of the mini-treatment team members and youth. Only one of the
five individualized treatment plans required one thirty-day review, and the review was completed
as required. None of the reviewed treatment plans were applicable for Prison Rape Elimination
Act (PREA) services. A review of three closed youth mental health records was conducted and
found each youth received a discharge plan documented on the Department’s required form
and documentation copies were provided to the youth, parent/guardian, and juvenile probation
officer (JPO). All documentation practices observed adhere to policy to include completion of
service date, signatures, and uploaded of documentation. A mini-treatment team meeting was
observed during the annual compliance review week, and all required elements were observed.
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The DMHCA confirmed intervention/strategies are based upon best practices and effective
treatment models appropriate to the individual characteristics and needs of the youth; this
includes psychiatric services when applicable. A review of the Individualized Mental
Health/Substance Abuse Treatment Plan (ITP) is conducted by the mini-treatment team every
thirty days. The mini-treatment team includes a representative from DJJ operations staff, mental
health staff, medical staff, and psychiatric staff when youth are prescribed a psychotropic
medication. Any modifications/updates of the Individualized Mental Health/Substance Abuse
Treatment Plan are recorded on the ITP. The therapist will provide individual counseling as
indicated on the youth's treatment plan. Any youth may submit a mental health referral for
mental health support. The DMHCA monitors and ensures services are delivered to youth who
need it, by reviewing records, unlicensed mental health staff work, and alerts.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility operating procedures (FOPs) for mental health and substance abuse
treatment planning to ensure interventions are provided to reduce or alleviate a youth’s mental
health and/or substance abuse issues. Six of seven reviewed youth mental health records
indicated youth required treatment; the remaining record was not applicable. Each of the six
applicable records contained documentation the youth was assigned a mini-treatment team
which included mental health clinical staff, center staff for a different service area, the youth,
and the parent/guardian, if possible. Each youth received mental health treatment in the
prescribed frequency and delivery method, at a minimum of once a week. Each record
contained a proper consent for treatment and treatment notes documented on the required
Department form. A review of logbooks and records was conducted and confirmed mental
health groups were conducted as scheduled with ten or fewer youth in each mental health group
session and with fifteen or fewer for substance abuse groups conducted during this annual
compliance review period. Mental health staff have adequate access to youth and confidential
space to provide treatment service in the center. Seven youth were interviewed; four of seven
stated the mental health services received have been very good. The remaining three youth
stated the services were good. The designated mental health clinician authority (DMHCA)
interview confirmed the center’s procedures regarding required treatment plans and reviews,
comprehensive assessments, mini-treatment teams, intervention/strategies of service delivery,
and modifications/updates for treatment plans. The DMHCA also confirmed the procedures for
treatment plans addressing substance dependence are the same, except for the requirement of
a licensed clinician who must conduct those groups and groups should be fifteen youth or fewer.
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3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures (FOPs) for psychiatric services to include
psychiatric evaluations and consultations, medication management, and medical supportive
counseling for youth with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnoses/symptoms. Psychiatric services were provided by a physician with a clear
and active license, under Chapter 459, with an expiration date of January 31, 2026. The back-
up psychiatrist has a clear and active license, under Chapter 459, with an expiration date of
March 31, 2026, and with equal education to the primary psychiatrist. The center had a contract
with tele-medicine/tele-psychiatry inclusion; however, the center has not utilized tele-
medicine/tele-psychiatry services during the annual compliance review period. The designated
mental health clinician authority (DMHCA) interview confirmed the psychiatrist is on-site once a
week and is available on-call if needed. Seven youth mental health records were reviewed and
three contained documentation showing youth were prescribed psychotropic medications and
required medication management services. The remaining four records were not applicable. All
three applicable records contained documentation to confirm each youth was admitted to the
center with psychotropic medication and was referred for and participated in a psychiatric
interview within fourteen days of admission. Each initial psychiatric interview was completed on
the required Department form and contained all the required elements to include referral reason,
youth history, mental status, DSM-5 diagnoses, treatment recommendations, the prescribed
medication name, explanation of need, and frequency of monitoring. Each applicable record
also contained a completed psychiatric evaluation. The center utilizes the entire three-page
Clinical Psychotropic Progress Note (CPPN) form to document each evaluation. All three initial
CPPNs were observed to be fully completed with all required elements, dated signatures, and
parent/guardian notifications, if applicable. All medication management and Tardive Dyskinesia
reviews, where applicable, were also completed on a CPPN every thirty days or as needed for
each youth. Two of the three youth records contained a proper Authority for Evaluation and
Treatment form; the remaining youth is over the age of eighteen and can provide consent. None
of the youth received tele-psychiatry services.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures (FOPs) for ensuring the safety and protection of
youth with an elevated risk of suicide. The center’s suicide prevention plan is reviewed and
signed by the superintendent and the designated mental health clinician authority (DMHCA)
annually. The plan contains all the required elements to include identification of youth with
suicide risk, staff training, suicide precautions, referral, communication and notification,
documentation, immediate staff response, and a review process. The center has an established
review process for every serious suicide attempt or serious self-inflicted injury requiring
hospitalization and a mortality review for completed suicides. The multidisciplinary review
includes circumstances surrounding each event, center procedures relevant to the incident, all
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relevant training received by involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, and recommendations, if any to changes in
policy, training, physical plant, medical or mental health services, and/or operational
procedures.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures (FOPs) for suicide precautions, which include
methods utilized for supervising, observing, monitoring, and housing identified suicide risk
youth. One of the seven reviewed youth mental health records contained documentation of
youth identified through staff observations with an elevated risk of suicide; the remaining six
records did not have any suicide prevention services documented. Two additional youth records
with elevated risk of suicide were requested for review. All three applicable youth were
immediately placed on precautionary observation (PO), with a constant level of supervision.
One of the two records contained documentation of a suicide alert entered into the
Department’s Juvenile Justice Information System (JJIS) within minutes of identification; the
remaining records did not have an alert open as required. A referral for an Assessment of
Suicide Risk (ASR) was made for each. Two of the three ASRs were completed on the required
Department form, and the remaining youth was transported off-site before the ASR could be
completed. A qualified and licensed mental health clinician completed each ASR within twenty-
four hours and the notification to the superintendent or designee was documented in each youth
record. Consultation with the designated mental health clinician authority (DMHCA) was
documented on the referral summary section of the ASR in both applicable records. Each
reviewed ASR contained all the required elements, to include the recommendations. One of the
two applicable youth were continued on precautions. The one applicable youth record contained
documentation of the conference with the superintendent and DMHCA to reduce the level of
supervision. The discontinuation of PO and closing the JJIS suicide alert in each record was
completed after this conference and in a timely matter and were recommended for a Follow-Up
ASR. None of the youth were released from the center while on PO status. Each PO event was
located in the logbook. The DMHCA interview confirmed any youth exhibiting suicide risk
behaviors or is identified at intake as a potential suicide risk is placed on suicide precautions
and maintained on constant supervision until an ASR is conducted. Staff are notified in writing
through a logbook entry, receiving a precautionary/secure observation log form, verbally through
briefing and relief of on-duty officer in the youth modules. Mental health staff are also now
notifying staff through email of any youth remaining on precautions at the end of their shift. If
mental health staff are on-site, mental health notifies the parent by telephone, and the youth's
juvenile probation officer (JPO) through email. If mental health is not on-duty, the on-duty shift
supervisor will notify the parent by telephone and a mental health referral is submitted
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electronically. If necessary, the center will contact the Department’s Central Communications
Center (CCC); email and telephone are used to notify the DMHCA, superintendent, JPO and
necessary guardians. Due to an open deficiency, PO logs were not able to be reviewed. Seven
direct care staff were interviewed and asked what staff responsibilities were when a youth
expresses suicidal thoughts: seven stated to notify the mental health authority; five said to
search the youth and his or her room for sharp objects; five said to start documentation of
supervision; six staff stated they needed to maintain constant sight and sound supervision; one
staff indicated a youth may be placed in a locked room. Additionally, staff mentioned they would
notify the supervisor and try to talk to the youth while waiting for mental health. Seven youth
were asked if they had ever been placed on suicide watch while at this center and five stated
they had, and staff watched them the entire time; the remaining two youth were not applicable.
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures (FOPs) for outlining the use of secure observation
(SO) for youth on suicide precautions when less restrictive means are not effective. One of the
seven reviewed youth mental health records contained documentation of youth on SO; the
remaining six records were not applicable. Two additional youth records with SO were
requested for review. All three applicable youth records contained documentation of
authorization of the placement from the superintendent and the designated mental health
clinician authority (DMHCA), written room designation, and a completed Health Status Checklist
completed prior to the SO placement. Two of the three records also contained a new
Assessment of Suicide Risk (ASR) completed within eight hours of the placement and
notification to the parent/guardian and juvenile probation officer; the remaining youth was sent
out for mental health services. One of the three youth remained in SO beyond twenty-four
hours, and the record documented the required mental health professional written support for
continuation, supportive counseling services, superintendent and mental health professional
conference for level reduction, and contained the discontinuation and step-down documentation;
the center’s logbook had correlating entries. Due to an open deficiency, SO logs were not able
to be reviewed during the week of the annual compliance review.
3.12 Suicide Precaution Observation Logs [Detention
Limited Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures (FOPs) to maintain precautionary observation (PO)
for youth identified with a suicide risk. Due to an open deficiency, PO logs were not able to be
reviewed. A major deficiency was identified August 7, 2024, and the Outcome Based Corrective
Action Plan anticipated correction date was set for November 11, 2024.The first deficiency
review was conducted by the Department’s Office of Health Services (OHS) on November 20,
2024, and it was continued for an additional verification. OHS identified documentation errors
such as Secure Observation Logs, Precautionary Observation logs, and Close Supervision Logs
had errors, including missing times, checks, signatures, warning signs, warning codes, and
Health Status Checklists were not located.
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3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures (FOPs) to ensure all staff who work with youth
receive training to identify suicide risk cues, learn suicide prevention, and precaution
implementation. Fourteen staff training records were reviewed; each staff received the required
two hours of suicide prevention on the Department’s Learning Management System (SkillPro)
and four hours of in-person suicide prevention training. The center had a deficiency for suicide
drills which was closed on February 10, 2025; since the closure the center held one suicide drill
applicable for review, which contained all required elements The center has five suicide
response kits with all the required items, and each suicide kit is equipped with a first-aid kit and
are located in master control and each of the four housing modules. The center has been
experiencing consistent video equipment issues; therefore, no video was reviewed during the
annual compliance review week. Seven staff were interviewed about the location of the suicide
response kits and six indicated a suicide response kit is located in master control. Six of seven
staff indicated suicide response kits are located in the living unit module sub controls. Four of
seven staff indicated a suicide response kit is located in medical.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures (FOPs) to ensure they respond in the least
restrictive means possible to protect the safety of each youth and others while maintaining
control when a youth is in crisis. A review of the center’s combined emergency services plan
confirmed the combined plan contains all the required elements, to include notification and alert
systems, means of referral, communication, supervision, documentation, and incident review.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures (FOPs) to ensure the center follows the emergency
care plan for any youth determined to be a danger to themselves or others. A review of the
center’s combined emergency care plan and crisis intervention plan was conducted and
confirmed the combined plan contains all required elements to include immediate staff
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response, notifications, communication, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for Baker Act and Marchman Act,
documentation, training, and review procedures. The center’s combined plan was approved and
last updated on March 3, 2025. All staff have access to the approved plan on the Department’s
K Drive and intranet; a copy of the plan is also in the superintendent’s office.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures (FOPs) to ensure youth demonstrating acute
psychological distress receive a detailed evaluation conducted by a licensed mental health
professional, or non-licensed staff under the supervision of a licensed mental health
professional, to determine the level and severity of risk. A Crisis Assessment is only utilized
when the presenting acute psychological distress is not related to suicide risk factors. None of
the seven reviewed youth mental health records were applicable for a Crisis Assessment. Three
youth mental health records received a Crisis Assessment during the annual compliance review
period were reviewed. Each reviewed record confirmed the Crisis Assessment was conducted
within twenty-four hours of the crisis identification by a licensed mental health clinician. Each
completed Crisis Assessment contained all the required elements and information to include the
reason for the assessment and identified acute emotional or behavioral problems, the youth’s
Mental Status Examination interview, determination of danger/risk, initial clinical impressions,
supervision and treatment recommendations, recommendations for follow-up or further
evaluation, and parent/guardian notification. Each youth had been involved in, or a witness to, a
Prison Rape Elimination Act (PREA) event. None of the youth required a mental health alert to
be entered into the Department’s Juvenile Justice Information System (JJIS) as the youth were
determined to not be in need of being placed on precautions. One of the three youth was an
alleged victim of a PREA event, and the youth was offered ongoing mental health treatment
services; the remaining two youth were not applicable.
3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures (FOPs) to ensure youth believed to be an imminent
danger to themselves or others due to mental health or substance abuse issues receive
emergency services through Baker or Marchman Act procedures. One of the seven reviewed
youth mental health records was applicable for Baker or Marchman Acts. Two additional youth
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records with Baker Acts were requested for review. Two of the three records contained
documentation of when the youth was identified to be in danger and in need of emergency
mental health services where the center immediately began to maintain constant supervision
and entered a suicide alert in the Department’s Juvenile Justice Information System (JJIS); the
remaining youth did not have an alert entered. Two of the three records showed the staff
initiated a mental health referral; the remaining youth was transported out of the center before
this could be completed. Both referred youth had a licensed clinical staff complete the
Assessment of Suicide Risk (ASR) which included the Mental Status Examination. Based on the
ASRs, one youth was sent to the Crisis Stabilization Unit for Baker Act services; however, this
youth did not return to the center. The second youth was transported out before the ASR was
completed and did not return to the center. The third youth was maintained at the center; this
youth had the alert closed upon discontinuation of the constant supervision.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has operating procedures (FOPs) outlining the duties and requirements for the
designated health authority (DHA), and the sign-in/sign-out procedures for telemedicine. The
center has a contract with an outside provider to provide medical services, which includes the
provision of a physician to serve as the DHA. The DHA has a clear and active license in the
State of Florida, which expires January 31, 2027, and is board-certified in pediatric medicine.
The center has a back-up DHA who is board-certified in pediatric medicine and has a clear and
active license in the State of Florida, which expires January 31, 2027. The DHA has
collaborative practice protocols in place with an advanced practice registered nurse (APRN) to
provide clinical services at the center. The APRN is certified as a family nurse practitioner and
has a clear and active license in the State of Florida which expires July 23, 2026. According to
the APRN collaborative practice protocol (CPP), the APRN will be on-site at least weekly. The
APRN was not on-site January 21, 2025, February 2, 2025, and March 3, 2025. A review of
sign-in logs since the last annual compliance review found the DHA was on-site weekly for at
least two hours, as contractually required. The center maintains a log of all telemedicine visits.
The back-up DHA was not used during the annual compliance review period. Telehealth was not
utilized during the annual compliance review period. The DHA was interviewed and confirmed
their duties of performing Comprehensive Physical Assessments (CPAs), conducting sick visits,
period evaluations, address outside appointments/labs, and assisting with policy and
procedures development. The DHA stated they are on site two hours weekly and available by
telephone when not on site. Nursing staff communicate with the DHA daily through telephone
calls.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has operating procedures (FOPs) regarding all healthcare protocols, policy, and
procedures used at the center which are reviewed annually. The designated health authority
(DHA) approved all healthcare protocols, policy, and procedures on March 6, 2025, and the
superintendent reviewed and signed all policies on March 6, 2025. The Psychiatrist last
reviewed and signed the FOPs October 24, 2024, and developed the FOP’s or other protocols
related to psychiatric and psychotropic medication management. There was a cover page on
which medical FOPs, treatment protocols, and other procedures were listed, which was signed
by all nursing staff and the advanced practice registered nurse (APRN) on October 24, 2024. All
healthcare staff hired during the annual compliance review period received a comprehensive
clinical orientation to the Department’s health care policies and procedures provided by a
registered nurse manager.
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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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the completion of an
Authority for Evaluation and Treatment (AET) and each contained a valid AET which was signed
by the youth’s parent/guardian, and a Department representative. No parent/guardian refused to
sign the AET. None of the seven youth had a pending court order. Each appliable youth’s IHCR
contained the original AET form and/or was stamped as “copy.” All AET forms were obtained
prior to providing medical services to youth. One of the seven youth had a court order granting
rights to the youth’ grandparents and was maintained in the youth IHCR/Electronic Medical
Record (EMR). Three of the seven youth were eighteen years of age or older and two of the
three youth signed a release of information form. For the remaining youth, according to Florida
Administrative Code an AET is not required because the youth is legally considered an adult
and can provide consent at the point of care for all medical services. The nurse was interviewed
and concurred what Florida Administrative Code states. If an AET is missing, nursing staff
contacts the juvenile probation officer (JPO).
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed, and seven youth were
applicable for parental notifications. None of the applicable youth received over the counter
medications beyond those covered by the Authority of Evaluation and Treatment (AET). Four of
seven youth IHCRs maintained verbal notification documented on each youth’s progress notes,
written notification was sent utilizing the Department’s Parental Notification of Health-Related
Care: General or Parental Notification of Health-Related Care: Medications forms, and where
applicable the Clinical Psychotropic Progress Note (CPPN) page three. Three of the seven
youth were not applicable for written notifications. Three youth were taking psychotropic
medication, and all three applicable youth records contained documentation to support a staff
witnessed telephone calls or attempted calls to the parent/guardian for psychotropic
medications. Four of the seven youth were not applicable for taking psychotropic medications.
One of the three applicable youth taking psychotropic medications was taking the medications
upon admission. Two of the seven youth were applicable for new medications being ordered
while in the center. Three youth were applicable for psychotropic medication being discontinued,
or the dosage being significantly changed, and each contained documentation of verbal consent
to the youth’s parent/guardian as well as documentation on page three of the CPPN and
chronological note. Four of the seven applicable youth records contained documentation of
attempts to contact the parent/guardian in the progress notes, and written notification was sent
regardless of telephone notifications. One youth had Department of Children and Families
(DCF) involvement and had a termination of parental rights court order granting custody to the
youth’s grandparents filed in the youth IHCR. The youth was eighteen and provided consent at
the point of care for all medical services. All seven youth were applicable for verification of
vaccines, and each had their vaccines verified within thirty days of admission. The nursing
interview indicated the center’s process for obtaining an AET is to notify the juvenile probation
officer (JPO). When asked what the policy is for documenting consent for youth who are
eighteen years of age or older the nurse stated once a youth turns eighteen an AET is not valid
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because the youth is legally considered an adult. The youth must provide consent at the point of
care for all medical services. If the youth require emergency medical services the center will call
the doctor, an order will be given to send to the youth to the emergency room , a call is placed to
the parent/guardian to notify them of the situation and a call is placed to the superintendent to
notify of the situation. When obtaining consent for new psychotropic medications,
discontinuances or adjustment parental notification must be documented and requires a witness
signature. Immunization records are obtained through the Florida Immunization. All medical
records are reviewed within seven days for every youth admission. The nurse stated
documentation of parental/guardian exemption from immunizations is obtained from Florida
shots, if applicable.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for admission screening
and rescreening. Each record contained documentation to support the Medical and Mental
Health Admission Screening form was completed on the day of admission by a juvenile justice
detention officer (JJDO), and a licensed healthcare staff reviewed the screening form within
twenty-four hours, as required. In all seven reviewed youth records, the designated health
authority was notified of each youth admission, and this was documented in each IHCR. One
youth was applicable for a change in physical custody, and two additional youth records were
requested. Each of the three applicable IHCRs contained documentation indicating the
rescreening was completed by a JJDO the day each youth returned to the center. Three
applicable youth IHCR’s records contained documentation of a licensed healthcare staff
reviewing the screening form within twenty-four hours, as required. None of the three youth
were applicable for a qualitative urine pregnancy screening test. The nurse interview indicated
the nursing staff see newly admitted youth within twenty-four hours. They receive notification of
pending admissions by the superintendent. A Department of Juvenile Justice staff will complete
the admission screening on the Facility Entry Physical Health Screening Form (FEPHS) and the
nurse will review it. If there is a change in custody the nurse will complete a new intake.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has operating procedures (FOPs) including access to medical care, sick call, what
constitutes an emergency and when to notify staff, medication process, 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 healthcare providers, and review of the list of healthcare
contacts. Seven youth Individual Healthcare Records (IHCRs) were reviewed, and all received a
general healthcare orientation of all required topics, which were included on the Health
Education form for each youth. The nursing interview indicated nursing staff email the
superintendent of youth being admitted to the center, an admission screening is completed by a
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Department of Juvenile Justice staff and the nursing staff will document their review on the
screening form. If youth have a change of custody a new intake is conducted.
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.
Five of the seven reviewed Individual Healthcare Records (IHCRs) were applicable for
notification of the designated health authority (DHA) upon youth admission; the remaining two
were not applicable. In five of the seven applicable IHCRs each youth was admitted with a
suspected chronic condition, the DHA was notified within twelve hours, and this was
documented in each IHCR. One youth was taking psychotropic medications upon admission,
and the psychiatrist was notified. None of the youth were identified as requiring emergency care
upon admission. The nurse interview indicated the nurse contacts the DHA by telephone as
soon as the youth is seen at the clinic. All nursing staff are responsible for this notification, and it
is documented on the intake log as well as the admission form.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of a Health-
Related History (HRH) form and each contained an HRH form completed within seven days of
admission by a licensed healthcare staff on the Department’s form and reviewed by the
Designated Health Authority (DHA). The HRH was completed prior to the Comprehensive
Physical Assessment (CPA) and contained signatures of the nurse who completed the CPA and
the most recent date of the form completion The nursing interview indicated the nursing staff are
responsible for completing the HRH and is normally completed within seven days.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has operating procedures (FOPs) addressing when any part of the Comprehensive
Physical Assessment (CPA) is not conducted or refused by the youth, as well as Tuberculosis
(TB) screening. Seven Individual Healthcare Records (IHCRs) were reviewed for completion of
a CPA. Each youth record contained a completed CPA, which was documented on the
Department form, and included each youth’s Medical Grade. Five of seven youth received a
new CPA completed by the designated health authority (DHA)/advanced practice registered
nurse (APRN) within seven days of admission, marked with “O” and “X” and containing all
required elements. The remaining two youth had an updated CPA wherein the DHA/APRN
reviewed, signed, and dated the CPA after conducting a focused evaluation with each youth.
Each of the five youth IHCRs contained a note by the DHA for the youth refusing the genital
exam and documented refusal on the form. The Department’s Problem List was updated, as
required for all seven youth. All seven IHCRs contained a Tuberculosis Skin Test (TST)
completed within the last year with the results having been documented on the Infectious
Communicable Disease (ICD) and the CPA forms. All seven youth received a TB screening
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within seventy-two hours of admission with no further evaluation required. The nurse interview
indicated new youth will be seen and need a CPA completed within seven days of admission. A
new CPA is needed every two years if youth are a grade one. If a youth Medical Grade changes
from one, a new CPA is needed yearly. For youth with a Medical Grade of two or higher, the
CPA is done yearly. TB screening shall be completed within seventy-two hours of admission if
one is not documented in the youth’s IHCR within the past year, and results are documented on
the CPA, Infectious and Communicable Disease Form (ICD), and the TB tracking log. The
center does not routinely conduct gynecological exams.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) screening. Each record contained documentation to support the youth received
an STI screening upon admission. Three youth were referred for further evaluation, and the
referral was documented on the appropriate form. Testing was ordered for all three of the youth,
and testing, screening results, clinical evaluations, and diagnosis was documented on the
Infectious Communicable Diseases ICD) form and filed in the lab section of each youth’s IHCR.
None of the applicable youth consented to a gynecological exam and none were out of the
center’s custody, requiring a rescreen. All seven reviewed records contained documentation to
support each youth were offered counseling and testing for human immunodeficiency virus
(HIV). None of the seven youth had HIV testing while in the center. Seven youth were
interviewed, and each confirmed they are able to request an HIV test. The nurse was
interviewed and stated youth are screened for sexually transmitted infections with the Sexually
Transmitted Infections Screening Form. If a screening form indicates a need for further
evaluation the doctor or advanced practice registered nurse (APRN) will assess during the
Comprehensive Physical Assessment (CAP). The sexually transmitted infection (STI)
screenings, evaluations, referrals, testing, and retesting are documented on the Infections and
Communicable Disease From (ICD). A youth will be rescreened by using the STI form when
they have been out of the center/Department’s physical custody for more than thirty days. HIV
results are maintained in the youth IHCR in a sealed envelope and the ICD form. Youth will
need to give consent for HIV testing, pre-counseling and post-counseling; this is documented on
the Individual Health Education Record and ICD form.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has operating procedures (FOPs) indicating the shift supervisor reviews all sick call
requests as soon as possible and within twenty-four hours after the request is submitted when
nursing staff are not on site, and only licensed nurses conduct sick call. One of the seven
Individual Healthcare Records (IHCRs) was applicable for having a sick call. At the time of the
annual compliance review, the center only had one youth applicable for a sick call. In the
applicable IHCR, the sick call was documented on the Sick Call Referral Log. The youth did not
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experience a similar sick call complaint three, or more times in a two-week period, or had a
complaint of severe pain with which the staff was unfamiliar with. One of the seven youth was in
restricted housing. The youth completed a Sick Call Request Form, and it was filled out entirely
by a nurse. A licensed practical nurse (LPN) conducted the sick call, and it was reviewed the
same day by a registered nurse (RN), or higher, which was documented on the form. The Sick
Call Request form was filed in the youth’s IHCR and was documented according to Florida
Administrative Code. The sick call was documented on the youth’s Sick Call Index correlating
with the Sick Call Request forms. The center provides sick calls every day from 8:30 a.m. to
10:30am, and 3:30 p.m. to 4:30 p.m. The hours were posted on the wall in the medical office
and supported this practice. There were no sick calls to observe during the annual compliance
review week. The nursing staff was interviewed and indicated youth request a sick call through
the detention staff. The nurse has twenty-four hours to see the youth once the sick call is input
into the Department’s Electronic Medical Form (EMR) system. Any nurse on-site can conduct
sick call in medical; if conducted by an LPN, the RN will review the sick call. The nurse indicated
the designated health authority (DHA) does not conduct sick calls. The nurse stated sick calls
will be conducted after 8:00 a.m. medication pass and throughout the day. If a youth presents
with repeated similar sick call complaints, the nurse will notify the DHA. If a youth is in restricted
housing or confinement the supervisor on each shift will question the youth about medical
related issues. If the youth has an issue which is non-emergent, the shift supervisor will input
the sick call request into the EMR which will schedule the youth for the next available sick call
time. If a youth has a known active medical condition, then observation may need to be as
frequent as every two hours. Seven youth were interviewed and five reported they can request a
sick call within a day, and two youth indicated they have never requested a sick call. Seven staff
were interviewed, and all seven stated the nurse reviews sick calls; one of the seven staff added
the doctor will review sick calls; one staff stated staff can review sick calls; and one staff added
medical will review 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.
The center has operating procedures (FOPs) which includes procedures for maintenance and
storage of first-aid kits to prevent expiration or deterioration of contents. Seven youth Individual
Healthcare Records (IHCRs) were reviewed for episodic care, and five youth were applicable. In
the five applicable IHCRs each youth required an on-site episodic/first-aid care event, and all
episodic care events were conducted by a licensed nurse on-site and documented in problem-
oriented charting; subjective, objective, assessment, and plan (SOAP) form. Five youth had six
episodic care events, which were all documented in the Episodic Care Log. Two of the five
youth required a referral for off-site care. All five of the applicable IHCR’s contained
documentation of education and instruction, plans for follow-up, or future care. Two of the five
applicable youth required an alert be entered into the Department’s Juvenile Justice Information
System (JJIS) and all alerts were entered as required. The five youth IHCR’s contained parental
notifications for the six episodic events, and an entry was made in the Episodic Care Log as
required. None of the five applicable youth required a follow-up evaluation by a licensed health
care staff. The center had seventeen first-aid kits, one in each of the four living modules, one in
master control,one in the intake and release area, one in the kitchen, one in the maintenance
area, and nine which are used for transportation. Three first-aid kits were checked, and each
was fully stocked with designated health authority (DHA) approved contents. A review of first-aid
kit checks since the last annual compliance review indicated they were conducted monthly since
the last annual compliance review as required. The center had two automated external
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defibrillators (AED); one in the clinic and one in master control. AED procedures for each AED
were located with the AED. All AEDs had a green light and were operational during the annual
compliance review. A review of AED checks since the last annual compliance review indicated
they were conducted monthly as required by the nursing staff. The AED batteries for each AED
were changed on January 28, 2023, and expire September 28, 2026. The pad for each AED
were last changed November 28, 2024, and expire on November 28, 2025. A review of medical
emergency drills since the last annual compliance review indicated drills simulated an episodic
care event which called for immediate first-aid, and/or administration of cardiopulmonary
resuscitation (CPR) techniques and the initiation of the emergency procedures to follow when a
life-threatening emergency does occur. The center practices CPR/AED demonstration at least
annually. The center’s FOP states drills are to be conducted monthly on each shift and Florida
Administrative Code requires quarterly on each shift. The center conducted medical drills
monthly on each shift in April 2024, May 2024, June 2024, July 2024, January 2025 and
February 2025. Missing monthly medical drills were August 2024, September 2024, October
2024, November 2024 and December 2024. The center met the quarterly requirement except
for the third quarter, completing 6 drills on each shift, exceeding the required 4. A list of
emergency telephone numbers was posted on the telephone where staff can access, and
inaccessible to the youth. All authorized direct care staff were appropriately trained on the
administration of the epinephrine auto-injector. Seven pre-service and seven in-service staff
training records were reviewed, and each contained documentation to support the staff were
trained in first-aid, episodic, and emergency care. The center stores Narcan in the locked
medication cart in the clinic, and nursing staff inventory Narcan weekly. Nursing staff and staff
who are approved to provide medication have access to the Narcan. All staff with access to the
Narcan have been trained on when and how to use it. The center’s policy regarding the use of
Narcan is for the emergency treatment of a known or suspected opioid overdose emergency
with signs of breathing problems and severe sleepiness, or not being able to respond. The
center is responsible for maintaining at least one. A perpetual inventory must be maintained.
Nursing staff and supervisory staff shall be trained on administration. Training and refreshers
must be conducted for all new supervisory staff and at least annually by a registered nurse (RN)
or higher. Youth must go out by emergency medical services (EMS) if utilized. The nursing
interview indicated first-aid kits are maintained in each mod, kitchen, master control,
maintenance and intake. There are nine available for transport. Episodic care by licensed staff is
documented in the Electronic Medical Record (EMR) in an Episodic Care Progress Note and will
cover all elements of a SOAP note. If non-licensed staff conduct episodic care, it is documented
on the Report of On-Site Care by Non-Healthcare Staff form and a follow-up evaluation is
completed by a nurse when back on-site. Youth who require off-site emergency care are
documented in the Off-Site Care Log in the EMR. Seven staff were interviewed, and each
reported they can contact 9-1-1 if they feel it is necessary. Seven youth were interviewed, and
five rated medical services as good and two rated them as very good.
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.
Three of the seven reviewed Individual Healthcare Records (IHCRs) were applicable for off-site
care, and four were not applicable. In the three applicable IHCRs each youth required off-site
care which was documented on the Summary of Off-Site Care form and on the Episodic Care
Log. All parental notification efforts were documented in each IHCR, as well as notification to the
designated health authority (DHA). Discharge instructions and findings were maintained in each
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IHCR, and the DHA/designee reviewed and signed all off-site documentation. None of the youth
required follow-up care. The nursing interview indicated off-site care is tracked in the off-site
care log in the Electronic Medical Record (EMR). Hospital orders are reviewed with the DHA,
who then gives orders to follow in the center. All follow-up is documented in a calendar and sent
by email communication to staff. The Summary of Off-Site Care form is utilized if youth is sent
off-site and follow-up testing, referrals, or additional appointments are requested by the provider.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions, and
each had a chronic condition, six of which were documented on the Medical/Mental Health
Screening form. One youth was prescribed medication after admission; therefore, the chronic
condition was not documented on the Medical/Mental Health Screening form upon admission.
Six of the youth were placed on the chronic condition list. One youth was prescribed an allergic
reaction medication as needed; therefore, was not placed on the chronic condition list. Only
three of the youth had been in the center long enough for a periodic evaluation, which was
completed as required with no lapses in care. One of the applicable youth was pregnant and
had only been at the center five weeks and had a periodic evaluation as required. A periodic
evaluation was completed prior to renewing an expired prescription for the three applicable
youth. The Department’s Problem List was updated as required for each youth. None of the
youth had a periodic evaluation completed offsite. The designated health authority (DHA)
interview indicated periodic evaluations are completed every ninety days or sooner, if needed.
The registered nurse (RN) manager tracks this and ensures the youth are seen. The nursing
interview indicated periodic evaluations are conducted within ninety days or sooner.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has operating procedures (FOPs) regarding medication management which prohibits
standing orders, emergency treatment orders, and pro re nata orders for psychotropic
medications. Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication
management, and five of the seven youth were taking medication while at the center. All five
youth were taking medication at the time of admission, each medication was verified prior to
being admitted to the center utilizing the Prescription Medication Verification
Checklist/Medication Receipt Transfer Disposition form, documentation was noted on the
chronological progress noted in each IHCR, and the designated health authority (DHA) and
psychiatrist were contacted to obtain the order to continue the medication on the Practitioner
Order Form. The parent/guardian was notified for all five youth when the current medication was
continued, discontinued, changed, or a new medication was ordered. None of the seven youth
were in restricted housing during the annual compliance review period. There were no over-the-
counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET)
administered. Each youth’s medication administration was tracked on the Department’s
Medication Administration Record (MAR), which contained all required information, utilizing start
and stop dates. Every medication administration entry was initialed by the youth and healthcare
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staff and the nurses documented weekly side effect monitoring on each MAR. There were no
instances of non-healthcare staff administering medications for the five youth. One youth had
medication refusals, and the youth signed a Refusal of Treatment form; the refusal was marked
on the MAR as required. All medications had a current, valid order and were given pursuant to a
prescription. One of the five applicable youth required parenteral medication, and a licensed
healthcare staff administered the medication. Three youth were prescribed psychotropic
medications prior to admission, and the psychiatrist was notified upon admission. The
psychiatrist conducted an initial diagnostic psychiatric interview with each youth within fourteen
days of admission. Two of the three applicable youth received a medication monitoring every
thirty days as required. One of the three youth was under the thirty-day requirement to receive
medication monitoring. Observations of medication pass for two youth during the annual
compliance review week indicated the center staff escorts each youth to the clinic, the nurse
administers each youth’s medication, while the center staff maintain security. Each youth
approached the nurse individually when it was their turn for medication. During the medication
pass, the allergy and alert status were verified for each youth. None of the medication was pre-
poured and the nurse ensured each youth swallowed the medication. The nurse and each youth
initialed the MAR. The nursing interview indicated nursing staff will confirm the medication with
the guardian or pharmacy when the youth is admitted with a medication. The center uses an
electric MAR. Non healthcare staff are trained by the nurse to administer medications and are
designated in writing and documentation is maintained in medical. Non-healthcare staff
medication Administering training occurred August 2024. Medication pass occurs 8:00 a.m.,
12:00 p.m., 5:00 p.m. and 7:00 p.m. For female youth, gynecological exams are not routinely
completed. The center holds a modified class 2 pharmacy permit. Medication is procured
through a local pharmacy and have a back-up pharmacy if needed. The psychiatrist is on-site
weekly and provides medication management. Seven staff were interviewed and asked if they
administer medications and two staff answered yes, five answered no Seven youth were
interviewed and asked if they take medication who administers the medication. Six youth stated
the nurse, one youth stated staff, one youth stated they do not take medications and one youth
stated if the nurse is not here, staff can give medications.
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.
An observation of medical was completed during the week of the annual compliance review
week, which was clean and organized. A review of sharps and sharps inventory confirmed all
medical sharps are secured and inventoried utilizing a routine perpetual inventory descending
count as each sharp is utilized and disposed. All observed medications were locked in the
medication cart or locked cabinet; all injectable, topical, and liquid medications were separated
in separate drawers in the medical cart. The medication cart was clean and organized. Youth
medications were separated in a separate bag for each youth's medication. All controlled
medications were in a locked box in the locked medical cart, separated from all other
medications. Each had a perpetual inventory and shift-to-shift count documented on a
Controlled Medication Inventory Record. All medications were stored in medical which is always
locked, and all medications were either locked in the medical cart or locked cabinet. The center
has two mini refrigerators in medical, one for personal use and one for medications requiring
refrigeration. There were two to-go food containers and a bag of pizza in the medication
refrigerator, along with medications. Nursing staff stated it was from lunch earlier in the day and
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was stored in the medication refrigerator due to no room in their personal refrigerator. The food
items were moved out of the medical refrigerator while the annual compliance review team was
on-site. A review of the over-the-counter (OTC) inventory binder confirmed OTC medications
were inventoried both perpetually and weekly, since the last annual compliance review. Seven
non-healthcare staff were trained on administration of medication by a registered nurse. Each
were trained between the months of January 2025 and March of 2025. An observation of three
controlled medications, three OTC medications and three sharps compared to each
medication’s inventory confirmed each matched except for one sharp. The inventory of
hemostats did not match the actual count. There were two on hand and the inventory had three
documented. The nursing staff stated she had recently thrown a pair of hemostats away;
therefore, as a result updated the inventory while the annual compliance review team was still
on-site. The nurse stated if there is a discrepancy in the medication inventory, the on-call
sergeant and the major are notified and a call is made to the Department’s Central
Communications Center (CCC). As a result of the discrepancy a retraining is completed related
to the reason for the discrepancy. The nurse stated medication which is expired and/or
discontinued, is destroyed utilizing a power destroying agent. The destruction is documented on
the medication destroy log and documents the date of destruction, name and amount of the
medication, reason for destruction, signatures of nursing staff destroying the medication and a
witness. If the medication being destroyed is a controlled medication, nursing staff, with a
witness can destroy if there is only one controlled medication tablet. If there is more than one
medication tablet, the pharmacist who comes on site monthly, together with a nurse, destroy the
medication. All controlled medication destruction is documented by the center and by the
pharmacist. The nursing interview results confirmed the process for new youth admission
medication regimen, which consist of confirming with the parent/guardian and the pharmacy.
Non-healthcare staff are not able to confirm the medication regimen; however, will document it
on a receipt form confirming receipt of the medication. Medical staff at the center utilize the
electronic Medication Administration Record (MAR) in the Department’s Juvenile Justice
Information System (JJIS). Non-healthcare staff, who are trained in administration of
medication, can provide medication to youth when there are no medical staff at the center.
According to the center’s clinical registered nurse manager there are designated staff who are
trained on the administration of medication by the registered nurse. This information is
maintained in medical in a binder. Medication pass is scheduled daily at 8:00 a.m., 12:00 p.m.,
5:00 p.m., and 7:00 p.m. Gynecological exams are not routine completely; however, are
completed as needed. The center maintains a Modified Class II Institutional Pharmacy Permit.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has operating procedures (FOPs) which includes needle stick post-exposure
evaluation and an exposure control plan. Seven youth Individual Healthcare Records (IHCRs)
were reviewed for infection control training and each youth record contained documentation to
support the youth received infection control training within seven days of admission, as well as
hand-washing techniques, universal/standard precautions, prevention/transmission of
communicable diseases, Center for Disease Control and Prevention (CDC) guidelines for
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infection control, and immunization training. The center’s Exposure Control Plan was written in
accordance with the Occupational Safety and Health Administration (OSHA) standards and
included all required elements of risk assessment and methods of compliance. The center’s
infection control procedures include prevention, containment, treatment, and reporting
requirements related to infectious diseases, according to OSHA and the CDC guidelines. The
plan also includes common infectious diseases of childhood, self-limiting, episodic contagious
illnesses, viral, or bacterial infectious diseases, tuberculosis (TB), Hepatitis A, B, C, and human
immunodeficiency virus (HIV), and infectious diseases caused by bloodborne pathogens. The
infection control plan also addresses other outbreaks, or epidemics caused by any other
infectious agent, outbreaks of pediculosis and/or scabies, Methicillin-Resistant Staphylococcus
Aureus, and other antibiotic-resistant microorganisms, foodborne illnesses, bio-terrorist agents,
and chemical exposures in the workplace. According to the center’s FOPs staff always have
access to protective equipment and can request Hepatitis B immunizations. The center did not
have any instances in which infectious diseases and sexually transmitted infections (STIs) were
reportable to the local health department, CDC, or the Department’s Central Communications
Center (CCC); or any instances involving the quarantining, or hospitalization of at least ten
percent of the total population of youth, or staff. The clinic maintains a separate file intended for
all documents when youth and staff have experienced a facility/occupational exposure;
however, the center has not had any exposures. Seven pre-service and seven in-service staff
training records were reviewed, and each had completed training regarding the center’s specific
Exposure Control Plan. The nursing interview indicated a copy of the Exposure Control Plan is
available to staff in the binder with the policies in medical and conducts inflection control training
for staff. Infection control training for youth in provided during admission by a registered nurse
(RN). The center routinely uses the county health department for TB Skin Testing, HIV treatment
and HIV testing.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has nursing protocols and treatment plans addressing pregnant youth. One of the
seven reviewed Individual Healthcare Records (IHCRs) were applicable for prenatal care.
Additional records were requested, and the center provided two applicable records from the
annual compliance review period. In the three applicable IHCRs the youth received prenatal
care immediately upon determination of pregnancy until release from the center. The three
youth were placed on the alert log for vital nutrition, health awareness for staff, and sleeping
arrangements, and received a focused medical evaluation at least every thirty days. Each youth
received training in alcohol and drug use, smoking, nutrition, sexually transmitted diseases,
contraception, prenatal care, birthing process, postpartum and basic baby care, child/infant
development, and parenting skills. All education was documented on each youth’s Health
Education Record. The three youth received nutritious food in quantities appropriate for
pregnant youth, as well as routine monitoring of nutritional and weight status. One of the three
youth complained of issues related to pregnancy and the designated health authority (DHA) was
notified immediately and nursing staff completed daily monitoring for signs of pregnancy
complications There is a documented plan and nursing protocols for treatment of pregnant
youth and post-birth psychological and physical care. Seven in-service staff training records
were reviewed, and each staff received training on observation and monitoring of emergency
care needs/symptoms of possible miscarriage and other prenatal education topics. Seven pre-
service staff training records were reviewed, and each had received training in prenatal
education topics. The nurse was interviewed and indicated service provided to pregnant youth
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are prenatal, postnatal and, neonatal care. Female youth are routinely tested for pregnancy
upon admission. Routine monitoring of pregnant youth monthly by the doctor or advanced
practical registered nurse (APRN). Pregnant youth are provided a special diet. The nurse
manager provides non-licensed healthcare staff education on girls’ healthcare monitoring,
observation, and emergency care. The nursing interview verified education is provided to
pregnant youth as required. One of seven interviewed youth stated she has received prenatal,
obstetrical, or gynecological services when needed at the center.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures (FOP’s) to ensure youth are actively supervised by
staff. During the annual compliance review, team members observed youth during daily
activities such as education, recreation, meals, breaks, and line movements. Center staff
requested all movements through master control, and the youth movements were cleared by
master control prior to any movement. All movements requested by staff were logged into the
master control logbook and the module logbooks. Seven staff were interviewed and six
indicated there are enough staff to provide for the safety and security of the youth and staff. One
staff responded they wish there were more staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) addressing the behavior management
system (BMS). The center provides a system of rewards, privileges, and consequences to
encourage youth to fulfill the center’s expectations. During the facility tour, the week of the
annual compliance review, the BMS information was observed throughout the center, including
all living areas which clearly specify appropriate and inappropriate behaviors, rules, norms, and
expectations. The system includes rewards for positive behavior and consequences for
inappropriate behavior. Daily activities were observed to determine implementation of the BMS.
A review of the center’s FOPs confirmed the BMS ensures compliance with the components
outlined in the center’s FOPs. A review of a BMS level board on each living area confirmed
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positive rewards are given to youth to match the BMS. A review of the level boards show staff
are properly changing the board every day and documenting positive and negative behaviors of
the youth. A review of the BMS level board did not find any instances of inappropriate use of
restrictions or group punishment. Seven staff were interviewed, and all were able to accurately
describe the BMS level system, to include the types of rewards provided by the center and each
indicated levels are only taken away from youth as a consequence. All seven staff reported the
center provides the following rewards as part of the BMS, access to the corner store, extra dorm
time, movie day, snacks, extra telephone calls, and pizza. Each staff reported the center’s BMS
to be effective and indicated the staff speak with the youth to discuss the consequence being
imposed and alternative acceptable behaviors. Furthermore, each stated the youth are given
the opportunity to explain their behavior. Each staff explained supervisors provided positive
feedback, constructive criticism, and explain the importance of the use of the BMS in shift
briefings, during rounds, and one on one. None of the seven staff have ever seen a co-worker
take meals, snacks, clothing, education, or medical care from a youth because they were acting
out nor have any of the interviewed staff observed any staff encouraging youth to beat up
another youth. Seven youth were interviewed, and four reported the BMS to be good and three
reported the BMS to be very good. All seven youth were able to explain how the BMS works
and how they move from level to level, how youth are rewarded with snacks, extra telephone
calls, and extra free time. All seven youth indicated all staff use rewards the same and no youth
are ever allowed to punish other youth. Five of the seven youth indicated they are sent to their
room for punishment, and two youth responded they are not. Five youth responded the doors
are locked when sent to their room for confinement purposes only, while two youth were not
applicable. Six youth stated they had received consequences which were fair. Seven youth
were asked when consequences were given, what rewards were taken away. Six youth stated
levels, and one youth stated they had never received consequences. Seven interviewed youth
stated they had never witnessed handcuffs or leg irons used on out-of-control youth to prevent
them from hurting themselves or others. The superintendent interview explained the center uses
a three-level system for rewarding positive behavior. As the youth level progresses, he or she
earns extra privileges such as extra telephone calls, television time, games, and extra snacks.
The BMS policy system is undergoing a new process.
5.03 Ten-Minute Checks (Critical) Failed 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 has facility operating procedures (FOPs) which require visual observation of 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 restrictions. The
center has sixty-four cameras in which fifty-eight were operational during the annual compliance
review. The video recording is stored for thirty-days. The center recently had deficiency closed
on December 12, 2024. During the week of the annual compliance review, the center’s video
surveillance system playback was not operating properly; therefore, a review of ten-minute
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checks was unable to be performed. The center did provide visual observation reports (VORs)
for January 23, 2025, mod G1, January 27, 2025, mod B2, January 26, 2025, mod B3, January
26, 2025, mod G1, January 26, 2025, mod B2, and January 23, 2025, mod B3. The VORs were
reviewed, and all checks were completed every ten minutes. The center was unable to provider
VORs for March 2024 to July 2024. Seven staff were interviewed and stated room checks are
conducted every ten-minutes when a youth (non-suicidal) is placed in their room for sleeping or
non-punishment reasons. The superintendent interview explained ten-minute checks are
conducted for all youth with the Timekeeper Wand or VOR at bedtime. While youth are in their
room for shift change, a routine room check form is completed for each youth in their room.
While in confinement ten-minutes checks are documented on a VOR. If a youth is on close
watch, checks are conducted every five minutes. During the week of the annual compliance
review, an observation of staff conducting ten-minute checks in mod B2, mod B3, and mod G1
were conducted on from 7:00 p.m. to 7:30 p.m., and no issues were noted.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures (FOPs) to ensure the census, counts, and tracking
of all youth. Staff must always know the exact number and location of all youth under their
supervision. A review of master control logbooks, modules B2, B3, G1 for each month of the
annual compliance review period, confirmed counts were conducted and documented at the
beginning and end of each shift, following any emergency, including a power outage, prior to
and following routine group movement, anytime a population change occurred, and randomly
once a shift. During the annual compliance review week, an observation of counts was
conducted with no issues noted. Seven interviewed staff stated counts are conducted at the
beginning and end of each shift. Six staff stated counts are conducted before and after school
and before and after meals. All seven interviewed staff stated if a headcount is off, all movement
is stopped, and a recount is done. If the count is still not correct the center prints out the youth
census and each youth is counted again. Seven interviewed staff stated emergency counts are
conducted when youth are believed to be missing, after major disturbance, and when visibility is
hindered or after an electrical outage.
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
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used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) to maintain a chronological record of
events, incidents, and activities in logbooks maintained at master control and in each living
area. A review of logbooks found they were bound with numbered pages, dates on top of each
page, all entries included the time of events, in a.m./p.m., name of the staff and youth, and a
brief description of the events and the initials of the staff making the entries. All entries
impacting the safety and security of the center, including medical/special needs and mental
health alerts, were highlighted and all errors were struck through with a single line and voided
with staff’s initials. Supervisors reviewed the master control logbook when accepting
responsibility of the center and each reviewed logbook designated the name and position of the
reviewer, the date and time the review was completed. The master control logbook had all the
requirements included. The center had a deficiency recently closed on December 12, 2024 for
logbook maintenance in master control. The superintendent interview explained supervisors are
required to document their reviews and security checks in the facility logbook at a minimum of
two times during their shift. Administrators are required to document their reviews and security
checks at a minimum of once a week on each shift in only blue or black ink.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) describing the center’s process for key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or
lost keys, and reporting and replacing damaged keys. Missing or lost keys must be
documented, and the supervisor must be notified immediately; the Department’s Central
Communications Center (CCC) report is generated if any key is not found or located. An
incident report is completed if any key is damaged, and the key is replaced by the
superintendent. An inventory of keys was conducted and all keys on the inventory matched the
actual key rings in use. Keys are stored in master control. At shift change staff are given facility
keys and personal keys are left in the breakroom behind a secure locked door. The master key
inventory included the ring number, number of keys on each ring, the capability of each key, and
to whom the key ring was issued. The facility keys were placed on color coordinated hubs and
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all colors matched the correct keys as required. Each time a key was issued to staff it was
documented on the shift report. The key boxes in master control were not easily accessible
while locked. An observation during the annual compliance review week, confirmed all staff who
were issued keys, always carried issued keys on their person, did not allow youth to handle
facility keys, and did not remove the keys from the facility or the facility grounds without
authorization form the superintendent. Provisions for restricted keys confirmed medical keys go
to the medical cart, and keys for the outside gate are stored in master control. Facility keys are
maintained on a tamper resistant key ring. There was one incident reported to the CCC relating
to key control. This incident is still open and under review. A review of three key rings was
conducted, and all key rings had the appropriate number of keys on the ring as reflected in the
inventory. Three staff were informally interviewed, and they were able to accurately describe
each function of the keys they possessed. An informal interview was conducted with the master
control operator who was able to explain the process for restricting key usage. Seven staff were
interviewed, and all were able to accurately explain the key control process and which of the
center’s keys are restricted. The superintendent interview explained permanent keys are issued
to administrative staff.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures (FOP’s) addressing transportation procedures and
the maintenance and operation of Department vehicles. Observations during the annual
compliance review week confirmed each of the four center vehicles had the appropriate number
of seatbelts, a seatbelt cutter, a window punch, a fire extinguisher, and a first-aid kit, with items
approved by the designated health authority (DHA). Each vehicle underwent an annual vehicle
inspection. A review of documentation supported monthly visual checks of the water coolant,
lights, oil, emergency equipment, brakes, horn, interior/exterior, and cleanliness of each vehicle.
Monthly checks of the tires, windshield, wipers, windows, and mirrors were confirmed during the
week of the annual compliance review. Each inspection was maintained and documented on the
mandatory inspection form. A review of logbook documentation determined staff are
acknowledging the vehicle was checked, the destination, the number of youth and staff
including names, the name of the officer riding in the back of the van, the time the transport
began, and the time the transport ended. During the annual compliance review week, a
transportation was observed. Prior to the transport, staff inspected the vehicle for contraband
and made sure the cage area of the vehicle was checked, ensured the vehicle had sufficient
gasoline for the transport, verified seatbelts were secure, ensured the vehicle binder contained
the vehicle log, and documented the inspection in the vehicle logbook. Staff searched youth
prior to placing them into the vehicle and ensured each youth and staff wore their seatbelts.
After the transport, the vehicle was searched by staff for contraband, staff ensured the vehicle
was locked, and ensured youth were searched upon return to the center. All four vehicles were
checked to ensure they were locked, and all four were locked. Seven youth were interviewed,
and each stated they feel staff are driving safely when transporting youth. Each youth reported
they have never seen anyone place contraband in a transport vehicle.
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5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOPs) addressing tool inventory and
management. The center’s FOPs indicate maintenance tools shall be on a shadow board with a
master inventory to reflect the shadow board. The kitchen knives and other hazardous sharps
shall be stored in a locked cabinet located in the kitchen. During the annual compliance review
week, observations confirmed all tools were secured and locked in the maintenance workshop,
and the maintenance and kitchen tools were not accessible to youth. An informal interview with
maintenance staff confirmed service vendors are always accompanied by designated center
staff when in a secure area of the facility. A review of the tool inventory confirmed the center has
an accurate count of all tools and a log indicating which tool has been signed out and returned.
Youth are allowed to use cleaning items such as mops, brooms, and common household items
under the direct care and supervision of staff. A review of ten tools in the maintenance shed was
completed. Observations confirmed each tool was secured, was marked for easy identification,
and the inventory accurately reflected the number of tools. An informal interview with
maintenance and kitchen staff to determine the practice for missing or damaged tools was
conducted. Missing tools will be reported to a supervisor, and the supervisor will call the
Department’s Central Communications Center (CCC) to inform them of the missing tool, and
when found the center will call the CCC back to provide an update. Seven youth were
interviewed and four responded they are permitted to use mops and brooms, three stated they
do not use any tools, and two stated they use scrub brushes. Seven staff were interviewed and
six staff responded if a tool is missing or damaged it is reported to the supervisor or
maintenance staff and one staff said broken tools are reported to maintenance, missing tools
are reported to supervisor and a call to the CCC is required. The superintendent was
interviewed was able to identify who has access to facility tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
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The center has facility operating procedures (FOPs) to ensure proper inventory of all
flammables, toxic, caustic, and poisonous items. These items can only be used by authorized
staff. The center had a deficiency closed on September 26, 2024. Safety Data Sheets (SDS’s)
were maintained in a binder near the stored chemicals and were available to staff. A review of
five SDS’s and corresponding items was completed, and all five chemicals were properly
accounted for and stored in a secure place with appropriate SDS sheets for each item. Seven
youth were interviewed and three stated they clean with cleaning chemicals and staff spray the
product and the youth wipe it down. Four stated they do not use cleaning chemicals. All seven
youth stated they do not have access to flammable, toxic, caustic, and poisonous items. Seven
staff were interviewed, and five stated youth are allowed to clean with cleaning chemicals and
two responded they are not. One staff stated staff spray the product and youth can then wipe it
down.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) addressing the proper use, storage, and
disposal of all flammables, toxic, caustic, and poisonous items. Since the last annual
compliance review, there have been no instances of chemical spills. The maintenance staff
stated all chemicals are either used or picked up by the center’s vendor to be removed for
proper disposal. The kitchen does not have a container for grease because they do not fry any
food. An interview with the maintenance staff confirmed chemicals are being disposed of
appropriately.
5.11 Confinement Under Twenty-Four Hours Failed Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures (FOPs) which outline the process of placing youth
in confinement under twenty-four hours. Since the last annual compliance review, the center
had six youth confinements. Six confinement reports were reviewed to confirm if the youth were
afforded rights while in temporary confinement. Two youth were provided three meals a day
plus school and evening snacks, and it was unable to be determined if four youth were provided
meals, snacks, and school based on the confinement report. One youth did have access to
healthcare, one youth was not applicable, and a review of four youth confinement reports could
not determine if mental health services were needed or not. Four youth confinement reports
could not determine if the youth received a shower, and two youth were not applicable. All six
youth confinement reports could not determine if they received clean clothing. Three youth
confinement reports could not determine if the youth received a mattress and bedding, two
youth did receive a mattress and bedding and one youth was not applicable. Two youth did
receive educational materials, three youth confinement reports could not determine if youth
received educational materials and one youth was not applicable. Six youth confinement reports
confirmed each youth was given a notice of the youth’s right to grieve a confinement placement.
Three youth confinement reports could not determine if the supervisor approved the
confinements. Three youth confinement reports confirmed they were approved by a supervisor.
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Three youth confinement reports could not determine if the staff placed only one youth in a
confinement room. Three youth confinement reports confirmed staff only placed one youth in a
confinement room. Six youth confinement reports reviewed confirmed the room was searched,
and the documentation was entered into Facility Management System (FMS).
The center could not provide the Visual Observation Reports (VORs) related to the confinement
for the six youth placed into confinement. There was no documentation the reason for
confinement was explained to any of the six youth. Three youth confinement reports confirmed
the supervisor did conduct an initial confinement review with the youth within one hour of the
incident. No supervisory reviews were completed for three youth. None of the six confinement
reports were completed by the end of the staff’s shift. One was completed one day late and the
remaining five were not completed. Three youth confinement reports confirmed supervisors did
conduct additional reviews with the youth at a minimum of every three hours and documented
the reviews in FMS. Three reviewed youth confinement reports confirmed no additional
supervisory reviews were completed. Four reviewed youth confinement reports confirmed the
supervisor nor staff continually counseled the youth nor considered removing the youth from
confinement as soon as the youth was able to join the general population with no threat to their
safety. Two reviewed youth confinement reports confirmed the supervisor or staff continually
counseled the youth and considered removing the youth from confinement as soon as the youth
was able to join the general population with no threat to their safety. Five reviewed youth
confinement reports documented the superintendent or designee reviewed all confinement
reports within forty-eight hours, excluding weekends and holidays (unless it is their regularly
scheduled workday) and determined whether each confinement was appropriate or
inappropriate. One reviewed youth confinement report confirmed the superintendent nor a
designee reviewed the confinement report within forty-eight hours. The windows and cameras
were free of obstruction making observations visually clear. Seven interviewed staff explained
the center’s step by step process for placing youth in confinement. All seven staff stated youth
who are placed in temporary confinement are provided education materials. The superintendent
explained regional management receives and reviews the alerts when a confinement report is
generated in FMS.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center had a deficiency recently closed on September 13, 2024. 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.
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The center has facility operating procedures (FOPs) in place which include the center’s Disaster
Preparedness Plan and the Continuity of Operations Plan (COOP). The plan specifies COOP
drills shall be conducted and documented, at a minimum, twice a year, with one drill being
completed prior to hurricane season. The center completed two COOP drills since the last
annual compliance review. The two drills had documentation containing the type of drill, time
and date, participants, a brief scenario, and findings and recommendations. An additional drill
was completed prior to the last annual compliance review and meets the requirement of
completing a COOP drill prior to the start of hurricane season. The superintendent interview
explained the center does not have a comprehensive safety/emergency program; however, the
center does have the COOP which encompasses safety and emergency procedures.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) regarding escape drills and an Escape
Prevention Plan. The center’s FOP requires escape drills to be completed on a quarterly basis.
The center was operating on two shifts during the annual compliance review period, shifts A and
C. Escape drills were completed each quarter on each shift with the exception of one drill one,
one quarter for shift A. The logbook contained documentation of the completed escape drills. A
review of seven staff training records confirmed five staff were trained in escape prevention
annually, and two staff were missing the trainings. Seven staff were interviewed, and all seven
staff reported they have participated in escape drills.
5.15 Fire Drills Failed Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has facility operating procedures (FOPs) and a Fire Prevention Plan addressing fire
drills. Fire drill documentation was reviewed since the last annual compliance review, and found
the center did not conduct fire drills monthly, on each shift. Fire drills were not conducted on
both A and C shifts for five of the eleven reviewed months; ten drills in total were missing. The
master control logbook included documentation of each completed drill. All drill forms were
reviewed and signed by facility administration. Fire extinguishers were inspected annually, and
the maintenance staff checked the extinguishers monthly. Seven youth were interviewed, and
each stated they have been instructed on what to do in the case of a fire. Seven staff were
interviewed and stated fire drills take place at least monthly.
5.16 Search and Contraband Procedures Failed 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,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 57 (Revised July 2023)
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
Searches were found not to be documented electronically in the Department’s Facility
Management System (FMS). There were two Department Central Communications Center
(CCC) incidents, one on March 20, 2024, and one on March 28,2024, indicating strip searches
were conducted; however, the center could not provide incident reports for either incident. A
review of logbooks was unable to determine if two staff of the same gender were present during
the search, and who conducted the search. Furthermore, logbooks did not indicate where the
searches were conducted. Electronic searches were conducted on all persons entering the
center. All bags, cases, jacket pockets, and other items were searched. All personal keys were
collected by master control before entering the secure floor. Personal cellular telephones and
other contraband items were prohibited. The center was unable to provide any documentation
regarding room searches. The center did not document any completed room searches during
the annual compliance review. A review of contraband procedures confirmed there were ten
instances during the annual compliance review period where the safety and security of the
center was compromised. The instances include, but are not limited to, vape pens being
located, staff cell phones on the floor, and youth testing positive for tetrahydrocannabinol (THC).
The center does not have a visitor log containing a contraband attestation statement; however,
the center does have a separate visitor contraband attestation form. The program indicated they
recently started utilizing the contraband attestation forms. There was only one signed form from
the annual compliance review period, which was in February 2024 by a visitor, despite having
fifteen pages of visitors during the annual compliance review period. Seven reviewed staff
personnel records confirmed each staff had a signed contraband attestation form included in
their personnel record. Forty-seven newly hired staff since the last annual compliance review
had a signed contraband attestation form in their personnel records. A review of five instances
of contraband were reviewed in the master control logbook for March 20, 2024, March 28, 2024,
June 21, 2024, September 6, 2024, and December 2, 2024. The logbook did not document the
confiscation of contraband, just noting contraband was located. Five of the six incidents
involving contraband were not documented on an incident report identifying findings and
disposition of the contraband. One incident report was documented for March 20, 2024. Law
enforcement was contacted if any found item was considered illegal as defined in Florida
Statutes, or if there was evidence of any type of unlawful activity. A determination of the chain of
custody was unable to be made on four of the five incidents because there were no incident
reports. One instance, March 20,2024, the confiscated items were secured by staff and hand
delivered to a supervisor. A review of logbooks and shift reports was unable to determine if the
shift supervisor documented the chain of custody of the secured items. The CCC was notified of
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 57 (Revised July 2023)
the discovery and confiscation of the contraband for all five incidents. The center was unable to
provide any documentation showing the regional director or designee was notified of the
discovery and confiscation of the contraband. The superintendent was able to explain the
center’s procedures if a youth or staff is found with contraband. Any item discovered during a
search of youth, staff, or visitors, which is determined to be unauthorized is removed and
secured in administration. Law enforcement is contacted if the contraband is illegal as defined
by Florida Statue or any unlawful intent or activity.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 57 (Revised July 2023)

excerpt: Right Interactions (RI)

rule: Indicator 1.07

excerpt: In-Service Training

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rule: Indicator 5.11

excerpt: Confinement Under Twenty-Four Hours

rule: Indicator 5.15

excerpt: Fire Drills

rule: Indicator 5.16

excerpt: Search and Contraband Procedures